Exercise as it relates to Disease/Aerobic and resistance exercise improves physical fitness in older adults with rheumatoid arthritis

This is a critique of the article: Effects of Aerobic and Resistance Exercise in Older Adults With Rheumatoid Arthritis: A Randomized Controlled Trial Elvira Lange, Daniel Kucharski, Sara Svedlund, Karin Svensson, Gunhild Bertholds, Inger Gjertsson, and Kaisa Mannerkorpi

What is the background to this research?

Rheumatoid Arthritis (RA), is an autoimmune disease that causes pain and swelling of the joints. It could lead to the destruction and deformation of the joint if not treated. Individuals affected with RA disease are commonly associated with limitation in range of motion, pain, fatigue and mental issues. These symptoms can obstruct the person's capabilities to perform their daily tasks which will implement on their quality of life.

Although some studies suggest that the onset of Rheumatoid Arthritis is detected in individuals aged between 35–64 years old, Another study suggested that individuals aged 75 and over had the highest percentage of individuals reporting with symptoms of RA, also slightly higher percentage in females as compared to males.

The aim of this study is to evaluate the effect of a moderate‐to‐high–intensity, aerobic and resistance exercise with person‐centered guidance in older adults with rheumatoid arthritis (RA), through a randomized controlled trial.

Where is the research from?

This study was conducted by Elvira Lange with the assistance of her colleagues, the study took place in Gothenburg and Skovede , Sweden which started in Jan 2015 and ended in November 2016. It was then published in January 2019 by Wiley Periodicals from the Arthritis Care and Research on the behalf of the American College of Rheumatology.

The assessed population were older adults aged between (65–75 years) and were selected from Sahlgrenska University Hospital, Gothenburg, and Skaraborg Hospital, Skövde. However, an article showed that Swedes are considered to be the most physically active population. In addition a survey done by the WHO showed that 61% of Swedish of individuals aged between (65–84 years) from both genders were achieving recommended physical activity levels

What kind of research was this?

This study is a Randomized controlled Trial (RCT)

The study consisted of two groups, individuals were randomly allocated into two different groups one undergoing exercise intervention at the gym (treatment group) , the other group performed light exercise at home(control group). Both groups were trialed for a period of 20 weeks.

What did the research involve?

The research included 1028 registered participant , these participants had to undergo a phone interview , medical record screening and medical assessment. Only 74 participants passed all three assessments and where randomly split into two group, 36 participant were selected for the exercise intervention and 37 participants in the control group.

Both the control and physical intervention group had to undergo a person-centered approach which focused on addressing training comfort , goal setting , familiarity with exercise and self introduction.

The control group performed the following exercises:

Frequency: low-intensity physical activities 5 days a week, and home exercises 2 times a week for 20 weeks. Home-exercise: 5 exercises for mobility, strength in the lower extremity, and one-leg standing balance conducted without any equipment.

The intervention group performed the following exercises:

Frequency: 3 times per week for 20 weeks, supervised by physiotherapists on 2 of 3 occasions.

Starting Phase:

Exercise sessions: 10 minutes of warm-up, aerobic exercise at 3-minute intervals with 1 minute of recovery between each repetition. Resistance exercise for 20 minutes using a standardized protocol that included leg-press, knee-extension and seated row using a weight machine, biceps curl using free weights, core stability using body weight and 5 minutes of cooling down. Aerobic exercise: weeks 1–3: 3 sets of 3 minutes; weeks 4–9: one added set of 3 minutes each week until reaching 9 sets, which were kept for the remainder of the intervention.

Progression Phase:

Resistance exercise: weeks 1–3: 40% of one repetition maximum (1RM), with 8–12 repetitions in 1–2 sets. Weeks 3–6: 60% of 1RM, with 8–12 repetitions in 2 sets. 7–12 weeks: 70–80% of 1RM, performed with 8–12 repetitions in 2 sets. Week 13: 1 set of power training with explosive contractions added at 60% of 1RM

 Assessment: 

The recordings and measurement were taken on 3 stages, baseline , post-intervention (20 weeks after) and Follow up (12 month after the intervention). The data was collected using the following methods and techniques:

Primary outcome (Disability):

HAQ-DI test

Secondary outcome (Functional):

1-Monark Exercise test 2-Functional balance test (https://www.physio-pedia.com/Timed_Up_and_Go_Test_(TUG)/TUG test] 3-Leg muscle strength was tested using [1] which was modified to 60 seconds instead. 4-[2] questionnaire scale, that was done during the post- intervention (20 weeks after intervention) and follow up (12 month after intervention). 5- Load was measured using Leisure Time Physical Activity Instrument (LTPAI).

Statistical Analysis: 

t-test , Mann-Whitney U test and Mantel-Haenszel test were used to analyse and compare the variables.

The intervention was well structured and organized , it included a variety of test measurements also the exercise program was structured for the individuals to adapt with however, the duration of the exercise is set on long period of time (20 weeks). The population that has been selected targeted a specific age group and also the majority of the participants were women 75% and 76.3% in the intervention and control group respectively.

What were the basic results?

	Intervention Group	Control Group
Disability (HAQ-DI)	Slight improvement within the group	No significant improvement
Functional Balance (TUG)	Significant Improvement	Significant improvement
Aerobic Capacity (Monark Test)	Significant Improvement	No significant improvement
Leg Muscle Strength (STS test)	Significant Improvement	Significant improvement
PGIC questionnaire	71.4% very much improved health	24.3% very much improved health

No significant improvement was recorded during the static elbow flexion test.

What conclusions can we take from this research?

Both light and moderate-high physical exercise activities have shown to improve the functional capabilities (strength and balance) of an individual with RA however, a moderate-high intensity exercise is more likely to improve their physical endurance. For this age category (64–75 years) muscular endurance is not essential in their daily activity , as older adults do not undergo pro-longed daily activity ( work , training , house cleaning ,etc) instead the need of explosive power and strength is more adequate. Convincing individuals in this age group to undergo a high and intensive training program can be inconvenient and cost efficient as they will most likely need to be monitored by an exercise specialist.

Practical advice

Individuals with RA arthritis must not practice independently unless declared with a medical clearance, also the exercise intervention should be targeting the muscles that are activated along the movement of the affected joint to help in strengthening these muscles such as the wrist joints. Also acknowledge the participants that exercise intervention does not cure them from RA disease instead it helps them restore their physical activity and muscular strength.

Further information/resources

Rhuematology Research Foundation

AIHW

Arthritis Australia