# Exercise as it relates to Disease/The therapeutic effects of hydrotherapy in rheumatoid arthritis

This is an analysis of the journal article “A randomized and controlled trial of hydrotherapy in rheumatoid arthritis” by Jane Hall, Suzanne Skevington, Peter Maddision and Kate Chapman (1996).

## What is the background to this research?

Rheumatoid Arthritis is a chronic inflammatory disease characterised by joint swelling, joint tenderness and destruction of synovial joints. Unlike osteoarthritis, Rheumatoid Arthritis, an autoimmune disorder, occurs not because of wear and tear damage but occurs when the immune system mistakenly attacks your own body tissues. There is currently an estimated 445000 Australians suffering from rheumatoid arthritis with this number continuing to rise.
The most common treatments for rheumatoid arthritis are aimed at stopping inflammation in the joints and in turn relieve symptoms, prevent joint and organ damage and improve overall physical well-being and function. Nonsteroidal anti-inflammatory drugs (NSAIDS) are the primary drugs used in treatment with research showing that temporary relief is shown. A long-term cure however has still not been found. NSAIDS commonly prescribed still display unfavourable side-effects (Heart problems and stroke risk, stomach problems, hindering of antidepressants) and due to this literature has started to favour intervention strategy’s to reduce Arthritic pain such as exercise and hydrotherapy.

## Where is this research from?

This study was primarily conducted at the hydrotherapy pool at the Royal National Hospital for Rheumatic Diseases. Funded by the Arthritis and Rheumatism Council, The study also received financial support from the Chartered Society of Physiotherapy and support by the American College of Rheumatology.
The authors of this publication at time have all contributed in further studies regarding Rheumatic Disease. Notably, Jane Halls research in particular further focusing on physiological benefits of hydrotherapy and water immersion. Some of research articles authored by Jane can be found here & here

## What kind of research was this?

This study is a Randomised Controlled trial (RCT), in which people are allocated randomly to one of the several interventions being performed and tested.. An RCT is one of the simplest tools in clinical research, is the 'gold standard' in medical testing and was ideal for this study.

## What did the research involve?

The study was aimed at evaluating therapeutic effects of interventions performed on patients suffering chronic rheumatoid arthritis. Aimed at improving physical and emotional complications due to arthritic pain; land exercise, seated water immersion, hydrotherapy or progressive relaxation were used.
The study was performed over 4 weeks, with two 30 minutes sessions a week. Only subjects who met Steinbroker functional class I, II or III were considered for recruitment. This meant subjects "incapacitated or confined to a wheelchair with little self-care" could not participant. Patients must have presented arthritic evidence in at least 6 joints and maintained a stable drug regime for a period of 3 months prior to be included in the study. After Recruitment and Screening this meant 139 patients participated in the study.
Physiological measures were the primary measures taken before, immediately after and 3 months post intervention:
| Physical Measure | Assessment Strategy/Tool |
| Morning Stiffness | Assessed using a questionnaire requesting patients to report the average duration of their morning stiffness |
| Grip Strength | Measured using a Dynamometer |
| Active Range of Movement | Evaluated using a Goniometer |
| C Reactive Protein | Calculated through the use of blood sampling |
| Joint Tenderness | Measured using the "Ritchie articular index” |
Numerous limitations exist regarding the methodology. The limited duration of the treatment provides a snapshot of the effect these interventions may have on participants, however it provides no indication for long term improvements to arthritic patients. Additionally, the subject criteria excluded those with any other know health condition that may be affected by exercise. Patients with Rheumatoid Arthritis have a tendency to become sedentary and due to this, results may show variation on what they would be like if the full population could be included.

## What were the basic results?

The study showed changes in many of the physical measures:
* Improvements in joint tenderness were shown with the hydrotherapy intervention patients showing better improvement (decrease of 27%)
* Increased total combined knee range of movement with a mean increase shown(~ 17 centimetres)
* All patients exhibited a reduction in pain (10% decrease in overall pain scores)
* No significant change in grip strength, wrist range of movement, morning stiffness or C reactive protein levels.
Interpreted as a success by the authors these results showed that hydrotherapy has positive effects on individuals with rheumatoid arthritis. This statement was not at the time supported by prior literature and shows the research’s may have overstated the results with no real long term evidence acquired when the research was published.

## What conclusions can we take from this research?

This trial was aimed at investigating the effects of exercise interventions in patients with rheumatoid arthritis. The study suggests that all the interventions performed have a degree of benefit for both the physical and emotional characteristics of rheumatoid arthritis. While all exercise is beneficial to patients suffering, hydrotherapy gave the greatest benefits in terms of decreased joint tenderness and reduction of pain. While the results are limited in terms of the population size and treatment duration, they provide evidence that exercise and in particular hydrotherapy is a practise that can be prescribed by health professionals to help Rheumatoid Arthritis Sufferers . Modern Literaturehas also reinforced the fact that hydrotherapy is a great treatment option for Rheumatoid Arthritis with articles such as Hydrotherapy For Pain Managament being published more recently.

## Practical advice

The results from the study provide practical evidence that show that hydrotherapy has features that benefit participants in terms of physical and psychological function. This justifies the continuation of these interventions activities in the treatment of patients with Rheumatoid Arthritis in cases outside the study. It should be noted that only exercise prescribed by health professionals should be undertaken by patients with rheumatoid arthritis.

## Further information/resources

Additional readings and subsequent resources involving background, treatment and exercise prescription can be found below:
* Further Reading About Rheumatoid Arthritis: http://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/home/ovc-20197388
* Rheumatoid Arthritis Treatments http://www.arthritis.org/about-arthritis/types/rheumatoid-arthritis/
* Medication Use With Rheumatoid Arthritis: https://www.healthline.com/health/rheumatoid-arthritis/medications-list
* Exercise and Rheumatoid Arthritis: http://www.arthritis.org/about-arthritis/types/rheumatoid-arthritis/articles/best-exercises-for-ra.php

## References

* ↑ Hall J, Skevington S, Maddison P, Chapman K. A randomized and controlled trial of hydrotherapy in rheumatoid arthritis. Arthritis & Rheumatism [Internet]. 1996 [cited 9 September 2017];9(3):206-215.]
* ↑ Chang-Miller A. Rheumatoid Arthritis [Internet]. Mayo Clinic. 2017 [cited 26 August 2017]. Available from: http://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/home/ovc-20197388
* ↑ 8. Arthritis Fact Sheet [Internet]. Arthritisnsw.org.au. 2013 [cited 5 September 2017]. Available from: https://arthritisnsw.org.au/arthritis/research/latest-statistics/
* ↑ Rheumatoid Arthritis Treatment [Internet]. Arthritis.org. 2015 [cited 5 September 2017]. Available from: http://www.arthritis.org/about-arthritis/types/rheumatoid-arthritis/treatment.php
* ↑ About Nonsteroidal Anti-inflammatories [Internet]. Arthritis.org. 2015 [cited 5 September 2017]. Available from: http://www.arthritis.org/living-with-arthritis/treatments/medication/drug-types/nsaids/
* ↑ Nickson C. Randomised control trials [Internet]. LITFL • Life in the Fast Lane Medical Blog. 2015 [cited 3 September 2017]. Available from: https://lifeinthefastlane.com/ccc/randomised-control-trials/
* ↑ Thornton H. Randomized Control Trial - National Library of Medicine - PubMed Health [Internet]. PubMed Health. [cited 3 September 2017]. Available from: https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0025811/
* ↑ KILINCER C. Steinbrocker Functional Classification [Internet]. Scientificspine.com. 2011 [cited 19 August 2017]. Available from: http://www.scientificspine.com/spine-scores/steinbrocker-functional-classification.html