Exercise as it relates to Disease/Does the prescription of regular exercise decrease the pain and decreased ROM associated with Arthritis?

What is the background to this research?

Article to be critiqued: Callahan LF, Mielenz T, Freburger J, Shreffler J, Hootman J, Brady T, et al. A randomized controlled trial of the people with arthritis can exercise program: symptoms, function, physical activity, and psychosocial outcomes. Arthritis Care & Research: Official Journal of the American College of Rheumatology. 2008;59(1):92-101.

Arthritis is a common condition with 18% of Australians falling within this category Osteoarthritis is the most common form which is characterized by the wearing down of the joint cartilage; closely followed by Rheumatoid arthritis which involves inflammation of a joint, causing a breakdown of cartilage due to an immune response. Cartilage is the primary protector of the joint allowing it to move smoothly through a range of motion, hence once there has been a breakdown it will negatively influence joint movement ability. . Common causes can be narrowed down to a number of factors including, autoimmune diseases, bone fractures, overuse injuries, or infection. When the issue is not resolved after treatment, it is considered as a chronic condition leaving the individual with symptoms of joint swelling and pain making it challenging to partake in physical activity. There is however, reason to believe that physical activity will improve these symptoms and increase overall function within this population.

Where is the research from?

The research was published by the American College of Rheumatology (ACR), using the People with Arthritis Can Exercise Program (PACE). The authors directing the research have a respected reputation working for an organisation that has conducted scientific research since 1934. The ACR have been associated with research directed by over 9600 worldwide Physicians while also participating in worldwide non for profit research making them a well known and trusted information source . This research paper was supplied with a grant from the Association of American Medical Colleges

What kind of research was this?

The research conducted within this article was a randomized control trial, meaning participants were allocated by chance into either a control or intervention group. The aim of using this method is to eliminate any chance of a bias, with the intention in finding reliable results. This trial has been conducted due to the need for a larger more accurate follow up from the initial People with Arthritis can Exercise Program (PACE) research conducted in 1999.

What did the research involve?

The randomized control trial involved following 346 individuals with self reported Arthritis over the period of an 8 week program. The first identified consideration here is that allowing self reported arthritis sufferers to partake in the program may have affected the final results due to the possibility of participants not clinically having arthritis. Self reports and physical assessments where taken initially, then again after 8 weeks. Having the participants complete self reports may also vary the results due to inconsistencies in reporting. The intervention group were additionally asked to participate in a self assessment questionnaire send out at 3 and 6 months. Having a follow up assessment is a useful tool to examine, however the participants were no longer following the PACE program, and were told to continue exercise in a form that suited them. Yet another inconsistency which could impact the long term recommendations to give arthritis suffers.

The primary intentions of the study were to access short term results of prescribing exercise to see changes in symptoms, function, and psycho-social behaviors. The accessed symptoms were broken down into pain, stiffness and fatigue. Two 1-hour sessions per week were prescribed to the intervention participants, in various locations and alongside trained exercise professionals. The exercise professionals had different levels of training which could have influenced how to programs were ran in each location.

What were the basic results?

The intervention group had significant improvements in pain, lower body strength, and the ability/willingness to partake independently in daily life activities at the 8 week point in comparison to the control. A total of 65% of participates completed more than 9 of the 16 classes on offer. These participates further improved in pain, fatigue, stiffness, and function. A total of 25 participants were not randomized due to family and transportation issues. This was overcome by dividing the results into two categories, intent to treat and as treated; those 25 participates were excluded within the intent to treat analysis ensuring the results were as accurate as the circumstance allowed. However, 13 participants that were randomized to control ended up being counted towards the as treated analysis, due to attending a minimum of one class. During the screening process people that were considered too active were not eligible to participate in the study, this could have conflicted towards a more clear positive result due to participants gaining neuro-muscular adaptations quickly compared to those that may have already been exercising above to the allocated cut off. Perhaps this even made the results not applicable to a number of the population they are attempting to target.

Symptoms	Intervention n=166	Control n=155
Pain mm on VAS	38.1	44.9
Fatigue mm on VAS	35.4	43.7
Stiffness mm on VAS	37.6	40.1

• VAS= Visual analog scales

Results for physical symptoms were collected by the individual completion of visual analog scale questionnaires. Above we can see how the rating for pain, fatigue and stiffness are all lower than the control group, representing a significant positive outcome from participating in the prescribed physical activity.

What conclusions can we take from this research?

For results to arise clients must be consistent with their physical activity levels. The results suggest that a moderate to high intensity form of exercise that is maintained is more likely to see clear improvements in pain, stiffness, fatigue and self efficacy. There were no negative results found within the study, and it appears to be safe for patients that fall within this population to partake in regular exercise to hopefully see improvements in their arthritis symptoms.

Newer research within this area has been able to suggest a stronger link between regular exercise and improvement in pain and function associated with arthritis. A study published in April this year (2018), concluded that a moderate to high intensity form of aerobic exercise had significant improvements in both dynamic balance and daily function which remained prevalent 12 months after the study started; with appropriate maintenance of exercise levels . The current research suggests that exercise within this population can manage if not reduce symptoms to the point where patients can continue to complete normal daily tasks with minimal pain and a normal amount of ROM/function.

Practical advice

Health issues such as high blood pressure, may need to be addressed prior to commencement of an exercise program. Local gyms often employee Exercise Physiologists that are qualified to program specific exercises for this population. A low to moderate intensity 30-minute form of aerobic activity five times per week is the recommended amount of physical activity to build up to . Brisk walking, water aerobics and bike riding are both low impact, and financially sustainable forms of physical activity. The main pieces of information here that should be taken into consideration are, patient safety, consistency and compliance. A recent update from the ARA (Australian Rheumatology Association) this year (July, 2018) have General Practitioners recommending exercise therapy as opposed to invasive arthroscopy surgeries due to evidence suggesting exercise is the most cost effective treatment plan, and have patients seeing positive results in pain and overall function .

Further readings

https://www.arthritis.org/living-with-arthritis/exercise/

https://www.mayoclinic.org/diseases-conditions/arthritis/diagnosis-treatment/drc-20350777