Research findings in an understudied patient group suggest tailored exercise therapy improves functioning with low risk of harm.
Long-term tailored exercise is beneficial for people with rheumatoid arthritis and severe functional limitations, a Dutch study has found.
After one year of physical therapy delivered by trained health professionals, RA patients who had reported severe limitations in daily activities and/or social participation showed significant improvements in physical function and quality of life compared with similar patients who received usual care.
“This study is the first evaluation of a personalised, longstanding, supervised therapy programme in patients with RA with severe disability due to persisting disease activity, joint damage and/or comorbidities,” wrote the authors in the Annals of the Rheumatic Diseases.
“At 52 weeks, the longstanding exercise therapy programme was more effective than usual care with respect to functional ability and physical quality of life.
“In people with RA and severe functional limitations, the provision of personalised, longstanding, supervised exercise therapy should be considered.”
The study included around 200 RA patients who reported severe limitations in daily activities such as self-care, getting in and out of bed, using the toilet or general mobility. They were randomised 1:1 to receive the exercise intervention or usual care.
The intervention was a personalised exercise program with a standardised treatment protocol delivered by a trained primary care physical therapist with specific expertise in rheumatic diseases.
Activities included aerobic, muscle strengthening, flexibility and functional exercises. Participants also received patient education and recommendations about physical activity in general. There were two sessions per week for the first three months, with one session weekly thereafter and optional additional sessions.
The main measure was the Patient-Specific Complaints Numerical Rating Scale (PSC NRS), where participants rank their three most limited activities and rate the difficulty on a scale of 0 to 10, where 0 is easy and 10 is impossible.
The primary outcome was change in the highest-ranked PSC NRS score at 52 weeks, with secondary outcomes including the 6-minute walk test, physical function, quality of life and mental functioning.
At 52 weeks, the change from baseline in PSC1 NRS was statistically significantly greater in the intervention group than the usual care group, with a mean difference of -2.7 and -1.0 respectively.
There were statistically significant improvements in the secondary outcomes, with the exception of the mental functioning score. The authors noted that the mental health scores were “relatively favourable” at baseline and suggested that there may have been “little room for improvement”.
There was only one adverse event reported over the study period, where a patient experienced dizziness while exercising that resolved after a few minutes of rest.
“Therefore, the results suggest that the risk of harms of active exercise therapy, if applied according to the intervention protocol, is very low in patients with RA with complex disease,” wrote the authors.
While exercise therapy is recommended for RA patients in various clinical guidelines, those with significant joint damage, multiple joint replacements and/or comorbidities are often not included in research, the authors noted.
“This is striking, as in particular, patients in this subgroup may have severe limitations in daily activities and/or social participation and are putatively in need of exercise therapy, most likely of longer duration due to fluctuations of health status over time,” wrote the authors.
The results of the study suggest that with specially trained physical therapists and a personalised program, exercise therapy is not only feasible but beneficial in this subgroup of RA patients.
Limitations of the study included insufficient blinding, which may have biased outcomes: most patients and assessors were able to guess which group the patients were in. The researchers didn’t collect potentially useful data on medication changes, changes in disease activity or specific symptoms such as pain, fatigue and muscle weakness.
It also turned out that the control group received a “substantial” amount of physical therapy as part of their usual care, which may have reduced the differences between the two groups.
“Further research is needed to explore the long-term outcomes and potential factors influencing treatment response, as well as the cost-effectiveness of the intervention,” concluded the authors.
