Exercise as it relates to Disease/Exercise interventions for arthritis sufferers
This article is a critique of the research paper The effects of strength and endurance training in patients with rheumatoid arthritis (Strasser, B. et al. 2010). 
What is the background to this research?
Rheumatoid arthritis (RA) is a chronic inflammatory disease that seriously impacts quality of life in general, and has links to several comorbidities, including cardiovascular disease, diabetes and some cancers. 
Since chronic inflammation is a factor in the development of cardiovascular disease (CVD) and type 2 diabetes, and is a key symptom in RA patients, it follows that RA patients will be at greater risk of developing these diseases than the general population. 
Regular physical activity has long been associated with reduced risk of developing CVD, diabetes and some cancers through its anti-inflammatory effect. The issue for RA patients is that the common symptoms of RA, e.g. joint pain, and conservative treatment approaches, e.g. rest, discourage physical activity. This leads to muscle loss, reduced muscle strength and endurance capacity, and subsequent loss of physical function and quality of life.  It can also contribute to increased risk of developing comorbidities.
While it has been suggested that there is a link between medications prescribed for RA and the onset of some comorbidities in RA patients , there remains a strong case for using exercise to alleviate the risk of developing these diseases, potentially more so than for the general “healthy” population.
The researchers in this study hypothesised that a combination of strength and endurance training could assist in alleviating some of the symptoms of RA. This, in turn, could improve quality of life and reduce the likelihood of several other comorbidities often associated with RA.
Where is the research from?
The study was conducted by a group of Austrian researchers, drawing on RA patients from the Rheumatology Unit at Wilhelminen Hospital, Vienna. Members of the research group have undertaken extensive research over several years into various forms of arthritis, CVD, diabetes and other life threatening medical conditions, as well as the role of physical activity in treatment of these conditions. The researchers’ individual areas of interest and expertise combine to suggest a well-balanced and well-informed approach to this investigation. The lead researcher, Professor Barbara Strasser, has been cited more than 2000 times since 2015, lending credibility to her research expertise.
The research was published on 8 October 2010 in Clinical Rheumatology, the Journal of the International League of Associations for Rheumatology and can be viewed online at https://link.springer.com/10.1007/s10067-010-1584-2.
What kind of research was this?
The research was conducted as a randomised control trial (RCT). RCT is widely considered the gold standard of comparative research, making it the ideal choice for this study. The main benefit of this type of research is that it eliminates any bias the researchers may have, for example, allocating patients with less serious RA symptoms to the test group if the selection was not randomised. It is also best suited to accurately determining cause and effect, one of the main aims of this study.
What did the research involve?
Forty patients clinically diagnosed with RA were randomly assigned to a supervised combined strength and endurance training program (19 women, one man) conducted over six months; or a control group (17 women, three men) who did not undertake any strength or endurance training during the same six month period. Prior to commencement, medical history was noted and clinical examination undertaken. The clinical examination included:
- blood pressure,
- blood analysis,
- current medications,
- clinical health status,
- functional ability,
- stress test,
- muscle strength,
- body weight,
- fat mass, and
- lean body mass.
The combined strength and endurance training group completed two sessions of strength based training on non-consecutive days of the week. The sessions involved a 10 minute warm up comprising stretching exercises. The strength component of the session included structured training to achieve hypertrophy over the six month duration of the program, targeting major muscle groups. Progressions were individualised for participants but followed the same sets and repetitions pattern. The endurance training component was undertaken on a cycle ergometer and comprised two sessions per week, with intensity controlled by maintaining 60% of the VO2max of participant, as calculated at the start of the study.
The control group completed stretching exercises twice a week, without additional resistance. They were permitted to continue recreational physical activity that didn’t involve strength or systematic endurance training.
What were the basic results?
The researchers concluded that “Long term training appears to be effective in reducing disease activity and associated pain and was found to have no deleterious effects.” 
General health (30%) and functional ability (18%) improved as a result of the strength and endurance program. Overall, the combination of strength and endurance training resulted in benefits in all areas for RT patients. Disease activity (p=0.06) and pain (p=0.05) were reduced after the six month training period; general health (p=0.04) and functional ability (p=0.06) improved; cardio respiratory endurance improved significantly (10%, p<0.001); strength increased (average 14%); lean body mass increased, and body fat (p<0.05) decreased.
In the control group, there were no significant changes in any of the same measures.
What conclusions can we take from this research?
In simple terms, this research supports the use of combined strength and endurance training to improve quality of life and reduced likelihood of common comorbidities for RA patients. Testing parameters were extensive and contributed to the capacity to draw valid conclusions.
The researchers acknowledged that the study had limitations around limited numbers (only 75% of the starting participants completed the strength and endurance program) and no follow up assessment of the participants post the six month study period. They also suggested further research is required into the impact of ongoing exercise programs for RA patients. However, this research and other investigations into physical activity for RA patients, specifically strength and endurance training, conducted at around the same time and subsequently, further support this modality as a valid option for RA patients. 
Reassure patients: Physical activity programs including strength and endurance training are not only safe for RA patients, but can provide considerable health and lifestyle benefits. However, many RA patients may be fearful of embarking on an exercise program. Therefore, a major consideration for any practitioner working in this area is reassuring the patient that strength and endurance programs are safe with RA.
Monitor and tailor programs: Given the variable nature of RA symptoms, exercise programs should be closely monitored and tailored to the abilities and limitations of the individual.
Collaborate with relevant professionals: It has been suggested that programs to increase physical activity for RA patients should be developed in collaboration with physiotherapists or rheumatology healthcare practitioners.  This may well be valid for advanced or complicated cases, however with education and professional development, it is reasonable and potentially more practical for knowledgeable and accredited exercise professionals to take on the development and management of strength and endurance programs for RA patients, while maintaining collaboration with those patients’ existing health care support workers. 
Further information on the value of, and advice on, exercise for RA patients can be found via the following links:
- Strasser, B., Leeb, G., Strehblow, C., Schobersberger, W., Haber, P., & Cauza, E. (2011). The effects of strength and endurance training in patients with rheumatoid arthritis. Clinical rheumatology, 30(5), 623-632.
- Turesson, C. (2016). Comorbidity in rheumatoid arthritis. Swiss medical weekly, 146(1314).
- Betteridge, N., Balsa, A., Buch, M., Dougados, M., Durez, P., Favalli, E., ... & Van Den Hoogen, F. (2019). PARE0018 ENABLING PATIENT-CENTRED CARE IN RHEUMATOID ARTHRITIS AND ASSOCIATED COMORBIDITIES.
- Pedersen, B. K. (2017). Anti‐inflammatory effects of exercise: role in diabetes and cardiovascular disease. European journal of clinical investigation, 47(8), 600-611.
- Hariton, E., & Locascio, J. J. (2018). Randomised controlled trials—The gold standard for effectiveness research. BJOG: an international journal of obstetrics and gynaecology, 125(13), 1716.
- Metsios, G. S., & Kitas, G. D. (2018). Physical activity, exercise and rheumatoid arthritis: effectiveness, mechanisms and implementation. Best Practice & Research Clinical Rheumatology, 32(5), 669-682.
- Hurkmans, E., van der Giesen, F. J., Vlieland, T. P. V., Schoones, J., & Van den Ende, E. C. (2009). Dynamic exercise programs (aerobic capacity and/or muscle strength training) in patients with rheumatoid arthritis. Cochrane Database of Systematic Reviews, (4).
- tavropoulos-Kalinoglou, A., Metsios, G. S., van Zanten, J. J. V., Nightingale, P., Kitas, G. D., & Koutedakis, Y. (2013). Individualised aerobic and resistance exercise training improves cardiorespiratory fitness and reduces cardiovascular risk in patients with rheumatoid arthritis. Annals of the rheumatic diseases, 72(11), 1819-1825.
- Withall, J., Haase, A. M., Walsh, N. E., Young, A., & Cramp, F. (2016). Physical activity engagement in early rheumatoid arthritis: a qualitative study to inform intervention development. Physiotherapy, 102(3), 264-271.