Physical Activity, Exercise Can Benefit Patients with RA

Improving lean muscle mass can be achieved through tailored strength exercise at 80% of one repetition maximum, twice a week for 24 weeks, yielding small effects (ES=0.28), but the physical exertion of these interventions comes with an increased energy expenditure that may accentuate aspects, such as malnutrition, if not adequately prescribed.¹⁸ At a three-year follow-up, the improvements in muscle mass experienced by the exercise group did not persist, indicating that supervision may play a big role in the exercise-treatments of RC.⁵⁰

The Cost of Treating RA

In a clinical setting, exercise interventions should be administrated by a specialist in the field of activity-related physiology. Although doctors specialize in the field of pharmaceuticals, physiotherapists are often regarded as experts because they have the background in exercise science, pathology and movement science.

When reviewing the benefits of exercise in RA, it is imperative to look at treatment costs. In a review, the biologic infliximab was cost effective to less than 1% if willingness to pay was set to $50,000/QALY.⁵¹ In early RA, the cost range of $27,346–44,881 per QALY was found for TNF antagonists, and a simple hand-strengthening program was $23,857 per QALY.⁵² Cost-effectiveness studies are scarce in nonpharmaceutical trials, but the few that exist are interesting. This is an area in need of further research.

One must consider patient-specific attributes, such as strength, cardiovascular fitness & metabolism, to properly describe energy expenditures for specific activities in a given patient.

Prescribe Exercise with Competence

The effects and potency of exercise and physical activity should not be underestimated when caring for patients with RA, but it cannot be prescribed without competence. A poorly dosed physical activity intervention can be counterproductive and enforce pain avoidance behaviors that make future exercise interventions problematic, if not impossible.¹⁷

Encouraging physical activity and exercise as main components of disease management is essential in clinical communications with patients. However, ensuring these interventions are prescribed properly is paramount.

Physical therapy is a suitable option for these patients. PTs are able to evaluate patient needs and prescribe appropriately tailored exercise and physical activity interventions at the correct dose and duration.

August Flodén, PT, is a physiotherapist in the Department of Physical Therapy at Kullbergska Sjukhuset, Sweden. Having completed his master’s thesis in public health, he is currently working as a research assistant at Karolinska Institute, Stockholm. His research interests are the effects of vigorous exercise on joint inflammation, quality of life and comorbidity in adults and children with rheumatoid arthritis.

References

1. Dale J. Advances in the management of rheumatoid arthritis. Scott Med J. 2015 Aug;60(3):108–114.
2. Daien CI, Hua C, Combe B, Landewe R. Nonpharmacological and pharmacological interventions in patients with early arthritis: A systematic literature review informing the 2016 update of EULAR recommendations for the management of early arthritis. RMD Open. 2017;3(1):e000404.
3. Singh JA, Saag KG, Bridges SL Jr., et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Rheumatol. 2016 Jan;68(1):1–26.
4. Kavuncu V, Evcik D. Physiotherapy in rheumatoid arthritis. MedGenMed. 2004 May 17;6(2):3.
5. Hurkmans E, van der Giesen FJ, Vliet Vlieland TP, et al. Dynamic exercise programs (aerobic capacity and/or muscle strength training) in patients with rheumatoid arthritis. Cochrane Database Syst Rev. 2009 Oct 7;(4):Cd006853.
6. Agca R, Heslinga SC, Rollefstad S, et al. EULAR recommendations for cardiovascular disease risk management in patients with rheumatoid arthritis and other forms of inflammatory joint disorders: 2015/2016 update. Ann Rheum Dis. 2017;76(1):17–28.
7. Bassett SF. The assessment of patient adherence to physiotherapy rehabilitation. N Z J Physiother. 2003;31(2):60–66.
8. Jack K, McLean SM, Moffett JK, Gardiner E. Barriers to treatment adherence in physiotherapy outpatient clinics: A systematic review. Man Ther. 2010 Jun;15(3):220–228.
9. Hurkmans EJ, Jones A, Li LC, Vliet Vlieland TP. Quality appraisal of clinical practice guidelines on the use of physiotherapy in rheumatoid arthritis: A systematic review. Rheumatology (Oxford). 2011 Oct;50(10):1879–1888.
10. Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: Definitions and distinctions for health-related research. Public Health Rep. 1985 Mar–Apr;100(2):126–131.
11. Cooney JK, Law RJ, Matschke V, et al. Benefits of exercise in rheumatoid arthritis. J Aging Res. 2011 Feb 13;2011:681640.
12. Iversen MD, Brawerman M, Iversen CN. Recommendations and the state of the evidence for physical activity interventions for adults with rheumatoid arthritis: 2007 to present. Int J Clin Rheumtol. 2012 Oct 1;7(5):489–503.
13. Kelley GA, Kelley KS. Dropouts and compliance in exercise interventions targeting bone mineral density in adults: A meta-analysis of randomized controlled trials. J Osteoporos. 2013;2013:250423.
14. Kothawala P, Badamgarav E, Ryu S, et al. Systematic review and meta-analysis of real-world adherence to drug therapy for osteoporosis. Mayo Clin Proc. 2007 Dec;82(12):1493–1501.
15. Heiberg T, Finset A, Uhlig T, Kvien TK. Seven year changes in health status and priorities for improvement of health in patients with rheumatoid arthritis. Ann Rheum Dis. 2005 Feb;64(2):191–195.
16. Metsios GS, Stavropoulos-Kalinoglou A, Sandoo A, et al. Vascular function and inflammation in rheumatoid arthritis: The role of physical activity. Open Cardiovasc Med J. 2010 Feb 23;4:89–96.
17. Lööf H, Demmelmaier I, Henriksson EW, et al. Fear-avoidance beliefs about physical activity in adults with rheumatoid arthritis. Scand J Rheumatol. 2015;44(2):93–99.
18. Lemmey AB, Marcora SM, Chester K, et al. Effects of high-intensity resistance training in patients with rheumatoid arthritis: A randomized controlled trial. Arthritis Rheum. 2009 Dec 15;61(12):1726–1734.
19. Mayoux-Benhamou A, Giraudet-Le Quintrec JS, Ravaud P, et al. Influence of patient education on exercise compliance in rheumatoid arthritis: A prospective 12-month randomized controlled trial. J Rheumatol. 2008;35(2):216–223.
20. del Rincón ID, Williams K, Stern MP, et al. High incidence of cardiovascular events in a rheumatoid arthritis cohort not explained by traditional cardiac risk factors. Arthritis Rheum. 2001 Dec;44(12):2737–2745.
21. Barra LJ, Pope JE, Hitchon C, et al. The effect of rheumatoid arthritis-associated autoantibodies on the incidence of cardiovascular events in a large inception cohort of early inflammatory arthritis. Rheumatology (Oxford). 2017 May 1;56(5):768–776.
22. Gonzalez A, Maradit Kremers H, Crowson CS, et al. Do cardiovascular risk factors confer the same risk for cardiovascular outcomes in rheumatoid arthritis patients as in non-rheumatoid arthritis patients? Ann Rheum Dis. 2008 Jan;67(1):64–69.
23. Meek IL, Vonkeman HE, van de Laar MA. Cardiovascular case fatality in rheumatoid arthritis is decreasing; first prospective analysis of a current low disease activity rheumatoid arthritis cohort and review of the literature. BMC Musculoskelet Disord. 2014 Apr 29;15:142.
24. Singh JA, Christensen R, Wells GA, et al. Biologics for rheumatoid arthritis: An overview of Cochrane reviews. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD007848.
25. van den Berg MH, de Boer IG, le Cessie S, et al. Are patients with rheumatoid arthritis less physically active than the general population? J Clin Rheumatol. 2007 Aug;13(4):181–186.
26. Metsios GS, Stavropoulos-Kalinoglou A, Panoulas VF, et al. Association of physical inactivity with increased cardiovascular risk in patients with rheumatoid arthritis. Eur J Cardiovasc Prev Rehabil. 2009 Apr;16(2):188–194.
27. AbouAssi H, Connelly MA, Bateman LA, et al. Does a lack of physical activity explain the rheumatoid arthritis lipid profile? Lipids Health Dis. 2017 Feb 10;16(1):39.
28. Lin X, Zhang X, Guo J, et al. Effects of exercise training on cardiorespiratory fitness and biomarkers of cardiometabolic health: A systematic review and meta-analysis of randomized controlled trials. J Am Heart Assoc. 2015 Jul;4(7):e002014.
29. Sui X, Sarzynski MA, Lee DC, Kokkinos PF. Impact of changes in cardiorespiratory fitness on hypertension, dyslipidemia and survival: An overview of the epidemiological evidence. Prog Cardiovasc Dis. 2017 Jun–Jul; 60(1):56–66.
30. Alishiri GH, Bayat N, Salimzadeh A, et al. Health-related quality of life and disease activity in rheumatoid arthritis. J Res Med Sci. 2011 Jul;16(7):897–903.
31. Hernández-Hernández V, Ferraz-Amaro I, F. Diaz-González F. Influence of disease activity on the physical activity of rheumatoid arthritis patients. Rheumatology (Oxford). 2014 Apr;53(4):722–731.
32. Anderson J, Caplan L, Yazdany J, et al. Rheumatoid arthritis disease activity measures: American College of Rheumatology recommendations for use in clinical practice. Arthritis Care Res (Hoboken). 2012 May;64(5):640–647.
33. Felson DT, Smolen JS, Wells G, et al. American College of Rheumatology/European League Against Rheumatism preliminary definiton of remission in rheumatoid arthritis for clinical trials. Arthritis Rheum. 2011 Mar;63(3):573–586.
34. Fransen J, Creemers MC, Van Riel PL. Remission in rheumatoid arthritis: Agreement of the disease activity score (DAS28) with the ARA preliminary remission criteria. Rheumatology (Oxford). 2004 Oct;43(10):1252–1255.
35. Van den Ende CH, Vliet Vlieland TP, Munneke M, Hazes JM. Dynamic exercise therapy in rheumatoid arthritis: A systematic review. Br J Rheumatol. 1998 Jun;37(6):677–687.
36. Van den Ende CH, Breedveld FC, le Cessie S, et al. Effect of intensive exercise on patients with active rheumatoid arthritis: A randomised clinical trial. Ann Rheum Dis. 2000 Aug;59(8):615–621.
37. Baillet A, Payraud E, Niderprim VA, et al. A dynamic exercise programme to improve patients’ disability in rheumatoid arthritis: A prospective randomized controlled trial. Rheumatology (Oxford). 2009 Apr;48(4):410–415.
38. de Jong Z, Munneke M, Zwinderman AH, et al. Is a long-term high-intensity exercise program effective and safe in patients with rheumatoid arthritis? Results of a randomized controlled trial. Arthritis Rheum. 2003 Sep;48(9):2415–2424.
39. Wells GA, Tugwell P, Kraag GR, et al. Minimum important difference between patients with rheumatoid arthritis: The patient’s perspective. J Rheumatol. 1993 Mar;20(3):557–560.
40. Baillet A, Zeboulon N, Gossec L, et al. Efficacy of cardiorespiratory aerobic exercise in rheumatoid arthritis: Meta-analysis of randomized controlled trials. Arthritis Care Res (Hoboken). 2010 Jul;62(7):984–992.
41. Marcora SM, Lemmey AB, Maddison PJ. Can progressive resistance training reverse cachexia in patients with rheumatoid arthritis? Results of a pilot study. J Rheumatol. 2005 Jun;32(6):1031–1039.
42. Masuko K. Rheumatoid cachexia revisited: A metabolic co-morbidity in rheumatoid arthritis. Front Nutr. 201 Nov 24;1:20.
43. Roubenoff R, Roubenoff RA, Cannon JG, et al. Rheumatoid cachexia: Cytokine-driven hypermetabolism accompanying reduced body cell mass in chronic inflammation. J Clin Invest. 1994 Jun;93(6):2379–2386.
44. Rall LC, Meydani SN, Kehayias JJ, et al. The effect of progressive resistance training in rheumatoid arthritis. Increased strength without changes in energy balance or body composition. Arthritis Rheum. 1996 Mar;39(3):415–426.
45. El Maghraoui A, Sadni S, Rezqi A, et al. Does rheumatoid cachexia predispose patients with rheumatoid arthritis to osteoporosis and vertebral fractures? J Rheumatol. 2015 Sep;42(9):1556–1562.
46. Baghdadi LR, Woodman RJ, Shanahan EM, Mangoni AA. The impact of traditional cardiovascular risk factors on cardiovascular outcomes in patients with rheumatoid arthritis: A systematic review and meta-analysis. PLoS One. 2015 Feb 17;10(2):e0117952.
47. Kremers HM, Nicola PJ, Crowson CS, et al. Prognostic importance of low body mass index in relation to cardiovascular mortality in rheumatoid arthritis. Arthritis Rheum. 2004 Nov;50(11):3450–3457.
48. Medrare L, Ngeuleu A, Mahdi A, et al. AB0361 rheumatoid cachexia: Prevalence and associated factors. Ann Rheum Dis. 2015;74(Suppl 2):1014.
49. Metsios GS, et al. Rheumatoid cachexia and cardiovascular disease. Clin Exp Rheumatol. 2009 Nov–Dec;27(6):985–988.
50. Lemmey AB, Williams SL, Marcora SM, et al. Are the benefits of a high-intensity progressive resistance training program sustained in rheumatoid arthritis patients? A 3-year followup study. Arthritis Care Res (Hoboken). 2012 Jan;64(1):71–75.
51. Curtis JR, Singh JA. Use of biologics in rheumatoid arthritis: Current and emerging paradigms of care. Clin Ther. 2011 Jun;33(6):679–707.
52. Williams MA, et al. Strengthening and stretching for rheumatoid arthritis of the hand (SARAH). A randomised controlled trial and economic evaluation. Health Technol Assess. 2015 Mar;19(19):1–222.