# Exercise as it relates to Disease/Effect of exercise on patients with Rheumatoid Arthritis

This is an analysis of the journal article “effect of intensive exercise on patients with Rheumatoid arthritis: a randomised clinical trial” by CHM Van den Ende et al (2000)

## Background to this research

Rheumatoid arthritis is a long term autoimmune disease affecting joints and cartilage. Elevation of white blood cells within the body affects the level of inflammation during active phases ( joints flare up and swell), causeing chronic pain, reduced muscle strength, swelling and stiffness leading to destruction and deformity of the joint, therefore impacting considerably on quality of life. Treatment previously involved medication, restricted exercise with quality bed rest allowing minimal stress on joints. Research has looked into effects exercise has on patients with active rheumatoid arthritis and the effects on limiting exercise to these patients$^.$ The aim of the study “effect of intensive exercise on patients with Rheumatoid arthritis: a randomised clinical trial” was to examine the effects intensive exercise has on disease activity, chronic pain and movement range of joints of patients, becoming important in determining if exercise can become a long term remedy for rheumatoid arthritis.

## Where is this research from?

Research conducted by CHM Van den Ende et al in 2000, from the department of Rheumatology at Leiden University Medical centre (The Netherlands). CHM Van den Ende has conducted other studies directly related to rheumatoid arthritis. This research may not be applicable to all countries, including Australia as rheumatoid patients are no longer admitted to hospitals for treatment but managed through advances in technology and medications.

## What kind of research is this?

This was a single blinded, randomised control trial on the effect of an intensive exercise program during patients stay in hospital. Patients randomly selected for either a standard exercise program or intensive doesn't take into consideration the level of inflammation individuals suffer, suggesting that a patient who suffers less chronic pain selected in intensive program may benefit more than another patient with a more severe case of arthritis in the same program. The level of evidence concluded a long term intensive exercise program for rheumatoid patients is beneficial is supported by several other studies, yet some are either still conducted by the same researcher or have a similar study design.

## What did the research involve?

64 inpatients (20–80 years) with active rheumatoid arthritis ( 5+ affected swollen joints and morning stiffness).
A standard exercise program involving range of motion and isometric strengthening exercises were performed by all participants twice and supervised by exercise therapists. Intensive program received additional exercises to existing program. (See table 1)
Table 1 - Intensive exercises
| Intensive program (34 participants) | Sets | Reps | Recovery (seconds) |
| Isometric strength (knee flexors & extenders) | 3 | 5 | 30 |
| Isokinetic strength (knees) | 3 | 8 | 30 |
| Cycle session | 3 per week | 15 minutes | 0 |
*All at 70% maximum voluntary contraction, cycle at 60% age predicted maximum heart rate
** determined and controlled by exercise therapists weekly
The methodology is biased because only inpatients were selected, not allowing this to be implemented successfully for outpatient sufferers. Some patients dropped out of the study due to increased pain therefore not being included in final results, impacting if the final outcome on an intensive program is more successful than a conservative one. Assessment on damage to joints isn’t included within the disease activity criteria.

## What were the basic results?

* Measured by changes within joint mobility, muscle strength, functional ability in intensive or conservative exercise.
* Patients in intensive exercise program showed substantial improvement of muscle strength and joint mobility, even after 6 months follow up.
* 16 patients involved in this research could not be reevaluated on follow up.
* Both exercise groups showed a slight decline in disease activity levels during the 24 weeks, with more improvement in the intensive exercise program.
* Patients within the intensive program had an increased number in swollen joints at the start but by the 24-week mark, swollen joints, and joint mobility improved
* There was also a 30% increase in muscular strength by the intensive exercise group.

## What conclusions can we take from this research?

* Exercise programs may benefit sufferers (applied based on level of pain, inflammation and medication).
* Research supports previous findings that implementation of an intensive exercise program to patients shows improvement in strength, range of movement and pain with minimal decline of health
* This study looks into patients only with active rheumatoid arthritis
* Advances in treatment, modification of appropriate exercise programs implemented still support this study that high intensity exercise is beneficial for rheumatoid patients
* Results suggest an exercise program is beneficial for rheumatoid patients
* Precaution should be considered in patients with severely damaged joints which may cause adverse effects

## Practical advice

* Rheumatoid patients may benefit from an intensive (pushing to your capabilities) exercise program (cardio training 3 times a week and strength training program designed and supervised by a health professional).
* Exercise programs are effective in improving the functional ability of rheumatoid patients along with improved mood and fitness, without negative effects of disease state.
* Limiting environmental factors (e.g smoking) that can contribute to rheumatoid arthritis will be beneficial in reducing the risk. developing rheumatoid arthritis.

## Further information/resources

1. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/rheumatoid-arthritis
2. http://www.arthritisaustralia.com.au/
3. http://www.bupa.com.au/health-and-wellness/health-information/az-health-information/rheumatoid-arthritis

## References

* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Van den Ende CHM, Breedveld F, le Cessie S, Dijkmans B, de Mug AW, Hazes J. Effect of intensive exercise on patients with active rheumatoid arthritis: a randomised clinical trial. Annals of the Rheumatic Diseases [Internet]. 2000 [cited 2016 Aug 19];59(8):615-621. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1753212/?tool=pmcentrezdoi:10.1136/ard.59.8.615.
* 1 2 1. Scott D, Wolfe F, Huizinga T. Rheumatoid arthritis. The Lancet [Internet]. 2010 October [cited 2016 Aug 19];376(9746):1094-1108. Available from:http://www.sciencedirect.com.ezproxy.canberra.edu.au/science/article/pii/S0140673610608264
* 1 2 3 2. Cooney J, Law R, Verena Matschke, Lemmey A, Moore J, Ahmad Y, Jone J, Maddison P, Thom J. Benefits of Exercise in Rheumatoid Arthritis. Journal of Aging Research [Internet]. 2010, cited 2016 Aug 19];2011(2011):14 pages. doi:10.4061/2011/681640
* ↑ InnovAiT. Rheumatoid arthritis. Sage Journals [Internet]. 2014 October [cited 2016 Aug 19];7(12):738-743. Available from http://ino.sagepub.com.ezproxy.canberra.edu.au/content/7/12/738.full.pdf+html. Doi 10.1177/1755738014553861
* 1 2 3 De Jong Z,nneke M, Kroon HM, Van Schaardenburg D, Dijkmans BA, Hazes JM, Vliet Vlieland TP. Long-term follow up of a high intensity exercise program in patients with rheumatoid arthritis. Clin Rheumatol [Internet]. 2009 Jun [cited 2016 Aug 19];28(6):663-71. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19247575?dopt=AbstractPlus Mu
* 1 2 3 De Jong Z, Munneke M, Zwinderman A,Kroon H, Jansen A, Ronday K, Van Schaardenburg D, Dijkmans B, Van Den Ende C, Breedveld F, Vliet Vlieland T, Haze J. Is a long-term high intensity exercise program effective and safe in patients with rheumatoid arthritis? Results of a randomised control trial. Arthritis Rheum [Internet]. 2003 Sept [cited 2016 Aug 19];48(9):2415-24. Available from: http://www.ncbi.nlm.nih.gov/pubmed/13130460?dopt=AbstractPlus