# Exercise as it relates to Disease/Physical training on Rheumatoid Arthritis

The following document is a critique of 'Physical Training in Rheumatoid Arthritis: A Controlled Long-Term Study. I' by Rolf Nordemar, Björn Ekblöm, Lars Zachrisson & Kristina Lundqvist (1981) found in the Scandinavian Journal of Rheumatology.

## What is the background to this research?

Rheumatoid Arthritis (RA) is an autoimmune disease that affects the joints within the body. An autoimmune disease involves the body's immune system attacking itself as opposed to its task of protecting against foreign substances. Joints are affected by the thickening of the synovial fluid in the joint which can cause swelling, pain, stiffness and damage in the affected joints. This can adversely impact on the mobility of the person with RA which is why physical activity is a major discussion point for these respective patients. Rheumatoid arthritis is more prevalent in women and affects around 458,000 Australians.
As evident with many diseases, obesity and inactivity are risk factors for Rheumatoid Arthritis clarifying the need for appropriate exercise programs. Contradictory though, RA causes patients to reduce physical activity due to the joint pain suffered and fear of worsening their condition. Studies and information available on arthritis websites do however stress the fact that physical activity is safe for people with RA to participate in. It does however need to be adapted to suit the severity of each specific case of the disease.

## Where is the research from?

This research was conducted in Sweden from the Department of Physical Medicine and Rehabilitation, Karolinska Hospital, the Department of Physiology III, Karolinska Institute and the Departments of Diagnostic Radiology and Rheumatology and St. Erik's Hospital, Stockholm. St. Erik's Hospital was the clinic where the patients were selected from. This research is published in the Scandinavian Journal of Rheumatology which is an International journal useful for different health practitioners and focuses on clinical and experimental rheumatology.
The authors for this research have ten years of experience in the field, specifically with RA, making them credible in this area. The lead author Rolf Nordemar has been at the helm of countless other RA studies surrounding different areas of physical activity and the disease.

## What kind of research was this?

The study conducted was a controlled long-term study, also regarded as a Randomised Controlled Trial. Studies that use a control involve monitoring a group that changes what it does with a variable, i.e. the exercising cohort, while the other group, the control, continues to live a lifestyle where they are not partaking in this change of variable.
Randomised Controlled Trials can be both highly positive and negative in the results that they produce. If done carefully with the control, it can help to influence the prescription of exercise. If done incorrectly however, prescriptions could be given with the possibility of causing potential harm to a patient.
Participant criteria included:
* Adhere to ARA criteria,
* Moderate disease activity and
* Functional stage I, II or III.
This criteria increased the reliability of the study due to the similarity of the patients.

## What did the research involve?

This research was a 4 to 8 year study where 23 patients from St. Erik's Hospital took part in a physical training study, with another 23 participants were also in the control group from 1970-1978. There were 19 females and 4 males in both groups within the study since females have a higher prevalence of Rheumatoid Arthritis. These patients ranged in age from 31–70 years old.
The training program consisted of both home-training (which requires high levels of intrinsic motivation) and group-training which was led by a physiotherapist (to ensure that physical activity is completed as safe as possible).
Strengths of the Study
* Had a control group as part of the study to have a basis for comparison.
* Completed the study over a number of years which eliminates short-term changes being the basis for the results.
* Used specific criteria to select participants to ensure certain level of the chronic disease.
Limitations of the Study
* Lost some participants along the way which reduced the participant pool.
* Some participants in the active group stopped partaking in physical activity and some from the control group started to exercise on their own accord, but were still classified as their original group classification which decreased reliability.
* Is an outdated study now, so new technology and studies would be able to reassess outcomes of this study.

## What were the basic results?

Key results made evident from the study include:
* Lower values in Lansbury's joint index in the Training Group (TG).
* The increase in sick-leave was higher over the 8 year period in the Control Group (CG) - 29% increase as opposed to 1% in the TG.
* CG spent more time in hospital than the TG - more than two times the amount.
* There was less progression of joint damage in the TG as opposed the to CG.
* Improvements in muscle was also seen in the TG along with improved ability to walk up stairs and complete the step test.
* Positive psychological changes occurred with most participants agreeing that physical activity was beneficial for them in relation to rheumatoid arthritis and that they were likely to participate in this type of exercise into the future.

## What conclusions can we take from this research?

Overall the outcome of this research was that physical activity is beneficial for patients with Rheumatoid Arthritis. The study found that physical activity can help to reduce the progression of the disease, which is beneficial for function in daily life. Further to this, it was evident that physical activity completed at an increased rate was more beneficial than less regular exercise.
These conclusions have been backed up by other, more recent studies and website information in the positive correlation between physical activity and Rheumatoid Arthritis. A study conducted in 2008 by Plasqui directly references this study being critiqued within the conclusion, which emphasises its precedence in this area of study. Studies conducted in 1989 and 2004 connecting muscle strength and conditioning in conjunction with moderate to vigorous activity, displayed positive results for RA patients. This confirms that modern studies continue to reinforce the ideas presented within this critiqued study for those with RA.

## Practical advice

Rheumatoid arthritis is currently incurable, so should be prevented where possible and treated at the earliest signs.
Preventative measures:
* Avoid smoking.
* Monitor environmental exposure to substances such as asbestos and silica.
* Maintain of a healthy weight range i.e. avoid obesity.
Unfortunately risk factors such as aging, being female and having a family history are unmodifiable determinants and therefore, cannot be avoided.
Treatment measures:
* Seek doctor advice as soon as possible.
* Participate in regular physical activity.
* Exercise at a moderate intensity where possible.

## Further information/resources

Information for people living with arthritis can be found on these sites:
* Arthritis Foundation - What is Rheumatoid Arthritis?
* Mayo Clinic - Rheumatoid Arthritis
* Arthritis Australia - Rheumatoid Arthritis - What is Rheumatoid Arthritis?
Information specifically linked to exercise and Rheumatoid Arthritis:
* Exercise and Rheumatoid Arthritis fact sheet by Arthritis Australia
* Exercise tips for people living with Rheumatoid Arthritis by the Arthritis Foundation

## References

* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Rolf Nordemar, Björn Ekblöm, Lars Zachrisson & Kristina Lundqvist (1981) Physical Training in Rheumatoid Arthritis: A Controlled Long-Term Study. I, Scandinavian Journal of Rheumatology, 10:1, 17-23
* 1 2 3 4 5 Australia, A. (2007). Rheumatoid arthritis. Retrieved from Arthritis Australia: https://arthritisaustralia.com.au/types-of-arthritis/rheumatoid-arthritis/
* 1 2 3 4 Foundation, A. (n.d.). What is Rheumatoid Arthritis? Retrieved from Arthritis Foundation: https://www.arthritis.org/about-arthritis/types/rheumatoid-arthritis/what-is-rheumatoid-arthritis.php
* 1 2 3 4 5 6 Research, M. F. (2019). Rheumatoid arthritis. Retrieved from Mayo Clinic: https://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/symptoms-causes/syc-20353648
* 1 2 AIHW. (2019, 08 30). Rheumatoid arthritis. Retrieved from Australian Institute of Health and Welfare: https://www.aihw.gov.au/reports/chronic-musculoskeletal-conditions/rheumatoid-arthritis/contents/what-is-rheumatoid-arthritis
* 1 2 K Loeppenthin, BA Esbensen, M Ostergaard, P Jennum, T Thomsen, J Midtgaard (2013) Physical activity maintenance in patients with rheumatoid arthritis: a qualitative study, 28:3, 289-299
* ↑ Australia, A. (2007). Exercise and RA. Retrieved from Arthritis Information Sheet: https://arthritisaustralia.com.au/wordpress/wp-content/uploads/2017/09/Exercise-and-RA.pdf
* ↑ ResearchGate. (2019). Scandinavian Journal of Rheumatology (SCAND J RHEUMATOL). Retrieved from ResearchGate: https://www.researchgate.net/journal/0300-9742_Scandinavian_Journal_of_Rheumatology
* ↑ Limited, I. U. (2019). Your search for Author: Nordemar, Rolf. Retrieved from Taylor & Francis Online: https://www.tandfonline.com/author/Nordemar%2C+Rolf
* ↑ Kendall, J. M. (2003). Designing a research project: randomised controlled trials and their principles. Emergency Medical Journal.
* ↑ Alonso-Aubin, A. D., Chulvi-Medrano, M. I., Picón, M. M., Rial, M. T., & Cortell-Tormo, M. J. (2018). Effects Of An Exercise Program On Quality Of Life On A Rheumatoid Arthritis Patient: A Case Study: 142 May 30 10: 50 AM - 11: 10 AM. Medicine & Science in Sports & Exercise, 17.
* ↑ Plasqui, G. (2008). The role of physical activity in rheumatoid arthritis. Physiology & Behavior, 270-275.
* ↑ Häkkinen, A. (2004). Effectiveness and safety of strength training in rheumatoid arthritis. Current Opinion in Rheumatology, 132-137.
* ↑ Marian, A., Richard, R., Donald, R., John, E., & Sharon, K. (1989). Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis. Arthritis; Rheumatism.