# Exercise as it relates to Disease/Can exercise assist in the self-management of Rheumatoid Arthritis?

This is an analysis of the journal article "Predictors of Exercise and Effects of Exercise on Symptoms, Function, Aerobic Fitness, and Disease Outcomes of Rheumatoid Arthritis (RA)" by Neuberger et al (2007).

## Background

RA is an autoimmune disease of that causes pain and inflammation of the joints. It affects the functional ability of an individual and worsens over time. Unsurprisingly, RA is responsible for a noticeable decrease in exercise, and those with RA often have high levels of psychological distress. Previous studies such as The Cochrane Review, concentrated on the benefits of dynamic, or high-intensity exercise in those with RA. This study found that there were benefits of performing a dynamic exercise, however, they did not address the psychosocial factors that influence exercise participation in those with RA. Neuberger et al, examined the implementation of a low-impact aerobic exercise program and whether it assists those with RA improve their general function (grip strength and walking speed), aerobic fitness and disease activity. Given that there is often a decrease in exercise in those with RA, due to inflammation and pain levels, this could be regarded as a more practical approach. The foundations of Neuberger et al’s study was the self-regulation theory, which suggests that an individual’s behaviour is often influenced by their goal.

## The current study
### Where is the research from?

The authors of this paper were based in Kansas City, United States of America. The research was supported by a grant from the National Institute of Nursing Research of the NIH, University of Kansas.

### What kind of research was this?

This study was focused on collecting statistical data through the use of numerous self-report questionnaires, each questionnaire was selected based on the relevance of the factor being assessed and RA.

### What did the research involve?

Given the severity and implications of RA, this study examined the predictors and effects of low-impact aerobic exercise program. These included:
* Psychosocial factors – such as optimism, exercise benefits/barriers, self-efficacy for exercise
* Functional benefits
* Aerobic fitness
* Disease-associated symptoms; and
* Disease activity.
Potential participants were screened against specific eligibility criteria for inclusion in the study. Approximately 154 participants were involved in the 12-week intervention. The participants were randomly selected into one of three groups:
* Group 1 participated in a low-impact aerobic exercise program P in a class setting with a gym instructor
* Group 2 participated in a low-impact aerobic exercise program using a videotape at home; or
* Group 3 which were the control group and had no intervention.

## Results
### Main findings

Those who exercised in a class setting were found to have improvements in their fatigue, pain and depression levels. There was no statistical difference between those who exercised watching the video recording or those who had no exercise intervention. The implementation of a low-impact aerobic exercise program , regardless of its setting, saw improvements in participants walk time, grip strength and aerobic fitness. The program did not negatively impact the disease activity. In addition to these two findings, the research that fatigue levels and the perceived benefits/barriers were the main predictors as to whether the participant would exercise.

## Discussion
### Interpretation

The study utilised a number models or questionnaires, such as the 14 item Global Fatigue Index of Multidimensional Assessment of Fatigue questionnaire which was developed to assess fatigue in RA patients and Astrand-Rhyming protocol to assess aerobic fitness level. Most of these methods were self-reported questionnaires. The core issue of using such methods is self-reporting bias, which can distort the results. This needs to be taken into consideration when interpreting the results. This issue was evident in the research, in regards to self-reported heart rates (HR) and exercise intensity. Those who exercised in a class environment were found to exercise at higher intensity and percentage of the maximal HR, than those who were exercising in a home setting. This could be a potential contributor the difference in results between the exercise interventions. Similarly, the researchers note that those participants’ who were in a class setting, perceptions of symptoms and associated ratings/scores were better than those with no interaction with an instructor. This could be another example of how communicating with others can impact on our psychosocial factors. The grip strength test and the walk time were tested as indicators of disease-associated symptoms. It should be noted that the group assessed were aged between 40-70 and that declines in these areas can be seen to be typical. As noted by the researchers, this could be considered to be a limitation of the research.

## Implications from research

This study demonstrates that a low-impact aerobic exercise program has a positive effect on RA, which builds upon and supports the notion that an exercise program should be implemented to assist in the self-regulation of RA. Subsequently, it found that fatigue and the perception of the benefits or barriers to exercise were the main factors to influence exercise participation. Those with RA should be presented educational opportunities/referrals to allied health professionals to assist in the self-management of the disease.
Further reading - For more information about RA and exercise, please see the below fact sheets:
* About rheumatoid arthritis - http://www.aihw.gov.au/rheumatoid-arthritis/
* Exercise and RA Information sheet - http://www.arthritissa.org.au/downloads/2015-05-11_224746_Exercise-and-RA.pdf
* Exercise and RA - http://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Living-Well-with-Rheumatic-Disease/Exercise-and-Arthritis

## References

* 1 2 3 4 5 6 7 8 9 10 Neuberger, G., Aaronson, L., Gajewski, B., Embretson, S., Cagle, P., Loudon, J., & Miller, P. (2007). Predictors of Exercise and Effects of Exercise on Symptoms, Function, Aerobic Fitness, and Disease Outcomes of Rheumatoid Arthritis. Arthritis & Rheumatism (Arthritis Care & Research), 57(6), 943-952. DOI:10.1002/art.22903
* ↑ Verhoeven, F., Tordi, N., Prati, C., Demougeot, C., Mougin, F., & Wendling, D. (2015). Physical activity in patients with rheumatoid arthritis. Joint Bone Spine, 83(3), 265-270. Retrieved from: http://dx.doi.org/10.1016/j.jbspin.2015.10.002
* ↑ Van den Ende, C., Vliet Vlieland, T., Munneke, M., & Hazes, J. (1998). Dynamic exercise therapy for treating rheumatoid arthritis. Cochrane Database Syst Rev, 37(6), 677-87. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/9667624
* ↑ Johnson, J. (1999). Self-regulation theory and coping with physical illness. Research in Nursing & Health, 22(6), 435-448. Retrieved from: http://onlinelibrary.wiley.com/doi/10.1002/(SICI)1098-240X(199912)22:6%3C435::AID-NUR2%3E3.0.CO;2-Q/abstract
* ↑ American College of Rheumatology. (n.d). Multidimensional Assessment of Fatigue (MAF). Retrieved from American College of Rheumatology web site: http://www.rheumatology.org/I-Am-A/Rheumatologist/Research/Clinician-Researchers/Multidimensional-Assessment-of-Fatigue-MAF
* ↑ Franklin, B. (1985). Exercise testing, training and arm ergometry [review]. Sports Med, 2(2), 100-119. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/3890067
* ↑ Herbert, J., Clemow, L., Pbert, L., Ockene, I., & Ockene, J. (1995). Social Desirability Bias may compromise the validity of dietary intake measures. Int. J. Epidemiol, 24(2), 398-398. DOI: 10.1093/ije/24.2.389
* ↑ Sarkisian, C., Liu, H., Gutierrez, P., Seeley, D., Cummings, S., & Mangione, C. (2000). Modifiable risk factors predict functional decline among older women: a prospectively validated clinical predictor tool. J Am Geriatr Soc, 48(2), 170-178. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/10682946