Non-pharmacological treatment in difficult-to-treat rheumatoid arthritis

Although the management of rheumatoid arthritis (RA) has improved remarkably with new pharmacological therapies, there is still a significant part of patients not reaching treatment goals. Difficult-to-treat RA (D2TRA) is a complex entity involving several factors apart from persistent inflammation, thereafter requiring a holistic management approach. As pharmacological treatment options are often limited in D2TRA, the need for non-pharmacological treatments (NPT) is even more pronounced. The mechanism of action of non-pharmacological treatments is not well investigated, NPTs seem to have a complex, holistic effect including the immune, neural and endocrine system, which can have a significant additive benefit together with targeted pharmacotherapies in the treatment of D2TRA. In this review we summarize the current knowledge on different NPT in rheumatoid arthritis, and we propose a NPT plan to follow when managing D2TRA patients.

Effects of physical exercise and body weight on disease-specific outcomes of people with rheumatic and musculoskeletal diseases (RMDs): systematic reviews and meta-analyses informing the 2021 EULAR recommendations for lifestyle improvements in people with RMDs

BACKGROUND

A European League Against Rheumatism (EULAR) taskforce was convened to develop recommendations for lifestyle behaviours in rheumatic and musculoskeletal diseases (RMDs). This paper reviews the literature on the effects of physical exercise and body weight on disease-specific outcomes of people with RMDs.

METHODS

Three systematic reviews were conducted to summarise evidence related to exercise and weight in seven RMDs: osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, axial spondyloarthritis (axSpA), psoriatic arthritis, systemic sclerosis and gout. Systematic reviews and original studies were included if they assessed exercise or weight in one of the above RMDs, and reported results regarding disease-specific outcomes (eg, pain, function, joint damage). Systematic reviews were only included if published between 2013-2018. Search strategies were implemented in the Medline, Embase, Cochrane Library of systematic reviews and CENTRAL databases.

RESULTS

236 articles on exercise and 181 articles on weight were included. Exercise interventions resulted in improvements in outcomes such as pain and function across all the RMDs, although the size of the effect varied by RMD and intervention. Disease activity was not influenced by exercise, other than in axSpA. Increased body weight was associated with worse outcomes for the majority of RMDs and outcomes assessed. In general, study quality was moderate for the literature on exercise and body weight in RMDs, although there was large heterogeneity between studies.

CONCLUSION

The current literature supports recommending exercise and the maintenance of a healthy body weight for people with RMDs.

Digital tools to support the maintenance of physical activity in people with long-term conditions: A scoping review

Objective

This scoping review aimed to bring together and identify digital tools that support people with one or more long-term conditions to maintain physical activity and describe their components and theoretical underpinnings.

Methods

Searches were conducted in Cumulative Index to Nursing and Allied Health Literature, Medline, EMBASE, IEEE Xplore, PsycINFO, Scopus, Google Scholar and clinical trial databases, for studies published between 2009 and 2019, across a range of long-term conditions. Screening and data extraction was undertaken by two independent reviewers and the Preferred Reporting Items for Scoping Reviews guidelines informed the review's conduct and reporting.

Results

A total of 38 results were identified from 34 studies, with the majority randomised controlled trials or protocols, with cardiovascular disease, type 2 diabetes mellitus and obesity the most common long-term conditions. Comorbidities were reported in >50% of studies but did not clearly inform intervention development. Most digital tools were web-browser-based ± wearables/trackers, telerehabilitation tools or gaming devices/components. Mobile device applications and combination short message service/activity trackers/wearables were also identified. Most interventions were supported by a facilitator, often for goal setting/feedback and/or monitoring. Physical activity maintenance outcomes were mostly reported at 9 months or 3 months post-intervention, while theoretical underpinnings were commonly social cognitive theory, the transtheoretical model and the theory of planned behaviour.

Conclusions

This review mapped the literature on a wide range of digital tools and long-term conditions. It identified the increasing use of digital tools, in combination with human support, to help people with long-term conditions, to maintain physical activity, commonly for under a year post-intervention. Clear gaps were the lack of digital tools for multimorbid long-term conditions, longer-term follow-ups, understanding participant's experiences and informs future questions around effectiveness.

Telerehabilitation During the COVID-19 Pandemic in Outpatient Rehabilitation Settings: A Descriptive Study

OBJECTIVE

COVID-19 has widely affected delivery of health care. In response, telerehabilitation (TR) has emerged as alternative care model. Aims were: (1) to describe baseline patient characteristics and available unadjusted outcomes for episodes of care administered during COVID-19 using TR versus traditional in-person care, and (2) to describe TR frequency levels by condition and telecommunication modes.

METHODS

A descriptive retrospective observational design was used to report patient variables and outcomes including physical function, number of visits, and patient satisfaction, by TR frequency (few, most, or all visits) and telecommunication modes. Standardized differences were used to compare baseline characteristics between episodes with and without TR.

RESULTS

Sample consisted of 222,680 patients (59% female; mean [SD] age = 55 [18] years). Overall TR rate was 6% decreasing from 10% to 5% between second and third quarters of 2020. Outcome measures were available for 90% to 100% of episodes. Thirty-seven percent of clinicians administered care via TR. Patients treated using TR compared with in-person care were more likely to be younger and live in large metropolitan areas. From those with TR, 55%, 20%, and 25% had TR during few, most, or all visits, respectively. TR care was administered equally across orthopedic body parts, with lower use for nonorthopedic conditions such as stroke, edema, and vestibular dysfunction. TR was primarily administered using synchronous (video or audio) modes. The rate of patients reported being very satisfied with their treatment results was 3% higher for no TR compared with TR.

CONCLUSIONS

These results provide new knowledge about to whom and how TR is being administered during the pandemic in outpatient rehabilitation practices throughout the United States. The database assessed was found to be suitable for conducting studies on associations between TR and diverse outcome measures, controlling for a comprehensive set of patient characteristics, to advance best TR care models, and promote high-quality care.

IMPACT

This study provided detailed and robust descriptive information using an existing national patient database containing patient health and demographic characteristics, outcome measures, and telerehabilitation (TR) administration data. Findings support the feasibility to conduct future studies on associations between TR care and patient outcomes, adjusting for a wide range of patient characteristics and clinical setting factors that may be associated with the probability of receiving TR. The finding of limited and decreasing use of TR over the study period calls for studies aimed to better understand facilitators and inhibitors of TR use by rehabilitation therapists during everyday practice to promote its use when clinically appropriate.

Prevention, screening, assessing and managing of non-adherent behaviour in people with rheumatic and musculoskeletal diseases: systematic reviews informing the 2020 EULAR points to consider

OBJECTIVE

To analyse how non-adherence to prescribed treatments might be prevented, screened, assessed and managed in people with rheumatic and musculoskeletal diseases (RMDs).

METHODS

An overview of systematic reviews (SR) was performed in four bibliographic databases. Research questions focused on: (1) effective interventions or strategies, (2) associated factors, (3) impact of shared decision making and effective communication, (4) practical things to prevent non-adherence, (5) effect of non-adherence on outcome, (6) screening and assessment tools and (7) responsible healthcare providers. The methodological quality of the reviews was assessed using AMSTAR-2. The qualitative synthesis focused on results and on the level of evidence attained from the studies included in the reviews.

RESULTS

After reviewing 9908 titles, the overview included 38 SR on medication, 29 on non-pharmacological interventions and 28 on assessment. Content and quality of the included SR was very heterogeneous. The number of factors that may influence adherence exceed 700. Among 53 intervention studies, 54.7% showed a small statistically significant effect on adherence, and all three multicomponent interventions, including different modes of patient education and delivered by a variety of healthcare providers, showed a positive result in adherence to medication. No single assessment provided a comprehensive measure of adherence to either medication or exercise.

CONCLUSIONS

The results underscore the complexity of non-adherence, its changing pattern and dependence on multi-level factors, the need to involve all stakeholders in all steps, the absence of a gold standard for screening and the requirement of multi-component interventions to manage it.

"A Necessary Investment in Future Health": Perceptions of Physical Activity Maintenance Among People With Rheumatoid Arthritis

OBJECTIVE

A few studies with a qualitative design have addressed physical activity (PA) maintenance in people with rheumatoid arthritis (RA), but none of them focused specifically on maintenance of PA according to public health recommendations. The purpose of this study was to describe perceptions of PA maintenance during the second year of an outsourced 2-year support program among people with RA.

METHODS

For this descriptive design with a qualitative inductive approach, semi-structured interviews were conducted with 18 participants with RA (3 men and 15 women). Variation in age, disease duration, activity limitation, pain, levels of PA, and PA maintenance was targeted through strategic sampling. Qualitative content analysis was used, and a pattern of theme, subthemes, and categories was constructed based on the participants' perceptions of PA maintenance.

RESULTS

A main overarching theme, "A necessary investment in future health"-with 3 subthemes of dedication, awareness, and affinity-was identified as participants' perceptions of PA maintenance. Eight categories further described are a changed mindset, habits, commitments, monitoring, insights in PA, health gains, social support, and PA context.

CONCLUSIONS

PA according to public health recommendations was perceived as a true investment in future health and wellness requiring dedication, awareness, and affinity. To promote PA maintenance, physical therapists working with people with chronic conditions should consider strengthening these prerequisites by targeting patients' negative attitudes to PA, supporting their creation of PA habits to incorporate in daily routines, introducing monitoring of PA intensity, supporting development of PA self-regulation skills, and providing suitable gym facilities with the possibility of peer support.

Twelve Weeks of Strengthening Exercise for Patients with Rheumatoid Arthritis: A Prospective Intervention Study

Rheumatoid arthritis (RA) patients may benefit from exercise for several reasons. However, whole-limb strengthening exercises for such patients remain poorly studied. We hypothesized that systemic strength training that includes the upper and lower extremities would improve strength per se and enhance the quality of life. Here, we investigated the effects of 12 weeks of upper- and lower-limb strengthening exercise on the strength and quality of life of RA patients using the International Classification of Functioning, Disability, and Health model. This was a prospective, interventional controlled trial. Forty female RA patients were recruited and assigned to two groups not based on willingness to exercise, with 20 patients in the exercise group and 20 in the control group. All patients in the exercise group received once-weekly training sessions of 60 min over 12 weeks. All participants were assessed before and after the 12-week intervention period. We measured the hand grip strength and isometric quadriceps contraction, the cross-sectional area of the rectus femoris (CSA-RF) (via ultrasonography), and performed the 30 s sit-to-stand test and the 6 min walk test (6MWT). We derived the Borg scale score after the 6MWT and assessed the extent of social participation and quality of life using a Korean version of the 36-Item Short Form Health Survey (SF-36). A total of 35 subjects completed the experiment (18 in the exercise group, 17 in the control group). After the 12-week intervention period, the lower-limb strength and the CSA-RF were significantly increased in the exercise group. The activity level did not change significantly in either group. The exercise group exhibited significant improvements in the SF-36 mental health domain scores. Thus, strengthening exercise is useful for patients with RA.

Long-time follow up of physical activity level among older adults with rheumatoid arthritis

BACKGROUND

Physical activity and exercise are acknowledged as important parts in the management of rheumatoid arthritis (RA). However, long-term maintenance of exercise is known to be difficult. The aim of this study was to evaluate change in physical activity and physical fitness after four years in older adults with RA who had previously participated in exercise with person-centred guidance compared to controls.

METHOD

A follow-up study was performed where older adults (> 65 years) who had participated in a randomized controlled trial where they were allocated to either exercise with person-centred guidance or home-based, light-intensity exercise (controls) were invited to one visit and assessed with performance-based test, blood-sampling and self-reported questionnaires. Forty-seven out of 70 older adults accepted participation, 24 from the exercise group and 23 from the control group. Comparisons of the result with baseline values were performed and explanatory factors for increase of physical activity were examined with logistic regression.

RESULTS

The result show that there was no significant difference in weekly hours of physical activity when groups where compared. However, participants in the exercise group rated significantly increased weekly hours of physical activity after four years (p = 0.004) when compared to baseline. Higher levels of fatigue, BMI and physical activity, at baseline were negatively associated with increased physical activity after four years. There was no significant difference in change of physical fitness between the groups. Within group analysis showed that the control group reported increased pain (p = 0.035), fatigue (p = 0.023) increased number of tender joints (p = 0.028) higher disease activity (p = 0.007) and worsening of global health (p = 0.004) when compared to baseline while the exercise group remained at the same level as at baseline.

CONCLUSION

These results indicate that introducing moderate- to high intensity exercise with person-centred guidance might favor increased physical activity after four years in older adults with RA. Previous partaking in moderate- to high intensity exercise might also be protective against increased disease activity, pain and fatigue over time.

High-quality RMD rehabilitation and telehealth: Evidence and clinical practice

Within rheumatology, telehealth is essential to modern rehabilitation due to the demographic development with more and more elderly people. At present, telehealth solutions are used as part of the rehabilitation process in assessment, interventions and evaluation. Telehealth interventions are as effective as conventional follow-ups or self-management assessments, but the evidence on the effect is still sparse. Telehealth interventions seem to support a physically active lifestyle in the short term. In general, telehealth solutions are well received by patients, but the development must be based on user involvement, behaviour theory and the World Health Organisation principles of creating health literate organisations in order to ensure usability, effectiveness and further implementation.

Theory-informed interventions to promote physical activity and reduce sedentary behaviour in rheumatoid arthritis: a critical review of the literature

Moderate-intensity physical activity (PA) is recommended for the management of Rheumatoid Arthritis (RA). Recent evidence suggests that reducing sedentary behaviour (promoting 'sedentary breaks' and light intensity PA) may also offer potential for improving RA outcomes, independently of the benefits of moderate-intensity PA. Unfortunately, people living with RA engage in very little moderate-intensity PA, and the spend the majority of the day sedentary. Interventions to support PA and sedentary behaviour change in this population are therefore required. Psychological theory can provide a basis for the development and implementation of intervention strategies, and specify the cognitive processes or mechanisms assumed to result in behavioural change. Application of psychological theory to intervention development and evaluation, therefore, permits evaluation of "how things work", helping to identify optimal intervention strategies, and eliminate ineffective components. In this review, we provide an overview of existing PA and sedentary behaviour change interventions in RA, illustrating the extent to which current interventions have been informed by psychological theories of behaviour change. Recommendations are provided for future interventional research in this domain, serving as a reference point to encourage proper application of behavioural theories into intervention design, implementation and appraisal.

Structured Goal Planning and Supportive Telephone Follow-up in Rheumatology Care: Results From a Pragmatic, Stepped-Wedge, Cluster-Randomized Trial

OBJECTIVE

To evaluate patient-reported health effects of an add-on structured goal-planning and supportive telephone follow-up rehabilitation program compared with traditional rehabilitation programs in patients with rheumatic diseases.

METHODS

In this pragmatic stepped-wedge, cluster-randomized, controlled trial, 389 patients with rheumatic diseases recruited from 6 rehabilitation centers received either traditional rehabilitation or traditional rehabilitation extended with an add-on program tailored to individual needs. The add-on program comprised a self-management booklet, motivational interviewing in structured individualized goal planning, and 4 supportive follow-up phone calls after discharge. Data were collected by questionnaires on admission and discharge from rehabilitation stay, and at 6 months and 12 months after discharge. The primary outcome was health-related quality of life (HRQoL) measured by the Patient Generated Index (range 0-100, where 0 = low). Secondary outcomes included patient-reported health status, self-efficacy, pain, fatigue, global disease activity, and motivation for change. The main statistical analysis was a linear repeated measures mixed model performed on the intent-to-treat population using all available data.

RESULTS

A significant treatment effect of the add-on intervention on HRQoL was found on discharge (mean difference 3.32 [95% confidence interval 0.27, 6.37]; P = 0.03). No significant between-group differences were found after 6 or 12 months. Both groups showed positive changes in HRQoL following rehabilitation, which gradually declined, although the values remained at higher levels after 6 and 12 months compared with baseline values.

CONCLUSION

The add-on program enhanced the short-term effect of rehabilitation with respect to patient-specific HRQoL, but it did not prolong the effect as intended.

Effects of exercise and physical activity promotion: meta-analysis informing the 2018 EULAR recommendations for physical activity in people with rheumatoid arthritis, spondyloarthritis and hip/knee osteoarthritis

Objective

To evaluate the effectiveness of exercise and physical activity (PA) promotion on cardiovascular fitness, muscle strength, flexibility, neuromotor performance (eg, balance) and daily PA in people with rheumatoid arthritis (RA), spondyloarthritis (SpA) and hip/knee osteoarthritis (HOA/KOA).

Methods

systematic review (SR) and meta-analysis (MA) were performed searching the databases PubMed/Medline, CENTRAL, Embase, Web of Science, Emcare and PsycInfo until April 2017. We included randomised controlled trials (RCTs) in adults (≥18 years) with RA, SpA and HOA/KOA, investigating the effects of exercise or PA promotion according to the public health PA recommendations by the American College of Sports Medicine. The time point of interest was the first assessment after the intervention period. If suitable, data were pooled in a MA using a random-effects model presented as standardised mean difference (SMD).

Results

The SR included 63 RCTs, of which 49 (3909 people with RA/SpA/HOA/KOA) were included in the MA. Moderate effects were found of aerobic exercises and resistance training on cardiovascular fitness (SMD 0.56 (95% CI 0.38 to 0.75)) and muscle strength (SMD 0.54 (95% CI 0.35 to 0.72)), respectively, but no effect of combined strength/aerobic/flexibility exercises on flexibility (SMD 0.12 (95% CI -0.16 to 0.41)). PA promotion interventions produced a small increase in PA behaviour (SMD 0.21 (95% CI 0.03 to 0.38)).

Conclusion

Exercises and PA promotion according to public health recommendations for PA improved cardiovascular fitness, muscle strength and PA behaviour, with moderate effect sizes in people with SpA, RA and HOA/KOA.

Trial registration number

CRD42017082131.

The effect of interactive digital interventions on physical activity in people with inflammatory arthritis: a systematic review

The aim of this systematic review was to evaluate the evidence from randomised controlled trials (RCTs) evaluating the effectiveness of interactive digital interventions (IDIs) for physical activity (PA) and health related quality of life (HRQoL) in people with Inflammatory Arthritis [rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA) axial Spondyloarthritis (AS) and psoriatic arthritis (PsA)]. Seven electronic databases identified published and unpublished studies. Two reviewers conducted independent data extraction and quality assessment using the Cochrane risk of bias tool (RoB). The primary outcome was change in objective PA after the intervention; secondary outcomes included self-reported PA and HRQoL after the intervention and objective or self-reported PA at least 1 year later. Five manuscripts, reporting four RCTs (three high and one low RoB) representing 492 (459 RA, 33 JIA) participants were included. No trials studying PsA or AS met the inclusion criteria. Interventions ranged from 6 to 52 weeks and included 3-18 Behaviour Change Techniques. Due to heterogeneity of outcomes, a narrative synthesis was conducted. No trials reported any significant between group differences in objective PA at end of intervention. Only one low RoB trial found a significant between group difference in self-reported vigorous [MD Δ 0.9 days (95% CI 0.3, 1.5); p = 0.004], but not moderate, PA in people with RA but not JIA. There were no between group differences in any other secondary outcomes. There is very limited evidence for the effectiveness of IDIs on PA and HRQoL in RA and JIA and no evidence for their effectiveness in PsA or AS.

The effectiveness of exercise-based telemedicine on pain, physical activity and quality of life in the treatment of chronic pain: A systematic review

Introduction The aim of this study was to systematically review the evidence on the effectiveness of exercise-based telemedicine in chronic pain. Methods We searched the Cochrane, PubMed, MEDLINE, EMBASE, CINAHL and PEDRO databases from 2000 to 2015 for randomised controlled trials, comparing exercise-based telemedicine intervention to no intervention or usual care in adults with chronic pain. Primary outcome data were pooled using random effect meta-analysis. Primary outcomes were pain, physical activity (PA), limitations in activities of daily living (ADL) and quality of life (QoL). Secondary outcomes were barriers, facilitators and usability of telemedicine. Results Sixteen studies were included. Meta-analyses were performed in three subgroups of studies with comparable control conditions. Telemedicine versus no intervention showed significantly lower pain scores (MD -0.57, 95% CI -0.81; -0.34), but not for telemedicine versus usual care (MD -0.08, 95% CI -0.41; 0.26) or in addition to usual care (MD -0.25, 95% CI -1.50; 1.00). Telemedicine compared to no intervention showed non-significant effects for PA (MD 19.93 min/week, 95% CI -5.20; 45.06) and significantly diminished ADL limitations (SMD -0.20, 95% CI -0.29; -0.12). No differences were found for telemedicine in addition to usual care for PA or for ADL (SMD 0.16, 95% CI -0.66; 0.34). Telemedicine versus usual care showed no differences for ADL (SMD 0.08, 95% CI -0.37; 0.53). No differences were found for telemedicine compared to the three control groups for QoL. Limited information was found on the secondary outcomes. Conclusions Exercise-based telemedicine interventions do not seem to have added value to usual care. As substitution of usual care, telemedicine might be applicable but due to limited quality of the evidence, further exploration is needed for the rapidly developing field of telemedicine.

2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis

Regular physical activity (PA) is increasingly promoted for people with rheumatic and musculoskeletal diseases as well as the general population. We evaluated if the public health recommendations for PA are applicable for people with inflammatory arthritis (iA; Rheumatoid Arthritis and Spondyloarthritis) and osteoarthritis (hip/knee OA) in order to develop evidence-based recommendations for advice and guidance on PA in clinical practice. The EULAR standardised operating procedures for the development of recommendations were followed. A task force (TF) (including rheumatologists, other medical specialists and physicians, health professionals, patient-representatives, methodologists) from 16 countries met twice. In the first TF meeting, 13 research questions to support a systematic literature review (SLR) were identified and defined. In the second meeting, the SLR evidence was presented and discussed before the recommendations, research agenda and education agenda were formulated. The TF developed and agreed on four overarching principles and 10 recommendations for PA in people with iA and OA. The mean level of agreement between the TF members ranged between 9.8 and 8.8. Given the evidence for its effectiveness, feasibility and safety, PA is advocated as integral part of standard care throughout the course of these diseases. Finally, the TF agreed on related research and education agendas. Evidence and expert opinion inform these recommendations to provide guidance in the development, conduct and evaluation of PA-interventions and promotion in people with iA and OA. It is advised that these recommendations should be implemented considering individual needs and national health systems.

An Outsourced Health-enhancing Physical Activity Program for People with Rheumatoid Arthritis: Study of the Maintenance Phase

OBJECTIVE

To describe changes of health-enhancing physical activity (HEPA), health perception, and functioning during the second year of a 2-year support program, determine aspects of adherence and response, and describe perceptions of the program.

METHODS

Out of 220 individuals with rheumatoid arthritis (RA), 177 participated in the followup. Group support, strength training, and moderate-intensity aerobic activity were encouraged. Data collection included HEPA, perceived health, functioning, and perceptions of the program. Participants with unchanged/improved general health perception and at least 2 of aerobic capacity, grip strength, or timed standing were considered responders.

RESULTS

Current and maintained HEPA decreased from 82% to 75% (p = 0.0141) and from 41% to 27% (p < 0.0001) during the second year. Minor declines in quality of life and activity limitation occurred (p = 0.0395 and 0.0038, respectively), while outcome expectations for benefits of physical activity increased (p = 0.0010 and 0.0186) and waist circumference tapered off (p = 0.0070). Strength training was performed on average 41 and 35 times among responders (n = 54) and nonresponders (n = 105), respectively (p = 0.2708); HEPA 194 and 171 days, respectively (p = 0.0828); and support group meetings 12 and 10 times, respectively (p = 0.0943). Strength training, aerobic activity, and short text message reminders were perceived as most valuable; step registration and the self-monitoring walk tests were less appreciated.

CONCLUSION

About one-fourth of the originally sedentary individuals with RA sustained their new HEPA behaviors after 2 years and most improvements of health and functioning were sustained. Structured use of behavior change techniques and a second year to support maintenance with a reduced program might help patients with RA to sustain HEPA behavior.

Web-based rehabilitation interventions for people with rheumatoid arthritis: A systematic review

BACKGROUND

Rehabilitation approaches for people with rheumatoid arthritis include joint protection, exercises and self-management strategies. Health interventions delivered via the web have the potential to improve access to health services overcoming time constraints, physical limitations, and socioeconomic and geographic barriers. The objective of this review is to determine the effects of web-based rehabilitation interventions in adults with rheumatoid arthritis.

METHODS

Randomised controlled trials that compared web-based rehabilitation interventions with usual care, waiting list, no treatment or another web-based intervention in adults with rheumatoid arthritis were included. The outcomes were pain, function, quality of life, self-efficacy, rheumatoid arthritis knowledge, physical activity and adverse effects. Methodological quality was assessed using the Cochrane Risk of Bias tool and quality of evidence with the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

Six source documents from four trials ( n = 567) focusing on self-management, health information or physical activity were identified. The effects of web-based rehabilitation interventions on pain, function, quality of life, self-efficacy, rheumatoid arthritis knowledge and physical activity are uncertain because of the very low quality of evidence mostly from small single trials. Adverse effects were not reported.

CONCLUSION

Large, well-designed trials are needed to evaluate the clinical and cost-effectiveness of web-based rehabilitation interventions in rheumatoid arthritis.

Interactive web-based pulmonary rehabilitation programme: a randomised controlled feasibility trial

OBJECTIVES

The aim of this study was to determine if an interactive web-based pulmonary rehabilitation (PR) programme is a feasible alternative to conventional PR.

DESIGN

Randomised controlled feasibility trial.

SETTING

Participants with a diagnosis of chronic obstructive pulmonary disease were recruited from PR assessments, primary care and community rehabilitation programmes. Patients randomised to conventional rehabilitation started the programme according to the standard care at their referred site on the next available date.

PARTICIPANTS

103 patients were recruited to the study and randomised: 52 to conventional rehabilitation (mean (±SD) age 66 (±8) years, Medical Research Council (MRC) 3 (IQR2-4)); 51 to the web arm (mean (±SD) age 66 (±10) years, MRC 3 (IQR2-4)). Participants had to be willing to participate in either arm of the trial, have internet access and be web literate.

INTERVENTIONS

Patients randomised to the web-based programme worked through the website, exercising and recording their progress as well as reading educational material. Conventional PR consisted of twice weekly, 2 hourly sessions (an hour for exercise training and an hour for education).

OUTCOME MEASURES

Recruitment rates, eligibility, patient preference and dropout and completion rates for both programmes were collected. Standard outcomes for a PR assessment including measures of exercise capacity and quality of life questionnaires were also evaluated.

RESULTS

A statistically significant improvement (p≤0.01) was observed within each group in the endurance shuttle walk test (WEB: mean change 189±211.1; PR classes: mean change 184.5±247.4 s) and Chronic Respiratory disease Questionnaire-Dyspnoea (CRQ-D; WEB: mean change 0.7±1.2; PR classes: mean change 0.8±1.0). However, there were no significant differences between the groups in any outcome. Dropout rates were higher in the web-based programme (57% vs 23%).

CONCLUSIONS

An interactive web-based PR programme is feasible and acceptable when compared with conventional PR. Future trials maybe around choice-based PR programmes for select patients enabling stratification of patient care.

TRIAL REGISTRATION NUMBER

ISRCTN03142263; Results.

Effects of a one-year physical activity programme for women with systemic lupus erythematosus - a randomized controlled study

OBJECTIVES

To study the effects of a one-year physical activity programme on aerobic capacity, physical activity and health-related quality of life (HRQL) in patients with systemic lupus erythematosus (SLE) by a randomized control design.

METHODS

Thirty-five women with low or moderate disease activity and organ damage were randomized to intervention (I) or control (C) group. The intervention during months 0-3 consisted of education, supervised aerobic exercise at high intensity and individual coaching, as well as self-managed physical activity at low-to-moderate intensity. During months 4-12, the physical activity was self-managed and the coaching was successively reduced over time. Outcome measures included: maximal oxygen uptake (VO2 max) from a bicycle ergometer test, self-reported physical activity and HRQL (SF-36).

RESULTS

VO2 at sub-max. and max. increased, independent of group, during the one-year study period (main effect of time p < 0.0001). VO2 max. increased between baseline and month 3 (p < 0.0001), between months 3 and 6 (p = 0.01) and the increase was sustained at month 12 (ns). Frequency of physical activity at high intensity also increased, independent of group, during the study period. It was increased at months 3, 6 and 12 compared to baseline (p = 0.02, p < 0.001, p = 0.03). Improvement in mental health between baseline and month 6 (p = 0.002) was seen for the I-group, not the C-group (p = 0.03). Disease activity and organ damage did not change.

CONCLUSIONS

Physical activity and aerobic capacity increased after supervised exercise and coaching, and the improvement was sustained during the one-year programme. However, no interactions between the group differences were seen, which suggests that repeated measurements could motivate to increased physical activity and thereby to increased aerobic capacity. As sub-max. VO2 increased over time, training-induced changes in VO2 on-kinetics could be another explanation. Little influence on HRQL was seen after the programme. The study indicates that physical activity at high intensity over one year is tolerated by patients with mild to moderate SLE.

Physical activity in patients with rheumatoid arthritis

INTRODUCTION

Rheumatoid arthritis (RA) is the most common chronic inflammatory joint disease and is associated with an excess risk of cardiovascular disease. For the general population, the World Health Organization has issued detailed recommendations on the type of physical activity appropriate for decreasing the cardiovascular risk. The objective of this work is to review available data on the effects of physical activity in patients with RA.

RESULTS

RA is responsible for a marked decrease in physical activity. Physical activity significantly diminishes both the cardiovascular risk and the DAS 28. Vascular benefits from physical activity include improved endothelial function and slowing of the atherosclerotic process. Physical activity also has favorable effects on bone, slowing radiographic disease progression in small joints and increasing bone mineral density at the femoral neck, although these effects are not statistically significant. Finally, engaging in physical activity increases self-esteem, alleviates symptoms of depression, improves sleep quality, and decreases pain perception. Aerobic exercise is the most commonly advocated type of physical activity. Most interventions were of short duration (4 weeks) and involved aerobic activity (running or cycling) for 60minutes a day 5 days a week. Resistance training has been shown to decrease systemic inflammation and increase muscle strength. The main obstacles to physical activity in patients with RA are related to both the patients, who lack both motivation and knowledge, and the rheumatologists, who also lack knowledge and place insufficient emphasis on promoting physical activity.

CONCLUSION

Physical activity provides many benefits in patients with RA and should be widely performed. Promoting physical activity should be among the objectives of therapeutic patient education for RA.

The evaluation of an interactive web-based Pulmonary Rehabilitation programme: protocol for the WEB SPACE for COPD feasibility study

INTRODUCTION

Pulmonary Rehabilitation (PR) is an evidence-based intervention that has been recommended in guidelines to be available to those who may benefit. However, not all patients with chronic obstructive pulmonary disease (COPD) have access to this service. Healthcare services have shown the need for the provision of PR in other forms to enable patient choice and service capacity. There is an increase in evidence for the use of the internet in the management of long-term conditions to provide education and promote self-management. The aim of this study is to see if an interactive web-based PR programme is a feasible alternative compared with conventional PR.

METHODS AND ANALYSIS

This is a feasibility study designed to evaluate the efficacy of providing a web-based PR programme to improve patients exercise capacity, quality of life and promote self-management in patients with moderate to severe COPD compared with conventional PR programmes. Eligible patients will be randomly allocated to receive either the web-based programme or conventional rehabilitation programme for 7 weeks using an internet-based randomisation system. Participants will be recruited from PR assessments, primary care and community rehabilitation programmes. Those randomised to the web-based programme work through the website which contains all the information that the patients receive in the PR classes. They receive weekly phone calls by a professional to help progress through the course on line. The outcome measures will be recruitment rates and eligibility as well as that standard for a PR assessment including measures of exercise capacity, quality of life questionnaires and physical activity.

ETHICS AND DISSEMINATION

The research ethics committee for Northampton has provided ethical approval for the conduct of the study. The results of the study will be disseminated through appropriate conference presentations and peer reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN03142263.

Behaviour change interventions to promote physical activity in rheumatoid arthritis: a systematic review

Research has shown that people who have rheumatoid arthritis (RA) do not usually participate in enough physical activity to obtain the benefits of optimal physical activity levels, including quality of life, aerobic fitness and disease-related characteristics. Behaviour change theory underpins the promotion of physical activity. The aim of this systematic review was to explore behaviour change interventions which targeted physical activity behaviour in people who have RA, focusing on the theory underpinning the interventions and the behaviour change techniques utilised using specific behaviour change taxonomy. An electronic database search was conducted via EBSCOhost, PubMed, Cochrane Central Register of Controlled Trials and Web of Science databases in August 2014, using Medical Subject Headings and keywords. A manual search of reference lists was also conducted. Randomised control trials which used behaviour change techniques and targeted physical activity behaviour in adults who have RA were included. Two reviewers independently screened studies for inclusion. Methodological quality was assessed using the Cochrane risk of bias tool. Five studies with 784 participants were included in the review. Methodological quality of the studies was mixed. The studies consisted of behaviour change interventions or combined practical physical activity and behaviour change interventions and utilised a large variety of behaviour change techniques. Four studies reported increased physical activity behaviour. All studies used subjective methods of assessing physical activity with only one study utilising an objective measure. There has been varied success of behaviour change interventions in promoting physical activity behaviour in people who have RA. Further studies are required to develop and implement the optimal behaviour change intervention in this population.

EULAR recommendations for patient education for people with inflammatory arthritis

Objectives

The task force aimed to: (1) develop evidence-based recommendations for patient education (PE) for people with inflammatory arthritis, (2) identify the need for further research on PE and (3) determine health professionals’ educational needs in order to provide evidence-based PE.

Methods

A multidisciplinary task force, representing 10 European countries, formulated a definition for PE and 10 research questions that guided a systematic literature review (SLR). The results from the SLR were discussed and used as a basis for developing the recommendations, a research agenda and an educational agenda. The recommendations were categorised according to level and strength of evidence graded from A (highest) to D (lowest). Task force members rated their agreement with each recommendation from 0 (total disagreement) to 10 (total agreement).

Results

Based on the SLR and expert opinions, eight recommendations were developed, four with strength A evidence. The recommendations addressed when and by whom PE should be offered, modes and methods of delivery, theoretical framework, outcomes and evaluation. A high level of agreement was achieved for all recommendations (mean range 9.4–9.8). The task force proposed a research agenda and an educational agenda.

Conclusions

The eight evidence-based and expert opinion-based recommendations for PE for people with inflammatory arthritis are intended to provide a core framework for the delivery of PE and training for health professionals in delivering PE across Europe.

Do patient-reported outcome measures cover personal factors important to people with rheumatoid arthritis? A mixed methods design using the International Classification of Functioning, Disability and Health as frame of reference

Background

Personal factors (PFs) are internal factors that determine functioning and the individuals’ experience of disability. Their coverage by patient-reported outcome measures (PROMs) has not been examined in rheumatoid arthritis (RA) so far. The aims of this study were to identify PFs important in the life stories of people with RA and to determine their coverage by PROMs used in RA.

Methods

The qualitative data of people with RA was explored to identify PFs. Additionally a systematic literature search was conducted to find PROMs used in RA. PROMs items were linked to the components, domains and categories of the International Classification of Functioning, Disability and Health (ICF) to determine the coverage of important PFs by PROMs.

Results

Twelve PFs were found to be important in the life stories of people with RA. The PFs coping and reflecting about one’s life in an optimistic way were covered most frequently, each by 14 of the 42 explored PROMs, while job satisfaction was not covered at all. The London Coping with Rheumatoid Arthritis Questionnaire, General Self-Efficacy Scale, Arthritis Self-Efficacy Scale, Rheumatoid Arthritis Self-Efficacy Questionnaire and Revised Ways of Coping Inventory covered most PFs. Nineteen PROMs did not cover any of the PFs.

Conclusion

Several PFs were identified as important in the life stories of people with RA, but only 55% of the PROMS covered some of these PFs. When evaluating PFs important to people with RA, health professionals should be alert on which PROMs can be used to assess which PFs.

"A gift from heaven" or "This was not for me". A mixed methods approach to describe experiences of participation in an outsourced physical activity program for persons with rheumatoid arthritis

Most persons with rheumatoid arthritis (RA) do not perform health-enhancing physical activity (HEPA). Evaluations of innovative HEPA programs need to be complemented with descriptive and qualitative data from the users. The aim of this mixed methods study was to explore and describe how a subgroup of the RA population perceives participation during the first year of an outsourced 2-year HEPA program. Data were collected by a study-specific postal survey to 220 program participants (response rate 87%, n = 191) and by interviews with a purposefully selected subsample of 35, including completers and dropouts. The survey data were analyzed by descriptive statistics and the interviews by qualitative content analysis.The survey demonstrated increased self-reported physical activity in 165 participants (86%). After the first year of the program, participants reported having performed "regular" or "periodical" circuit training (78%) and physical activity in daily life (92%). The most valued program components were circuit training and physical activity in daily life, both rated median 5/5. Coach support, prompts by text messages, and expert lectures were rated median 4/5. Five categories emerged from the interviews describing expectations, facilitators, gains, maintenance, and obstacles/suggestions for improvement of the program. The results demonstrate that HEPA outside health care is highly appreciated by a subgroup of the RA population. Professional coaching and prompts by text messages seem to be particularly useful facilitators. Individual preferences emphasize the need to tailor settings, exercise formats, and behavioral support for HEPA even in a narrow, self-selected group with RA.

Physical activity maintenance in patients with rheumatoid arthritis: a qualitative study

Objective:

To describe the experience of physical activity maintenance in patients with rheumatoid arthritis.

Design:

A qualitative salutogenic-oriented interview study.

Setting:

A rheumatology outpatient clinic.

Subjects:

A purposive sample of 16 physically active patients (mean age 50, range 37–67) diagnosed with rheumatoid arthritis on average 21 years previously (range 4–46 years).

Methods:

In-depth interviews were conducted using a semi-structured interview guide to illuminate how the phenomenon ‘physical activity maintenance’ was experienced by patients with rheumatoid arthritis. The interviews were analysed using systematic text condensation, inspired by Giorgi’s descriptive phenomenological methodology.

Results:

The analysis revealed three categories: (1) knowing and enjoying the body; (2) responsibility and challenges; (3) autonomy and social belonging. On the basis of these categories, the essential meaning of the phenomenon of physical activity maintenance for patients with rheumatoid arthritis was summarized into ‘striving for a transparent body and participation’, pointing to experiences of sensations of wellbeing, liberation from restrictions and social participation on equal terms with non-arthritis populations.

Conclusion:

This study demonstrates that physical activity in patients with rheumatoid arthritis may be understood as a resource to resist disability and to feel and stay healthy while creating and sustaining meaningfulness in life.

Health behaviour change interventions for the promotion of physical activity in rheumatoid arthritis: a systematic review

BACKGROUND

Rheumatoid arthritis (RA) is a chronic, inflammatory, autoimmune disease with typical onset between the ages of 40 and 50 years. Increasing levels of physical activity (PA) have been shown to decrease inflammation, reduce pain, increase functional ability and improve self-esteem in people with RA. Health behaviour change (HBC) interventions have recently shown promise in facilitating the promotion of PA within a range of long-term conditions. There is currently no evidence synthesis relating to HBC interventions to increase PA in the RA population.

OBJECTIVES

The aim of the present study was to determine whether HBC interventions can increase PA in people with RA and identify optimal interventions or promising constituent components of the HBC interventions.

METHODS

A systematic literature search was conducted to identify randomized, controlled trials investigating the effect of HBC interventions on PA level in adults with RA. Four review authors independently assessed the methodological quality of studies and extracted data based upon predefined criteria.

RESULTS

Following the application of inclusion/exclusion criteria, three studies remained for inclusion. Two studies reported significant short-term (<9 months) beneficial effects of HBC upon PA (p < 0.05). Individualized interventions were significantly more effective (p < 0.05).

CONCLUSIONS

Due to methodological flaws and a lack of comparison with usual care, it is not possible to conclude whether HBC interventions can increase PA in the RA population. Although it is possible to highlight promising elements of HBC interventions, such as goal setting and feedback on performance, further research on all specific components, including information provision, behaviour contracts and problem solving, is required to establish conclusive clinical guidelines.

Differences in physical activity patterns in patients with spondylarthritis

OBJECTIVE

To study patient-reported physical activity in patients with spondylarthritis (SpA) and possible differences in physical activity patterns between the SpA subtypes and sexes.

METHODS

In 2009, a questionnaire including inquiries concerning physical activity was sent to patients with a SpA diagnosis (n = 3,711). The World Health Organization (WHO) global recommendations of physical activity for health requiring 150 minutes of moderate-intensity physical activity (MI-PA) or 75 minutes of vigorous-intensity physical activity (VI-PA) per week were used as recommended levels. Standardized risk ratios (RRs) were calculated by using physical activity data from the Swedish population. The association within the SpA group between sex, age, disease-related variables, anxiety, and depression and meeting recommended levels of MI-PA and VI-PA (dependent variables) was studied with multivariate analysis.

RESULTS

A total of 2,167 patients with SpA (48% men, mean ± SD age 55 ± 14 years) responded to the questionnaire. Sixty-eight percent of the patients met the WHO recommendations, more frequently in women than in men (70% versus 66%). The recommendations were more often met in the SpA group (RR 1.09, 95% confidence interval [95% CI] 1.04-1.15) compared with the Swedish population. There was a tendency for young women to meet the WHO recommendations less often than the Swedish population (RR 0.94, 95% CI 0.63-1.25). Different factors were found to influence whether the patients were exercising with a moderate or vigorous intensity.

CONCLUSION

Seven of 10 patients with SpA met the WHO recommendations of physical activity for health, but we found sex and disease subtype differences. This information can be useful in clinical practice when coaching patients to have a healthier lifestyle.

Recommendations and the state of the evidence for physical activity interventions for adults with rheumatoid arthritis: 2007 to present

Patients with rheumatoid arthritis (RA) are twice as likely as their healthy peers to suffer from cardiovascular disease. RA is also a major cause of disability and reduced quality of life. Clinical trials of exercise and physical activity interventions demonstrate positive effects on muscle strength, function, aerobic capacity, mood and disability. While RA management guidelines emphasize the role of exercise and physical activity in the management of RA, the description of physical activity and exercise is vague and patients with RA remain less physically active than their healthy counterparts. This review discusses the benefits of physical activity and current physical activity recommendations in RA, describes measurement techniques to assess physical activity, and synthesizes the data from interventions to promote physical activity and improve health outcomes in adults with RA.

Internet based vascular risk factor management for patients with clinically manifest vascular disease: randomised controlled trial

OBJECTIVE

To investigate whether an internet based, nurse led vascular risk factor management programme promoting self management on top of usual care is more effective than usual care alone in reducing vascular risk factors in patients with clinically manifest vascular disease.

DESIGN

Prospective randomised controlled trial.

SETTING

Multicentre trial in secondary and tertiary healthcare setting.

PARTICIPANTS

330 patients with a recent clinical manifestation of atherosclerosis in the coronary, cerebral, or peripheral arteries and with at least two treatable risk factors not at goal.

INTERVENTION

Personalised website with an overview and actual status of patients' risk factors and mail communication via the website with a nurse practitioner for 12 months; the intervention combined self management support, monitoring of disease control, and drug treatment.

MAIN OUTCOME MEASURES

The primary endpoint was the relative change in Framingham heart risk score after 1 year. Secondary endpoints were absolute changes in the levels of risk factors and the differences between groups in the change in proportion of patients reaching treatment goals for each risk factor.

RESULTS

Participants' mean age was 59.9 (SD 8.4) years, and most patients (n=246; 75%) were male. After 1 year, the relative change in Framingham heart risk score of the intervention group compared with the usual care group was -14% (95% confidence interval -25% to -2%). At baseline, the Framingham heart risk score was higher in the intervention group than in the usual care group (16.1 (SD 10.6) v 14.0 (10.5)), so the outcome was adjusted for the separate variables of the Framingham heart risk score and for the baseline Framingham heart risk score. This produced a relative change of -12% (-22% to -3%) in Framingham heart risk score for the intervention group compared with the usual care group adjusted for the separate variables of the score and -8% (-18% to 2%) adjusted for the baseline score. Of the individual risk factors, a difference between groups was observed in low density lipoprotein cholesterol (-0.3, -0.5 to -0.1, mmol/L) and smoking (-7.7%, -14.9% to -0.4%). Some other risk factors tended to improve (body mass index, triglycerides, systolic blood pressure, renal function) or tended to worsen (glucose concentration, albuminuria).

CONCLUSION

An internet based, nurse led treatment programme on top of usual care for vascular risk factors had a small effect on lowering vascular risk and on lowering of some vascular risk factors in patients with vascular disease.

TRIAL REGISTRATION

Clinical trials NCT00785031.

Physical activity coaching of patients with rheumatoid arthritis in everyday practice: a long-term follow-up

OBJECTIVES

To investigate the long-term effects on perceived general health, disease activity, pain, activity limitation and cognitive behavioural factors of a one-year coaching programme performed in ordinary physical therapy practice to promote the adoption of health-enhancing physical activity in patients with early rheumatoid arthritis (RA).

METHODS

A total of 228 patients with early RA, from 10 rheumatology clinics in Sweden, were randomly assigned to an intervention group (IG; n = 94) or a control group (CG; n = 134). The IG was coached by physical therapists during the first year to adopt health-enhancing levels of physical activity (30 minutes/day, moderately intensive, ≥ 4 days/week). No coaching was given during the subsequent year between post-intervention and follow-up. Follow-up assessment consisted of a postal questionnaire on physical activity and of visual analogue scales for ratings of general health perception and pain. The Health Assessment Questionnaire Disability Index (HAQ) and the Disease Activity Score in 28 joints (DAS 28) were collected at regular medical check-ups.

RESULTS

Sixty-five (69%) participants in the IG and 92 (69%) in the CG completed the entire study period by filling in the follow-up questionnaire on physical activity two years after baseline. The intervention seemed to lack any significant influence on long-term outcome. However, different patterns of change in physical activity behaviour were observed in the two groups.

CONCLUSIONS

No long-term improvement in perceived general health or other outcomes were found in the follow-up. This may partly be because the intervention lacked several important behavioural elements for physical activity maintenance.