# Exercise as it relates to Disease/Effects of short-term physical training on rheumatoid arthritis sufferers
## What is the background to this research?

Rheumatoid Arthritis (RA) is a progressive and chronic inflammatory autoimmune disease which causes the body to attack its own healthy bone joints, in turn causing inflammation (1). The research attempts to analyse some of the effects on a persons’ daily living and examine whether incorporating physical training can contribute to the reduction of symptoms of Rheumatoid Arthritis. This disease has the ability to impair the skeletal system and cause swelling, tenderness, pain and stiffness (1). Over long periods of time these symptoms can damage and weaken bone and cartilage in a person’s body. Once weakened or damaged, there is a detrimental impact on the range of motion and in the long-term can potentially lead to deformed joints (1).

## Where is the research from?

This study was conducted at St. Erik’s hospital in Stockholm, Sweden, by Bjorn Ekblom and four colleagues, using a sample of thirty-four volunteer patients. They were aged between 38 and 63, with a mean age of 56, split into two groups, a training group (TG) of 23 participants, and a control group (CG) of 11 participants. Each participant exhibited second or third-degree RA, for a duration from three and 18 (mean 9.6) years. The aim of this study was to examine the effects of a six-week intensive physical exercise training program on a group of RA sufferers.

## What kind of research was this?

The research was a quantitate randomised control trial (RCT), using two experimental groups that looked at repeated observations of the same variable over a six-week period. RCT’s are considered the gold standard for observing results as the randomisation prevents the skewing or deliberate manipulation of results.

## What did the research involve?

Over the six-week period, each participant took part in an ordinary physical rehabilitation program for between 15 and 20 minutes, five days a week, focusing on muscular strength training and joint mobility training.
Both the CG and TG participated in a walk test of 850 metres at a fast as possible speed on even ground, a stair test, again done as fast as possible, and a footstool test that measured participants ability, including different step heights.
Along with this physical exercise, the TG participants performed additional physical training between 20–40 minutes each day of the week. Additional training encompassed blocks of 3–5 minutes on a cycle ergometer and muscle strength training on the quadriceps table. This is important as when muscles are sedentary in RA populations, the bones can fuse together as the cartilage between the joints is eradicated and bones come into direct contact. As the body attempts to repair the damaged bone, bone growth fuses the two bones within the joint (2).
Each participant’s oxygen uptake was captured at the end of each training session. Heart rate was also measured each minute, and continuously at the end of maximal training. Blood lactate concentration and the participants rating of perceived exertion (RPE) was evaluated after each workload. This is important to measure as the pain and discomfort that RA can induce can limit one’s ability to perform aerobic exercise.

## What were the basic results?

Walk test In the TG, time to perform the exercise decreased for all participants over the duration of the six-week trial. Heart rate (HR) at the end of the six weeks was not statistically different, similarly in the CG the work time was almost unchanged.
Stair test In both groups the average time taken for this test decreased over the observation period, yet significantly in the TG.
Foot stool test In both groups there were average increases for both “best” and “worst” leg over the observation period. However, the increases were greater and only significant in the TG.
Cardio-respiratory tests During submaximal exercise the VO2 was lower in the TG compared with pre-training values, while it was unchanged in the CG. As a result of the physical training, average heart rate on a fixed submaximal workload in the TG was reduced while stayed unchanged in the CG. In both groups, blood lactate was unchanged. Overtime, the inflammation of RA affects the lining of the lungs, causing discomfort while breathing, especially when breathing heavily during exercise in turn limiting VO2max (3).
Rate of perceived exertion (RPE) Perceived exertion during submaximal exercise was much lower in the TG following the exercise. As a result, less discomfort was experienced throughout the exercise. This demonstrates how periods of physical activity can decrease the inflammation and discomfort of RA symptoms (4).

## What conclusions can we take from this research?

The intensive physical training program and study resulted in positive improvement in physical performance capacity, cardio-respiratory fitness and leg muscle strength in the TG. This indicates that a lack of physical activity could be a major reason for the low physical fitness in the RA patient. In contrast, yet similar, the CG experienced some increase in muscle strength and the different muscle groups during the six-week program of daily physical testing. However, there were no large or significant improvements in performance capacity or cardio-respiratory fitness.
The majority of these tests demonstrate a greater positive response to training in the TG group when compared to the CG group. This suggests that future research should aim to test beyond six weeks. Results then may be amplified or may be able to show more significant improvements in all areas of study, including VO2max, exercise testing results and pain perception (5). The TG positive results are not attributed to any one single physiological factor studied.

## Practical advice

This study highlights the influence and benefits of physical training on joint status and the patients’ perception of physical exertion during the different tests. Regular exercise over long periods of time has the ability to increase respiratory function, circulatory function and decrease the inflammatory symptoms of RA. Greater functional capacity improves the ability to perform everyday activities and has the potential to create a better lifestyle. This can be investigated in a future study.

## Further information/resources

Physical Activity for Arthritis
Physical Activity and Exercise - Rheumatoid Arthritis Support Program
Support Group - Arthritis Australia

## References

1. Firestein GS. Evolving concepts of rheumatoid arthritis. Nature. 2003;423(6937):356-61.
2. Lautenbach M, Millrose M, Langner I, Eisenschenk A. Results of Mannerfelt wrist arthrodesis for rheumatoid arthritis in relation to the position of the fused wrist. International Orthopaedics. 2013;37(12):2409-13.
3. Astorino T, Edmunds R, Clark A, King L, Gallant R, Namm S, et al. High-Intensity Interval Training Increases Cardiac Output and VO2max. Medicine & Science in Sports & Exercise. 2016;49:1.
4. Cooney JK, Law R-J, Matschke V, Lemmey AB, Moore JP, Ahmad Y, et al. Benefits of exercise in rheumatoid arthritis. Journal of aging research. 2011;2011.
5. Allen DB. Limitations of short-term studies in predicting long-term adverse effects of inhaled corticosteroids. Allergy. 1999;54 Suppl 49:29-34.