# Exercise as it relates to Disease/The effect of high-intensity resistance exercise on patients with rheumatoid arthritis

This critique is on the article "The effects of high-intensity resistance training in patients with rheumatoid arthritis: A randomised controlled trial". The journal piece has been produced by the authors Andrew B. Lemmey, Samuele M. Marcora, Kathryn Chester, Sally Wilson, Francesco Casanova and Peter J. Maddison.

## What is the Background this Research?

Rheumatoid arthritis (RA) is a chronic inflammatory disorder that attacks an individual's own joint tissue causing damage to a wide variety of different body systems. This disorder is characterised as an autoimmune condition which attacks the body's own tissue causing bone erosion and joint deformity. Even though this disease is caused through an autoimmune condition, it is unknown the trigger that causes this. The use of exercise can be significant for individuals possessing RA and can be used to increase muscle mass and restore physical function. Resistance exercise can be particularly beneficial for individuals with RA and is highly recommended.
This condition is lifelong affecting many if not all joints in the body causing deformity as well as painful bone erosion. In Australia this condition is rare with approximately 456,000 individual's possessing the condition. This research allows us to understand that with constant maintenance of this condition, individuals can fight the effects of RA and sustain a healthy lifestyle.

## Where is this Research from?

This study was conducted at the Bangor University located in Wales, United Kingdom. The study was ethically approved by the Northwest Wales National Health Service Trust Research Ethics Committee. This study was published in 2009 by The Wiley Online Library. This is a highly ranked, dependable journal recognised all over the world covering a wide variety of journals in many different areas of research.
Andrew B. Lemmey was the lead author in this study. Lemmey is a clinical exercise physiologist in the School of Sport, Health and Exercise Sciences at Bangor University. This is one of his 50 peer journals therefore showing his background and work has good credibility. Lemmey's research and work for the past 14 years is focused on restoring physical function and attenuating disabilities in patients with RA. All other authors are exercise physiologists at Bangor University with ranging expertise in a variety of different fields.
The authors have no apparent conflicts of interest.

## What Kind of Research was this?

The research conducted was a randomised controlled trial (RCT) taken over two and half years. A RCT consists of participants being randomly assigned into one of two groups. The first group are receiving the intervention and the second is a control group receiving an alternate procedure. RCTs are used frequently as they determine whether there is a cause and effect relationship between the intervention and outcome. Other research in this field uses this same trial structure as it provides reliable and valid data and is the most ideal trial type.

## What did the Research Involve?

During this intervention, 36 volunteers were chosen from the Gwynedd Rheumatology Department as participants in the study. Although at baseline assessment only 28 persons fit the requirements for the study. 13 individuals were assigned to the progressive high intensity resistance training (PRT) group with 15 individuals assigned to the control group. All participants were randomised into each group and then given a 24 week training program to follow. Individuals in the PRT group trained twice a week at a community gym under the supervision of exercise physiologists while the control group were asked to perform range of motion (ROM) exercises twice weekly at home.
The PRT group's program consisted of 3 sets of 8 repetitions with a load corresponding to 80% of the 1-repetition maximum with between 1-2 minutes of rest between each set. Although these guidelines were subject to change to cater for adaptation and muscle soreness. The main resistance exercises were completed on multi stack machines which included leg press, chest press, and leg extension. PRT sessions were also preceded by a warmup and ended by a cool down, each comprising 10 minutes of low-intensity ROM exercises.
To test the differences between the groups, 3 main areas were analysed.
* Body composition
* Physical function
* IGF system
Limitations
There are some limitations in this trial such as chance error and experimenter bias. Unfortunately, it cannot be known whether experimenter bias has occurred. Due to the small sample size chance error can still occur. Another limitation that could have hindered the results is that the trial was conducted in Wales. The population is from that specific part of the world and therefore could have been biased to a particular population. A larger sample size would have also allowed for greater credibility and a wider range of results within the study. Overall, the methodology of this study is correctly used as most biases were minimised.

## What were the Basic Results?

Body Composition (BC) - The PRT group showed significant improvement in the tests assessing BC. The control group showed a slight decline in the tests assessing BC.
Physical Function (PF) - The PRT group showed a significant improvement in the test assessing PF. The control group showed a slight decline in the tests assessing PF.
IGF System - The PRT group showed a significant improvement in the IGF system tests. The control group showed a significant decline in the IGF system tests.
Through these areas, investigators were able to measure the overall effect high-intensity resistance training on the body. The participants stated they enjoyed contributing to the study. No injuries were sustained by both groups and individuals were satisfied that the intensity of the exercise was catered to their abilities. During this study many tests for each area were used. These tests were completed by every participant in both groups before and after the 24 week program. Tests included muscle mass, total fat mass, total protein, 50 foot walk test and many others. Overall, these tests allowed for the primary objectives and areas of the study to be tested.

## What Conclusions can be Taken from this Research?

Overall, the results showed that through high intensity resistance training, individuals with RA had found an effective way of restoring muscle mass and functional capacity. The PRT group also showed an improvement in the 3 main areas compared to the control group allowing for better maintenance of RA. Different ROM exercises completed were shown to complement the high intensity resistance training rather just completing ROM exercises respectively as shown in the control group where the results were ineffective.
In other studies, focused on high intensity resistance exercise and RA, similar results were displayed, and that high intensity resistance exercise can be used as a treatment against the effects of RA.

## Practical Advice

As the research above shows that high intensity resistance exercise does have a benefit against the effects of RA. It is vital individuals possessing it both maintain and prevent the long-lasting effects of the disease.
Exercises recommended:
* Standing calf raises
* Goblet squats
* Romanian deadlifts
Other exercises to compliment:
* Aerobic Exercises
* ROM exercises

## Further Resources

RA in Australia:
https://www.aihw.gov.au/reports/chronic-musculoskeletal-conditions/rheumatoid-arthritis/contents/what-is-rheumatoid-arthritis
Exercise and RA:
* https://arthritisaustralia.com.au/managing-arthritis/living-with-arthritis/physical-activity-and-exercise/exercise-and-ra/
* https://www.arthritis.org/health-wellness/healthy-living/physical-activity/other-activities/best-exercises-for-rheumatoid-arthritis

## References

* ↑ Rheumatoid arthritis - Symptoms and causes [Internet]. Mayo Clinic. ; 2021 [cited 2021 Sep 5]. Available from: https://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/symptoms-causes/syc-20353648#:~:text=Rheumatoid%20arthritis%20is%20a%20chronic,lungs%2C%20heart%20and%20blood%20vessels.
* 1 2 NHS Choices. Causes - Rheumatoid arthritis [Internet]. 2021 [cited 2021 Sep 6]. Available from: https://www.nhs.uk/conditions/rheumatoid-arthritis/causes/
* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Lemmey AB, Marcora SM, Chester K, Wilson S, Casanova F, Maddison PJ. Effects of high-intensity resistance training in patients with rheumatoid arthritis: A randomized controlled trial. Arthritis & Rheumatism [Internet]. 2009 Dec 15 [cited 2021 Sep 5];61(12):1726–34. Available from: https://onlinelibrary.wiley.com/doi/10.1002/art.24891 ‌
* ↑ Rheumatoid arthritis, What is rheumatoid arthritis? - Australian Institute of Health and Welfare [Internet]. Australian Institute of Health and Welfare. 2020 [cited 2021 Sep 6]. Available from: https://www.aihw.gov.au/reports/chronic-musculoskeletal-conditions/rheumatoid-arthritis/contents/what-is-rheumatoid-arthritis ‌
* ↑ Wiley Online Library [Internet]. Wiley Online Library. 2021 [cited 2021 Sep 9]. Available from: https://onlinelibrary.wiley.com/ ‌
* 1 2 3 Andrew Lemmey [Internet]. Intechopen.com. 2021 [cited 2021 Sep 9]. Available from: https://www.intechopen.com/profiles/63624
* 1 2 3 Kendall JM. Designing a research project: randomised controlled trials and their principles. Emergency Medicine Journal [Internet]. 2003 Mar 1 [cited 2021 Sep 11];20(2):164–8. Available from: https://emj.bmj.com/content/20/2/164 ‌
* 1 2 Lemmey AB, Williams SL, Marcora SM, Jones J, Maddison PJ. Are the benefits of a high-intensity progressive resistance training program sustained in rheumatoid arthritis patients? A 3-year followup study. Arthritis Care & Research [Internet]. 2011 Dec 28 [cited 2021 Sep 13];64(1):71–5. Available from: https://onlinelibrary.wiley.com/doi/epdf/10.1002/acr.20523 ‌
* 1 2 Rall LC, Meydani SN, Kehayias JJ, Dawson-Hughes B, Roubenoff R. The effect of progressive resistance training in rheumatoid arthritis. Increased strength without changes in energy balance or body composition. Arthritis & Rheumatism [Internet]. 1996 Mar [cited 2021 Sep 13];39(3):415–26. Available from: https://onlinelibrary.wiley.com/doi/epdf/10.1002/art.1780390309 ‌