# Exercise as it relates to Disease/The effect of Rheumatoid Arthritis on physical activity ability

This is a critique of the original research article "Physical Activity, Physical Fitness, and General Health Perception Among Individuals with Rheumatoid Arthritis" by Eva Eurenius and Christina H. Stenstrom published in 2005.

## What is the background to this research?

Rheumatoid Arthritis is a chronic disease characterized by joint swelling, joint tenderness, and destruction of synovial joints, causing a restriction in physical activity ability which can lead to severe disability and premature mortality.
Individuals that have rheumatoid arthritis have be associated with reduced levels of physical activity and physical fitness due to the high amount of inflammation that occurs within the joints. This can lead to a decrease in aerobic capacity, muscular strength and endurance, flexibility, and standing balance. Exercise has been shown to be extremely beneficial in people with rheumatoid arthritis as it can decrease the risk of comorbidities, all cause mortality, and decrease joint pain. An appropriate physical exercise program achieved without joint damage or exacerbation of disease activity can increase the physical ability, and quality of life of the individual.

## Where is the research from?

The research in this article was conducted at the Skellefteå Hospital in Sweden. The Authors both came from Karolinska Institutet in Sweden and although the research from this article is from 2005, the implications and findings are still relevant in the world and Australia.

## What kind of research was this?

This study was a cross-sectional study comparing self-reported physical activity with actual physical activity. Cross-sectional studies are useful for public health monitoring and planning, but can have limitations as cross-sectional studies are prone to certain biases as it is difficult to derive casual relationships from these studies.

## What did the research involve?

This study involved 298 participants with diagnosed Rheumatoid Arthritis. Each of the participants were asked to fill out a questionnaire, designed specifically for this study, that looked at physical activity and health status. The participants then performed a submaximal aerobic fitness test on either a bicycle or treadmill ergometer, to estimate VO$_2$ Max. Time stands tests were then performed on the subjects to assess lower limb muscle function. Grip force peak was then measured in the participants in newtons (N). The Escola Paulista de Medicina-Range of Motion scale was used to estimate the subjects general range of motion. Functional balance was then determined while walking in a figure-8 with inner circles. Self-reported pain was recorded on a visual analog scale of 1-100.
The participants then came in the following week to assess estimated physical activity performance and disease activity. Estimated physical activity performance was assessed by using the Health Assessment Questionnaire to determine functional disability index. The disease activity was determined by measuring C-reactive protein and Disease Activity Score and self-reported general health perception scored on a visual analog scale.
The methodology that was used in this study might have been improved if the aerobic fitness test was completed on one type of ergometer, either the bicycle or the treadmill. This would reduce random error between ergometers. The limitations that exist within the self-reported measures are that the participants might misinterpret the scaling system causing inaccuracies.

## What were the basic results?

The study found that 47% of the participants did not reach recommended physical activity levels. This was found to be slightly lower than the normative data for groups of the same age from a representative sample. The majority of the subjects were found to have a moderate-low level of aerobic fitness similar to the normative data of same age groups from a representative sample. The participants lower-limb muscle function, grip force peak, average grip force, general range of motion, and functional balance were all decreased. The level of disease activity found within the participants was in the low-moderate range. There was also found to be a moderate impact on general health perception and pain in regards to activity limitations.
| | Normal (%) | Decreased (%) | Missing (%) |
| Lower-Limb Muscle Function | 28 | 67 | 5 |
| Grip Force Peak | 4 | 92 | 4 |
| Average Grip Force | 6 | 91 | 3 |
| General Range of Motion | 6 | 94 | 0 |
| Functional Balance | 33 | 65 | 2 |
The researchers interpreted the physical activity levels of the 47% not reaching recommended guidelines to support previous findings of low physical activity levels among individuals with Rheumatoid Arthritis, implicating the reason of this is because of the pain associated with physical activity and the barriers it causes. As a result of this, these individuals develop a contentedness with a physically inactive lifestyle. They interpreted the disease activity levels to indicate that other factors are involved such as the influence of cognitive-behavioural factors. This includes motivation and self efficacy.
These implications that the authors have presented of their findings are justified and provide area for follow up research.

## What conclusions can we take from this research?

This study shows the need for more recommendations on and support for healthy physical activity among people with Rheumatoid Arthritis. Looking at the results, we can conclude that a supervised exercise training program focused on increasing aerobic fitness, lower-limb strength, grip strength, range of movement, and functional balance will have a beneficial effect on reducing disease activity and the barrier to exercise.
The findings of this paper provide key initial insights into physical activity and Rheumatoid Arthritis, but a more updated paper concluded that by more effectively tailoring physical activity promotion to vulnerable socioeconomic groups, men, and those with high activity limitation and anxiety/depression, there will be a greater longitudinal benefit of reduced risk of comorbidity and premature mortality.

## Practical advice

Individuals with Rheumatoid Arthritis should be encouraged to undertake exercise training programs supervised by a certified professional but before undertaking any exercise training programs, individuals should consult their doctor about possible contraindications to exercise and coordinate this with the exercise trainer.

## Further Information

For further reading regarding Rheumatoid Arthritis, please visit the following links:
* https://arthritisaustralia.com.au/types-of-arthritis/rheumatoid-arthritis/
* https://empowered.org.au/
* https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Living-Well-with-Rheumatic-Disease/Exercise-and-Arthritis

## References

* ↑ Eurenius E, Stenström C. Physical activity, physical fitness, and general health perception among individuals with rheumatoid arthritis. Arthritis Care & Research. 2005;53(1):48-55.
* ↑ Cohen S, Emery P. The American College of Rheumatology/European League Against Rheumatism criteria for the classification of rheumatoid arthritis: A game changer. Arthritis & Rheumatism. 2010;62(9):2592-2594.
* ↑ Minor M, Hewett J, Webel R, Dreisinger T, Kay D. Exercise tolerance and disease related measures in patients with rheumatoid arthritis and osteoarthritis. Journal of Rheutamology. 1988;15(6):905-11.
* ↑ Ekblom B, Lövgren O, Alderin M, Fridström M, Sätterström G. Physical Performance in Patients with Rheumatoid Arthritis. Scandinavian Journal of Rheumatology. 1974;3(3):121-125.
* ↑ Cooney J, Law R, Matschke V, Lemmey A, Moore J, Ahmad Y et al. Benefits of Exercise in Rheumatoid Arthritis. Journal of Aging Research. 2011;2011:1-14.
* ↑ Setia M. Methodology series module 3: Cross-sectional studies. Indian Journal of Dermatology. 2016;61(3):261.
* ↑ Demmelmaier I, Björk A, Dufour A, Nordgren B, Opava C. Trajectories of Fear-Avoidance Beliefs on Physical Activity Over Two Years in People With Rheumatoid Arthritis. Arthritis Care & Research. 2018;70(5):695-702.