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Physical Activity in Rheumatoid Arthritis: A Systematic Review
Abstract
Physical activity is associated with improved health outcomes in many populations. It is assumed that physical activity levels in the rheumatoid arthritis (RA) population may be reduced as a result of symptoms of the disease. The objective of this review is to establish the current evidence base for levels of physical activity in the RA population.
A systematic review was performed of 7 databases (Emabase, MEDLINE, AMED, Biomedical Reference Collection Expanded, CINAHL, Nursing and Allied Health Collection, and SportsDiscus) up to February 2011 to examine the evidence in the area.
One hundred and thirty-six studies were identified through electronic searching. One hundred and six were excluded based on title and/or abstract analysis and a further 14 were excluded based on full text analysis. Sixteen studies meeting the criteria were deemed suitable for inclusion. The results of the included studies indicate that the level of physical activity may be lower among individuals with RA when compared with healthy controls or normative data.
There are a number of methodological considerations at play within the studies reviewed which prohibits definitive conclusion on the physical activity levels of this population group. Given the known health benefits of physical activity, further research in this area appears indicated.
... Despite the mounting evidence supporting the value of regular physical activity (PA), anywhere from 56% to 96% of adults do not meet the 2018 Physical Activity Guidelines for Americans of 150 minutes of moderate PA per week [1][2][3][4]. In some populations, such as those with clinical conditions or older adults, even fewer are routinely achieving 150 minutes of moderate-to-vigorous PA [5][6][7]. Independent of meeting physical activity guidelines, sedentary time is also a risk factor for poorer health outcomes [8]. The health benefits of regular light PA and/or reducing sedentary time across a wide range of populations have been postulated and supported by strong evidence across a range of populations [5,9,10]. ...
... Independent of meeting physical activity guidelines, sedentary time is also a risk factor for poorer health outcomes [8]. The health benefits of regular light PA and/or reducing sedentary time across a wide range of populations have been postulated and supported by strong evidence across a range of populations [5,9,10]. Thus, effective means to differentiate sedentary, light, moderate, and vigorous PA are needed. ...
... While PA is not without risks, it is widely recognized as providing many physical and mental health benefits, including older adults and those with clinical conditions [5,6,9,10,33]. The use of wearable sensors has great potential to aid clinicians in caring for their patients as well as provide objective assessments for patients to self-monitor their health and provide a degree of locus of control over their selfmanagement. ...
Aim: Physical activity (PA) is increasingly used as a patient-centered means to treat and/or cope with pain and other symptomology resulting from clinical health conditions. Despite the increasing use of wearable sensors to track PA in healthy and patient cohorts, few algorithms are equally accurate in assessing sedentary and light PA as moderate and vigorous. Given that many older adults and patient cohorts are less active, there is a need for simple algorithms that are easily implemented and valid for the assessment of even low activity levels. Thus, the purpose of this study was to test a simple nonlinear modification to a validated linear algorithm for hip- and wrist-worn accelerometry to measure human PA energy expenditure. Methods: Triaxial accelerometers were worn on the wrist and hip during 14 standardized laboratory-based activities in 37 healthy adults across the lifespan [19–65 years, 19 females (F)]. Combined with previously reported energy expenditure data, linear and power equations transforming accelerations to estimates of oxygen consumption (VO2) were compared. Results: The nonlinear algorithm provided equally accurate measures of PA energy expenditure as linear approaches, with the added advantage of being able to estimate even low energy expenditure, a necessary outcome to differentiate sedentary and light PA. Further, the nonlinear algorithm produced a slightly better estimate of PA when using wrist than hip accelerometry. Conclusions: A simple nonlinear algorithm provides a better means for monitoring PA in populations with low activity levels due to its improved ability to discern sedentary from light PA. This is particularly relevant for older and clinical populations as even light levels of PA may provide therapeutic benefits.
... According to previous studies (7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22), factors associated with arthritis include sociodemographic factors, health risk behaviors, poor mental health, and chronic conditions. Sociodemographic factors associated with arthritis include older age (7)(8)(9)(10)(11), female sex (7)(8)(9)(10)(11), higher economic status (9) and lower education (10,12). ...
... Sociodemographic factors associated with arthritis include older age (7)(8)(9)(10)(11), female sex (7)(8)(9)(10)(11), higher economic status (9) and lower education (10,12). Specific health risk behaviors, such as smoking (13), low physical activity or sedentary behavior (12,(14)(15)(16), non-alcohol use (17) and obesity (5,8,14,18) have shown to increase the risk of arthritis. Moreover, poor mental health (5,19,20), including sleep problems (19) and depressive symptoms (10,18,21), increased the odds of arthritis. ...
... Obesity may 'exhibit a chronic subclinical inflammatory state' increasing the risk of rheumatoid arthritis (42). Some studies found an association between physical inactivity and arthritis (12,14,15,23,43), while this study did not find this association. The non-significant association between physical inactivity and SRA in this study may be related to how physical activity was measured, it only included exercise and no other physical activity. ...
Background
The study aimed to assess the prevalence and associated factors of cross-sectional and incident arthritis or rheumatism among a national community sample of middle-aged and older adults in Thailand.
Methods
We analyzed cross-sectional and longitudinal data from two consecutive waves (2015 and 2017) of the Health, Aging, and Retirement in Thailand (HART) study. Arthritis or rheumatism (SRA) was assessed by self-reported health care provider diagnosis.
Results
The cross-sectional (baseline) sample included 5,616 participants (≥45 years, median age 66 years, interquartile range 57 to 76 years) and the incident (follow-up) sample included 3,545 participants. The prevalence of SRA in the cross-sectional sample (baseline) was 4.0% and in the incident (follow-up) sample 5.3%. In the cross-sectional multivariable model, obesity class I (aOR: 1.78, 95% CI: 1.19 to 2.67), obesity class II (aOR: 1.82, 95% CI: 1.02 to 3.25), hypertension (aOR: 1.90, 95% CI: 1.35 to 2.66), brain disease and/or psychiatric problems (aOR: 4.79, 95% CI: 2.27 to 10.62), sleep problem (aOR: 1.45, 95% CI: 1.01 to 2.07) and prescription drug use (aOR: 1.63, 95% CI: 1.14 to 2.33) were positively associated, and not in the labor force (aOR: 0.53, 95% CI: 0.34 to 0.84), and employed (aOR: 0.63, 95% CI: 0.41 to 0.99) were negatively associated with SRA. In the incident multivariable model, obesity class I (aOR: 1.78, 95% CI: 1.17 to 3.61), obesity class II (aOR: 2.01, 95% CI: 1.12 to 3.61), poor mental health (aOR: 1.69, 95% CI: 1.19 to 2.41), and functional disability (aOR: 2.04, 95% CI: 1.01 to 4.13) were positively associated, and current alcohol use (aOR: 0.50, 95% CI: 0.25 to 0.99) was negatively associated with SRA.
Conclusion
The middle and older Thai adults had a low prevalence and incidence of SRA, and several physical and mental risk factors for cross-sectional and/or incident SRA were identified.
... Although this paradox is still not well understood, it appears that this works in a Stat3-dependent manner. Stat3 signaling is often increased in skeletal muscle wasting, especially under conditions of high circulating IL-6 (65,66). Moreover, IL-6-induced cardiac hypertrophy is regulated by Stat3 (53). ...
... In humans, physical inactivity is associated with greater RA disease activity (54), poorer immune function (55,56), CVD (57)(58)(59)(60), and skeletal muscle pathology (61)(62)(63)(64)(65)(66). Here, in K/BxN animals, regular wheel exercise reduced paw swelling and inflammation in concert with remarkable improvements in cardiac and skeletal muscle phenotypes. ...
... In an adjuvant induced model of RA (AIA), eccentric exercise prevents weakness associated with skeletal muscle inflammation (44). However, in CAIA mice, voluntary running conversely promotes arthritis onset and slowed the resolution of inflammation (66). In this CAIA mouse model of arthritis, mechanical strain is implicated in the localization of joint inflammation and erosions (5). ...
Rheumatoid arthritis (RA) is a systemic inflammatory arthritis impacting joints as well as cardiac and skeletal muscle. RA's distinct impact on cardiac and skeletal muscle tissue is suggested by studies showing that new RA pharmacologic agents strongly improve joint inflammation, but have little impact on RA associated mortality, cardiovascular disease and sarcopenia. Thus, the objective is to understand the distinct effects of RA on cardiac and skeletal muscle, and to therapeutically target these tissues through endurance-based exercise as a way to improve RA mortality and morbidity. Methods We utilize the well characterized RA mouse model, the K/BxN mouse to investigate cardiac and skeletal muscle pathologies, including the use of wheel running exercise to mitigate these pathologies. Results Strikingly, we found that K/BxN mice, like human RA patients, also exhibit both cardiac and skeletal muscle myopathies that were correlated with circulating IL-6 levels. Three months of wheel running exercise significantly improved K/BxN joint swelling and reduced systemic IL-6 concentrations. Importantly, there were morphologic, gene expression and functional improvements in both the skeletal muscle and cardiac myopathies with exercise. Conclusion The K/BxN mouse model of RA recapitulated important RA clinical comorbidities, including altered joint, cardiac and skeletal muscle function. These morphological, molecular and functional alterations were mitigated with regular exercise, thus suggesting exercise as a potential therapeutic intervention to lessen disease activity in the joint and the peripheral tissues, including the heart and skeletal muscle.
... In that study, physical inactivity was associated with low functional capacity and higher levels of disease activity, pain, and fatigue (18). When | 1835 PA is objectively assessed by accelerometry, the main disparity between RA patients and healthy individuals can be seen in the time devoted to different intense activities: RA patients spend less time engaging in moderate-to-vigorous PA (MVPA) than healthy controls (8,(13)(14)(15)20). ...
... Regular exercise of moderate-to-high levels of intensity has proven to be effective in improving muscle strength and cardiovascular fitness in healthy populations and in patients with chronic illnesses, including patients with RA and psoriasis (2,19,34,35). Because PsA is a chronic joint disease that leads to deformity and joint destruction, it has been assumed that patients with this disorder, as happens in RA (8,(13)(14)(15)20), are less active than the general population. However, no study has analyzed PA in patients with PsA compared to healthy controls using objective techniques. ...
... Questionnaire-based surveys, as well as studies using accelerometers, have shown that patients with RA tend to exercise less than what is currently recommended (17)(18)(19). The main disparity in the PA of patients with RA compared to healthy controls is that the former dedicate less time than controls to engaging in MVPA (8,(13)(14)(15)20). Based on this, as well as on the preliminary results of our pilot study for sample size calculation, we expected that patients with PsA would show lower PA than controls in terms of time spent engaged in MVPA, as assessed by accelerometry. ...
Objective
The purpose of this study was to compare physical activity (PA) in a group of patients with psoriatic arthritis (PsA) versus healthy controls and to determine whether the mobility of these patients is affected by disease activity.
Methods
A group of 52 patients with PsA and 53 controls were included in this case–control study. PA was assessed by accelerometry in both groups and additionally with the International Physical Activity Questionnaire (IPAQ) in patients with PsA. Multiple regression analysis was used to compare PA between groups and to determine the relationship between PA and PsA features, including disease activity, as assessed by the 28‐joint Disease Activity Score (DAS28) and the Disease Activity Index for Psoriatic Arthritis (DAPSA) score. In a group of 36 patients, a test–retest study was carried out after 6 months.
Results
The time engaged in moderate‐to‐vigorous physical activity (MVPA) per day, as evaluated by accelerometry, and adjusted by confounders, proved similar in patients with PsA and controls. In patients with PsA, disease activity was inversely related to PA as assessed either by IPAQ or accelerometry. When PA was compared in patients with PsA between the 2 visits, a significant difference in the amount of time doing MVPA was found (42 ± 33 versus 30 ± 22 minutes/day; P = 0.004). Interestingly, in the test–retest study, variations in disease activity over time based on DAPSA scores (r = –0.49, P = 0.002) and DAS28 using the C‐reactive protein level (r = –0.4, P = 0.017) were inversely correlated with changes in PA, as determined by accelerometry.
Conclusion
Patients with PsA show levels of PA like healthy controls. In patients with PsA, disease activity and PA are inversely correlated and the evaluation of PA by accelerometry is sensitive to changes in disease activity.
... However, available data indicate that people with RA typically do not engage in sufficient levels of physical activity to yield positive health outcomes, and spend long periods of the day sedentary. 32,33 Until recently, our understanding of the levels and health consequences of sedentary behaviour and physical activity in RA has largely been based on studies employing self-report methods to quantify engagement in these behaviours. The selection of self-report instruments introduces issues around measurement validity and reliability, such as social desirability bias and errors in participant recall, 32,[34][35][36] limiting the accuracy of such measures in sedentary behaviour and physical activity research. ...
... Further, to ensure progress in this field, it is essential that the validity of these accelerometer cut-points for the measurement of free-living behaviour is established. Despite several advantages relative to self-report, accelerometers are still limited in their ability to measure posture -an important facet of the characterisation of 127 32,33 Until recently, our understanding of the levels and health consequences of sedentary behaviour and physical activity in RA has largely been based on studies employing self-report methods to quantify engagement in these behaviours. The selection of self-report instruments introduces issues around measurement validity and reliability, such as social desirability bias and errors in participant recall, 32,[34][35][36] limiting the accuracy of such measures in sedentary behaviour and physical activity research. ...
... However, available data indicate that people with RA typically do not engage in sufficient levels of physical activity to yield positive health outcomes, and spend long periods of the day sedentary. 32,33 Until recently, our understanding of the levels and health consequences of sedentary behaviour and physical activity in RA has largely been based on studies employing self-report methods to quantify engagement in these behaviours. The selection of self-report instruments introduces issues around measurement validity and reliability, such as social desirability bias and errors in participant recall, 32,34-36 limiting the accuracy of such measures in sedentary behaviour and physical activity research. ...
Background:
The accurate measurement of sedentary time and physical activity in Rheumatoid Arthritis (RA) is critical to identify important health consequences and determinants of these behaviours in this patient group. However, objective methods have not been well-validated for measurement of sedentary time and physical activity in RA.
Aims:
Specific objectives are to: 1) validate the ActiGraph GT3X+ accelerometer and activPAL3μTM against indirect calorimetry and direct observation respectively, and define RA-specific accelerometer cut-points, for measurement of sedentary time and physical activity in RA; 2) validate the RA-specific sedentary time accelerometer cut-points against the activPAL3μTM; 3) compare sedentary time and physical activity estimates in RA, using RA-specific vs. widely-used non-RA accelerometer cut-points.
Methods:
Objective 1: People with RA will wear an ActiGraph GT3X+, activPAL3μTM, heart rate monitor and indirect calorimeter, whilst being video-recorded undertaking 11 activities representative of sedentary behaviour, and light and moderate intensity physical activity. Objectives 2 and 3: People with RA will wear an ActiGraph GT3X+ and activPAL3μTM for 7 days to measure free-living sedentary time and physical activity.
Discussion:
This will be the first study to define RA-specific accelerometer cut-points, and represents the first validation of the ActiGraph accelerometer and activPALTM, for measurement of sedentary time and physical activity in RA. Findings will inform future RA studies employing these devices, ensuring more valid assessment of sedentary time and physical activity in this patient group.
... [4] The typical age of onset falls between 40 and 60 years. [5] The main symptoms include joint pain, swelling, morning stiffness, and functional limitation. As the disease progresses, joint damage becomes progressive and irreversible, potentially leading to disability. ...
... Year Title Periodicals van den Berg MH [33] 0. 12 2006 Using internet technology to deliver a home-based physical activity intervention for patients with rheumatoid arthritis: A randomized controlled trial Arthrit Rheum-Arthr Steultjens EMJ [34] 0.11 2002 Occupational therapy for rheumatoid arthritis: a systematic review Arthrit Rheum-Arthr de Jong Z [35] 0 [5] 28 2012 Physical activity in rheumatoid arthritis: a systematic review J Phys Act Health Metsios GS [7] 28 2018 Physical activity, exercise and rheumatoid arthritis: Effectiveness, mechanisms and implementation Best Pract Res Cl Rh Verhoeven F [15] 26 2016 Physical activity in patients with rheumatoid arthritis Joint Bone Spine Thomsen T [46] 24 2017 ...
Rheumatoid arthritis (RA) is a prolonged multifactorial autoimmune disease of unknown etiology. With the global population aging, the incidence of RA is increasing, highlighting the need for more effective treatments. Exercise interventions have been recognized as safe and effective for managing pain, improving function, and reducing fatigue in RA patients. However, the existing literature in this field lacks a thorough, organized, and clear line of analysis. In this study, we conducted a comprehensive analysis of the 20-year literature on exercise interventions for RA, aiming to identify hotspots and cutting-edge trends. Our objective is to provide subsequent researchers with valuable ideas and references. Using Cite Space, VOS viewer, and R-bibliometrix software for visualization and analysis, we compiled the main dataset from the web of science database, consisting of 1790 articles on exercise interventions in RA published between 2000 and 2023. Among these articles, the United States contributed the highest number of papers (433), while Karolinska Institutet ranked first institutionally with 90 papers. The study focused on the keyword’s quality of life, cardiovascular disease, aerobic exercise, social support, psychology, and multidisciplinary care. The research highlighted the importance of clinical efficacy studies that investigate different types of exercise modalities (cardiorespiratory aerobic, resistance, aquatic, and neurological) either alone or in combination, to improve pain and function and reduce cardiovascular disease risk in patients with RA. Additionally, sedentary behavior, fatigue, and multidisciplinary care were identified as potential areas for further research. Overall, this study provides a scientific perspective on exercise interventions for RA and offers valuable insights for academics, funding organizations, and policymakers.
... There is a wealth of evidence supporting the beneficial effects of physical activity (PA) in improving joint health, physical function, and mental well-being, as well as reducing cachexia and fatigue in patients with RA [14,15]. Additionally, it was shown that physical activity is a protective factor in the etiology of RA. ...
... In addition, it is recommended that resistance training should be performed twice a week [17]. Even though RA patients commonly report that they are aware of the positive effects of physical activity [18,19], systematic reviews have shown that physical activity is lower in RA patients than in healthy controls [14,20]. In a cross-sectional study of 21 countries, only 13.8% of patients with RA reported regular physical activity [21]. ...
Background: Rheumatoid arthritis (RA) is a chronic autoimmune disease, which is associated with low levels of physical activity (PA). However, the factors related to low physical activity levels have rarely been studied. Methods: In this cross-sectional study, 70 seropositive RA patients were included. Physical activity was objectively assessed with an ActiGraph GT3X+ accelerometer. In addition, body mass index, smoking status, work ability, and clinical parameters (functional disabilities, disease activity, disease duration, pain, and inflammation parameters) were measured. Results: RA patients performed a mean of 215.2 (SD: 136.6) min a week of moderate physical activity and 9.1 (SD: 26.3) min of vigorous physical activity. The total amount of moderate and vigorous physical activity (MVPA) was associated with BMI, and functional disabilities. In addition, non-smokers and patients with better work ability did more MVPA. No association could be seen with disease activity, disease duration, pain, and inflammatory markers. After mutual adjusting of all the variables, only BMI showed a significant relationship with MVPA. Conclusions: RA patients perform de facto no physical activity with vigorous intensity. Factors related to low physical activity are BMI, functional disabilities, workability and smoking status, whereas due to the study design no causal and temporal link could be made.
... Therefore, for elderly patients with RA, exercise might be important to maintain physical function. However, previous studies reported that the level of physical activity in elderly patients with RA is lower than that in healthy elderly people 11,12) , with only 13.8 % of patients exercising at least three times per week 13) . This is partly because, although these patients understand the importance of exercise, they do not know what type of exercise will not adversely affect their joints 14,15) . ...
Objectives The number of elderly patients with rheumatoid arthritis (RA) is increasing due to the extension of life expectancy and advances in pharmacotherapy. Although exercise therapy has shown to be effective in patients with RA, there is a lack of evidence specifically focusing solely on elderly patients. We aimed to review the evidence for the effects of exercise therapy on elderly patients with RA.
Design Systematic review.
Methods An electronic search was conducted on June 30th, 2023, in five online databases. Controlled clinical trials investigating the effects of exercise therapy on elderly patients with RA were included. No restrictions were placed on the exercise therapy or outcomes to examine the effects of exercise therapy broadly. The risk of bias in the included studies was assessed using the revised Cochrane risk-of-bias tool for randomized trials and the risk of bias in non-randomized studies of interventions.
Results Out of the 4,177 articles identified, only three studies were included. All three studies were judged to have a high or serious risk of bias. The exercise therapies in the included studies were Arthritis self-management programs, Tai Chi, and grip-strengthening exercise. Arthritis self-management programs and Tai Chi showed the positive effects, whereas grip-strengthening exercise reported no effectiveness.
Conclusions In a few controlled clinical trials, the effects of exercise therapy on elderly patients with RA have been investigated, suggesting that the evidence on these effects is very limited. Considering that the society will continue to age, further studies on this topic are required.
... Specifically, these studies have demonstrated that PA, such as walking, can effectively reduce the burden of inflammation and improve functional ability 33,34 . Unfortunately, individuals with RA tend to exhibit a preference for sedentary behavior, which may be attributed to factors such as pain, fatigue, or fear of joint damage [35][36][37] . However, this behavior can lead to the exacerbation of RA-related symptoms, perpetuating a vicious cycle. ...
Walking pace is a simple and functional form of exercise and a strong predictor of health, but little is known about its causal association with rheumatoid arthritis. This study aimed to investigate the causal effect of WP on the developing RA using Mendelian randomization analysis. The genetic variation associated with WP was selected as an instrumental variable from the latest genome-wide association studies. Summary-level data for the outcomes were obtained from the corresponding GWAS. The inverse-variance weighted method was used as the primary MR analysis. The results were further tested using a multivariable MR approach based on Bayesian model averaging. Confounders (BMI, SMK, HBP, TD) with close associations with RA were included in the analysis. An observational study with individual data from UK Biobank was performed to reinforce our findings. The MR results indicated the significant inverse associations of WP with the risk of RA (odds ratio (OR), 0.31; 95% confidence interval (CI), 0.15, 0.62; p = 1.05 × 10 −3). After adjusting for the risk factors, the associations for WP and RA did not change substantially. Observational study results demonstrated the same effect of WP on reducing the risk of RA. The Mendelian randomization analysis and observational study provide evidence suggesting that walking pace is a protective factor for rheumatoid arthritis. Given its simple measurement, walking pace may be a pragmatic target for interventions.
... The AS group showed higher levels of physical activity compared with the RA group in our study. Both groups are known to have lower levels of physical activity than the healthy population, but compared to each other, the AS group is more active in sports activities (Fongen, Halvorsen and Dagfinrud 2013;Peres et al. 2023;Tierney, Fraser and Kennedy 2012;van den Berg et al. 2007). These differences might be due to RA patients not following physical activity recommendations because of a fear of exacerbating pain more than AS patients (Demmelmaier et al. 2018; Luque-Suarez, Martinez-Calderon and Falla 2019; Manning et al. 2012). ...
Objective/Aim
The aim was to compare the levels of physical activity, kinesiophobia, pain catastrophizing, body awareness, and depression in patients with Ankylosing Spondylitis (AS) and Rheumatoid Arthritis (RA) and to explore the associations between these outcomes and disease activity.
Methods
Seventy‐eight patients with AS ( n = 30) and RA ( n = 48) were included. Outcomes were assessed using the International Physical Activity Questionnaire‐Short Form, the Tampa Scale of Kinesiophobia, the Pain Catastrophizing Scale, the Body Awareness Questionnaire, and the Beck Depression Inventory. Disease activity levels were determined using the Bath Ankylosing Spondylitis Disease Activity Index for AS and the Disease Activity Score 28 score for RA.
Results
AS patients were younger, had a higher proportion of men, and were more physically active than RA patients ( p < 0.05). Both groups exhibited high levels of kinesiophobia but low levels of pain catastrophizing, similar body awareness and mild depression scores. Moderate correlations ( r ≥ 0.5) were observed between kinesiophobia and depression, body awareness and pain catastrophizing and depression, and pain catastrophizing and disease activity in AS patients. In RA patients, moderate correlations ( r ≥ 0.5) were found between kinesiophobia and pain catastrophizing.
Conclusion
Addressing physical activity, kinesiophobia, pain catastrophizing, body awareness, and depression is important in managing AS and RA patients. Notably, correlations among outcomes differed between groups, with more significant correlations in AS. Further studies are needed to explore these in greater detail.
... Rheumatoid arthritis (RA) is a chronic inflammatory disorder of unknown etiology [9] that has a prevalence rate of approximately 0.5 to 1% [10]. Rheumatoid arthritis and metabolic syndrome are considered to be diseases with common traits that can increase the risk of cardiovascular disease [11], with previous research showing an association between the two [12]. ...
... Our findings align with another study [16] that evaluated PR patients' adherence to physical activity, a crucial aspect of non-pharmacological care. Individuals with RA tend to exhibit more sedentary behavior and engage in less physical activity compared to healthy individuals. ...
Introduction
Our study aimed to evaluate the integration level of non-pharmacological management (NPM) for rheumatoid arthritis (RA), analyze attitudes, practices, and perceived barriers towards NPM implementation, and identify factors contributing to the underutilization of non-pharmacological treatment in RA.
Material and methods
A descriptive and analytical cross-sectional study was conducted among rheumatologists in Morocco. Rheumatologists received an online questionnaire gathering sociodemographic data, NPM integration level for RA, exploring their attitudes, practices and perceived barriers regarding the integration of NPM for RA, using a Likert scale ranging from 1 to 5. Univariate analyses were conducted to identify risk factors for under-integration of NPM for RA.
Results
Out of 440 questionnaires sent, 132 rheumatologists responded to the survey (mean age of 44 ±12 years, 112 (84.8%) females, median professional experience of 15 years [4.7; 26.3]) with a response rate of 30%. All rheumatologists agreed on the importance of NPM integration into their practice with 130 (98.5%) supporting the necessity of tailored recommendations of NPM of RA for the Moroccan context. Sixty-nine (52.3%) reported a lack of NPM integration for RA. Only 36 (27.3%) consistently provided personalized NPM from RA diagnosis and 47 (35.6%) involved patients in decision-making. Comment perceived barriers included difficulties in organizing multidisciplinary care (122; 92.4%), difficulties with time management in consultation (119; 90.2%), and lack of multidisciplinary team members (116; 87.9%). In univariate analysis, lack of suitable training and lack of knowledge on NPM of RA were risk factors of under-integration of NPM of RA with respectively an odds ratio (OR) of 0.09, 95% CI: 0.01–0.86 and OR of 0.34, 95% CI: 0.15–0.76.
Conclusions
Our study revealed significant insufficiencies in the integration of NPM of RA among Moroccan rheumatologists. Perceived barriers, including insufficient training, lack of knowledge, and infrastructural limitations, hinder effective implementation. Addressing these through tailored education and multidisciplinary collaboration is essential for improving RA management.
... Despite the known benefits of walking, individuals who struggle with OA, RA, and FM are less likely to be physically active than the general population. [11][12][13] Reasons identified for this challenge include patient fear of pain, concerns about efficacy, and perception of disease severity. [14][15][16] When patients are active, walking is among the most common behaviors. ...
Objective
This study investigated the association of perceived neighborhood qualities with likelihood of transit walking, leisure walking, neighborhood walking, and meeting physical activity (PA) recommendations among US adults with arthritis.
Methods
This cross‐sectional study used 2020 National Health Interview Survey data. Included participants were adults who reported with clinician‐diagnosed arthritis and who reported the ability to walk. Exposures of interest were perceived neighborhood attributes. Outcomes were transit walking, leisure walking, neighborhood walking, and meeting PA recommendations. Standardized mean difference percentage (SMD%) was used to assess relationships between exposures and outcomes, with an SMD% >10% resulting in inclusion in final adjusted multivariate logistic regression models for odds of outcomes. All analyses were weighted to account for complex survey methodology.
Results
The analytic sample included 7,322 adults with arthritis. Fully adjusted logistic regression models showed the presence of roads to walk on was associated with meeting PA recommendations (odds ratio [OR] 1.26, 95% confidence interval [CI] 1.07–1.49]). Three attributes were positively associated with transit walking, whereas safety from crime was negatively associated (OR 2.33, 95% CI 1.75–3.10; OR 1.49, 95% CI 1.17–1.91; OR 1.67, 95% CI 1.34–2.08; and OR 0.70, 95% CI 0.53–0.92, respectively). Roads to walk and places to walk and relax were associated with leisure and neighborhood walking (OR 1.46, 95% CI 1.21–1.76; OR 1.56, 95% CI 1.34–1.82; OR 1.58, 95% CI 1.29–1.93; and OR 1.63, 95% CI 1.40–1.90, respectively).
Conclusion
This study identified several neighborhood characteristics associated with higher a likelihood of walking behaviors among adults with arthritis. Factors associated with walking behavior varied by the type of walking. The shared correlates between leisure and neighborhood walking imply they occur in the same setting. Patients with arthritis may benefit from exercise recommendations that are informed by the presence or absence of facilitating infrastructure in their neighborhoods.
... Studies have shown that physical activity levels among RA patients, particularly among those above the age of 55 years, is lower than the level recommended by international guidelines for health-enhancing physical activity and is also lower than that among healthy persons [57]. In this study, although regular physical activity was emphasised in both dietary intervention groups, improvement in physical activity levels were only found among participants assigned to the MedDiet. ...
Objective
To compare the effects a Mediterranean diet (MedDiet) versus the Irish Healthy Eating Guidelines (HEG) on physical function and quality of life in adults with rheumatoid arthritis (RA) in Ireland.
Methods
Forty-four adults with RA were randomised (1:1) to the MedDiet or HEG for 12 weeks. The intervention included three video teleconsultations and two follow-up telephone calls facilitated by a Registered Dietitian (RD). Changes in physical function by Health Assessment Questionnaire- Disability Index (HAQ-DI) and quality of life by Rheumatoid Arthritis Quality of Life Questionnaire (RAQoL) were the primary outcomes measured. Secondary outcomes included changes in dietary adherence, physical activity by Yale Physical Activity survey (YPAS), patient-perceived pain and general health, and anthropometric measures. All measurements were administered at baseline and repeated at 6 and 12 weeks.
Results
Forty participants completed the study. Participants were primarily females (87.5%), mean age was 47.5 ± 10.9 years. At the end of the intervention, participants in the MedDiet group reported significantly better physical function (p = 0.006) and quality of life (p = 0.037) compared to HEG group. From baseline to 12 weeks, physical function significantly improved in both diet groups, MedDiet (0.9 ± 0.5 to 0.5 ± 0.4 units, p < 0.001) and HEG (1.4 ± 0.7 to 1.0 ± 0.6 units, p < 0.001). Quality of life also significantly improved in the MedDiet (10.1 ± 7.5 to 4.0 ± 4.7 units, p < 0.001) and HEG group (11.25 ± 7.2 to 7.9 ± 6.4 units, p = 0.048). Physical activity improved significantly in the MedDiet (56.7 ± 28.6 to 70.6 ± 33.5 points, p = 0.01) but not within the HEG group despite similar recommendations.
Conclusion
Adhering to the MedDiet and Irish Healthy Eating Guidelines resulted in improvements in RA patient-reported outcomes. The changes observed in both diet groups are likely due to the improvement in overall diet quality irrespective of dietary prescription.
Trial registration number
NCT04262505.
... Several studies have consistently shown that individuals with RA also tend to have lower levels of physical activity compared to those without this issue [29,30]. However, multiple studies have consistently found that exercise and increased physical activity are linked to reduced disease activity and systemic inflammation in individuals with RA [31][32][33]. ...
Arthritis is associated with health challenges. Lifestyle traits are believed to influence arthritis development and progression; however, data to support personalized treatment regimens based on holistic lifestyle factors are missing. This study aims to provide a comprehensive list of associations between lifestyle traits and the health status of individuals with arthritis in the Canadian population, using binary logistic regression analysis on data from the Canadian Community Health Survey, which includes 104,359 respondents. Firstly, we explored the association between arthritis and various aspects of health status including self-reported lifestyle factors. Secondly, we examined the associations between self-reported dietary intake and smoking status with general, mental, and oral health, and sleep disturbance among individuals both with and without arthritis. Our analysis revealed that individuals with arthritis reported considerably poorer general, mental, and oral health, and poorer sleep quality compared to those without arthritis. Associations were also found between self-reported dietary intake and various measures of health status in individuals with arthritis. Smoking and exposure to passive smoking were associated not only with arthritis but also with compromised sleep quality and poorer general, mental, and oral health in people with and without arthritis. This study highlights the need for personalized and holistic approaches that may include a combination of dietary interventions, oral health improvements, sleep therapies, and smoking cessation for improved arthritis prevention and care.
... Recommended management of RA includes pharmacological and non-pharmacological treatments with physical activity (PA) being an important component in the nonpharmacological management of RA [3,4]. However, people with RA tend to have low PA levels [5,6] thus improving PA levels in this group is an important part of treatment. ...
Physical activity (PA) is recommended as a key component in the management of people with rheumatoid arthritis (RA). The objective of this study was to examine the feasibility of a physiotherapist led, behaviour change (BC) theory-informed, intervention to promote PA in people with RA who have low levels of current PA. A feasibility randomised trial (ClinicalTrials.gov NCT03644160) of people with RA over 18 years recruited from outpatient rheumatology clinics and classified as insufficiently physically active using the Godin−Shephard Leisure Time Physical Activity Questionnaire. Participants were randomised to intervention group (4 BC physiotherapy sessions in 8 weeks) delivered in person/virtually or control group (PA information leaflet only). Feasibility targets (eligibility, recruitment, and refusal), protocol adherence and acceptability were measured. Health care professionals (HCPs) involved in the study and patients in the intervention and control arms were interviewed to determine acceptability. Descriptive statistics were used to analyse the data with SPSS (v27) with interviews analysed using content analysis using NVivo (v14). Three hundred and twenty participants were identified as potentially eligible, with n = 183 (57%) eligible to participate, of which n = 58 (32%) consented to participate. The recruitment rate was 6.4 per month. Due to the impact of COVID-19 on the study, recruitment took place over two separate phases in 2020 and 2021. Of the 25 participants completing the full study, 23 were female (mean age 60 years (SD 11.5)), with n = 11 allocated to intervention group and n = 14 to control. Intervention group participants completed 100% of sessions 1 & 2, 88% of session 3 and 81% of session 4. The study design and intervention were acceptable overall to participants, with enhancements suggested. The PIPPRA study to improve promote physical activity in people with RA who have low PA levels was feasible, acceptable and safe. Despite the impact of COVID-19 on the recruitment and retention of patients, the study provides preliminary evidence that this physiotherapist led BC intervention is feasible and a full definitive intervention should be undertaken. Health care professionals involved in the study delivery and the patient participants described a number of positive aspects to the study with some suggestions to enhance the design. These findings hence inform the design of a future efficacy-focused clinical trial.
... Exercise, being a subset of physical activity [4], is a cornerstone of treatment for symptoms among people with RA [5,6], with current rheumatology guidelines recommending exercise as an integral management of people with RA [7,8]. Benefits of participation in regular exercise for people with RA include improvements in cardiovascular health, muscle strength and functional ability, reduced pain and fatigue, in addition to improvements in health-related quality of life [9][10][11]. ...
Objective
The purpose of this study was to explore the experiences of people with RA of participating in an exercise intervention to improve their sleep.
Methods
Using a qualitative descriptive design, semi-structured face-to-face interviews were conducted with 12 people with RA who had completed an 8-week walking-based exercise intervention to improve their total sleep time, sleep quality and sleep disturbance. Data were analysed using thematic analysis.
Results
Four themes were generated: positive impact of exercise on participants’ sleep (‘I really didn’t think any type of exercise would help me sleep better, if I’m honest’); positive experiences of the exercise intervention (‘I learnt so much regarding walking that I didn’t even think about’); clear mental health benefits (‘If you don’t sleep well then it will have a knock-on effect to your mental health’); and achieving empowerment and ownership when exercising (‘I feel empowered now and confident that I’m not doing harm to myself’).
Conclusion
The findings demonstrated that participants had not expected exercise to improve their sleep. Although there is a growing consensus that exercise will benefit sleep and mitigate some disease symptoms, research is severely lacking in people with RA.
... Rheumatoid Arthritis (RA) is a chronic inflammatory autoimmune condition, characterised by high levels of pain and fatigue [1,2]. Consequently, people with RA frequently report low levels of physical activity (PA), with a significant proportion of daily life engaged in sedentary behaviours (SB) [3][4][5]. PA is defined as any bodily movement produced by skeletal muscles that leads to an energy expenditure beyond the resting rate, and SB is defined as any waking activity expending energy ≤ 1.5 metabolic equivalents (METs) whilst in a sitting/reclining/lying posture [6]. In people with RA, participating in PA has shown reductions in disease activity and markers of systemic inflammation, and improvements in functional ability, pain, fatigue, depression and anxiety [7][8][9][10][11]. ...
Background
Lifestyle physical activity (PA) is defined as any type of PA undertaken as part of daily life. It can include engagement in activities of daily living (i.e., household chores, gardening, walking to work), incidental PA, walking and/or reducing sedentary or sitting behaviours (SB). Regular PA is recommended for people with Rheumatoid Arthritis (RA) to reduce disease activity and systemic inflammation, as well as to improve patient- and clinician-important health outcomes. However, there is no summarised evidence of the effectiveness of interventions specifically targeting lifestyle PA and SB in this population. The aims of this systematic review with meta-analysis were to evaluate interventions targeting lifestyle PA and/or SB on 1) disease activity; 2) PA, SB and 3) patient- and clinician-important outcomes in people with RA.
Methods
Eight databases [Medline, Cochrane Library CENTRAL, Web of Science, PsychINFO, Cumulative Index to Nursing & Allied Health Literature, Scopus, Excerpta Medica database and Physiotherapy Evidence Database] were searched from inception-August 2022. Inclusion criteria required interventions to target lifestyle PA and/or SB, conducted in adults with RA, assessing patient- and/or clinician-important outcomes.
Results
Of 880 relevant articles, 16 interventions met the inclusion criteria. Meta-analyses showed statistically significant effects of interventions on disease activity (standardised mean difference = -0.12 (95% confidence interval = -0.23 to -0.01, I² = 6%, z = 2.19, p = .03), moderate-to-vigorous PA, light/leisure PA, steps, functional ability, and fatigue. Whereas, no intervention effects were visualised for total PA, pain, anxiety or quality of life.
Conclusions
Lifestyle PA interventions led to increased PA, reductions in SB and improvements in disease activity and other patient- and/or clinician-important health outcomes in people with RA. Future interventions should be less heterogenous in content, structure, focus and outcome measures used to aid understanding of the most effective intervention components for improving health. More SB interventions are needed to determine their effectiveness at producing clinical benefits.
... It is alarming to note that, despite the huge benefits of exercise, physical activity participation is low in RA patients and lower than the recommended level required to maintain a healthy lifestyle. 36 Interestingly, RA patients' body composition improved after participation in a short-term bout of an exercise intervention. 29 Similarly, a once-a-week supervised exercise intervention elicited positive gains in body composition in RA patients. ...
Background
In rheumatoid arthritis (RA) patients, an adverse change in body composition, which usually results in muscle wasting and increased fat mass, is high, contributing to increased functional disability. There are indications that resistance and dynamic exercise interventions could improve body composition and functional capacity in RA patients and should be recommended to manage RA.
Purpose
The scoping literature review aimed to analyze available literature about the effects of exercise on body composition in RA patients. Secondly to identify the contribution of exercise to improve physical function in RA patients, thirdly to identify gaps in the literature about physical exercises and health outcomes in RA patients, and make recommendations for future research.
Methods
A scoping literature review design was employed following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines. A systematic search of three databases (PubMed, CINAHL, and Scopus) for studies published from 2012 to 2022 was conducted. The words searched include “exercise intervention” AND “body fat” OR “muscle wasting” OR “lean body mass” AND “functional ability” OR “health assessments”. The search strategy was limited to studies published in English on RA patients and exercise interventions.
Results
This search yielded 2693 studies, of which 11 met the inclusion criteria and were selected for review. The findings showed significant, positive effects of exercise interventions on RA patients’ body composition and functional capacity, with exercise being highly beneficial. It is evident that high-intensity resistance exercise, as a stand-alone intervention, is feasible and safe for managing RA conditions.
Conclusion
Physical exercises, following scientific guidelines, should be included as an integrated approach to managing RA conditions.
... Healthy behaviours such as achieving sufficient PA is a challenge for most people but may be even more challenging for people with inflammatory joint diseases (IJDs), as IJDs are characterised by functional limitations, pain and fatigue. 1 2 PA defined as 'any bodily movement produced by skeletal muscles that result in energy expenditure' 3 is safe and can improve disease activity, pain, fatigue, quality of life and sleep in people with IJDs. 4 5 Despite these beneficial health outcomes, people with IJDs have lower PA levels than their healthier counterparts and many do not meet the required PA recommendations. [6][7][8][9][10] Self-monitoring of PA has the potential to contribute to successful behaviour change in PA interventions in different populations, including people with IJDs. [11][12][13][14] PA can be monitored in different ways, although ...
Objectives
Self-monitoring of physical activity (PA) has the potential to contribute to successful behaviour change in PA interventions in different populations, including people with inflammatory joint diseases (IJDs). The objectives of this study were to describe the use and knowledge of self-report-based and device-based PA measures in people with IJDs in four European countries, and to explore if the use of such devices, sociodemographic or disease-related variables were associated with adherence to the recommendations of at least 150 min of moderate to vigorous PA per week.
Setting
Cross-sectional survey, performed in 2015–2016.
Participants
People with IJDs in Belgium, Denmark, Ireland and Sweden.
Primary and secondary outcome measures
Use of self-report and device-based PA measures, receipt of instructions how to use PA measures, confidence in using them, adherence to PA recommendations and associated factors for adherence to PA recommendations.
Results
Of the 1305 respondents answering questions on PA measures, 600 (46%) reported use of any kind of self-report or device-based measures to self-monitor PA. Between country differences of 34%–58% was observed. Six per cent and four per cent received instructions from health professionals on how to use simple and complex devices, respectively. Independent associated factors of fulfilment of recommendations of PA were living in Ireland (OR=84.89, p<0.001) and Sweden (OR=1.68, p=0.017) compared with living in Denmark, not perceiving activity limitations in moderate activities (OR=1.92, p<0.001) and using a device to measure PA (OR=1.56, p<0.001). Those living in Belgium (OR=0.21, p<0.001) were less likely to fulfil recommendations of PA.
Conclusions
Almost half of the participants with IJDs used self-report-based or deviced-based PA measures, although few used wearable devices regularly. The results indicate that participants meeting public PA health guidelines were engaged in self-monitoring of PA.
... Furthermore, foot symptoms associated with RA can cause biomechanical alterations, as well as a lack of joint proprioception. The level of physical activity may also be lower among individuals with RA when compared with healthy controls [10,12,13]. Consequently, patients with RA present a higher risk of falls, showing decreased postural stability and difficulty maintaining postural control during everyday activities [11]. ...
The main objective of the present study was to determine the relationship between kinesiophobia and pain (general and foot pain), foot function, and disease activity in patients with rheumatoid arthritis (RA). A total of 124 interviews were carried out with participants with RA. Participants were recruited from the Hospital Universitario Virgen de las Nieves de Granada in Spain. Interviews took place in January 2021. Participants completed the following questionnaires during an appointment with their rheumatologist: Foot Function Index (FFI), Tampa Scale for Kinesiophobia (TSK-11), and the Visual Analogue Scale Pain foot (VAS Pain). Furthermore, the Simplified Disease Activity Index (SDAI) was used to measure disease activity. Of the 124 participants, 73% were women, and their mean age was 59.44 years (SD 11.26 years). In the statistical analysis, positive linear correlations (p < 0.001) were obtained between the variables TSK-11 and VAS (related to general pain or foot pain) and FFI (in its three subscales). Additionally, a negative correlation between the TSK-11 and the educational background was shown. This study provided information about the relationship between foot function and pain with different levels of kinesiophobia in patients with RA. Additionally, the educational background of the patient was considered a predictor of whether or not a patient suffered from kinesiophobia.
... 18,19 Furthermore, different BMI cut-offs have been suggested for patients with RA, reduced by 2 kg/m 2 for each weight status tier, to better depict the changes in body composition due to RC. 20 RC appears to be the result of several synergistic mechanisms, including an excessive production of inflammatory cytokines and hypermetabolism. 21 Hypermetabolism in particular is the result of increased protein degradation and decreased muscle mass, 13,21 which, in the presence of low physical activity levels and sedentary lifestyle, result to an increased accumulation of FM, [22][23][24] further propelling inflammation. 25 Moreover, the underlying testosterone deficiency and hypogonadism, paired with the observed decrease in the production of insulin and the intake of GC medication, pave the way for the development of RC. 21,22,[26][27][28] The limited available studies on the effect of pharmacotherapy on RC suggest that the intake of corticosteroids (CG) and tumour necrosis factor α (TNF-α) inhibitors tend to increase FM accumulation, whereas the use of tocilizumab (TCZ) might induce a gain in lean body mass (LBM). ...
Cachexia is an early result of rheumatoid arthritis (RA) (rheumatoid cachexia, RC), characterised mainly by involuntary loss of fat-free mass. RC is apparent in 1-67% of patients with RA, depending on the diagnostic criteria applied and the method used for the assessment of body composition. RC is associated with increased inflammation and disability, lower health perception, and greater mortality risk. These changes in body composition are driven by the inflammation process, the low levels of physical activity, the underlying testosterone deficiency and hypogonadism, and the pharmacotherapy required for RA. Chronic inflammation enhances resting energy expenditure as a response to stress, inducing an energy deficit, further propelling protein turnover. The use of corticosteroids and tumour necrosis factor α (TNF-α) inhibitors tend to increase fat accumulation, whereas other disease-modifying antirheumatic drugs (DMARDs) appear to induce increments in fat-free mass. The present review presents all information regarding the prevalence of RC, diagnostic criteria, and comorbidities, as well as the effects of pharmacotherapy and medical nutrition therapy on body composition of patients with RA.
... 9,[16][17][18] Despite this, people with RA are less physically active than the general population. 19,20 Fear of acute post-exercise pain and disease aggravation (i.e., a flare-up) may partially explain this. 10,21 Therefore, their concerns regarding pain and disease activity post-exercise need to be addressed. ...
Background
Exercise is advocated in the treatment of rheumatoid arthritis (RA). However, uncertainty around the acute effects of exercise on pain and inflammation may be stopping people with RA from exercising more regularly.
Objectives
To determine the acute effects of exercise on pain symptoms, clinical inflammatory markers, and inflammatory cytokines in RA.
Design
A systematic review of the literature.
Data sources and methods
Five databases were searched (PubMed, Cochrane Library, CINAHL, Scopus and SPORTDiscus); inclusion criteria were studies with acute exercise, a definite diagnosis of RA and disease characteristics assessed by clinical function (i.e., disease activity score, health assessment questionnaire and self-reported pain), clinical markers associated with inflammation (i.e., c-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)), and inflammatory cytokines (i.e., interleukin 6 (IL-6) and tumour necrosis factor alpha (TNF-α)).
Results
From a total of 1544 articles, initial screening and full text assessment left 11 studies meeting the inclusion criteria. A total of 274 people were included in the studies (RA = 186; control = 88). Acute bouts of aerobic, resistance, and combined aerobic and resistance exercise did not appear to exacerbate pain symptoms in people with RA.
Conclusion
Post-exercise responses for pain, clinical inflammatory markers and inflammatory cytokines were not different between people with or without RA. Exercise prescription was variable between studies, which limited between-study comparisons. Therefore, future investigations in people with RA are warranted, which combine different exercise modes and intensities to examine acute effects on pain symptoms and inflammatory markers.
Registration
The PROSPERO international prospective register of systematic reviews – CRD42018091155.
... For adults aged 65 years and older, multicomponent PA focusing on strength training and functional balance is also recommended. Despite the recommendations, those with SpA and RA have been shown to be more sedentary and less physically active than their healthy counterparts [16,17]. ...
Physical activity (PA) is a primary non-pharmacological treatment option for those living with rheumatoid arthritis (RA) and spondyloarthritis (SpA). The aim of this systematic literature review was to summarize and present an updated synthesis of the factors associated with PA in the RA and SpA populations. A tailored search of PubMed (inc. Medline), Web of Science, Embase, APA PsycNET, and Scopus was conducted for research published between 2004 and June 2019. Methodological quality was assessed using The National Institutes of Health (NIH) Quality Assessment Tools for Observational Cohort and Cross-sectional Studies, Case–Control Studies, and Controlled Intervention Studies. Forty RA and eleven SpA articles met the inclusion criteria. Methodological quality was generally fair to good, with two RA studies rated as poor. Correlates are discussed in the sociodemographic, physical, psychological, social, and environmental categories. Environmental factors were not measured in any RA study. In individuals living with RA, consistent positive associations were found between PA and high-density lipoprotein, self-efficacy, and motivation. Consistent negative associations were found for functional disability and fatigue. In individuals with SpA, consistent positive associations were found between PA and quality of life, and consistent negative associations with functional disability. Physical and psychological factors are most consistently related with PA parameters in those living with RA and SpA. Many variables were inconsistently studied and showed indeterminant associations. Studies with prospective designs are needed to further understand the factors associated with PA in these populations, especially in those living with SpA.
... Whether the patients had difficulty performing a certain activity or problems with the duration or intensity of the activity could unfortunately not be determined by our assessments. The effect of inflammatory arthritis on PA has been reported in previous studies on children and adolescents with JIA as well as in adults with rheumatoid arthritis (RA), [32][33][34][35] supporting the findings of our study. We found an association between older age, pain interference, and morning stiffness and nomination of PA. ...
Objective:
To explore quality of life (QOL) using the individualized Patient Generated Index (PGI) in young adults who were diagnosed with JIA in childhood, and examine associations between PGI ratings and standardized health-related outcome measures.
Methods:
Patients (N=79, mean 25.1 ±4.2 yrs, 72% female) completed the PGI and the standardized measures: Health Assessment Questionnaire Disability Index, Medical Outcome Study 12-item Short-Form (SF-12; physical and mental health-related QOL), Brief Pain Inventory Short-Form (pain severity and interference), Hopkins Symptom Checklist-5 and visual analogue scale for fatigue. Information on morning-stiffness, medications, and demographics was also collected. Patients were compared to 79 matched controls.
Results:
The most frequently nominated areas of importance for patients' personally-generated QOL (assessed by PGI) were physical activity (n=38, 48%), work/school (n=31, 39%), fatigue (n=29, 37%) and self-image (n=26, 33%). Nomination of physical activity was associated with older age, more pain interference and morning-stiffness. Nomination of fatigue was associated with current use of disease-modifying antirheumatic drugs, while nomination of self-image was associated with polyarticular course JIA and pain interference. Nomination of work/school was not associated with other factors. Higher PGI scores (indicating better QOL) correlated positively with all SF- 12 subscales except role-emotional and negatively with disability, pain severity, pain interference and morning-stiffness. Compared to controls, patients had more pain, poorer physical health-related QOL and less participation in full-time work or school.
Conclusion:
Physical activity, work/school, fatigue and self-image were frequently nominated areas affecting QOL in young adults with JIA. The PGI included aspects of QOL not covered in standardized measures.
... 5 Studies among persons with RA, however, have typically found lower levels of physical activity than is recommended by existing guidelines. [6][7][8] The use of wearables to self-monitor physical activity may be a promising approach to support people with RA to reach evidenceinformed physical activity recommendations. 9 A wearable is a worn device that tracks movement through sensors or companion smartphone or computer applications. ...
Introduction
Using wearables to self‐monitor physical activity is a promising approach to support arthritis self‐management. Little is known, however, about the context in which ethical issues may be experienced when using a wearable in self‐management. We used a relational ethics lens to better understand how persons with rheumatoid arthritis (RA) experience their use of a wearable as part of a physical activity counselling intervention study involving a physiotherapist (PT).
Methods
Constructivist grounded theory and a relational ethics lens guided the study design. This conceptual framework drew attention to benefits, downsides and tensions experienced in a context of relational settings (micro and macro) in which participants live. Fourteen initial and eleven follow‐up interviews took place with persons with RA in British Columbia, Canada, following participation in a wearable‐enabled intervention study.
Results
We created three main categories, exploring how experiences of benefits, downsides and tensions when using the intervention intertwined with shared moral values placed on self‐control, trustworthiness, independence and productivity: (1) For some, using a wearable helped to ‘do something right’ by taking more control over reaching physical activity goals. Some, however, felt ambivalent, believing both there was nothing more they could do and that they had not done enough to reach their goal; (2) Some participants described how sharing wearable data supported and challenged mutual trustworthiness in their relationship with the PT; (3) For some, using a wearable affirmed or challenged their sense of self‐respect as an independent and productive person.
Conclusion
Participants in this study reported that using a wearable could support and challenge their arthritis self‐management. Constructing moral identity, with qualities of self‐control, trustworthiness, independence and productivity, within the relational settings in which participants live, was integral to ethical issues encountered. This study is a key step to advance understanding of ethical issues of using a wearable as an adjunct for engaging in physical activity from a patient's perspective.
Patient or Public Contribution
Perspectives of persons with arthritis (mostly members of Arthritis Research Canada's Arthritis Patient Advisory Board) were sought to shape the research question and interpretations throughout data analysis.
... Patients with RA commonly experience fatigue and arthralgias (7); consequently, they are less active than healthy adults (8,9). As a result, studies have reported that a large proportion of patients (up to 90%) (10) with radiologic evidence of RA-associated ILD (RA-ILD) do not report respiratory symptoms (11,12). ...
Objective
To identify the incidence, risk factors, and outcomes of rheumatoid arthritis–associated interstitial lung disease (RA‐ILD) and to assess time trends in the incidence and mortality in RA‐ILD.
Methods
We included adult residents of Olmsted County, Minnesota with incident RA between 1999 and 2014. Subjects were followed until death, emigration, or April 30, 2019. ILD was defined as the presence of a radiologist‐defined pattern consistent with ILD on chest computed tomography (CT). When chest CT was absent, the combination of chest radiograph abnormalities compatible with ILD and restrictive pattern on pulmonary function testing was considered consistent with ILD. Potential risk factors included age, sex, smoking, obesity, seropositivity, extraarticular manifestations (EAMs), and medications. For survival analysis, we matched RA‐ILD patients to RA–non‐ILD comparators. The frequency and mortality from clinician‐diagnosed RA‐ILD from 1999 to 2014 was compared against a cohort from 1955 to 1994.
Results
During the 1999–2014 time period, 645 individuals (70% women) had incident RA, were a median age of 55.3 years, and 53% never smoked. Twenty‐two patients had ILD before RA, and 51 (67% women) developed ILD during follow‐up. The 20‐year cumulative incidence of RA‐ILD was 15.3%. Ever‐smoking (hazard ratio [HR] 1.92), age at RA onset (HR 1.89 per 10‐year increase), and severe EAMs (HR 2.29) were associated with incident RA‐ILD. The RA‐ILD cases had higher mortality than their matched RA comparators (HR 2.42). Incidence of RA‐ILD was non‐significantly lower from 1999 to 2014 than from 1955 to1994, but mortality was improved.
Conclusions
RA‐ILD occurs in nearly 1 in 6 patients with RA within 20 years and is associated with shorter survival. Lack of significant change in RA‐ILD incidence over 6 decades deserves further investigation.
... MF, GAP y JM: redacción y edición del manuscrito, aprobación teórica. Se han publicado estudios en los cuales se ha constatado que los pacientes con AR realizan menor AF que los controles 1, 36 . Se presume que este hallazgo estaría en relación con varios factores como el temor a presentar daño articular, aumentar la actividad inflamatoria de la enfermedad así como la falta de información sobre los beneficios de la realización de AF regular 18,26,37 . ...
Introducción: La actividad física (AF) ha recibido un interés creciente como terapia adyuvante para los pacientes con enfermedades reumatológicas. Sin embargo, existe escasa información sobre la AF realizada por los pacientes con artritis reumatoide (AR) de Paraguay.
Objetivo: Analizar la AF de los pacientes con diagnóstico de AR y los factores asociados a la realización de la misma.
Metodología: El estudio fue transversal y los pacientes con AR fueron incluidos de forma consecutiva al momento de su control habitual con su reumatólogo tratante. La AF fue calculada con el GPAQ (Global Physical Activity Questionnaire) y se registraron variables sociodemográficas y clínicas para analizar su relación con la realización de AF.
Resultados: Se incluyó a 187 pacientes, de los cuales el 45,5% no fueron suficientemente activos considerando las recomendaciones de la Organización Mundial de la Salud (OMS). La edad, el sexo y el hipotiroidismo fueron las variables asociadas a la AF.
Conclusión: En nuestro estudio se observó que una proporción importante de pacientes con AR no realizó suficiente AF según las recomendaciones de la OMS. Esto resalta la importancia de analizar los factores implicados en este resultado para lograr superarlos y encontrar estrategias que favorezcan la realización de AF regular.
... Little is currently known about the impact of the pandemic and its response strategy on the physical activity of individuals with RA, a population already characterized by lower levels of physical activity and higher levels of sedentary behaviour than the general population. 26,27 Early evidence suggests lower levels of physical activity in a general population during periods of total lockdown with strict advisory home confinement (e.g., in the United Kingdom), but the same has not been found in areas without a total or a partial lockdown. 28,29 The latter is characterized by closures of schools, restaurants and bars, and cancellation of public meetings without strict home confinement, such as the case in BC. ...
Objectives
This study aimed to explore the impact of the coronavirus disease 2019 (COVID‐19) pandemic on self‐care of individuals living with rheumatoid arthritis (RA).
Methods
Guided by a constructivist, qualitative design, we conducted one‐to‐one in‐depth telephone interviews between March and October 2020 with participants with RA purposively sampled for maximum variation in age, sex and education, who were participating in one of two ongoing randomized‐controlled trials. An inductive, reflexive thematic analysis approach was used.
Results
Twenty‐six participants (aged 27–73 years; 23 females) in British Columbia, Canada were interviewed. We identified three themes: (1) Adapting to maintain self‐care describes how participants took measures to continue self‐care activities while preventing virus transmissions. While spending more time at home, some participants reported improved self‐care. (2) Managing emotions describes resilience‐building strategies such as keeping perspective, positive reframing and avoiding negative thoughts. Participants described both letting go and maintaining a sense of control to accommodate difficulties and emotional responses. (3) Changing communication with health professionals outlined positive experiences of remote consultations with health professionals, particularly if good relationships had been established prepandemic.
Conclusion
The insights gained may inform clinicians and researchers on ways to support the self‐care strategies of individuals with RA and other chronic illnesses during and after the COVID‐19 pandemic. The findings reveal opportunities to further examine remote consultations to optimize patient engagement and care.
Patient or Public Contribution
This project is jointly designed and conducted with patient partners in British Columbia, Canada. Patient partners across the United Kingdom also played in a key role in providing interpretations of themes during data analysis.
... A positive association was found between CRF with step count and MVPA time and, a negative association was found between CRF with sedentary time. These associations are also reported by studies on people who have RA without CVD risks [1,7,8,[33][34][35][36]. ...
Lower cardiorespiratory fitness (CRF) and physical activity (PA) associate with higher cardiovascular disease (CVD) risk, but the relationship between CRF and PA in people who have rheumatoid arthritis (RA) at an increased CVD risk (CVD-RA) is not known. The objectives of this study were to determine the levels of CRF and PA in people who have CVD-RA and to investigate the association of CRF with PA in people who have CVD-RA. A total of 24 consecutive patients (19 women) with CVD-RA (> 4% for 10-year risk of fatal CVD development as calculated using the Systematic Coronary Risk Evaluation)—were included in the study. CRF was assessed with a graded maximal exercise test determining maximal oxygen uptake (VO2max). PA was assessed with an accelerometer to determine the amount of step count, sedentary, light and moderate-to-vigorous physical activity (MVPA) minutes per day. Mean age of patients was 65.3 ± 8.3 years. CRF mean values were 16.3 ± 1.2 ml·kg−1 min−1, mean step count per day was 6033 ± 2256, and the mean MVPA time was 16.7 min per day. Significant positive associations were found for CRF with step count (B = 0.001, P = 0.01) and MVPA time (B = 0.15, P = 0.02); a negative association was found for CRF with sedentary time (B = − 0.02, P = 0.03). CRF is low and is associated with step count, sedentary time and MVPA time in people who have RA at an increased CVD risk.
... Mesure de l'activité de course (spontaneous wheel running) L'action de courir dans une roue est un comportement naturel pour un rongeur [90]. La réduction de l'activité de course en condition de douleur chronique (inflammatoire, neuropathique, migraineuse [88,[91][92][93][94][95][96][97]) s'apparenterait à une réduction d'activité qui peut apparaître chez le patient [98,99] et donc être le reflet d'une altération de la qualité de vie. Les difficultés principales de ce test résident dans la difficulté d'obtenir une activité de base stable (il faut en général plusieurs semaines de tests pour l'obtenir), compte tenu de la variabilité entre les rongeurs et de l'effet propre de l'exercice prolongé sur la douleur [100][101][102]. ...
... INTRODUCTION Good-quality evidence has accumulated over the past two decades on the effectiveness of aerobic and muscle-strengthening physical activity (PA) to reduce disease-related symptoms and comorbidity risk in people with rheumatoid arthritis (RA). [1][2][3] Since PA is effective and safe, it is recommended to be included in the standard care of patients with RA. 4 Nevertheless, PA levels remain low in people with RA [5][6][7] and a number of factors challenge the participation in and maintenance of regular PA. Such factors include, for example, time and cost, pain, fatigue and activity limitation, poor selfregulation skills and low autonomous motivation, as well as a lack of knowledge and reluctance on the part of health professionals (HPs) to implement evidence-based PA guidelines. ...
Background
Physical activity (PA) in rheumatoid arthritis (RA) is considered a cornerstone in the treatment. To highlight aspects involved in supporting a positive PA behaviour, it is important to understand the patients’ perceptions of the phenomenon.
Objective
The aim of this qualitative meta-synthesis was to explore and synthesise patient perceptions of PA in RA.
Methods
A purposeful search was conducted across three online databases (PubMed, CINAHL and Web of Science). The methodological quality of the included studies was appraised, and data were extracted and analysed using an interpretive inductive thematic synthesis.
Results
Fifteen studies met the inclusion criteria and were included. PA was identified as an agile lifelong behaviour, with one main theme: The disease as a persistent catalyst for or against PA illustrating how the constant presence of the disease itself underlies the entire process of a life with or without regular PA. Seven subthemes: ‘considering aggravated symptoms’, ‘acknowledging the impact on health’, ‘becoming empowered and taking action’, ‘keeping informed to increase awareness’, ‘creating body awareness’, ‘dealing with social support’ and ‘feeling satisfied with circumstances and achievements’ were interpreted as facilitators and/or challenges.
Conclusion
This synthesis has identified PA as an agile lifelong behaviour in which the disease pervades all aspects of an individuals’ perception of PA. Placed in a theoretical context, our findings outline a model for tailoring PA support to the drivers and determinants of a certain individual, which will improve clinical practice for the benefit of both health professionals and patients with RA.
... Physical activity is recommended as a crucial component in managing arthritis well (1)(2)(3). Despite this recommendation, participation in physical activity among persons with arthritis often does not meet recommendations (4)(5)(6)(7). Current evidence suggests that using consumer wearable devices (e.g., pedometers, fitness bands) could support persons with chronic illness to be physically active (8)(9)(10)(11)(12). ...
Objective
We aimed to broaden understanding of the perspectives of persons with arthritis on their use of wearables to self‐monitor physical activity, through a synthesis of evidence from qualitative studies.
Methods
We conducted a systematic search of 5 databases (including Medline, CINAHL, and Embase) from inception to 2018. Eligible studies qualitatively examined the use of wearables from the perspectives of persons with arthritis. All relevant data were extracted and coded inductively in a thematic synthesis.
Results
Of 4,358 records retrieved, 7 articles were included. Participants used a wearable during research participation in 3 studies and as part of usual self‐management in 2 studies. In remaining studies, participants were shown a prototype they did not use. Themes identified were: 1) the potential to change dynamics in patient–health professional communication: articles reported a common opinion that sharing wearable data could possibly enable patients to improve communication with health professionals; 2) wearable‐enabled self‐awareness, whether a benefit or downside: there was agreement that wearables could increase self‐awareness of physical activity levels, but perspectives were mixed on whether this increased self‐awareness motivated more physical activity; 3) designing a wearable for everyday life: participants generally felt that the technology was not obtrusive in their everyday lives, but certain prototypes may possibly embarrass or stigmatize persons with arthritis.
Conclusion
Themes hint toward an ethical dimension, as participants perceive that their use of wearables may positively or negatively influence their capacity to shape their everyday self‐management. We suggest ethical questions pertinent to the use of wearables in arthritis self‐management for further exploration.
... people with airways disease) [28] or in cohorts with impaired mobility (i.e. elderly individuals +/-those with underlying musculoskeletal disorders) [29]. ...
Purpose:
The aim of this pilot validation study was to determine the accuracy of a smartphone (iPhone®) pedometer in adults with and without asthma.
Methods
: Ten adults with asthma and ten healthy controls underwent clinical assessment prior to completing two separate trials.
Phase 1.
standardised treadmill and self-paced walking tests. Total steps were recorded via: (i) Yamax Digiwalker™ SW800 pedometer positioned on the waistband, (ii) iPhone® pedometer positioned on the upper body, (iii) iPhone® pedometer positioned on the lower body and evaluated against a video-verified manual step-count.
Phase 2.
step-count was evaluated over seven-days during habitual free-living conditions via Yamax Digiwalker™ SW800 and iPhone® pedometers.
Results:
During treadmill walking, the iPhone® positioned on the lower body correlated strongly (r = 0.96) and produced the highest level of agreement (mean bias: -11 steps, LOA: -43 to 21 steps) in comparison to video-verified manual step-count. During self-paced walking, all devices provided an excellent step-count estimate. During free-living conditions, no difference was observed between the Yamax Digiwalker™ SW800 pedometer and iPhone® (P = 0.10) and a strong correlation (r = 0.94) and acceptable agreement (mean bias: -343, LOA: -1963 to 1276 steps) was observed.
Conclusion:
Our findings indicate that an in-built iPhone® pedometer offers a practical approach to physical activity assessment in adults with and without asthma. Future research is now required to further validate the precision of this approach and evaluate the efficacy and effectiveness of smartphone pedometers to monitor and promote physical activity when employed during medical consultation and/or clinical research trials.
... With sleep being identified as a major concern for people with RA, and disturbed sleep and fatigue known to affect up to 70% in this population [8], health professionals (HPs) should be concerned with the effect low TST and poor sleep quality has on HRQoL. Low TST and poor sleep quality, in addition to their effect on mental and physical health [9,10], may lead to people with RA being less active [11]. Therefore, aiming to increase TST and improving sleep quality through exercise, may be a health promotion strategy that is feasible and safe for this population. ...
Current rheumatology guidelines recommend exercise as a key component in the management of people with RA, however, what is lacking is evidence on its impact on sleep. Objective is to assess the feasibility of a walking-based intervention on TST, sleep quality, and sleep disturbance and to generate potential effect size estimates for a main trial. Participants were recruited at weekly rheumatology clinics and through social media. Patients with RA were randomized to a walking-based intervention consisting of 28 sessions, spread over 8 weeks (2–5 times/week), with 1 per week being supervised by a physiotherapist, or to a control group who received verbal and written advice on the benefits of exercise. Primary outcomes were recruitment, retention, protocol adherence and participant experience. The study protocol was published and registered in ClinicalTrials.gov NCT03140995. One hundred and one (101) people were identified through clinics, 36 through social media. Of these, 24 met the eligibility criteria, with 20 randomized (18% recruitment; 100% female; mean age 57 (SD 7.3 years). Ten intervention participants (100%) and eight control participants (80%) completed final assessments, with both groups equivalent for all variables at baseline. Participants in the intervention group completed 87.5% of supervised sessions and 93% of unsupervised sessions. No serious adverse events were related to the intervention. Pittsburgh Sleep Quality Index global score showed a significant mean improvement between the exercise group-6.6 (SD 3.3) compared to the control group-0.25 (SD 1.1) (p = 0.012); Intervention was feasible, safe and highly acceptable to study participants, with those participants in the exercise group reporting improvements in sleep duration and sleep quality compared to the control group. Based on these findings, a fully powered randomized trial is recommended. Trial registration number: ClinicalTrials.gov Identifier: NCT03140995 (April 25th, 2017)
... These are all different examples on how the current pandemic can encourage less physical activity and more sedentary behaviour in RA, a population that is already characterised by lower levels of physical activity and higher levels of sedentary behaviour. 17,18,32 Since the start of the pandemic, there has been a plethora of advice and recommendations readily available in the news and online, suggesting ways in which people can stay physically active during the pandemic and imposed "lockdown" restrictions. For example, social media has seen an exponential growth in recommendations and suggestions for home-based exercise, which can be carried out during the lockdown. ...
In response to the COVID-19 pandemic, many countries have adopted community containment to manage COVID-19. These measures to reduce human contact, such as social distancing, are deemed necessary to contain the spread of the virus and protect those at increased risk of developing complications following infection with COVID-19. People with rheumatoid arthritis (RA) are advised to adhere to even more stringent restrictions compared to the general population, and avoid any social contact with people outside their household. This social isolation combined with the anxiety and stress associated with the pandemic, is likely to particularly have an impact on mental health and psychological wellbeing in people with RA. Increasing physical activity and reducing sedentary behaviour can improve mental health and psychological wellbeing in RA. However, COVID-19 restrictions make it more difficult for people with RA to be physically active and facilitate a more sedentary lifestyle. Therefore, guidance is necessary for people with RA to adopt a healthy lifestyle within the constraints of COVID-19 restrictions to support their mental health and psychological wellbeing during and after the COVID-19 pandemic.
... Physical activity reduces the risk of these comorbidities in the general population [7], and there is some evidence that it might also be an effective treatment for patients with RA [8,9]. It is well known that a large number of patients with RA have a sedentary lifestyle and are less active than their healthy counterparts [10]. Large population-based studies have found a prevalence of health-enhancing physical activity ranging from 20 to 70% in people with chronic inflammatory arthritis [11][12][13], depending on the methodology used and the country investigated. ...
Background
A large number of patients with RA do not adhere to the recommended levels of physical activity to enhance health. According to EULAR recommendations, physical activity should be part of standard care in people with rheumatic diseases. There have been few larger studies on maintenance of physical activity over longer periods of time. The aim was to study self-reported physical activity levels over 7 years in patients with established rheumatoid arthritis (RA). In addition, to determine variables associated with maintenance or change of physical activity behavior.
Methods
Questionnaires were sent to the BARFOT cohort in 2010 ( n = 1525) and in 2017 ( n = 1046), and 950 patients responded to both questionnaires. Patients were dichotomized according to meeting MVPA recommendations (physically active at a moderate level ≥ 150 min/week or at an intense level ≥ 75 min/week) or not. Body mass index, smoking habits, tender joint count (TJC), swollen joint count (SJC), Patient Global Assessment (PatGA), pain intensity and distribution, fatigue, physical function (HAQ), health-related quality of life (EQ. 5D), comorbidities, and medical treatment were assessed. We used logistic regression analysis to study variables associated with maintenance and/or change of MVPA behavior.
Results
Forty-one per cent ( n = 389) of the patients met MVPA recommendations on both occasions. Patients who met MVPA recommendations over 7 years were younger and a higher proportion were never-smokers. There was a negative association with being overweight or obese, having cardiovascular or pulmonary diseases, pain, fatigue, and physical function, whereas there was a positive association between QoL and maintaining MVPA recommendations. Similar factors were positively associated with a deterioration in physical activity level over time.
Conclusions
Maintenance of physical activity over a long period of time is challenging for patients with established RA. Reports of high quality of life supported maintenance of physical activity while disease related and unhealthy lifestyle factors had a negative effect. Health professionals should consider the patient’s standpoint when encouraging maintenance of physical activity, preferably using coordinated lifestyle interventions.
... 1 Despite the strong evidence for PA, most people with chronic disability do not reach and/or maintain recommended PA levels. [2][3][4][5][6] Supporting not only the adoption of healthy PA behaviors but also their maintenance among patients with chronic disability is an important, yet challenging, task for physical therapists. 7,8 A few intervention studies to support PA maintenance in people with rheumatoid arthritis (RA) have been reported. ...
Objective:
A few studies with a qualitative design have addressed physical activity (PA) maintenance in people with rheumatoid arthritis (RA), but none of them focused specifically on maintenance of PA according to public health recommendations. The purpose of this study was to describe perceptions of PA maintenance during the second year of an outsourced 2-year support program among people with RA.
Methods:
For this descriptive design with a qualitative inductive approach, semistructured interviews were conducted with 18 participants with RA (3 men and 15 women). Variation in age, disease duration, activity limitation, pain, levels of PA, and PA maintenance was targeted through strategic sampling. Qualitative content analysis was used, and a pattern of theme, subthemes, and categories was constructed based on the participants' perceptions of PA maintenance.
Results:
A main overarching theme, "A necessary investment in future health"-with 3 subthemes of dedication, awareness, and affinity-were identified as participants' perceptions of PA maintenance. Eight categories further described are a changed mindset, habits, commitments, monitoring, insights in PA, health gains, social support, and PA context.
Conclusions:
PA according to public health recommendations was perceived as a true investment in future health and wellness requiring dedication, awareness, and affinity. To promote PA maintenance, physical therapists working with people with chronic conditions should consider strengthening these prerequisites by targeting patients' negative attitudes to PA, supporting their creation of PA habits to incorporate in daily routines, introducing monitoring of PA intensity, supporting development of PA self-regulation skills, and providing suitable gym facilities with the possibility of peer support.
... In their study, Margiotta et al. investigated the physical activity level in 93 SLE patients and reported that 60 % of them didn't meet the WHO recommendations for physical activity [22]. ...
Background Patients with rheumatic disease are assumed to have low muscle performance, but few studies have been performed to prove this.
Objective To investigate and compare muscle performance in rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) patients and detect its correlation with disease activity, physical function level and quality of life.
Patients and Methods Fifty RA patients, 50 SLE patients and 50 healthy controls were recruited for this observational, cross-sectional study. Muscle performance tests for the upper and lower limbs and the fatigue severity score were recorded. Assessments of the physical activity level using the frequency intensity time index and quality of life using the SF36 questionnaire were performed. The study was conducted over 4 months from January to April 2019.
Results SLE patients showed better results of muscle performance than RA patients; however, both had lower results as compared to control. Disease activity was correlated to muscle performance tests in both diseases, except for the 30-second chair stand test in SLE (p=0.247). All domains of SF36 had a significant correlation with the performance tests in SLE (p≤0.05); however, only domains of physical function correlated with the tests in the RA group.
Conclusion RA patients tend to have a lower muscle performance and physical activity level as compared to SLE patients and control.
... It has been demonstrated that aerobic and muscle strengthening exercise increases physical function and decreases pain, fatigue, disease activity and disability [15,[17][18][19][20]. Therefore, it has been proposed that exercise should be included in the routine management of RA [21][22][23][24]. However, the amount of exercise performed among patients with RA is lower than the level recommended by international guidelines [25,26]. This reduced level of physical activity among RA patients is often due to the misconception that exercise may further damage the joints [18,[27][28][29]. ...
Objectives:
RA patients often present with low muscle mass and decreased strength. Quantitative MRI offers a non-invasive measurement of muscle status. This study assessed whether MRI-based measurements of T2, fat fraction, diffusion tensor imaging and muscle volume can detect differences between the thigh muscles of RA patients and healthy controls, and assessed the muscle phenotype of different disease stages.
Methods:
Thirty-nine RA patients (13 'new RA'-newly diagnosed, treatment naïve, 13 'active RA'-persistent DAS28 >3.2 for >1 year, 13 'remission RA'-persistent DAS28 <2.6 for >1 year) and 13 age and gender directly matched healthy controls had an MRI scan of their dominant thigh. All participants had knee extension and flexion torque and grip strength measured.
Results:
MRI T2 and fat fraction were higher in the three groups of RA patients compared with healthy controls in the thigh muscles. There were no clinically meaningful differences in the mean diffusivity. The muscle volume, handgrip strength, knee extension and flexion were lower in all three groups of RA patients compared with healthy controls.
Conclusion:
Quantitative MRI and muscle strength measurements can potentially detect differences within the muscles between RA patients and healthy controls. These differences may be seen in RA patients who are yet to start treatment, those with persistent active disease, and those who were in clinical remission. This suggests that the muscles in RA patients are affected in the early stages of the disease and that signs of muscle pathology and muscle weakness are still observed in clinical remission.
... people with airways disease) (28) or in cohorts with impaired mobility (i.e. elderly individuals and/or those with underlying musculoskeletal disorders) (29). ...
Introduction: Regular physical activity and structured exercise are often reported to be associated with improved asthma control - however the majority of published evidence is limited by short-term studies employing subjective measures of assessment (i.e. self-report / questionnaires). Modern smartphones typically include built-in activity sensors (i.e. possess the capability to monitor daily step-count) and thus may offer a cost-effective and pragmatic solution to the assessment of physical activity in clinical practice and/or research trials. The primary aim of this proof-of-concept study was therefore to evaluate the validity of the iPhone® (Apple Inc, USA) step-counter in adults with asthma and healthy controls.
Methods: The study was conducted as a cross-sectional laboratory based-trial. Ten healthy adults with no prior history of respiratory disease and ten adults with a prior physician diagnosis of asthma were enrolled. All completed baseline clinical assessment followed by a standardised walking treadmill challenge consisting of 3 x 3-minute stages at pre-determined speeds: 2.5kph, 5.0kph and 7.5kph. Steps were recorded using the following devices: (i) Yamax Digiwalker™ SW-200 Pedometer (Yamax, UK), (ii) iPhone® step-counter (upper body arm-band), (iii) iPhone® step-counter (lower body trouser pocket) - and evaluated against a video-verified manual step-count (i.e. gold-standard comparator) conducted by the investigator (CR).
Results: No difference was observed in manual total step-count between individuals with asthma (1018 steps) and healthy controls (1038 steps) (P=0.44). The iPhone® step-counter (both upper and lower body) provided close agreement with video-verified manual step-count, and importantly, outperformed the Yamax Digiwalker® SW-200 Pedometer across the majority of test stages. Specifically, the iPhone® (lower body) correlated strongly (r = 0.96; P<0.006) and produced the highest level of agreement with video-verified total step-count (mean bias: -11; limits of agreement: -43 to 21) (Table 1).
Conclusion: Our findings indicate that the iPhone® provides an accurate estimate of step-count in adults with asthma and healthy controls completing a standardised laboratory-based treadmill test. Prior to implementation, further research is required to determine the validity and reliability of this approach during daily active / free living conditions.
... Both prospective and experimental studies indicate higher levels of PA engagement to lead to improvements in inflammatory disease activity, physical function, CVD risk, and psychological health [4][5][6][7]. However, research suggests that people living with RA participate in very low levels of PA, especially at the intensity required to accrue health benefits-that is, moderateto-vigorous PA (MVPA; ≥3 metabolic equivalents) [8,9]. Common barriers to PA reported by RA patients are pain, fatigue, and fear of causing further joint damage [10], despite conclusive evidence that Testing a self-determination theory-based process model of physical activity behavior change in rheumatoid arthritis: results of a randomized controlled trial Sally A. M. Fenton, 1,2, Jet JCS Veldhuijzen van Zanten, 1,2 George S. Metsios, 2,3 Peter C. Rouse,4 Chen-an Yu, 1 Nikos Ntoumanis, 5 George D. Kitas, 1,2 Joan L. Duda 1 PA is safe in this population [11]. ...
Physical inactivity is prevalent in rheumatoid arthritis (RA) patients, increasing the risk of poor physical health and compromised well-being. Interventions are therefore required to support physical activity (PA) behavior change in this population. This study examined whether a self-determination theory (SDT) based exercise intervention for people with RA, increased autonomous motivation for PA and in turn, moderate-to-vigorous PA (MVPA) and subjective vitality RA patients (n = 115) were randomized to a 3-month SDT-based psychological intervention + RA-tailored exercise program (experimental group, n = 59) or a RA-tailored exercise program only (control group, n = 56). During the program, the SDT-based intervention group received one-on-one consultations with a PA advisor trained in delivering strategies to promote autonomous motivation for PA. Well-established questionnaires assessed autonomous and controlled motivation for PA, MVPA (min/week), and subjective vitality at baseline (T1) and 3 months (T2). Path analysis examined the hypothesized theoretical process model. The model demonstrated an excellent fit to the data (n = 70, χ2 (26) = 28.69, p = .33, comparative fit index = 0.99, root square mean error of approximation = 0.04). The intervention corresponded to higher autonomous motivation and lower controlled motivation for PA at T2, after controlling for T1 autonomous and controlled motivation. In turn, changes in autonomous motivation from T1 to T2 significantly positively predicted changes in MVPA and subjective vitality. Results suggest an SDT based psychological intervention comprising autonomy-supportive strategies for PA predicted greater reported autonomous reasons for PA in RA patients participating in a tailored 3-month exercise program. Increased autonomous motivation linked to increased engagement in MVPA and feelings of vitality in these patients.
This cross-sectional study investigated the factors affecting pain intensity among Korean women with rheumatoid arthritis (RA) (n = 246). Data included pain site and intensity, physical function, fatigue, medication attitudes, and learned helplessness (LH) from patient self-report, and Disease Activity Score 28 (DAS28) from chart review. The overall pain intensity was 3.59 out of 10, with a median of 3. The mean number of painful joints was 8.4, with the most commonly reported painful joint groups being the fingers, wrists, and knees. Higher DAS28, impaired physical function, eight or more painful joints, higher levels of fatigue, and higher levels of LH were significantly associated with pain intensity. Our results suggest that pain in women with RA is closely associated with cognitive or psychological variables such as fatigue and LH in addition to inflammation itself. For improved pain management, patients with RA should receive regular counseling to address their feelings of LH and fatigue.
Objectives
The overall aim of the current study was to quantify physical activity levels in inflammatory rheumatic diseases (IRDs) and to explore its role in fatigue.
Methods
Secondary analysis of data from the Lessening the Impact of Fatigue in IRDs (LIFT) trial of the personalized exercise programme (PEP) intervention for fatigue. Participants with IRDs were recruited from 2017–2019 and the current analysis used the fatigue, measured by the chalder fatigue scale (CFS) and the fatigue severity scale (FSS), and accelerometer measured physical activity data collected at baseline and at 6 months follow up. Physical activity levels were quantified, associations with fatigue and effects of PEP investigated.
Results
Of the 337 included participants, 195 (68.4%) did not meet the current recommendations for moderate-vigorous physical activity (MVPA). In baseline cross-sectional analysis, many dimensions of physical activity were associated with fatigue. After mutual adjustment, overall physical activity (vector magnitude) was associated with CFS (-0.88(-0.12, -1.64)) and distribution of time spent at different activity intensity was associated with FSS (-1.16 (-2.01, -0.31)). Relative to usual care, PEP resulted in an increase in upright time, with trends for increases in step count and overall physical activity. People who increased overall physical activity (vector magnitude) more had greater improvements in CFS and FSS, whilst those that increased step count and MVPA more had greater improvements in FSS.
Conclusion
Increasing physical activity is important for fatigue management in people with IRDs and further work is needed to optimize PEP to target the symptoms and impact of fatigue.
Trial registration
ClinicalTrials.Gov, NCT03248518
Sarcopenia, a disorder that involves the generalized loss of skeletal muscle strength and mass, was formally recognized as a disease by its inclusion in the International Classification of Diseases in 2016. Sarcopenia typically affects older people, but younger individuals with chronic disease are also at risk. The risk of sarcopenia is high (with a prevalence of ≥25%) in individuals with rheumatoid arthritis (RA), and this rheumatoid sarcopenia is associated with increased likelihood of falls, fractures and physical disability, in addition to the burden of joint inflammation and damage. Chronic inflammation mediated by cytokines such as TNF, IL-6 and IFNγ contributes to aberrant muscle homeostasis (for instance, by exacerbating muscle protein breakdown), and results from transcriptomic studies have identified dysfunction of muscle stem cells and metabolism in RA. Progressive resistance exercise is an effective therapy for rheumatoid sarcopenia but it can be challenging or unsuitable for some individuals. The unmet need for anti-sarcopenia pharmacotherapies is great, both for people with RA and for otherwise healthy older adults.
Objective
Rheumatoid arthritis (RA) is an autoimmune disease, characterised by high-grade systemic inflammation, pain, and swollen joints. RA patients have an increased risk for cardiovascular disease (CVD). This study examined if a 3-month individualised RA-tailored exercise programme with one-on-one Self-Determination Theory (SDT)-based support for physical activity (PA), facilitated autonomous motivation, increased PA behaviour, and induced greater improvements in cardiovascular and RA-related disease characteristics, and wellbeing in RA, compared to a standard provision tailored exercise programme.
Methods
115 RA patients were randomised into either the SDT-based psychological intervention + exercise programme (experimental group) or an exercise programme only (control group). Cardiorespiratory fitness (primary outcome), self-reported PA, disease characteristics, CVD risk, wellbeing, and SDT constructs were assessed at baseline (pre-intervention), 3-months (post-intervention), 6-months, and 12-months follow-up. Mixed linear modelling was used to examine within- and between participant changes in these outcome measures.
Results
In 88 patients with complete baseline data, cardiorespiratory fitness did not change from baseline to 3-, 6- or 12-months in either group. CVD risk, disease characteristics, wellbeing, and need satisfaction did not change, with the exception of diastolic blood pressure. Significant group by time interaction effects were found for functional ability (6- & 12-m), CVD risk (6-m) and PA (3-m). Autonomous motivation increased and controlled motivation decreased more in the experimental compared to the control group at 3-m.
Conclusions
Despite improving quality of motivation for exercise, no changes in cardiorespiratory fitness or other psychological and physiological health outcomes were found. This suggests more intensive support is needed when initiating an exercise programme to achieve health benefits in RA.
In 1995 the American College of Sports Medicine and the Centers for Disease Control and Prevention published national guidelines on Physical Activity and Public Health. The Committee on Exercise and Cardiac Rehabilitation of the American Heart Association endorsed and supported these recommendations. The purpose of the present report is to update and clarify the 1995 recommendations on the types and amounts of physical activity needed by healthy adults to improve and maintain health. Development of this document was by an expert panel of scientists, including physicians, epidemiologists, exercise scientists, and public health specialists. This panel reviewed advances in pertinent physiologic, epidemiologic, and clinical scientific data, including primary research articles and reviews published since the original recommendation was issued in 1995. Issues considered by the panel included new scientific evidence relating physical activity to health, physical activity recommendations by various organizations in the interim, and communications issues. Key points related to updating the physical activity recommendation were outlined and writing groups were formed. A draft manuscript was prepared and circulated for review to the expert panel as well as to outside experts. Comments were integrated into the final recommendation.
Primary recommendation:
To promote and maintain health, all healthy adults aged 18 to 65 yr need moderate-intensity aerobic (endurance) physical activity for a minimum of 30 min on five days each week or vigorous-intensity aerobic physical activity for a minimum of 20 min on three days each week. [I (A)] Combinations of moderate- and vigorous-intensity activity can be performed to meet this recommendation. [IIa (B)] For example, a person can meet the recommendation by walking briskly for 30 min twice during the week and then jogging for 20 min on two other days. Moderate-intensity aerobic activity, which is generally equivalent to a brisk walk and noticeably accelerates the heart rate, can be accumulated toward the 30-min minimum by performing bouts each lasting 10 or more minutes. [I (B)] Vigorous-intensity activity is exemplified by jogging, and causes rapid breathing and a substantial increase in heart rate. In addition, every adult should perform activities that maintain or increase muscular strength and endurance a minimum of two days each week. [IIa (A)] Because of the dose-response relation between physical activity and health, persons who wish to further improve their personal fitness, reduce their risk for chronic diseases and disabilities or prevent unhealthy weight gain may benefit by exceeding the minimum recommended amounts of physical activity. [I (A)]
OBJECTIVE--To encourage increased participation in physical activity among Americans of all ages by issuing a public health recommendation on the types and amounts of physical activity needed for health promotion and disease prevention. PARTICIPANTS--A planning committee of five scientists was established by the Centers for Disease Control and Prevention and the American College of Sports Medicine to organize a workshop. This committee selected 15 other workshop discussants on the basis of their research expertise in issues related to the health implications of physical activity. Several relevant professional or scientific organizations and federal agencies also were represented. EVIDENCE--The panel of experts reviewed the pertinent physiological, epidemiologic, and clinical evidence, including primary research articles and recent review articles. CONSENSUS PROCESS--Major issues related to physical activity and health were outlined, and selected members of the expert panel drafted sections of the paper from this outline. A draft manuscript was prepared by the planning committee and circulated to the full panel in advance of the 2-day workshop. During the workshop, each section of the manuscript was reviewed by the expert panel. Primary attention was given to achieving group consensus concerning the recommended types and amounts of physical activity. A concise \"public health message was developed to express the recommendations of the panel. During the ensuing months, the consensus statement was further reviewed and revised and was formally endorsed by both the Centers for Disease Control and Prevention and the American College of Sports Medicine. CONCLUSION--Every US adult should accumulate 30 minutes or more of moderate-intensity physical activity on most, preferably all, days of the weekType: CONSENSUS DEVELOPMENT CONFERENCEType: JOURNAL ARTICLEType: REVIEWLanguage: Eng
This paper aims to highlight the importance of exercise in patients with rheumatoid arthritis (RA) and to demonstrate the multitude of beneficial effects that properly designed exercise training has in this population. RA is a chronic, systemic, autoimmune disease characterised by decrements to joint health including joint pain and inflammation, fatigue, increased incidence and progression of cardiovascular disease, and accelerated loss of muscle mass, that is, "rheumatoid cachexia". These factors contribute to functional limitation, disability, comorbidities, and reduced quality of life. Exercise training for RA patients has been shown to be efficacious in reversing cachexia and substantially improving function without exacerbating disease activity and is likely to reduce cardiovascular risk. Thus, all RA patients should be encouraged to include aerobic and resistance exercise training as part of routine care. Understanding the perceptions of RA patients and health professionals to exercise is key to patients initiating and adhering to effective exercise training.
Several lines of evidence have emphasized an improvement in aerobic capacity and muscle strength after physical exercise programs in rheumatoid arthritis (RA) patients. Our objective was to evaluate the efficacy of aerobic exercises in RA on quality of life, function, and clinical and radiologic outcomes by a systematic literature review and a meta-analysis.
A systematic literature search was performed in the Medline, EMBase, and Cochrane databases up to July 2009 and in the abstracts presented at rheumatology scientific meetings during the last 5 years. Randomized controlled trials (RCTs) comparing aerobic exercises with non-aerobic interventions in RA patients were included. Outcomes studied were postintervention quality of life, function assessed by the Health Assessment Questionnaire (HAQ), a pain visual analog scale (VAS), joint count, the Disease Activity Score in 28 joints (DAS28), and radiologic damage. Efficacy was assessed by standardized mean differences (SMDs; difference between groups of mean outcome variation from baseline/SD at baseline) of aerobic exercises versus non-aerobic rehabilitation. Heterogeneity was tested. SMDs were pooled by a meta-analysis using the inverse of variance model.
Fourteen RCTs, including 1,040 patients, met the inclusion criteria. Exercise improved the postintervention quality of life (SMD 0.39, P < 0.0001), HAQ score (SMD 0.24, P = 0.0009), and pain VAS (SMD 0.31, P = 0.02). Exercise in this RA population appeared safe, since global compliance, DAS28, and joint count were similar in both groups.
Cardiorespiratory aerobic conditioning in stable RA appears to be safe and improves some of the most important outcome measures. However, the degree of the effect of aerobic exercise on the abovementioned parameters is small.
To explore the associations between measures of physical activity (PA) and measures of physical function (PF) in women with rheumatoid arthritis (RA). We hypothesized that the strength of the associations between PA and PF would be moderate, and that after controlling for social and biomedical characteristics, the associations would decrease.
Women with RA (n = 47, mean +/- SD age 56.5 +/- 7.0 years) participated in the cross-sectional analysis of this study. Social and biomedical characteristics explored included age, ethnicity, disease duration, marital and educational status, height, weight, comorbidity, and disease activity. PF was measured by the self-reported Health Assessment Questionnaire (HAQ) and by a battery of performance-based measures that included self-selected gait speed, the 5 chair rise test, and the single leg stance test. PA was measured by a portable activity monitor worn for 10 days, and was characterized in 2 ways: daily average number of steps and daily energy expenditure during moderate levels of PA.
Correlations between measures of PA and PF were small to moderate (zero-order correlations = 0.189-0.479). After controlling for social and biomedical characteristics, the correlations became smaller (semi-partial correlations = 0.095-0.277) and only HAQ score remained significantly associated with PA.
Associations between measures of PA and measures of PF were explained, in part, by social and biomedical characteristics in women with RA. The results indicate that measures of PF and PA may represent different constructs and support the need to measure PA in rehabilitation research in RA.
Exercise is commonly used in the management of patients with rheumatoid arthritis (RA); however, there is little consensus in the literature to support its use. This systemic review aimed to determine the effects of dynamic exercise on patients with RA. A systematic search of Medline (1949–2007), Cinahl (1982–2007), Embase (1974–2007) and Cochrane library was performed for randomised-controlled trials using the keywords “rheumatoid arthritis” and “exercise” or “training” or “sport”. The methodological quality of studies was assessed using a ten-point scale. Eighteen papers relating to 12 different studies met inclusion criteria. The mean methodological quality score was 6.9/10. Studies using aerobic training, strength training and combinations of both were included. Patients with early, stable, and active RA were studied. A number of studies reported improvement in muscle strength, physical function and aerobic capacity with dynamic exercise. Some studies also reported improvements in disease activity measures, and small improvements in hip bone mineral density. One study reported significantly less progression of small joint radiographic damage of the feet in the dynamic exercise group. However, one study also reported worse large joint radiographic damage in patients using dynamic exercise who had pre-existing large joint damage, though this was a retrospective analysis. No studies reported worse outcomes for function, disease activity or aerobic capacity with dynamic exercise. Cardiovascular outcomes were not reported in any study, and no data were presented to assess the effect of exercise on patients with significant underlying cardiovascular disease. This systematic review suggests that the majority of patients with RA should be encouraged to undertake aerobic and/or strength training exercise. Exercise programmes should be carefully tailored to the individual, particularly for patients with underlying large joint damage or pre-existing cardiovascular disease.
Rheumatoid cachexia, loss of muscle mass and strength and concomitant increase in fat mass, is very common in patients with rheumatoid arthritis (RA). Despite great advances in the treatment of RA, it appears that rheumatoid cachexia persists even after joint inflammation improves. Rheumatoid cachexia may be an important risk factor for cardiovascular disease and excess mortality in RA. In this issue of Arthritis Research & Therapy, Elkan and colleagues demonstrate a link between rheumatoid cachexia and metabolic syndrome, further reinforcing the need for therapy directed beyond inflammation and at the metabolic consequences of RA.
To evaluate the functional, clinical, radiological and quality of life outcomes of a 4-week dynamic exercise programme (DEP) in RA.
Patients matched on the principal medico-social parameters were randomly assigned to either the DEP or the conventional joint rehabilitation group. Primary end point for judging effectiveness was functional status assessed by HAQ. Secondary outcomes included Nottingham Health Profile (NHP), Arthritis Impact Measurement Scale 2-Short Form (AIMS2-SF) and radiological worsening measured by Simple Narrowing Erosion Score (SENS). Clinical evaluation consisted of disease activity score (DAS 28), cycling aerobic fitness and dexterity. Dexterity was measured using Sequential Occupational Dexterity Assessment (SODA) and Duruoz Hand Index (DHI). Data were collected at baseline 1, 6 and 12 months.
Fifty patients were enrolled. HAQ improved throughout the length of the trial in the DEP group. This improvement was greater in DEP than in the standard joint rehabilitation group at 1 month (-0.2 vs no variation from baseline, P = 0.04), but not at 6 months (-0.2 vs -0.1 in control group, P = 0.25) or 12 months (-0.1 vs no variation in control group, P = 0.51). DEP improved NHP (-23 vs + 7% in control group, P = 0.01) and aerobic fitness (+0.3 vs + 0.1 km per 5 min in control group, P = 0.02) at 1 month but the progress was not statistically significant thereafter. DEP also improved DHI, SODA, DAS 28 and AIMS2-SF, although not significantly.
DEP was effective on functional status assessed by HAQ, quality of life and aerobic fitness at 1 month.
Accurate assessment is required to assess current and changing physical activity levels, and to evaluate the effectiveness of interventions designed to increase activity levels. This study systematically reviewed the literature to determine the extent of agreement between subjectively (self-report e.g. questionnaire, diary) and objectively (directly measured; e.g. accelerometry, doubly labeled water) assessed physical activity in adults.
Eight electronic databases were searched to identify observational and experimental studies of adult populations. Searching identified 4,463 potential articles. Initial screening found that 293 examined the relationship between self-reported and directly measured physical activity and met the eligibility criteria. Data abstraction was completed for 187 articles, which described comparable data and/or comparisons, while 76 articles lacked comparable data or comparisons, and a further 30 did not meet the review's eligibility requirements. A risk of bias assessment was conducted for all articles from which data was abstracted.
Correlations between self-report and direct measures were generally low-to-moderate and ranged from -0.71 to 0.96. No clear pattern emerged for the mean differences between self-report and direct measures of physical activity. Trends differed by measure of physical activity employed, level of physical activity measured, and the gender of participants. Results of the risk of bias assessment indicated that 38% of the studies had lower quality scores.
The findings suggest that the measurement method may have a significant impact on the observed levels of physical activity. Self-report measures of physical activity were both higher and lower than directly measured levels of physical activity, which poses a problem for both reliance on self-report measures and for attempts to correct for self-report - direct measure differences. This review reveals the need for valid, accurate and reliable measures of physical activity in evaluating current and changing physical activity levels, physical activity interventions, and the relationships between physical activity and health outcomes.
We describe the usage of various assistive devices and identify factors associated with usage in patients with rheumatoid arthritis (RA). A cross-sectional, multicentre study was performed in three outpatient rheumatology clinics in the Netherlands. Two hundred forty patients with RA participated in the study. The main measures were questionnaires and a semi-structured interview regarding the possession and usage of 21 common assistive devices in the ISO9999 categories orthopaedic footwear, personal care, mobility, household and adaptations for housing. Potential factors associated with usage included sociodemographic variables, health status, quality of life, coping strategies, self-efficacy, outcome expectations and satisfaction. Out of 240 patients, 213 (89%) had one or more assistive devices in possession (median number of devices 3.0, interquartile range 3.0). The proportions of patients never using a device in possession varied between 8% for orthopaedic insoles and 23% for grab bars. The main factors related to usage varied among categories, but common determinants were a specific impairment or disability, satisfaction with the device or related services, self-efficacy and the number of devices in possession. In conclusion, in patients with RA, possession rates are high, with 23% or less of the devices in possession being abandoned. Overall, satisfaction rates were high. Factors associated with usage varied among categories and comprised, apart from the number of devices in possession and variables related to health status, also aspects of satisfaction with the device or related services or self-efficacy. The latter findings underline the need for a systematic evaluation of the outcomes of assistive devices by prescribing health professionals or suppliers in every individual case.
The cytokines IL-1 beta and TNF-alpha cause cachexia and hypermetabolism in animal models, but their role in human inflammation remains controversial. The relationship between in vitro cytokine production and metabolism was examined in 23 adults with RA and 23 healthy control subjects matched on age, sex, race, and weight. Body composition was measured by multicompartmental analysis of body cell mass, water, fat, and bone mass. Resting energy expenditure (REE) was measured by indirect calorimetry. Cytokine production by PBMC was measured by radioimmunoassay. Usual energy intake, physical activity, disability scores, medication use, and other confounders were also measured. Body cell mass was 13% lower (P < 0.00001), REE was 12% higher (P < 0.008), and physical activity was much lower (P < 0.001) in subjects with RA. Production of TNF-alpha was higher in RA than controls, both before and after stimulation with endotoxin (P < 0.05), while production of IL-1 beta was higher with endotoxin stimulation (P < 0.01). In multivariate analysis, cytokine production was directly associated with REE (P < 0.001) in patients but not in controls. While energy and protein intake were similar in the two groups and exceeded the Recommended Dietary Allowances, energy intake in subjects with RA was inversely associated with IL-1 beta production (P < 0.005). In this study we conclude that: loss of body cell mass is common in RA; cytokine production in RA is associated with altered energy metabolism and intake, despite a theoretically adequate diet; and TNF-alpha and IL-1 beta modulate energy metabolism and body composition in RA.
It is 40 yr since the last age- and sex-specific estimates of the prevalence of rheumatoid arthritis (RA) for the UK were published. Since then the classification criteria for RA have been revised and there has been evidence of a fall in the incidence of RA, especially in women.
To estimate the age- and sex-specific point prevalence of RA (defined as fulfilment of a modification of the 1987 ACR classification criteria for RA on the day of assessment). The estimate was made in the primary care setting in Norfolk, UK.
A stratified random sample was drawn from seven age and gender bands. The 7050 individuals selected were mailed a screening questionnaire. Positive responders were invited to attend for a clinical examination. The sample was matched against the names in the Norfolk Arthritis Register (NOAR), a register of incident cases of inflammatory polyarthritis which has been in existence since 1990.
The overall response rate was 82%. Sixty-six cases of RA were identified. Extrapolated to the population of the UK, the overall minimum prevalence of RA is 1.16% in women and 0.44% in men. A number of incident cases of RA previously notified to NOAR were not identified as cases in the survey because they had entered into treatment-induced remission. In addition, some cases who failed to attend for examination had significant disability. These prevalence figures are therefore an underestimate.
The prevalence of RA in women, but not in men, in the UK may have fallen since the 1950s.
The accurate measurement of physical activity is fraught with problems in adults, but more especially in children because they have more complex and multi-dimensional activity patterns. In addition, the results of different studies are often difficult to interpret and compare, because of the diversity of methodological approaches, differences in data analysis and reporting, and the adoption of varying definitions of what constitutes an appropriate level of activity. Furthermore, inactivity is seldom quantified directly. Although there exists an extensive literature documenting the health benefits of regular physical activity in adults, activity-health relationships in children are not clear-cut. Current recommendations reinforce the concept of health-related activity, accumulating 30 min moderate-intensity exercise on at least 5 d/week (adults) and 1 h moderate-intensity exercise/d (children). Evidence suggests a high prevalence of inactivity in adults, but whether or not inactivity is increasing cannot be assessed currently. Similarly, no definite conclusions are justified about either the levels of physical activity of children, or whether these are sufficient to maintain and promote health. Data to support the belief that activity levels in childhood track into adulthood are weak. Inactivity is associated with an increased risk of weight gain and obesity, but causality remains to be established. In children there is strong evidence to demonstrate a dose response relationship between the prevalence and incidence of obesity and time spent viewing television. Future research should focus on refining methodology for physical activity assessment to make it more sensitive to the different dimensions and contexts of activity in different age-groups.
The aim of the study was to validate a diet history interview (DHI) method and a 3-day activity registration (AR) with biological markers.
The reported dietary intake of 33 rheumatoid arthritis patients (17 patients on a Mediterranean-type diet and 16 patients on a control diet) participating in a dietary intervention study was assessed using the DHI method. The total energy expenditure (TEE), estimated by a 3-day AR, was used to validate the energy intake (EI). For nine subjects the activity registration was also validated by means of the doubly labelled water (DLW) method. The excretion of nitrogen, sodium and potassium in 24-h urine samples was used to validate the intake of protein, sodium and potassium.
There was no significant difference between the EI and the TEE estimated by the activity registration or between the intake of protein, sodium and potassium and their respective biological markers. However, in general, the AR underestimated the TEE compared to the DLW method. No significant differences were found between the subjects in the Mediterranean diet group and the control diet group regarding the relationship between the reported intakes and the biological markers.
The DHI could capture the dietary intake fairly well, and the dietary assessment was not biased by the dietary intervention. The AR showed a bias towards underestimation when compared to the DLW method. This illustrates the importance of valid biological markers.
Physical inactivity is a modifiable risk factor for cardiovascular disease. However, little is known about the effects of physical activity on life expectancy with and without cardiovascular disease. Our objective was to calculate the consequences of different physical activity levels after age 50 years on total life expectancy and life expectancy with and without cardiovascular disease.
We constructed multistate life tables using data from the Framingham Heart Study to calculate the effects of 3 levels of physical activity (low, moderate, and high) among populations older than 50 years. For the life table calculations, we used hazard ratios for 3 transitions (healthy to death, healthy to disease, and disease to death) by levels of physical activity and adjusted for age, sex, smoking, any comorbidity (cancer, left ventricular hypertrophy, arthritis, diabetes, ankle edema, or pulmonary disease), and examination at start of follow-up period.
Moderate and high physical activity levels led to 1.3 and 3.7 years more in total life expectancy and 1.1 and 3.2 more years lived without cardiovascular disease, respectively, for men aged 50 years or older compared with those who maintained a low physical activity level. For women the differences were 1.5 and 3.5 years in total life expectancy and 1.3 and 3.3 more years lived free of cardiovascular disease, respectively.
Avoiding a sedentary lifestyle during adulthood not only prevents cardiovascular disease independently of other risk factors but also substantially expands the total life expectancy and the cardiovascular disease-free life expectancy for men and women. This effect is already seen at moderate levels of physical activity, and the gains in cardiovascular disease-free life expectancy are twice as large at higher activity levels.
To compare leisure activities and associated factors in a group with recent onset RA and matched community derived controls, to examine whether leisure activities are altered during the early years of disease and to seek predictors.
One hundred and forty-seven consecutive persons with early RA were followed for 0.9-5.9 yr. One hundred and forty-four RA patients were compared cross-sectionally at baseline with community-derived controls matched for age, gender and residential area. Leisure activities were evaluated with an interest checklist (20 domains). Socio-demographic variables, disease activity (DAS) and disability (HAQ) were evaluated as possible predictors for loss of participation in leisure activities at baseline and longitudinally (using area under the curve analyses).
At baseline (mean disease duration 7 months) RA patients performed less (8.2 vs 9.9 domains, P < 0.001) but did not have significantly less interest (10.9 vs 11.4 domains, P = 0.15) in leisure activities compared with controls. Decrease in performed leisure activities was only significant in those with a low level of education. At baseline, in RA patients, low education (P = 0.035), age (P = 0.019) and HAQ (P < 0.001) significantly predicted performed leisure activity. No loss in performed leisure activities was seen during follow-up and no significant predictors were found for individual change.
Loss of performed leisure activities occurs early in RA and chiefly in those with low formal education. Disability was associated with early loss, but not with change during follow-up. Other factors, possibly related to individual personality and resources, may be more important for predicting changes in leisure activities.
To determine geographical variation in the prevalence of rheumatoid arthritis (RA) and spondyloarthropathies (SpA) in France.
The survey sample was drawn from 7 areas of France. Households were randomly selected using the national telephone directory, and an individual within each household was randomly chosen by the next-birthday method. All cases of suspected RA and SpA were confirmed by the patient's rheumatologist or by clinical examination. Standardized estimates of prevalence were compared between regions and groups of regions.
In total 15,219 anonymous telephone numbers were selected. An average response rate of 64% led to a total of 9395 respondents included in the study. The highest regional rates of RA were observed in the south (range 0.59-0.66%), and the lowest in the north (range 0.14-0.24%), with a national rate of 0.31% (95% CI 0.18-0.48%). Regional heterogeneity was observed for SpA, with the highest rates in Bretagne (0.47%) and the Sud-Est (0.53%) and a national rate of 0.30% (95% CI 0.17-0.46%).
This study is the largest of its kind conducted in France. It shows inter-regional variations, mainly in RA, with a higher prevalence in the south of the country. The many potential reasons for the heterogeneity observed, including genetic and environmental factors, warrant further research.
This systematic review investigates the effectiveness of exercise interventions in improving disease-related characteristics
in patients with rheumatoid arthritis (RA). It also provides suggestions for exercise programmes suitable for improving the
cardiovascular profile of RA patients and proposes areas for future research in the field. Six databases (Medline, Cochrane
Library, CINAHL, Google Scholar, EMBASE and PEDro) were searched to identify publications from 1974 to December 2006 regarding
RA and exercise interventions. The quality of the studies included was determined by using the Jadad scale. Initial searches
identified 1342 articles from which 40 met the inclusion criteria. No studies were found investigating exercise interventions
in relation to cardiovascular disease in RA. There is strong evidence suggesting that exercise from low to high intensity
of various modes is effective in improving disease-related characteristics and functional ability in RA patients. Future studies
are required to investigate the effects of exercise in improving the cardiovascular status of this patient population.
Context Although it is widely recommended that clinical trials undergo some
type of quality review, the number and variety of quality assessment scales
that exist make it unclear how to achieve the best assessment.Objective To determine whether the type of quality assessment scale used affects
the conclusions of meta-analytic studies.Design and Setting Meta-analysis of 17 trials comparing low-molecular-weight heparin (LMWH)
with standard heparin for prevention of postoperative thrombosis using 25
different scales to identify high-quality trials. The association between
treatment effect and summary scores and the association with 3 key domains
(concealment of treatment allocation, blinding of outcome assessment, and
handling of withdrawals) were examined in regression models.Main Outcome Measure Pooled relative risks of deep vein thrombosis with LMWH vs standard
heparin in high-quality vs low-quality trials as determined by 25 quality
scales.Results Pooled relative risks from high-quality trials ranged from 0.63 (95%
confidence interval [CI], 0.44-0.90) to 0.90 (95% CI, 0.67-1.21) vs 0.52 (95%
CI, 0.24-1.09) to 1.13 (95% CI, 0.70-1.82) for low-quality trials. For 6 scales,
relative risks of high-quality trials were close to unity, indicating that
LMWH was not significantly superior to standard heparin, whereas low-quality
trials showed better protection with LMWH (P<.05).
Seven scales showed the opposite: high quality trials showed an effect whereas
low quality trials did not. For the remaining 12 scales, effect estimates
were similar in the 2 quality strata. In regression analysis, summary quality
scores were not significantly associated with treatment effects. There was
no significant association of treatment effects with allocation concealment
and handling of withdrawals. Open outcome assessment, however, influenced
effect size with the effect of LMWH, on average, being exaggerated by 35%
(95% CI, 1%-57%; P=.046).Conclusions Our data indicate that the use of summary scores to identify trials
of high quality is problematic. Relevant methodological aspects should be
assessed individually and their influence on effect sizes explored.
The revised criteria for the classification of rheumatoid arthritis (RA) were formulated from a computerized analysis of 262 contemporary, consecutively studied patients with RA and 262 control subjects with rheumatic diseases other than RA (non-RA). The new criteria are as follows: 1) morning stiffness in and around joints lasting at least 1 hour before maximal improvement; 2) soft tissue swelling (arthritis) of 3 or more joint areas observed by a physician; 3) swelling (arthritis) of the proximal interphalangeal, metacarpophalangeal, or wrist joints; 4) symmetric swelling (arthritis); 5) rheumatoid nodules; 6) the presence of rheumatoid factor; and 7) radiographic erosions and/or periarticular osteopenia in hand and/or wrist joints. Criteria 1 through 4 must have been present for at least 6 weeks. Rheumatoid arthritis is defined by the presence of 4 or more criteria, and no further qualifications (classic, definite, or probable) or list of exclusions are required. In addition, a “classification tree” schema is presented which performs equally as well as the traditional (4 of 7) format. The new criteria demonstrated 91–94% sensitivity and 89% specificity for RA when compared with non-RA rheumatic disease control subjects.
Objective
To evaluate the impact of a 2-year program of strength training on muscle strength, bone mineral density (BMD), physical function, joint damage, and disease activity in patients with recent-onset (<2 years) rheumatoid arthritis (RA).Methods
In this prospective trial, 70 RA patients were randomly assigned to perform either strength training (all major muscle groups of the lower and upper extremities and trunk, with loads of 50–70% of repetition maximum) or range of motion exercises (without resistance) twice a week; all were encouraged to engage in recreational activities 2–3 times a week. All patients completed training diaries (evaluated bimonthly) and were examined at 6-month intervals. All were treated with medications to achieve disease remission. Maximum strength of the knee extensors, trunk flexors and extensors, and grip strength was measured with dynamometers. BMD was measured at the femoral neck and lumbar spine by dual x-ray densitometry. Disease activity was determined by the Disease Activity Score, the extent of joint damage by the Larsen score, and functional capacity by the Health Assessment Questionnaire (HAQ); walking speed was also measured.ResultsSixty-two patients (31 per group) completed the study. Strength training compliance averaged 1.4–1.5 times/week. The maximum strength of all muscle groups examined increased significantly (19–59%) in the strength-training group, with statistically significant improvements in clinical disease activity parameters, HAQ scores, and walking speed. While muscle strength, disease activity parameters, and physical function also improved significantly in the control group, the changes were not as great as those in the strength-training group. BMD in the femoral neck and spine increased by a mean ± SD of 0.51 ± 1.64% and by 1.17 ± 5.34%, respectively, in the strength-training group, but decreased by 0.70 ± 2.25% and 0.91 ± 4.07% in the controls. Femoral neck BMD in the 17 patients with high initial disease activity (and subsequent use of oral glucocorticoids) remained constantly at a statistically significantly lower level than that in the other 45 patients.Conclusion
Regular dynamic strength training combined with endurance-type physical activities improves muscle strength and physical function, but not BMD, in patients with early RA, without detrimental effects on disease activity.
Objectives: To describe the characteristics of patients with rheumatoid arthritis (RA) attending for physiotherapy management in Ireland.
Methods: Managers of physiotherapy departments in the 53 hospitals in Ireland were invited to participate in a multi-centre observational study over a 6-month period. Data on patients with RA the day of presentation for physiotherapy management were recorded. These data related to patient demographic details, disease management, aids and appliances, splint and orthoses usage and occupational issues. The Health Assessment Questionnaire was also recorded for each patient.
Results: A total of 273 patients from eight physiotherapy departments participated in the survey (n = 199; 73% female). Mean age of the participants was 59.3 (SD 12.5) years with mean disease duration of 13.8 (SD 10.6) years. The majority of the patients were inpatients (n = 170, 62%). Sixty-eight per cent of patients had attended for previous physiotherapy treatment and 98% were under current rheumatologist care. Biologic therapies were prescribed to 11% of patients. Use of splint and foot orthoses was high with 133 patients (49%) wearing splints and 75 (31%) wearing foot orthoses. The majority of patients had moderate (n = 119, 44%) or severe (n = 94, 35%) disability as per Health Assessment Questionnaire (HAQ) score. Mean HAQ score was 1.5, with HAQ scores showing increasing disability with increasing age, disease duration and erythrocyte sedimentation rate (ESR) levels.
Conclusions: Patients with RA attending for physiotherapy management present with varied profiles. This study provides valuable information on the characteristics of patients with RA attending for physiotherapy management which will contribute to physiotherapy service planning and delivery and will optimize patient care. Copyright
Objective
To compare the incidence of cardiovascular (CV) events in persons with rheumatoid arthritis (RA) with that in people from the general population, adjusting for traditional CV risk factors.Methods
Two hundred thirty-six consecutive patients with RA were assessed for the 1-year occurrence of 1) CV-related hospitalizations, including myocardial infarction, stroke or other arterial occlusive events, or arterial revascularization procedures, or 2) CV deaths. Both outcomes were ascertained by medical records or death certificates. For comparison, we used CV events that occurred during an 8-year period among participants in an epidemiologic study of atherosclerosis and CV disease who were ages 25–65 years at study entry. We calculated the age- and sex-stratified incidence rate ratio (IRR) of CV events between the 2 cohorts and used Poisson regression to adjust for age, sex, smoking status, diabetes mellitus, hypercholesterolemia, systolic blood pressure, and body mass index.ResultsOf the 236 RA patients, 234 were observed for 252 patient-years, during which 15 CV events occurred. Of these, 7 incident events occurred during the 204 patient-years contributed by patients ages 25–65 years, for an incidence of 3.43 per 100 patient-years. In the comparison cohort, 4,635 community-dwelling persons were followed up for 33,881 person-years, during which 200 new events occurred, for an incidence of 0.59 per 100 person-years. The age- and sex-adjusted IRR of incident CV events associated with RA was 3.96 (95% confidence interval [95% CI] 1.86–8.43). After adjusting for CV risk factors using Poisson regression, the IRR decreased slightly, to 3.17 (95% CI 1.33–6.36).Conclusion
The increased incidence of CV events in RA patients is independent of traditional CV risk factors. This suggests that additional mechanisms are responsible for CV disease in RA. Physicians who provide care to individuals with RA should be aware of their increased risk of CV events and implement appropriate diagnostic and therapeutic measures.
Over the last decades, substantial epidemiological evidence has been accumulated on the protective role of increased physical activity (PA) for the prevention and management of certain chronic diseases. To better address the impact of physical activity on health, valid and reliable instruments for its measurement are essential. Because of its dimensionality, a large number of methods exist for the assessment of various aspects of physical activity. This review provides a summary of available tools for measuring physical activity and total energy expenditure (TEE) and addresses their advantages and limitations in assessing PA in epidemiological surveys. The selection of the appropriate method for a specific survey should be based on criteria such as experimental goals, sample size, budget, cultural and social/environmental factors, physical burden for the subject, and statistical factors such as validity and reliability. The instruments that are very precise in measuring total energy expenditure such as doubly-labeled water method and direct and indirect calorimetry tend to be impractical on a population basis. On the other hand, methods such as self-report techniques are applicable for epidemiological studies, but they lack accuracy in measuring energy expenditure (EE).
To examine the association between weather and pain in rheumatoid arthritis (RA).
Systematic review of longitudinal observational studies (up to September 2009) with data on the association between weather variables and severity of pain in RA. The methodological quality was rated independently by the two authors according to an adapted Newcastle-Ottawa Scale. We analyzed the data on an aggregated (group) level with a meta-analysis of correlations between pain and weather, and at an individual level as the proportion of patients for whom pain was significantly affected by the weather.
Nine studies were included. Many different weather variables have been studied, but only three (temperature, relative humidity and atmospheric pressure) have been studied extensively. Overall group level analyses show that associations between pain and these three variables are close to zero. Individual analyses from two studies indicate that pain reporting in a minority (<25%) of RA patients is influenced by temperature, relative humidity or atmospheric pressure. We were not able to relate the findings to methodological quality or other aspects of the studies.
The studies to date do not show any consistent group effect of weather conditions on pain in people with RA. There is, however, evidence suggesting that pain in some individuals is more affected by the weather than in others, and that patients react in different ways to the weather. Thus, the hypothesis that weather changes might significantly influence pain reporting in clinical care and research in some patients with RA cannot be rejected.
A sufficient level of physical activity is important in reducing the impact of disease in rheumatoid arthritis (RA) patients. According to self-determination theory, the achievement and maintenance of physical activity is related to goal setting and ownership, which can be supported by health professionals. Our objective was to examine the association between physical activity and the extent to which RA patients 1) believe that physical activity is a goal set by themselves (autonomous regulation) or by others (coerced regulation) and 2) feel supported by rheumatologists (autonomy supportiveness).
A random selection of 643 RA patients from the outpatient clinics of 3 hospitals were sent a postal survey to assess current physical activity level (Short Questionnaire to Assess Health-Enhancing Physical Activity), regulation style (Treatment Self-Regulation Questionnaire), and the autonomy supportiveness of their rheumatologists (modified Health Care Climate Questionnaire).
Of the 271 patients (42%) who returned the questionnaire, 178 (66%) were female, their mean +/- SD age was 62 +/- 14 years, and their mean +/- SD disease duration was 10 +/- 8 years. Younger age, female sex, higher education level, shorter disease duration, lower disease activity, and a more autonomous regulation were univariately associated with more physical activity. Hierarchical multiple regression analyses demonstrated that younger age and a more autonomous regulation were significantly associated with a higher physical activity level (P = 0.000 and 0.050, respectively).
Regulation style was a significant determinant of physical activity in RA patients. This finding may contribute to further development of interventions to enhance physical activity in RA patients.
It is well-established that increasing physical activity (PA) is important for the prevention and management of cardiovascular disease (CVD). Although it has been demonstrated that PA predicts CVD independent of commonly measured cardiometabolic risk factors in women, it is unclear whether this association is true in men. The study participants consisted of 5,882 adults (age >or=18 years) from the 1999 to 2004 United States National Health and Nutrition Examination Survey. Blood pressure, triglycerides, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, glucose, and waist circumference were categorized using standard clinical thresholds. The participants were divided into the following groups according to the volume of their moderate-to-vigorous intensity PA: active (>or=150 min/wk), somewhat active (30 to 149 min/wk), and inactive (<30 min/wk). Logistic regression analyses were used to calculate the odds ratios for CVD according to PA. After controlling for the basic confounders (age, gender, race, smoking), inactive participants were 52% (95% confidence interval 16% to 98%) more likely than the active participants to have CVD. Additional adjustment for cardiometabolic risk factors did not change the odds ratio for CVD in the inactive group. To further delineate the effects of PA on CVD, the participants were cross-classified according to their PA level and their number of cardiometabolic risk factors. Both PA and cardiometabolic risk factors were independent predictors of CVD (P(trend) <0.0001). The results were not modified by gender. In conclusion, PA was associated with CVD, independent of the common cardiometabolic risk factors, in men and women. The association between PA and CVD risk was not mediated by the measured cardiometabolic risk factors.
To evaluate whether five-year changes in self-reported physical activity level were associated with changes in waist circumference, weight, serum lipids and blood pressure.
In the Inter99 study (1999-2006) in Copenhagen, Denmark, 4039 men and women (30-60 years) answered questions on lifestyle and provided blood samples and anthropometric measures at baseline and after five years. Multiple regression analyses were performed with five-year value of each cardiovascular biomarker as outcome and change in physical activity level as explanatory variable.
Approximately 50% of the study population were men (n=2023). Change in physical activity level was inversely associated with change in weight (p<0.0001), waist (p<0.0001), diastolic blood pressure (p=0.04), total cholesterol (p=0.006), LDL (p=0.007), triglycerides (p=0.02) and with a composite risk score "the Copenhagen risk score" (p<0.0001), and positively associated with HDL in men (p=0.01).
Five-year changes in physical activity level were significantly associated with relevant changes in weight, waist circumference, diastolic BP and serum lipids in a population-based cohort of adult men and women. Change in physical activity level induced a significant change in HDL concentration in men only. Women's use of hormone replacement therapy may partly explain this gender difference.
Both fibromyalgia and rheumatoid arthritis (RA) patients self-report similar disability. These diseases are viewed differently by the medical profession as one has ample evidence of tissue damage and inflammation and the other does not. We were interested to see if an objective measure produced similar results. Twelve patients with RA were matched with 12 fibromyalgia patients by sex, age, and Health Assessment Questionnaire (HAQ) score. The 24-h ambulatory activity of these patients was recorded using the Numact monitor. Statistical analysis was performed using independent group t test for the ambulatory activity data and Spearman's correlation coefficients for HAQ and total energy. There were no significant differences found between the two groups in terms of total activity. Other compared analyses for activity included the number of steps taken, vigor of steps, and time spent standing, which were not statistically different. The correlation coefficients of HAQ and total ambulatory activity for the fibromyalgia group were rho = -0.638 (p = 0.026). Patients with RA and fibromyalgia displaying similar levels of self-reported disability have objective evidence of similar levels of total ambulatory activity. There is a statistically significant correlation between self-reported and objective measurements of disability for the fibromyalgia patients. Either of these measures merits further study as outcome measures for fibromyalgia.
To determine the magnitude of risk of cardiovascular mortality in patients with rheumatoid arthritis (RA) compared with the general population through a meta-analysis of observational studies.
We searched Medline, EMBase, and Lilacs databases from their inception to July 2005. Observational studies that met the following criteria were assessed by 2 researchers: 1) prespecified RA definition, 2) clearly defined cardiovascular disease (CVD) outcome, including ischemic heart disease (IHD) and cerebrovascular accidents (CVAs), and 3) reported standardized mortality ratios (SMRs) and 95% confidence intervals (95% CIs). We calculated weighted-pooled summary estimates of SMRs (meta-SMRs) for CVD, IHD, and CVAs using the random-effects model, and tested for heterogeneity using the I(2) statistic.
Twenty-four studies met the inclusion criteria, comprising 111,758 patients with 22,927 cardiovascular events. Overall, there was a 50% increased risk of CVD death in patients with RA (meta-SMR 1.50, 95% CI 1.39-1.61). Mortality risks for IHD and CVA were increased by 59% and 52%, respectively (meta-SMR 1.59, 95% CI 1.46-1.73 and meta-SMR 1.52, 95% CI 1.40-1.67, respectively). We identified asymmetry in the funnel plot (Egger's test P = 0.002), as well as significant heterogeneity in all main analyses (P < 0.0001). Subgroup analyses showed that inception cohort studies (n = 4, comprising 2,175 RA cases) were the only group that did not show a significantly increased risk for CVD (meta-SMR 1.19, 95% CI 0.86-1.68).
Published data indicate that CVD mortality is increased by approximately 50% in RA patients compared with the general population. However, we found that study characteristics may influence the estimate.
To provide a single source for the best available estimates of the national prevalence of arthritis in general and of selected musculoskeletal disorders (osteoarthritis, rheumatoid arthritis, juvenile rheumatoid arthritis, the spondylarthropathies, systemic lupus erythematosus, scleroderma, polymyalgia rheumatica/giant cell arteritis, gout, fibromyalgia, and low back pain).
The National Arthritis Data Workgroup reviewed data from available surveys, such as the National Health and Nutrition Examination Survey series. For overall national estimates, we used surveys based on representative samples. Because data based on national population samples are unavailable for most specific musculoskeletal conditions, we derived data from various smaller survey samples from defined populations. Prevalence estimates from these surveys were linked to 1990 US Bureau of the Census population data to calculate national estimates. We also estimated the expected frequency of arthritis in the year 2020.
Current national estimates are provided, with important caveats regarding their interpretation, for self-reported arthritis and selected conditions. An estimated 15% (40 million) of Americans had some form of arthritis in 1995. By the year 2020, an estimated 18.2% (59.4 million) will be affected.
Given the limitations of the data on which they are based, this report provides the best available prevalence estimates for arthritis and other rheumatic conditions overall, and for selected musculoskeletal disorders, in the US population.
Patients can have several illnesses concurrently, yet some of these diseases may be neglected if one problem consumes attention. We conducted a population-based analysis in Ontario, Canada - where universal health insurance is provided - to determine whether unrelated disorders are less likely to be treated in patients with chronic diseases.
We studied the 1,344,145 residents of Ontario in 1995 who were 65 or older and eligible to receive prescription medications free of charge as part of the Ontario Drug Benefit program. Patients with diabetes mellitus were identified by prescriptions for insulin, pulmonary emphysema by prescriptions for ipratropium bromide, and psychotic syndromes by prescriptions for haloperidol. For each chronic disease, we selected an unrelated treatment: estrogen-replacement therapy for patients with diabetes mellitus, lipid-lowering medications for those with pulmonary emphysema, and medical treatment of arthritis for those with psychotic syndromes.
The 30,669 patients with diabetes mellitus were less likely to receive estrogen-replacement therapy than the other subjects in the study (2.4 percent vs. 5.9 percent, P<0.001). The disease was associated with a 60 percent reduction in the odds of estrogen treatment (odds ratio, 0.40; 95 percent confidence interval, 0.37 to 0.43). Findings were similar for the 56,779 patients with pulmonary emphysema, who were less likely to receive lipid-lowering medications (odds ratio, 0.69; 95 percent confidence interval, 0.67 to 0.72; P<0.001), and the 17,336 patients with psychotic syndromes, who were less likely to receive medical treatments for arthritis (odds ratio, 0.59; 95 percent confidence interval, 0.57 to 0.62; P<0.001).
In patients 65 or older who have chronic medical diseases and who receive prescription medications free of charge, unrelated disorders are undertreated. Clinicians caring for patients with chronic diseases should remain alert to other disorders and minimize the number of missed opportunities for treating them.
To determine if the altered insulin-like growth factor (IGF) status in rheumatoid arthritis (RA) is due to inflammation, altered body composition, or lack of exercise.
Subjects included 73 patients with RA, 54 patients with other rheumatic diseases, both inflammatory and noninflammatory, and 28 healthy, physically active controls. Serum levels of IGF-I, IGF-II, and IGF binding protein-3 (IGFBP-3) were measured by radioimmunoassay. Body composition was estimated by bioelectrical impedance analysis, and habitual exercise level approximated by questionnaire. Statistical analysis was performed by 2 and 3 way ANOVA and moderated hierarchical regression.
Serum IGF-I (p < 0.001), IGFBP-3 (p < 0.001), and the BP-3:total IGF molar ratio (p < 0.001) were depressed in both patient groups relative to controls. In contrast, IGF-II levels were depressed only in patients with RA (p < 0.01). Differences in the IGF proteins between patients and controls could not be attributed to inflammation. Habitual exercise level, but not body composition, was shown to be a significant predictor for IGF-I, IGFBP-3, and BP-3:total IGF molar ratio (p < 0.001).
Our results indicate that the reduction in circulating IGF proteins observed in our patients is more related to their sedentary lifestyle than to the inflammatory process. This conclusion is in agreement with reports that show that highly active individuals typically exhibit higher levels of systemic IGF proteins than age matched sedentary controls.
Rheumatoid arthritis (RA) causes cachexia, a metabolic response characterized by loss of muscle mass and elevated resting energy expenditure (REE). However, energy expenditure in physical activity in subjects with RA is lower than that in healthy subjects. It is not known which effect predominates in regulating total energy expenditure (TEE), and thus whether the dietary energy requirements of subjects with RA are higher or lower than those of healthy subjects.
Our objective was to determine TEE in women with RA by using the reference method of doubly labeled water ((2)H(2)(18)O).
In this case-control study, we examined 20 women with RA and 20 healthy women who were matched for age and body mass index.
The patients with RA were cachectic (their body cell mass was 14% lower than that of the controls, P < 0.001), but REE was not elevated, reflecting good disease control. Mean (+/- SD) TEE was 1344 kJ/d lower in the patients than in the controls (9133 +/- 1335 compared with 10 477 +/- 1992 kJ/d; P < 0.02). The energy expenditure in physical activity of the patients was 1034 kJ/d lower than that of the controls (P < 0.04), which accounted for 77% of the difference in TEE between the 2 groups. The physical activity level (TEE/REE) of the patients also tended to be lower than that of the controls (1.70 +/- 0.24 compared with 1.89 +/- 0.36; P < 0.07).
A low physical activity level is the main determinant of lower-than-normal TEE, and thus energy requirements, in women with RA.
Rheumatoid arthritis may be associated with an increased risk of cardiovascular disease. We compared the incidence rates of myocardial infarction and stroke in subjects with and without rheumatoid arthritis.
A prospective cohort study was conducted among the 114 342 women participating in the Nurses' Health Study who were free of cardiovascular disease and rheumatoid arthritis at baseline in 1976. All self-reported cases of rheumatoid arthritis were confirmed by medical record review. Fatal and nonfatal myocardial infarctions and strokes were similarly confirmed. Multivariate pooled logistic regression was used to adjust for potential cardiovascular risk factors. Five hundred twenty-seven incident cases of rheumatoid arthritis and 3622 myocardial infarctions and strokes were confirmed during 2.4 million person-years of follow-up. The adjusted relative risk of myocardial infarction in women with rheumatoid arthritis compared with those without was 2.0 (95% confidence interval [CI], 1.23 to 3.29). For stroke, the adjusted relative risk was 1.48 (95% CI, 0.70 to 3.12). Women who had rheumatoid arthritis for at least 10 years had a risk for myocardial infarction of 3.10 (95% CI, 1.64 to 5.87).
In this large prospective cohort of women, participants with rheumatoid arthritis had a significantly increased risk of myocardial infarction but not stroke compared with those without rheumatoid arthritis. If these data are confirmed, aggressive coronary heart disease prevention strategies should be tested for persons with rheumatoid arthritis.
The present study investigated the use of a tri-axial accelerometer, Tracmor2, for the measurement of physical activity in children. Eleven children [age 6.9 (2.2) years, body mass 19.5 (5.3) kg and height 112.3 (14.4) cm] were studied. Total daily energy expenditure (TDEE) was measured using the doubly labeled water method over a 2-week period. In addition, basal metabolic rate (BMR) was determined by the ventilated hood system. Physical activity level (PAL) was defined as TDEE/BMR. Tracmor2 was worn during the same 2-week period throughout waking hours after which average counts per day were calculated. The average counts per day were shown to be highly correlated to PAL values measured by doubly labeled water: PAL = 1.156 x 10(-5) x Tracmor2 average counts day(-1) + 0.978 (r=0.79, P<0.01). In conclusion, Tracmor2 is a valid instrument to measure physical activity in children under free-living conditions.
To identify physical activity behaviors of older (>/=60 years) women with rheumatoid arthritis, and to determine if physical activity behavior differed by demographic characteristics or disease duration.
Cognitively intact, ambulatory women with rheumatoid arthritis seen at an urban university arthritis center (n = 185) responded to a survey that included demographics, number of years since RA diagnosis, and physical activity assessed with the Yale Physical Activity Survey.
Participants had a mean age of 70 years and a mean disease duration of 17.6 years. Mean total of physical activity, including low-, moderate-, and high-intensity activity, was 23 hours/week, with 47 different physical activities identified. Housework comprised 67% of total physical activity time, whereas leisure activities and planned exercise comprised only 15% and 10%, respectively. Sixty percent of the women reported participation in some type of vigorous activity, and 88% reported they had done leisure walking in the past month. Age was negatively associated with scores on the activity summary index (r = -0.195, P < 0.01), and there was a significant difference on the activity summary index by employment status, with women in the work force (n = 47) and those involved in housekeeping (n = 105) scoring significantly higher (P = 0.003) than the women (n = 33) who described themselves as retired (F = 7.81, 2 degrees of freedom, P = 0.001).
Older women with rheumatoid arthritis may participate in a broader array of physical activities than previously assumed, and could benefit from increasing the proportion of moderate or vigorous activity incorporated into their daily routines.
To analyze the energy expenditure of patients with rheumatoid arthritis (RA) of functional classes I, II, and III during walking at different speeds on a treadmill.
Thirty-five consecutive patients selected from the rheumatology outpatient clinic were studied and compared with a control group consisting of 35 healthy individuals paired for age, sex, body weight, and body mass index. An incremental test on a treadmill consistent with normal walking was developed, with metabolic analysis performed at 30 s intervals using a gas analyzer connected to a computerized system. Heart rate, rate of perceived exertion, visual analog scale of pain, Ritchie index, the Scale of the Escola Paulista de Medicina for Evaluation of Articular Movement Range, and the Health Assessment Questionnaire were also used to evaluate functional capacity.
Patients with RA showed a greater energy expenditure than controls at the following walking speeds: 3.0 km/h (RA = 229.36 +/- 56.47 kcal/h; controls = 197.44 +/- 52.59), 4.5 km/h (RA = 266.41 +/- 58.94 kcal/h; controls = 231.41 +/- 56.14), and 5.0 km/h (RA = 289.11 +/- 65.35 kcal/h; controls = 250.18 +/- 56.67). Patients with RA presented higher values for all test measures except heart rate. The functional class II group differed significantly from the controls, whereas the functional class I group had values close to normal.
Patients with RA had a greater energy expenditure during walking compared to healthy controls under the same conditions, and patients with functional class II experienced a greater energy expenditure compared to controls.
Developing policy and strategic initiatives to increase population levels of physical activity (PA) requires constant referral to the epidemiological evidence base. This paper updates the evidence that PA confers a positive benefit on health, using research studies in the peer-reviewed scientific literature published between 2000-2003. Areas covered include updates in all-cause mortality and in cardiovascular disease prevention, diabetes, stroke, mental health, falls and injuries, and in obesity prevention. Recent evidence on PA and all-cause mortality replicates previous findings, and is consistent with current Australian moderate PA recommendations. Recent papers have reinforced our understanding of the cardiovascular protective effects of moderate PA, with new evidence that walking reduces the risk of CVD and, in two studies, at least as much as vigorous activity. The evidence base for protective effects of activity for women, older adults and for special populations has strengthened. Cancer prevention studies have proliferated during this period but the best evidence remains for colon cancer, with better evidence accumulating for breast cancer prevention, and uncertain or mixed evidence for the primary prevention of other cancers. Important new controlled-trial evidence has accumulated in the area of type 2 diabetes: moderate PA combined with weight loss, and a balanced diet can confer a 50-60% reduction in risk of developing diabetes among those already at high risk. Limited new evidence has accumulated for the role of PA in promoting mental health and preventing falls.
The number of people who are overweight, obese and/or lead a sedentary lifestyle is increasing, and numerous studies have shown that physical activity has beneficial cardiovascular effects.
The aim of this study was to evaluate the relationship between physical activity and the anthropometric, cardiovascular and metabolic variables involved in coronary risk. The study population consisted of 1075 adult men aged 25-75 years, all of whom were workers in Olivetti factories. Physical activity was assessed by means of a questionnaire and the sample was divided into two groups: those practising sport and those who said they were sedentary.
Age-adjusted BMI was higher in the participants practising sport, whereas the values of all of the remaining variables (i.e. abdominal circumference, skinfolds, heart rate, blood pressure, serum cholesterol, triglyceride, glucose, insulin and HOMA) were lower; however, the only statistically significant differences were in heart rate and blood pressure. After the subjects were classified as being normal weight, overweight or obese on the basis of BMI, the active participants tended to have lower values for all of the parameters than their sedentary counterparts in each BMI category. In a subgroup undergoing OGTT, glucose and insulin levels at T0 and T60 were significantly lower in the active participants.
These findings confirm the usefulness of physical activity in preventing cardiovascular disease.
Given that most deaths among patients with diabetes mellitus are due to cardiovascular disease, we sought to determine the extent to which medications proven to reduce cardiovascular mortality are prescribed for patients with type 2 diabetes who have symptomatic atherosclerosis (i.e., coronary artery disease [CAD], cerebrovascular disease [CBVD] or peripheral arterial disease [PAD]).
Administrative records from Saskatchewan Health were used to evaluate the use of antiplatelet agents, statins and angiotensin-converting enzyme (ACE) inhibitors by people with treated type 2 diabetes with and without symptomatic atherosclerosis. CAD and CBVD were defined by International Classification of Diseases (ninth revision) codes, and PAD was defined on the basis of pentoxifylline use or lower limb amputation. Multivariate logistic regression analysis was used to compare medication use in patients with and without PAD, with adjustments for differences in age, sex and comorbidity.
In this cohort of 12,106 patients with type 2 diabetes (mean age 64 years, 55% male, mean follow-up 5 years), fewer than 25% received an antiplatelet agent or statin, and fewer than 50% received an ACE inhibitor. Although patients with CAD were more likely to receive antiplatelet agents, statins or ACE inhibitors than people without CAD (p < 0.001 for all), the overall use of these medications was suboptimal (37%, 29% and 60% respectively among patients with symptomatic CAD). Similar patterns of practice were found for patients with symptomatic CBVD and PAD. All 3 proven efficacious therapies were prescribed for only 11% of patients with CAD, 22% with CBVD and 12% with PAD. Patients with PAD who had undergone lower limb amputation were no more likely to subsequently receive antiplatelet agents or statins than those without an amputation.
Diabetic patients with symptomatic atherosclerotic disease are undertreated with medications known to reduce cardiovascular morbidity and mortality, perhaps because of a "glucocentric" view of diabetes. Programs to improve the quality of cardiovascular risk reduction in these high-risk patients are needed.
To describe self-reported physical activity and physical fitness and to identify correlates of physical activity and general health perception.
Data on self-reported physical activity, physical fitness, activity performance, and disease activity were collected from a sample of 298 patients with rheumatoid arthritis (RA).
Forty-seven percent of our sample reported physical activity behaviors that did not comply with public health recommendations. A majority of the patients had decreased lower-limb muscle function (72%), grip force (94%), joint motion (94%), and functional balance (68%). Correlations between self-reported physical activity and other variables were r(s) = 0.25 or less. Variation in general health perception was explained (total adjusted R(2) = 0.65) by pain and activity performance.
Our findings indicate that there is a case for recommendations on and support for healthy physical activity behaviors among people with RA.
We aimed to examine the impact of exercise on mortality from cardiovascular disease (CVD) in Asian populations.
Few data have been available in Asian countries, where job-related physical activity is higher than that in Western countries.
Between 1988 and 1990, 31,023 men and 42,242 women in Japan, ages 40 to 79 years with no history of stroke, coronary heart disease (CHD), or cancer, completed a self-administered questionnaire. Systematic mortality surveillance was performed through 1999, and 1,946 cardiovascular deaths were identified. We chose the second lowest categories of walking and sports participation as the reference to reduce a potential effect of ill health.
Men and women who reported having physical activity in the highest category (i.e., walking > or =1 h/day or doing sports > or =5 h/week) had a 20% to 60% lower age-adjusted risk of mortality from CVD, compared with those in the second lowest physical activity category (i.e., walking 0.5 h/day, or sports participation for 1 to 2 h/week). Adjustment for known risk factors, exclusion of individuals who died within two years of baseline inquiry, or gender-specific analysis did not substantially alter these associations. The multivariate-adjusted hazard ratios (95% confidence interval) for the highest versus the second lowest categories of walking or sports participation were 0.71 (0.54 to 0.94) and 0.80 (0.48 to 1.31), respectively, for ischemic stroke (IS); 0.84 (0.64 to 1.09) and 0.51 (0.32 to 0.82), respectively, for CHD; and 0.84 (0.75 to 0.95) and 0.73 (0.60 to 0.90), respectively, for CVD.
Physical activity through walking and sports participation might reduce the risk of mortality from IS and CHD.
Researchers are increasingly interested in the potential of accelerometers to improve our ability to measure and understand the health impacts of physical activity. Although accelerometers have been available commercially for more than 25 yr, broad consensus about how to use these tools has not been established. At a scientific conference in December 2004, a number of scientists were invited to present papers, serve as reactors or moderators to papers, present posters of original research, or serve as members of an audience knowledgeable about the use of accelerometers. During 2 1/2 d, information about best practices of accelerometer use was presented and suggestions for future research were made. From the collective experience of papers presented and discussions held, five areas of accelerometer use were described. This paper summarizes the best practices and future research needs from those five areas: monitor selection, quality, and dependability; monitor use protocols; monitor calibration; analysis of accelerometer data; and integration with other data sources. Suggestions for reporting standards for journal articles also are presented.
Physical activity and exercise play a critical role in the management of arthritis. Understanding the factors affecting physical activity and exercise behavior is a necessary first step toward identifying the needs of, and intervention strategies for, people with arthritis. The purpose of this study was to identify factors affecting physical activity and exercise behavior in urban subjects with osteoarthritis (OA) and rheumatoid arthritis (RA).
Seventy-two consecutive subjects were recruited from the rheumatology clinic at a large urban public hospital. The sample was predominantly African American (92%), female (87%), and not working (90%). The subjects' average age was 60.9 years (SD=13.9, range=30-90).
Time per day spent sitting or lying down and time per week spent in exercise, leisure, and household activities were determined by individual interview. Self-efficacy, outcome expectations, disability, pain, body mass index, and social support were measured as possible explanatory factors.
The average daily total activity time was 3.1 hours. Household and leisure activities accounted for 85% of that time. Explanatory factors for physical activity behavior were not the same for subjects with OA and RA, despite similar between-group characteristics. Self-efficacy was present in all of the significant explanatory models.
The results indicate that factors that affect physical activity behavior among urban and predominantly African-American adults are dependent upon the type of physical activity and are different for people with OA and RA. Self-efficacy was the most consistent explanatory factor.
Low energy expenditure is a risk for cardiovascular morbidity. The goals of this study were to compare energy expenditure between patients with rheumatoid arthritis (RA) and healthy controls.
A total of 121 RA patients and 120 healthy controls in New York City completed the Paffenbarger Physical Activity and Exercise Index at time of enrollment (1999-2000) and 1 year later to measure energy expenditure from walking, climbing stairs, and exercise/sports. Analyses were adjusted for age, sex, education, pain, social support, and depressive symptoms and were compared with recommended thresholds of energy expenditure.
Participants' mean age was 49 years, and 87% were women. Patients with RA expended fewer kilocalories per week than controls (mean +/- SD 1,474 +/- 1,198 versus 1,958 +/- 1,940, P = 0.003), with most of this difference from less walking as opposed to high-intensity activities. Although similar percents of RA patients and controls met national recommendations for total weekly energy expenditure (56% versus 64% for the lower [> or =1,000 kilocalories per week] threshold; P = 0.14, and 41% versus 48% for the higher [> or =1,400 kilocalories per week] threshold; P = 0.17), fewer RA patients met the recommendations (> or =700 kilocalories per week) for walking (32% versus 48%; P = 0.01). The strongest predictor of more energy expenditure at 1 year for both groups was more energy expenditure at enrollment.
Most of the difference in energy expenditure between RA patients and healthy controls was due to less walking. Given that walking is an effective and relatively safe lifestyle activity, increasing walking should be a priority to improve cardiovascular risk in RA.
Although promoting physical activity (PA) and exercise among patients with rheumatoid arthritis (RA) is highly advocated nowadays, little is known about actual PA levels of these patients. In particular, the literature investigating how these PA levels are in proportion to the levels among the general population is scarce.
To compare the self-reported PA levels of patients with RA with those of the general Dutch population.
A sample of 400 RA patients were sent the Short QUestionnaire to ASsess Health-Enhancing PA comprising 10 questions about PA. From these data the proportions meeting the Dutch public health recommendation for PA (i.e., moderate PA for 30 minutes on > or = 5 days/wk) and the total number of minutes of PA per week were calculated. These data were compared with similar data from a representative sample of the general Dutch population.
Two hundred fifty-two patients returned the questionnaire (response 63%). The proportions of RA patients meeting the PA recommendation were similar to those of the general population (57% in categories 45-64 years; 59% in categories > or = 65 years, and 58% in the total groups). The average number of minutes of PA per week was significantly lower in the RA population compared with the general population in the category 45 to 64 years (1836 vs. 2199, respectively, P = 0.001), whereas the difference in the category > or = 65 years was not significant (1115 vs. 1218 minutes, respectively, P = 0.33).
The proportion of RA patients meeting the Dutch PA recommendation was similar to the general Dutch population. However, with respect to the average number of minutes of PA per week, the RA patients were less physically active. Because patients with RA have an increased risk of chronic conditions such as osteoporosis or cardiovascular diseases along with their arthritis, it remains a matter of utmost importance for health care professionals such as rheumatologists, physical therapists, and clinical nurse specialists to promote PA in daily clinical practice and guide patients in achieving and maintaining a healthy lifestyle.
This review focuses on the ability of different accelerometers to assess daily physical activity as compared with the doubly labeled water (DLW) technique, which is considered the gold standard for measuring energy expenditure under free-living conditions. The PubMed Central database (U.S. NIH free digital archive of biomedical and life sciences journal literature) was searched using the following key words: doubly or double labeled or labeled water in combination with accelerometer, accelerometry, motion sensor, or activity monitor. In total, 41 articles were identified, and screening the articles' references resulted in one extra article. Of these, 28 contained sufficient and new data. Eight different accelerometers were identified: 3 uniaxial (the Lifecorder, the Caltrac, and the CSA/MTI/Actigraph), one biaxial (the Actiwatch AW16), 2 triaxial (the Tritrac-R3D and the Tracmor), one device based on two position sensors and two motion sensors (ActiReg), and the foot-ground contact pedometer. Many studies showed poor results. Only a few mentioned partial correlations for accelerometer counts or the increase in R(2) caused by the accelerometer. The correlation between the two methods was often driven by subject characteristics such as body weight. In addition, standard errors or limits of agreement were often large or not presented. The CSA/MTI/Actigraph and the Tracmor were the two most extensively validated accelerometers. The best results were found for the Tracmor; however, this accelerometer is not yet commercially available. Of those commercially available, only the CSA/MTI/Actigraph has been proven to correlate reasonably with DLW-derived energy expenditure.