By Sue Kennedy - Senior Medical Educator and Physiotherapist & Anne Hardy - Physiotherapy Clinical Lead Rheumatology, Rheumatology Out-patients Department, Royal Derby Hospital.
Exercise for Patients with Rheumatoid Arthritis (RA)
A significant proportion of patients with rheumatoid arthritis (RA) will experience negative biophysical and psychological effects as a result of their inflammatory condition (Table 1) and rheumatology therapists are involved in advising patients on exercises to help mitigate these effects (NRAS 2011).
Table 1: Negative Biophysical and Psychological Effects of RA (Summers et al 2008)
Negative effects of Rheumatoid Arthritis
Joint stiffness and pain
Increased cardio-vascular risk
Reduced lean body mass
Depression and low mood
Increased fat mass
Reduced exercise tolerance
Reduced bone mineral density
However, there is some confusion amongst patients, allied health professionals and medical colleagues as to the most appropriate exercise programme for patients with RA (Law et al 2010).
Exercise programmes for patients with RA have historically focussed on stretching exercises and gentle active/resisted range of motion exercises (low-intensity exercise) (Munneke et al 2004). High-intensity, progressive strength training programmes, delivered in an NHS out-patient gym setting, are not commonly offered to patients with RA (Munneke et al 2004). However, low-intensity exercise may not be the most effective form of exercise for addressing the negative effects of the disease process listed in Table 1(Cooney et al 2011) and the advent of more effective immuno-suppressive drug therapy may enable many more patients to participate in more strenuous and beneficial forms of exercise. In addition, membership of public gyms is a popular social and physical activity amongst the general public, but patients with RA are unsure of what exercises and what intensity of exercise they should be doing(Law et al 2010).
Our rheumatology therapy team undertook a literature review to explore these topics and to identify whether we should be changing how we deliver exercise training in our out-patient department. The results from the literature review led to our development of a Progressive Resistance Training Programme (PRTP) for patients with RA, based in the out-patient physiotherapy gym.
The literature review identified that high-intensity, progressive resistance training programmes (PRTPs) can have a positive effect on the negative consequences of inflammatory arthritis (Table 1) (Lemmey et al 2009, Flint-wagner et al 2009, Baillet et al 2009). Increases in lean muscle mass and reductions in fat mass were observed using bio-electric impedence (Lemmey et al 2009). Improvements in strength, function, health scores and pain have been identified (Speed and Campbell 2010, Lemmey et al 2009, Flint-Wagner et al 2009). In addition, high-intensity PRTPs appear to be safe with minimal reporting of adverse incidents resulting from exercise (Baillet et al 2009). A Cochrane review concluded that ‘based on the evidence, aerobic capacity training combined with muscle strength training is recommended as routine practice in patients with RA’ (Hurkmans et al 2009).
Progressive Resistance Training Programme (PRTP)
As a result of the literature review and discussions with experts in the field (personal communication with Professor Lemmey 2012), a progressive resistance training programme was instigated.
Patient Inclusion Criteria
Patients complaining of muscle weakness, functional deficits and /or reduced exercise capacity or those wishing to gain a better understanding of what exercises they can safely undertake are referred to the class. All patients undergo a full physiotherapy assessment prior to enrolment in the PRTP, which enables assessment of the patient’s specific biopsychosocial problems; whether there are any medical conditions which contraindicate involvement in the class and allow patient-specific goals to be agreed. Patients’ disease activity levels are assessed to ensure that their RA is well-controlled. In addition, patients complete a questionnaire which assesses their readiness for participation in exercise (PAR-Q).
At the initial gym induction session, the patient’s baseline strength measurements are assessed and a working weight calculated based on best-practice advice (Thompson et al 2010) and the research literature (Lemmey et al 2009).
The PRTP takes place within the physiotherapy out-patient gymnasium within the Royal Derby Hospital. The programme begins with 10 minutes of cardio-vascular warm-up exercises using gym equipment such as the cross-trainer, treadmill, rower and static bike. This is followed by 10 minutes stretching exercises aimed at mobilising joints and soft tissues. A half hour progressive strengthening programme follows, during which patients use a variety of gym equipment to progressively strengthen the major muscle groups of the body. Seven exercises have been devised using dumbells and weight stack machines to exercise the biceps, triceps, pectorals, deltoid, gluteals, quadriceps and calf muscles. Patients work with a weight based on 60-80% of their 1 repetition maximum and complete three sets of 8-12 repetitions (Lemmey et al 2009). A 10 minute cool down concludes the programme, during which patients repeat a cardio-vascular work-out using gym equipment. Throughout the 1 hour session patients are encouraged to keep hydrated using the water cooler provided.
Patients currently attend the class once a week for 10 weeks. However, it has been agreed that access to the class will be increased to twice weekly in the New Year based on best evidence which indicates that strength training at least twice a week produces better results (Thompson et al 2010).
Each patient is given a laminated exercise chart which outlines the exercises, the resistance to be used and the number of repetitions they are to try and undertake at each session. This programme is gradually progressed over time and as the muscles gain in strength.
Royal Derby Hospital Gym Membership Scheme
Once patients have completed their 10 weeks in the PRTP, they are encouraged to either join a local gym or to sign up to the Royal Derby Hospital Gym Membership Scheme. The latter allows patients to use the hospital gym as often as they choose (recommended 2-3 times a week) to continue their cardio-vascular and strengthening programme at the cost of £30 per 3 calendar months. The hospital gym is open Monday to Thursday from 8am until 6pm and Friday 8am to 12am. It is hoped that this initiative will help with long-term patient adherence to exercise, which has been highlighted as a major problem with exercise prescription (Lemmey et al 2012).
Patient and Multi-disciplinary Team Involvement
Patients have been involved in this project in a number of ways. The initial idea of an exercise group was piloted and patient feedback concerning group exercise collated and used in planning. One patient wrote, “Small enough group to get individual attention and care. Thoroughly benefited from the exercises which showed me what I was capable of”, which highlighted to us the importance of keeping the gym class numbers small so that patients felt supported whilst they learnt their exercise routine. Another patient wrote, “I wish there was a follow-up class of a keep-fit nature. I am lucky to have found one in my village but others had problems”, which lead to the development of the Hospital Gym Membership Scheme.
In addition, patients have been consulted concerning the use of joint protection techniques whilst using the gym equipment. For example, patients identified the best way of teaching other patients how to safely adjust the height of the weight stack. Patients have also had helpful contributions to make concerning the terminology employed in the laminated patient exercise sheets used in the class. It was suggested that descriptors of the exercises rather than medical terminology should be used to aid patients understanding of what exercises they needed to do. In addition, photographs were added demonstrating the exercise technique and machine positions.
Occupational Therapy, Physiotherapy, Nursing and Consultant Colleague Involvement
Occupational and physiotherapy colleagues were consulted and suggestions made regarding joint protection techniques, such as the use of an assistive devise to help patients to undo the static bike seat-adjustment mechanism. In addition, starting in February 2013 the PRTP will be running twice a week rather than just the once, which has been made possible through the use of a therapy assistant for the additional weekly session. The member of staff has been trained and achieved competencies in the use of the gym equipment and will able to supervise patients whilst they undertake their exercise programmes. However, progression of patients’ exercise programmes will be left to a qualified physiotherapist. Rheumatology nurses and consultants within the team have been involved in the planning of the audit of the PRTP and through talking to patients about exercise and referring appropriate patients for the group.
The PRTP is currently being audited to assess a number of outcomes. Functional outcome is being assessed through the use of the Health Assessment Questionnaire (HAQ) and the EQ5D5L questionnaire. Patient satisfaction and self-efficacy are being assessed through a local department questionnaire and the Arthritis self-efficacy questionnaire respectively. Improvements in strength are being evaluated through calculation of the total weekly weight lifted and total repetitions and through the 30 second sit-to-stand timed test. In addition, the number of patients taking up the offer of joining the hospital gym and the income generated is being recorded.
Resources, Staffing and Sustainability
No additional resources have been required in order to set up this initiative. The physiotherapy out-patient gymnasium was fully equipped and under-utilised and as a result the PRTP makes good use of existing resources. In addition, it is anticipated that income generation will result from patients’ signing up for the hospital gym programme.
Staffing of this initiative has been possible through the use of existing staffing hours. Prior to the development of the PRTP, physiotherapy staff would have developed and monitored individual patient exercise programmes or would have referred patients through for other group exercise programmes such as hydrotherapy. By setting up the PRTP we have extended patients’ choice regarding involvement in exercise and have improved our efficiency through the use of group exercise rather than individual programmes. A group atmosphere also creates an environment which may help with patient adherence to exercise, as patients find that they can give and receive support and encouragement during the sessions.
We would like to purchase a further weight-stack machine which would enable us to have more patients undertaking their exercise regimes in the gym at one time.
We would like to undertake further literature reviews and consult dietetic colleagues exploring the evidence regarding the effect of protein consumption and development of muscle strength, with view to providing advice for patients undertaking a PRT programme.
Patient Testimonials and Video
Please see attached testimonials from past and current patients and the pictures and video clips of the exercise class in action.
Submitted on behalf of
Anne Hardy, Ruth Machej, Tony Moore, Bill Wilsdon, Julie Tougher, Heather Spooner, Carrie Robinson
Baillet A, Payraud E, Niderprim V, Nissen M et al (2009) A dynamic exercise programme to improve patients' disability in rheumatoid arthritis: a prospective randomised controlled trial Rheumatology 48 pp.410-415
Cooney J, Law R, Matschke V et al (2011) Benefits of exercise in rheumatoid arthritis Journal of Aging Research. Available from: http://www.hindawi.com/journals/jar/2011/681640/abs/
Flint-Wagner H, Lisse J, Lohman T, going S et al (2009) Assessment of a Sixteen Week Training Programme on Strength, Pain and Function in Rheumatoid Arthritis Patients Journal of Clinical Rheumatology 15 (4) pp. 165-171
Hurkmans E, Giesen F, Vlieland T et al (2009) Dynamic exercise programmes in patients with rheumatoid arthritis. Available from: http://onlinelibrary.wiley.com.doi.10.1002.14651858.CD006853.pub2/abstract
Law R, Breslin A, Oliver E, Mawn L, Markland D, Maddison P, Thom J (2010) Perceptions of the effects of exercise on joint health in rheumatoid arthritis patients Rheumatology 49 pp.2444-2451
Lemmey A, Marcora S, Chester K et al (2009) Effects of High-intensity Resistance Training in Patients with Rheumatoid Arthritis: a randomised controlled trial Arthritis and rheumatism 61 (12) pp. 1726-1734
Lemmey A, Williams S, Marcora S, Jones J and Maddison P (2012) Are the benefits of a high-intensity resistance trainging program sustained in rheumatoid arthritis patients? A 3 year follow-up study Arthritis Care and Research 64 (1) pp. 71-75
Munneke M, Jong Z, Zwinderman A et al (2004) High intensity exercise of conventional exercise for patients with rheumatoid arthritis? Outcome expectations of patients, rheumatologists and physiotherapists Ann Rheum Dis 63 pp. 804-808
NRAS (2011) RA and Physiotherapy: a national survey
http://www.nras.org.uk/includes/documents/cm docs/2011/r/ra and physiotherapy report 12 october 2011.pdf
Summers G, Deighton C, Rennie M, Booth A (2008) Rheumatoid Cachexia: a clinical perspective Rheumatology 47 pp. 1124-1131
Thompson W, Gordon N and Pescatello L (2010) (eds) ACSM's Guidelines for Exercise Testing and Prescription (8thed), Lippincott Williams and Wilkins, Philadelphia