# Exercise as it relates to Disease/Benefits of exercise on rheumatoid arthritis patients

This critique is of the journal article "Benefits of exercise on physical and mental health in rheumatoid arthritis patients" by Zippenfiening and Sirbu (2015).
This review has been written for an Health Disease and Exercise assignment at the University of Canberra.

## What is the background to this research?

Rheumatoid arthritis (RA) is a common chronic degenerative autoimmune disease affecting many joints characterised by progressive pain, stiffness and inflammation. It is most prevalent in people aged 40-60 years. This may lead to severe permanent damage and structural deformities of affected joints leaving the sufferers in pain, less mobile and fatigued. The progressive disease is also associated with systemic complications affecting vital organs such as heart, lungs and blood vessels.
Depression is commonly reported in RA patient’s due to the painful, debilitating nature of the disease. The symptoms lead many sufferers to an inactive lifestyle despite the research demonstrating the many benefits of exercise in rheumatoid patients
This research was conducted to demonstrate the physiological and psychological benefits of aerobic exercise in RA patients compared to a sedentary control group.

## Where is the research from?

This study was conducted through West University of Timisoara, Romania, using American testing criteria. Published in the Timisoara Physical Education Journal, which states to inform readers about the importance of physical education in order to maintain a healthy life.
Although the authors are not known in this field, the articles findings are constant with similar studies.

## What kind of research was this?

This is a quantitative randomized control trial which is commonly used throughout similar research. Using these methods to analyse data can provide pragmatic advantages, analysis and comparisons can be precisely displayed in the way of statistical and numeric results. Self-assessed questionnaires in the article can be a limitation due to the subjective nature of results which could alter day to day.

## What did the research involve?

22 rheumatoid arthritis patients who met the American College of Rheumatology criteria were selected to take part in this study. Two groups were formed, a training group (TG) of 10 subjects and control or sedentary group (SG) of 12 subjects, both with a mean age of 67.
Testing involved pain scales as well as mental and physical self-assessments.
The following exercise protocol was prescribed over the 6-month trial period.
| Group | Training group | Sedentary group |
| Frequency | 3-5 (per week) | No intervention |
| Duration | 45mins | No intervention |
| Intensity | 60-85% of max HR (monitored) | No intervention |
| Activity | Aqua gym Walking Cycling Aerobics class | No intervention |
Limitations of the study include; small sample size and subjective testing methods were used, testing more participants and incorporating a blood analysis could provide more reputable results. No consideration for resistance training is considered, having a separate training group would show a nice comparison of training modalities.
The authors are Romanian, a possible language barrier should be considered when interpreting the results. Although the article doesn’t state where the subjects are from it would also have to be considered the environmental and lifestyle factors may differ if comparing to other nationalities.

## What were the basic results?

The results indicated no significant difference in pain intensity nor the number of joints presenting painful and inflamed between the TG and SG. However, there was a significant difference in the Mental Composite Scale (MCS), with a p value of .04 and Physical Composite Scale (PCS) with a p value of .03 meaning the TG subjects who performed the moderate aerobic exercise protocol reported improved physical and mental health measures.
All subjects were being treated with one or more disease modifying antirheumatic drug or biologic drug prior to and during the study. Interestingly the training group reported a lower adherence rate, indicated to be due to the side effects of the drugs.
The researchers used tables, graphs and brief written interpretations of results to outline their findings.

## What conclusions can we take from this research?

The goal of the article was to validate the benefits of Aerobic exercise in RA patients. The results outline a significant improvement from the TG subjects over the 6-month intervention, reporting they feel better both mentally and physically.
These results align with other research, stating physical activity has tremendous benefits both physically and mentally. Currently there doesn’t seem to be an ideal physical activity protocol for RA sufferers however research shows that mix modalities, such as aerobic and strength training provide positive results and benefits, similar to the general population recommendations.
Benefits include:
* Improved pain and other symptoms of RA
* Reduced risk of cardiovascular disease, diabetes, obesity and other health issues.
* Increased Vo2 max
* Improved self-reported health status outcome (physical and mental)
* Improve depressive symptoms
* Improved mood and well being
* Reduction in functional disability and increased independence
* Increased range of motion
Interestingly, other research suggests that the barriers involved in exercising with RA were consistent with those who chose to exercise and those who chose to be sedentary despite education and encouragement from medical professions, family and friends.
It has been reported that patients feel a lack of available information and knowledge of practitioners in prescribing exercise and is a considerable barrier.

## Practical advice

Getting active can fit into any schedule and is a great opportunity to socialise, meet new people and get outside. It’s inexpensive and generally very safe, the below links provide further reading and information on exercising with rheumatoid arthritis.
* Rheumatoid arthritis, Arthritis Australia:
* Arthritis Foundation
* Exercise and RA
* Can I exercise if I have rheumatoid arthritis?
* Rheumatoid arthritis support network
The below sample program can be beneficial for otherwise healthy RA sufferers and adapted to suit your schedule. Seek advice from a qualified trainer if needed.
Before you commence an increase in physical activity caution should be taken and consulting with your medical practitioner is advised to ensure it is medically safe to do so. It’s also important to listen to your body, if you are experiencing a flare up, reduce the intensity and duration of your exercise.
| Monday | Tuesday | Wednesday | Thursday | Friday | Saturday | Sunday |
| 30min walk with 15min stretching (45min) | | Resistance training (30mins) + 15mins walk or cycle (45mins) | Swimming or aqua aerobics (45min) | | Resistance training (30mins) + 15mins walk or cycle (45mins) | |
Above program: based off the Australia’s Physical Activity & Sedentary Behaviour Guidelines for Adults (18-64 years).

## References

Add in the references using this code
* 1 2 3 4 5 6 Zippenfening H, Sirbu. E. Benefits Of Exercise On Physical And Mental Health In Rheumatoid Arthritis Patients.Timișoara Physical Education and Rehabilitation Journal. 2014;7(13):58-63
* 1 2 3 Breedland I, van Scheppingen C, Leijsma M, Verheij-Jansen N, van Weert E. Effects of a Group-Based Exercise and Educational Program on Physical Performance and Disease Self- Management in Rheumatoid Arthritis: A Randomized Controlled Study. Physical Therapy [serial on the Internet]. (2011, June), [cited September 9, 2018]; 91(6): 879-893. Available from: Academic Search Complete.
* 1 2 3 4 Elramli A. Exercises interventions in people with rheumatoid arthritis. Clin Trials Orthop Disord. 2017;2(4):160-163
* 1 2 3 Veldhuijzen van Zanten, J.J.C.S., Rouse, P.C., Hale, E.D. et al. Perceived Barriers, Facilitators and Benefits for Regular Physical Activity and Exercise in Patients with Rheumatoid Arthritis: A Review of the Literature. Sports Med (2015) 45: 1401.
* ↑ LUMS Effective Learning. Qualitative and quantitative research. [Internet]. LUMUS Effective Learning; 2016 June 28[cited September 14 2018]. https://www.lancaster.ac.uk/media/lancaster-university/content-assets/documents/learning-skills/quantitativevqualitativeresearchanswers.pdf
* ↑ Weinstein. A, Koehmstedt. C, Kop. Willem. Mental health consequences of exercise withdrawal: A systematic review. General Hospital Psychiatry 49 (2017) 11–18
* 1 2 3 Baxter. S, Smith. C. Treharne. G, Stebbings. S, Hale. L. What are the perceived barriers, facilitators and attitudes to exercise for women with rheumatoid arthritis? A qualitative study. Disability and Rehabilitation Journal. 2015 June 30;38(8):773-780.
* 1 2 Kapale P, Vardharajulu G, Warude T. Effect of Free Exercise and Rheumatoid Arthritis. Indian Journal Of Physiotherapy & Occupational Therapy [serial on the Internet]. (2017, July), [cited September 12, 2018]; 11(3): 62-65. Available from: CINAHL Plus with Full Text.
* ↑ Have M, De Graaf, R, Monshouwer. K. Physical exercise in adults and mental health status: Findings from the Netherlands Mental Health Survey and Incidence Study (NEMESIS): Journal of Psychosomatic Research. 2011; 71(5), pp.342–348.
* ↑ Australian Government, Department of Health. Australia’s Physical Activity and Sedentary Behaviour Guidelines [Internet]. Canberra: Department of Health; 2017 [cited 2018 Sept 15]. Available from: http://www.health.gov.au/internet/main/publishing.nsf/content/health-pubhlth-strateg-phys-act-guidelines