Effect of intensive exercise on patients with active rheumatoid arthritis: a randomised clinical trial.

Abstract

Objective--To investigate the effects of a dynamic, intensive exercise regimen on pain, disease activity, and physical functioning in active rheumatoid arthritis (RA).

Methods--64 patients with RA with a mean age of 60 (13) years and mean disease duration of 8 (8) years, admitted to hospital because of active disease, were randomly assigned to an intensive exercise programme or to a conservative exercise programme during their period in hospital with a mean length of 30 (14) days. The intensive exercise programme consisted of knee and shoulder dynamic and isometric muscle strengthening exercises against resistance five times a week and conditioning bicycle training three times a week and was supplemental to the conservative exercise programme of range of motion and isometric exercises. Indices of disease activity, pain, muscle strength, and functional ability were assessed at 0, 3, 6, 12, and 24 weeks by a blinded observer.

Results--The medical treatment during the study was the same in both groups. Both groups improved in measures of disease activity, differences between groups were not statistically significant. The mean improvement in disease activity score at 24 weeks in the intensive and conservative exercise group was -1.4 (1.5) and -0.7 (1.4), respectively. Measures of physical functioning improved significantly for patients in the intensive exercise group, and differences between groups were statistically significant for measures of muscle strength.

Conclusion--A short term intensive exercise programme in active RA is more effective in improving muscle strength than a conservative exercise programme and does not have deleterious effects on disease activity.

(Ann Rheum Dis 2000;59:615-621)

Owing to a fear of enhancing joint inflammation and accelerating cartilage destruction it has been advocated that exercise treatment in active rheumatoid arthritis (RA) should be restricted to gentle assisted range of motion (ROM) exercises.[1-3] In subacute phases isometric exercises which put little stress on the joints are recommended. So far, research on the conservative management of active RA has focused on the best amount of immobilisation and bed rest, [4-6] which are considered important components of the management of active RA. However, the risks of bed rest and immobilisation are well known. Loss of muscle strength during immobilisation may add up to 1-2% a day,[7-11] and is more pronounced in the presence of joint disease or injury.[12-14] A decline of cardiorespiratory function even occurs in healthy subjects during voluntary bed rest with a moderate exercise regimen.[15] In healthy subjects the time to recover exceeds the time of immobilisation.[7 8]

Active disease may persist for a prolonged period of time and a conservative exercise regimen may be inadequate to prevent a decline in physical functioning. Dynamic exercises have been shown to be more effective in improving muscle strength and cardiorespiratory function than a conservative exercise regimen in patients with stable RA.[16-18] An intensive exercise regimen including dynamic exercises against resistance might also be of value in active RA, provided that these exercises do not increase symptoms. The primary aim of this study was to examine the consequences of an intensive exercise regimen on disease activity in active RA. In addition, the efficacy of an intensive exercise programme in active RA on physical functioning was studied.

Patients and methods

Sixty four consecutive patients admitted to hospital for multidisciplinary treatment in a rheumatology clinic because of active RA and loss of functional ability participated in the study. All patients fulfilled the following inclusion criteria: (1) RA according to the 1987 American Rheumatism Association criteria[19]; (2) active disease as determined by the presence of six or more swollen joints and at least two of the following criteria: (a) morning stiffness of more than 45 minutes; (b) tender joint count [is greater than] 9; and (c) Westergren erythrocyte sedimentation rate (ESR) [is greater than] 28 mm/ 1st h; (3) age between 20 and 80 years; and (4) ability to walk 50 feet (15 m) indoors. Exclusion criteria were the presence of arthroplasties of the knee joints and inability to tolerate training owing to the presence of serious cardiac or lung disease. All patients received primary nursing care and had to keep to fixed hours for rest--about two hours a day. ROM and isometric muscle strengthening exercises supervised by exercise therapists were carried out daily. An occupational therapist informed the patients about joint protection and provided joints splints if considered necessary. A social worker focused on psychosocial problems related to the disease. The medical treatment consisted of optimisation of the use of non-steroidal anti-inflammatory drugs (NSAIDs), the institution of disease modifying antirheumatic drugs (DMARDs), and intra-articular injections with corticosteroids, if necessary.

STUDY DESIGN

The study design was a single blinded, randomised trial of the effect of an intensive exercise programme additional to the conservative exercise regimen during the period of stay in hospital. The study was approved by the medical ethical committee of the hospital. After informed consent patients were included in the trial within the first three days after admission to hospital. Patients were stratified by sex and randomly allocated by an independent person to the intensive or the conservative exercise programme by means of sealed, opaque envelopes. Allocation took place immediately after the baseline assessments.

EXERCISE PROGRAMMES

All patients participating in the study followed the usual conservative exercise programme of ROM exercises and isometric exercises. All joint movements of the hands and feet were exercised throughout the entire possible range of motion and repeated twice. The movements were active-assisted, performed at a low pace. In addition, isometric exercises of the larger joints were performed without resistance. Exercises were carried out in prone and sitting positions. The exercises were individually supervised by exercise therapists …