Lifestyle factors in patients with rheumatoid arthritis-a cross-sectional study on two Scandinavian cohorts

Self-determined motivation and physical activity in patients with rheumatoid arthritis: a cross-sectional study

OBJECTIVE

To identify factors associated with two self-reported measures of physical activity (PA) in patients with rheumatoid arthritis (RA).

METHOD

Hospital outpatients with RA from central Norway filled in questionnaires about symptoms, psychological factors, and PA. Outcomes were two alternative self-reported measures of PA: (i) fulfilling the aerobic PA recommendations of ≥ 150 min/week at moderate intensity or ≥ 75 min/week at vigorous intensity; or (ii) being in the PA maintenance stage of the Stages of Exercise Behaviour Change framework. Logistic regression was applied to identify factors associated with PA. Step 1 included the independent variables sex, age, and smoking habits. Step 2a added self-reported function, joint pain during the past 6 months, and fatigue to Step 1. Step 2b added Exercise Self-Efficacy and the Relative Autonomy Index (RAI), calculated from the Behavioural Regulation in Exercise Questionnaire-2, to Step 1. Step 3 included all the mentioned independent variables. Steps 1-3 were analysed for each PA measure.

RESULTS

In total, 227 patients participated. The RAI had a statistically significant positive association with being physically active according to both PA definitions. Joint pain had a significant negative association with meeting the aerobic PA recommendations but was not associated with being in the PA maintenance stage.

CONCLUSION

The degree of self-determined motivation was the most consistent variable associated with self-reported PA behaviour. Joint pain was associated with one of the two PA measures. Motivation and joint pain may be useful targets for intervention in clinical practice to improve PA engagement among patients with RA.

Patients' perspectives on adherence to cardiovascular screening consultation and lifestyle changes

BACKGROUND

Rheumatoid arthritis (RA) poses a significant health burden, with patients facing a twofold higher risk of cardiovascular diseases compared to the general population. As a results, the international recommendations set forth by the European Alliance of Associations for Rheumatology, advocate for a structured cardiovascular (CV) risk management and adherence to a healthy lifestyle for patients with RA. Unhealthy lifestyle factors not only impact overall health but also worsen inflammation and hinder treatment response in patients with RA Despite these recommendations, there remains a knowledge gap regarding patients' attitudes towards screening participation and lifestyle changes. Therefore, the aims of this study were firstly to explore the perspectives of patients with rheumatoid arthritis on participation and adherence to cardiovascular screening. Secondly, to explore patients' perspectives on lifestyle changes.

METHODS

Semi-structured interviews based on a hermeneutic approach were conducted. The analysis was guided by qualitative content analysis, employing an inductive approach.

RESULTS

Nine women and seven men, aged 47 to 76 years, diagnosed with RA, and who had attended at least one CV screening session, took part in the study. Two primary themes, along with four sub-themes, emerged from the analysis. The first main theme, Accepting an offer, encompassed the sub-themes of Engagement in the screening consultation and Risk awareness, reflecting participants' views on their involvement in, and commitment to, CV screening. The second theme pertained to participants' perspectives on lifestyle changes: Living with a chronic disease and embracing changes, described through the sub-themes of Motivation for lifestyle changes and Strategies to achieve lifestyle changes.

CONCLUSION

Motivations for taking part in the screening differed among the participants, ranging from simply accepting an invitation to joining as a proactive precaution. In general, there was unanimous agreement among the participants that the screening proved to be a positive encounter. While it may not have immediately prompted significant lifestyle alterations, it did enhance their awareness of risks and underscored the significance of maintaining a healthy lifestyle. Overall, the individual guidance and support for patients with rheumatoid arthritis should entail awareness of CV risk combined with support to lifestyle changes the participants want to pursue.

Participation in cardiovascular screening consultations, the who, when and why - A cohort study on patients with rheumatoid arthritis

BACKGROUND

In accordance with the EULAR recommendations, the Danish Hospital for Rheumatic Diseases have systematically invited patients with rheumatoid arthritis (RA) to cardiovascular (CV) risk assessment since 2011. Patients with high risk are invited to a follow-up screening after one year. To optimize the screening and tailor it to individual needs, information about who accepts vs. declines follow-up is needed. Thus, the aim of this study was to explore participation in systematic CV risk assessment among patients with RA. Furthermore, to explore differences between patients with low vs. high risk, and between patients with high risk who accept vs. decline follow-up.

METHODS

Data from 2,222 outpatients with RA in the period 2011-2021 were retrieved, and of these 1,522 were under 75 years and eligible to be invited. To assess the 10-year risk for CV death, the modified Systematic Coronary Risk Evaluation (mSCORE), derived by multiplying the SCORE by 1.5, was used. Logistic regression analyses were used to explore differences in CV risk factors (triglycerides, HbA1c, lifestyle factors) and measures of disease impact (pain, fatigue, patient global assessment, HAQ, EQ-5D-5L) between patients with low vs. high risk. Differences between high risk patients who accepted vs. declined follow-up were analysed using Wilcoxon rank sum test and chi-squared test for groups.

RESULTS

One thousand one hundred forty-nine received a CV screening invitation and 91 declined participation. Patients with high risk had significantly longer disease duration (OR; 95 CI) (1.017; 1.002-1.032), higher levels of triglycerides (1.834; 1.475-2.280), HbA1C (1.046; 1.020-1.070), pain (1.006; 1.001-1.012), and HAQ-score (1.305; 1.057-1.612) compared to patients with low risk and they more often declined follow-up (43% vs. 28%, p < 0.001). Those who declined a follow-up invitation were older (p = 0.016) and had shorter disease duration (p = 0.006) compared to those who accepted follow-up.

CONCLUSION

A first CV screening consultation was accepted by most patients with RA, while only every other patient with high to very high CV risk adhered to a follow-up screening consultation. Neither measures of disease impact nor lifestyle factors were associated with adherence. Further studies are needed to explore the patients' motivation, barriers and facilitators for adherence or non-adherence to a follow-up consultation.

Healthcare professionals' perceptions of working on lifestyle management for patients with early rheumatoid arthritis - a qualitative study

AIM

To explore HPs' perceptions of working on lifestyle management for patients with early rheumatoid arthritis (RA).

METHODS

In this qualitative study, individual interviews were conducted with 20 HPs. Qualitative content analysis was used, and three categories and six subcategories were identified.

RESULTS

HPs' perceptions of working on lifestyle management for patients with early RA revealed a need for commitment from different levels. This included commitment from healthcare managers and organizations prioritizing work on lifestyle management and providing competence development for HPs. Commitment within the team regarding coordination of interdisciplinary teamwork and development of a structured lifestyle management approach, and commitment to involving patients in lifestyle management, by facilitating patient engagement and a person-centred approach.

CONCLUSIONS

HPs' perceptions of working on lifestyle management for patients with early RA revealed that commitment from healthcare managers, organizations, and the interdisciplinary team was essential to facilitate collaboration, patient involvement, and a person-centred approach.

Associations between cardiovascular risk factors, disease activity and cardiorespiratory fitness in patients with inflammatory joint disease: a cross-sectional analysis

BACKGROUND

Inflammatory joint diseases (IJD) are accompanied by an increased risk of cardiovascular disease (CVD). Cardiorespiratory fitness (CRF) is a modifiable CVD risk factor and low levels of CRF associate with an elevated CVD risk. This study aimed to investigate the associations between CVD risk factors, disease activity and CRF in patients with IJD and to explore differences between patients with normal versus low levels of CRF.

METHODS

CRF was measured as peak oxygen uptake (VO_2peak) with a cardiopulmonary exercise test. Participants were also evaluated for: Body composition, blood pressure, blood lipids, inflammatory markers and disease activity. Patient-reported use of cigarettes/snuff, medication, disease duration, pain, fatigue, CVD history, habitual physical activity and exercise beliefs and self-efficacy were collected by questionnaire. Cross-sectional associations between CVD risk factors, disease-related factors and CRF were analyzed by multiple linear regression. CRF was categorized to normal CRF (VO_2peak ≥ 80%) or low CRF (VO_2peak < 80%) according to age- and gender-stratified reference data. Differences in demographic, CVD and disease-related factors between patients with normal versus low CRF were explored.

RESULTS

In 60 Norwegian patients with IJD [34 females, age 59 years (IQR: 52-63)], mean VO_2peak was 30.2 (± 6.9) mL/kg/min, corresponding to 83% (± 18) of normative reference values. Age (coefficient: - 0.18 years, p = 0.01) and fat mass (coefficient: - 0.67 %, p < 0.001) were inversely associated with CRF, while physical activity index (coefficient: 0.13 points, p = 0.05) was positively associated with CRF (R² = 0.66). There were no significant associations between CRF, classical CVD risk factors and disease-related variables. Compared to patients with low CRF (n = 30), patients with normal CRF (n = 30) had higher peak oxygen uptake (+ 9.4 mL/kg/min, p < 0.001), high-density lipoprotein cholesterol (+ 0.5 mmol L^-1, p < 0.001), and exercise self-efficacy (+ 6.9, p < 0.01) as well as lower fat mass (- 8.7%, p < 0.001), resting heart rate (- 8.0 beats/min, p < 0.01) and triglycerides (- 0.5 mmol L^-1, p < 0.01).

CONCLUSIONS

In this sample of IJD-patients, age, fatmass and physical activity level were associated with CRF. CRF was lower than reference values and patients with normal CRF presented with a more favorable health profile. There is a continued need for exercise interventions to improve CRF in patients with IJD.

TRIAL REGISTRATION

NCT04922840.

Exercise Self-Efficacy and patient global assessment were associated with 6-min walk test distance in persons with rheumatoid arthritis

INTRODUCTION

Low functional capacity is related to future loss of daily function and cardiovascular events. The present study explored the associations of patient-reported outcome measures (PROMs) and disease-specific measures with functional capacity as measured by the 6-min walk test (6MWT) in persons with rheumatoid arthritis (RA).

METHODS

Seventy-nine participants from rheumatology outpatient clinics were included. The distance walked during the 6MWT (6MWD) was the dependent variable in multivariable regression analyses. Model 1 included the independent variables sex, age (in tertiles to improve model fit), and body mass index (BMI). Building on Model 1, Model 2 added smoking, patient global assessment (PGA), Exercise Self-Efficacy, Hospital Anxiety and Depression Scale's Depression score, and Cohen's Perceived Stress Scale score, whereas Model 3 added smoking, disease duration, present use of glucocorticosteroids, seropositivity, Disease Activity Score 28-C-Reactive Protein (DAS28-CRP), and a comorbidity variable.

RESULTS

Median age was 65 years, 76% were female, and median 6MWD was 493 m. In Model 1, BMI and age were significantly associated with the 6MWD (R2 = 0.42). In Model 2, PGA and Exercise Self-Efficacy were also significantly associated with the 6MWD, with standardized regression coefficients of - 0.21 (p = 0.03) and 0.26 (p = 0.004) respectively (R2 = 0.54). The RA-specific variables in Model 3 were not significantly associated with the 6MWD (R2 = 0.49).

CONCLUSION

The PROMs PGA and Exercise Self-Efficacy were significantly associated with functional capacity as measured by the 6MWT in persons with RA, whereas disease-specific measures such as DAS28-CRP and disease duration were not. Key Points • Functional capacity measured with the 6-minute walk test was significantly associated with body mass index, age, patient global assessment, and Exercise Self-Efficacy in persons with RA. • Patient-reported outcome measures explained more of the variation in functional capacity than objective or composite measures of disease and are relevant measures in clinical follow-up. • Techniques that enhance self-efficacy for exercise should be incorporated into clinical practice to promote physical activity.

A combination of two or more unhealthy lifestyle factors is associated with impaired physical and mental health in patients with spondyloarthritis: a cross-sectional study

BACKGROUND

There is increasing knowledge of how individual lifestyle factors affect patients with spondyloarthritis, while studies exploring the combination of unhealthy lifestyle factors are lacking. Thus, our aim was to study the frequency of two or more unhealthy lifestyle factors and their associations with physical and mental health in patients with spondyloarthritis (SpA).

METHODS

A population-based postal survey involving questions on lifestyle factors was completed by 1793 patients with ankylosing spondylitis (AS), psoriatic arthritis (PsA), and undifferentiated spondyloarthritis (USpA). Self-reported physical activity, body mass index, and tobacco use were respectively dichotomized as "healthy" or "unhealthy", summarized for each patient and stratified into four groups (0-3; 0 = no unhealthy lifestyle factors). Group comparisons were performed with Chi-squared tests, and associations with physical and mental health outcomes were performed with analysis of covariance and logistic regression analysis.

RESULTS

Out of 1426 patients (52% women) with complete information for all studied lifestyle factors, 43% reported ≥ two unhealthy lifestyle factors-more frequently patients with PsA (48%) than AS (39%) or USpA (38%)-and with no difference between women and men (p = 0.399). Two or more unhealthy lifestyle factors were associated with worse health-related quality of life, disease activity, physical function, pain, fatigue, anxiety, and depression, adjusted for age and SpA-subgroup. If an unhealthy level of physical activity was one of the two unhealthy lifestyle factors, patients reported worse health outcomes.

CONCLUSION

Reporting two or more unhealthy lifestyle factors were associated with worse physical and mental health in patients with SpA. This highlights the need to screen for a combination of unhealthy lifestyle factors and offer individualized coordinated interventions, and tailored coaching to support behavioral change, in order to promote sustainable health.

Maximal strength training in patients with inflammatory rheumatic disease: implications for physical function and quality of life

PURPOSE

Patients with inflammatory rheumatic disease (IRD) have attenuated muscle strength in the lower extremities, resulting in impaired physical function and quality of life. Although maximal strength training (MST), applying heavy resistance, is documented to be a potent countermeasure for such attenuation, it is uncertain if it is feasible in IRD given the pain, stiffness, and joint swelling that characterize the population.

METHODS

23 patients with IRD (49 ± 13 years; 20 females/3 males), diagnosed with spondyloarthritis, rheumatoid arthritis, or systemic lupus erythematosus, were randomized to MST or a control group (CG). The MST group performed four × four repetitions dynamic leg press two times per week for 10 weeks at ~ 90% of one repetition maximum (1RM). Before and after training 1RM, rate of force development (RFD), and health-related quality of life (HRQoL) were measured.

RESULTS

Session attendance in the MST group was 95%, of which 95% conducted according to MST protocol. Furthermore, MST increased 1RM (29 ± 12%, p = 0.001) and early and late phase RFD (33-76%, p < 0.05). All improvements were different from the CG (p < 0.05). MST also resulted in HRQoL improvements in the dimensions; physical functioning, general health, and vitality (p < 0.05). Physical functioning was associated with 1RM (rho = 0.55, p < 0.01) and early phase RFD (rho = 0.53-0.71, p < 0.01; different from CG p < 0.05).

CONCLUSIONS

Despite being characterized by pain, stiffness, and joint swelling, patients with IRD appear to tolerate MST well. Given the improvements in 1RM, RFD, and HRQoL MST should be considered as a treatment strategy to counteract attenuated muscle strength, physical function, and HRQoL.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04998955, retrospectively registered.