EULAR 2015: Benefits of Individualizing Exercise Therapy

Individualized exercise improves RMD symptoms
without negative impact to organs.
Image Credit: Photographee.eu/shutterstock.com

ROME, Italy—The medical environment is increasingly adapting to the possibilities of optimizing care by individualizing medical treatment and tailoring treatment to disease phenotypes. Data suggest that individualizing exercise therapy, an important treatment modality for rheumatic and musculoskeletal diseases, can help control disease, maximize function, minimize functional barriers and decrease the risk of co-morbidity.^1,2,3

Personalizing exercise interventions implies each patient is physically assessed and that exercise interventions are adjusted to address individual deficits and designed based on current knowledge about rheumatic and musculoskeletal disease (RMD) phenotypes, functioning, co-morbidity, accessibility and current knowledge regarding exercise intensity and progression for the specific phenotype. For example, individuals who have a low sensitivity to their exercise program may need to increase intensity or vary activity to achieve the intended response. Others who experience severe RMD with significant involvement of inner organs may need close monitoring and frequent adjustments of exercises.

Exercise therapy is generally recommended as a primary component of RMD management;¹ however, there are indications that the intensity of exercise therapy has been suboptimal.² In general terms, the American College of Sports Medicine recommendations for the prescription of exercise apply to people with RMDs; however, individual and disease-specific adjustments are needed.³

What’s Appropriate?

At EULAR 2015, the annual congress of the European League Against Rheumatism (EULAR), a team of international experts synthesized the data on the beneficial effects of exercise for different RMDs. Specifically, the session focused on appropriate intensity levels of exercise in RMDs, how to measure intensity, barriers and facilitators for applying optimal exercise intensity, and potential adverse effects of exercise.⁴

Research demonstrates individualized exercise improves RMD symptoms without negative impact to organs and improves cardiovascular health and disease activity in inflammatory diseases, such as rheumatoid arthritis, spondyloarthropathies and myositis.^5-9

Based on the knowledge of an increased risk of cardiovascular disease in certain RMDs, Hanne Solveig Dagfinrud, PT, PhD, emphasized that exercise prescriptions to manage RMDs have become increasingly important. Exercise programs should aim to improve cardiovascular fitness and reduce cardiovascular risk factors. The level of intensity of cardiorespiratory fitness and muscle strength should be individually assessed and exercise should be tailored accordingly.

Several simple clinical tests can be used to determine the level of strength, balance and aerobic capacity of each individual to optimally tailor exercise to each person. A heart rate monitor and/or a scale for personal rating of exertion (i.e., Borg Scale) may be used to control the intensity level.

Helena Alexanderson, PT, PhD, emphasized that even people with connective tissue disease with high levels of disease activity can tolerate and benefit from low- to moderate-intensity exercises.¹⁰ However, among individuals with interstitial lung disease involvement, supervised exercise of lower intensity is recommended along with close follow-up. Data suggest patients with severe fibromyalgia symptoms should be exercising with lower duration, frequency and intensity than typically prescribed.¹¹

In her presentation, Emalie Hurkmans, PT, PhD, focused on how to overcome barriers to obtain and maintain optimal levels of exercise intensity. She suggested that future studies should examine how to make exercise programs more attractive, for example, by including elements that make people happy, such as music, doing good for others or exercising outdoors.

In her presentation, Maura Iversen, PT, DPT, SD, MPH, synthesized the data on adverse outcomes related to trials of exercise in adults with OA, RA and myositis. Dr. Iversen noted that individuals conducting clinical trials of exercise appear to use varying definitions of adverse events, some of which classify outcomes as reasons for drop out vs. adverse events (e.g., chest pain during exercise). Dr. Iversen noted that clinical trials of exercise in dermatomyositis and polymyositis appear to be highly controlled, of lower intensity and report the fewest adverse events. Whereas, exercise trials in OA and RA appear to have more risk for adverse events in the short term and long term, particularly among activities that involve joint loading (such as running). Dr. Iversen suggested a more uniform method for classifying adverse events in exercise trials be considered.

Rikke Helene Moe, PT, MSc, PhD, is a physical therapist and researcher at the National Advisory Unit on Rehabilitation in Rheumatology in Norway. She has been working in the field of rheumatology since 1998, both as a clinician and a researcher. She is active in the European League Against Rheumatism (EULAR), and in the EUMUSC.NET collaboration project supported by EULAR and the European Union. Her major research interests are in the fields of osteoarthritis and rheumatoid arthritis, especially in the areas of functioning, disability and health.

References

1. Hagen KB, Dagfinrud H, Moe RH, et al. Exercise therapy for bone and muscle health: An overview of systematic reviews. BMC Med. 2012 Dec 19;10:167.
2. Dagfinrud H, Halvorsen S, Vollestad NK, et al. Exercise programs in trials for patients with ankylosing spondylitis: Do they really have the potential for effectiveness? Arthritis Care Res (Hoboken). 2011 Apr;63(4):597–603.
3. Garber CE, Blissmer B, Deschenes MR, et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. Med Sci Sports Exerc. 2011 Jul;43(7):1334–1359.
4. EULAR. Abstract archive.
5. Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2012 Apr;64(4):465–474.
6. Stavropoulos-Kalinoglou A, Metsios GS, Veldhuijzen van Zanten JJ, et al. Individualised aerobic and resistance exercise training improves cardiorespiratory fitness and reduces cardiovascular risk in patients with rheumatoid arthritis. Ann Rheum Dis. 2013 Nov;72(11):1819–1825.
7. Yu CA, Rouse PC, Veldhuijzen Van Zanten JJ, et al. Subjective and objective levels of physical activity and their association with cardiorespiratory fitness in rheumatoid arthritis patients. Arthritis Res Ther. 2015 Mar 13;17:59.
8. Sveaas SH, Berg IJ, Provan SA, et al. Efficacy of high intensity exercise on disease activity and cardiovascular risk in active axial spondyloarthritis: A randomized controlled pilot study. PloS One. 2014 Sep 30;9(9):e108688.
9. Alemo Munters L, Dastmalchi M, Katz A, et al. Improved exercise performance and increased aerobic capacity after endurance training of patients with stable polymyositis and dermatomyositis. Arthritis Res Ther. 2013 Aug 13;15(4):R83.
10. Alexanderson H, Munters LA, Dastmalchi M, et al. Resistive home exercise in patients with recent-onset polymyositis and dermatomyositis—A randomized controlled single-blinded study with a 2-year followup. J Rheumatol. 2014 Jun;41(6):1124–1132.
11. Garcia-Hermoso A, Saavedra JM, Escalante Y. Effects of exercise on functional aerobic capacity in adults with fibromyalgia syndrome: A systematic review of randomized controlled trials. J Back Musculoskelet Rehabil. 2014 Nov 18 [Epub ahead of print].