No Gain with Pain: Exercise & Physical Function in Patients with Rheumatic Disease

MADRID—In 2018, the European League Against Rheumatism (EULAR) issued recommendations for physical activity in patients with inflammatory arthritis and osteoarthritis (OA). The recommendations note that physical activity is integral to the standard of care and the role of all healthcare providers is to promote such activity. Additionally, individual aims and goals for physical activity levels should be patient centered. In this report, EULAR also indicated several general and disease-specific barriers to achieving activity goals, including symptoms of pain, stiffness, fatigue and reduced mobility.¹

With these themes in mind, presenters addressed the role of physical activity in a Challenges in Clinical Practice session during the 2019 European Congress of Rheumatology (EULAR), June 12–15.

In a discussion titled, Can Drugs and Surgery Help People with Joint Pain Increase Activity? physiotherapist Kristine Røren Nordén, MSc, of the Department of Rheumatology at Diakonhjemmet Hospital, Oslo, Norway, presented the opening case. Ms. Nordén described the story of a 24-year-old man with HLA-B27-positive ankylosing spondylitis who was unsuccessfully treated with four tumor necrosis factor (TNF) inhibitors. The patient was admitted to the Norwegian National Unit for Rehabilitation for Rheumatic Patients with Special Needs (NBRR), which offers person-centered, specialized, interdisciplinary rehabilitation for patients with complex illness challenges and functional issues.

Through the efforts of myriad health professionals and staff, including a rheumatologist, a psychologist, physical and occupational therapists, and a social worker, the patient noted improvement in his ability to exercise without pain and a decrease in fatigue with exercise. These improvements aided the patient’s return to part-time work as an electrician. The key factors identified as contributing to these positive results were:

• The use of a biopsychosocial approach to pain management;
• The use of patient-centered communication, which sought to understand the patient’s perspective; and
• The increase in physical capacity and decrease in fatigue with exercise, which allowed the patient to maintain a regular exercise regimen.

The model described by Ms. Nordén is not always typical of general clinical practice, in which medications alone represent the first-line therapy for pain management in rheumatic diseases.

Physical activity is integral to the standard of care for OA patients, & the role of all healthcare providers is to promote such activity.

Medications for Pain
On the subject of medications, physiotherapist Silje Halvorsen Sveaas, PhD, Diakonhjemmet Hospital, Oslo, Norway, noted that although commonly prescribed medications, such as non-steroidal anti-inflammatory medications (NSAIDs) and acetaminophen, certainly contribute to the treatment of rheumatologic conditions, they can represent a double-edged sword. Example: NSAIDs clearly play a role in both pain control and reduction in inflammation associated with many rheumatic conditions, but it has been shown that in reducing cyclooxygenase (COX) activity, NSAIDs can contribute to reduced muscle size and strength, because COX activity is important in muscle protein synthesis.²

Dr. Sveaas spoke about ongoing work with her research team to evaluate the effect of pain medications (NSAIDs, acetaminophen and opioids) on physical function and exercise in patients with rheumatoid arthritis (RA), axial spondyloarthritis (SpA) and hip and knee OA. In evaluating the major Cochrane reviews, meta-analyses and randomized clinical trials in the field, Dr. Sveaas and colleagues described the evidence for short-term beneficial effects of NSAIDs on physical function in patients with RA, axial SpA and OA. They also described a small, short-term benefit from treatment with opioids in OA patients and no clear benefit in patients treated with acetaminophen.

Interestingly, although pain is often a barrier to achieving target goals for physical activity, exercise itself appears to reduce pain symptoms in these patients. In the Exercise for Spondyloarthritis (ESpA) study, a multi-center, randomized, controlled trial of 100 patients with axial SpA, three months of high intensity exercise in the intervention group showed a significant treatment effect on the Ankylosing Spondylitis (AS) Disease Activity Scale (ASDAS), the Bath AS Disease Activity Index (BASDAI), inflammatory markers, physical function and cardiovascular health.³ Dr. Sveaas explained that similar effects have also been shown in patients with OA.⁴

Surgery
The final speaker in the session addressed the role of hip and knee arthroplasty in the treatment of degenerative and painful joints, as well as the effects of such surgery on improving physical activity. This topic is significant, because the lifetime risk of total knee replacement surgery due to OA in Western countries is as high as one in five among women and one in seven among men.⁵ Additionally, the lifetime risk of total hip replacement surgery is one in seven for women and 1 in 10 for men.⁶

 Maaike Gademan, PhD, a clinical epidemiologist and human movement scientist at Leiden University Medical Center, The Netherlands, noted that in a systematic review and meta-analysis of seven studies evaluating changes in physical activity at six and 12 months after total hip or knee arthroplasty, no significant increase in physical activity occurred at six months. At 12 months, only a small to moderate increase in physical activity was shown.⁷

 Several possible reasons exist for this lack of significantly increased physical activity after arthroplasty. They may include difficult-to-change sedentary lifestyle habits that were habituated prior to surgery and the restrictive recommendations for suggested exercises after arthroplasty. Dr. Gademan noted that, in The Netherlands, surveys of orthopedic surgeons revealed that either no advice is given, or patients are discouraged from such activities as badminton, handball, running or volleyball. Although details of which sports are or are not recommended may represent minutiae, the overarching point is that patients may be either discouraged from physical activity or confused by what activities are or are not recommended, resulting in less activity after surgery.

The conclusions reached by the speakers in this session indicate that relying on traditional medications for pain management and resorting to arthroplasty for hip and knee OA may not lead to increased physical activity. Although symptoms of pain, stiffness and reduced mobility play a large role in whether patients with inflammatory arthritis or OA exercise, it is not clear that treating pain pharmacologically or surgically eliminates other factors that influence the degree to which patients choose to exercise.

The prospect of interdisciplinary, holistic care models, such as those described in Scandinavia, may be explored more and more in other parts of the world, though even this model will need to demonstrate efficacy and cost effectiveness. What does appear clear is that the area of research on exercise and physical activity in patients with rheumatic disease is ripe for further exploration and will hopefully yield information needed to help patients hit the road running.

Jason Liebowitz, MD, recently completed his fellowship in rheumatology at Johns Hopkins University, Baltimore, where he also earned his MD. He is currently in practice with Arthritis, Rheumatic, and Back Disease Associates, New Jersey.

References

1. Rausch Osthoff AK, Niedermann K, Braun J, et al. 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis. Ann Rheum Dis. 2018 Sep;77(9):1251–1260.
2. Lilja M, Mandić M, Apró W, et al. High doses of anti-inflammatory drugs compromise muscle strength and hypertrophic adaptations to resistance training in young adults. Acta Physiol (Oxf). 2018 Feb;222(2).
3. Sveaas SH, Bilberg A, Berg IJ, et al. High intensity exercise for three months reduces disease activity in axial spondyloarthritis (axSpA): A multicentre randomized trial of 100 patients. Br J Sports Med. 2019 Feb 11. pii: bjsports-2018-099943. [Epub ahead of print]
4. Fransen M, McConnell S, Hernandez-Molina G, et al. Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev. 2014 Apr 22;(4):CD007912.
5. Ackerman IN, Bohensky MA, de Steiger R, et al. Substantial rise in the lifetime risk of primary total knee replacement surgery for osteoarthritis from 2003 to 2013: An international, population-level analysis. Osteoarthritis Cartilage. 2017 Apr;25(4):455–461.
6. Ackerman IN, Bohensky MA, de Steiger R, et al. Lifetime risk of primary total hip replacement surgery for osteoarthritis from 2003 to 2013: A multinational analysis using national registry data. Arthritis Care Res (Hoboken). 2017 Nov;69(11):1659–1667.
7. Hammett T, Simonian A, Austin M, et al. Changes in physical activity after total hip or knee arthroplasty: A systematic review and meta-analysis of six- and twelve-month outcomes. Arthritis Care Res (Hoboken). 2018 Jun;70(6):892–901.