Patients With Rheumatoid Arthritis Should Participate in Exercise Programs

Laurie Barclay, MD

October 8, 2009 — Patients with rheumatoid arthritis (RA) should participate in regular exercise programs, according to the results of a review reported online in the October 7 issue of the Cochrane Database of Systematic Reviews.

"Based on the evidence in this study, we would recommend aerobic capacity training combined with muscle strength training as routine practice for RA patients," lead author Dr. Emalie Hurkmans, from the Leiden University Medical Center in Leiden, the Netherlands, said in a news release. "But we need more research to establish the recommended length and type of exercise programs, whether patients need to be supervised and if these programs are cost effective."

The goal of this review was to determine the efficacy and safety for people with RA of land or water-based dynamic exercise therapy programs consisting of aerobic capacity and/or muscle strength training. Short-term exercise programs were defined as less than 3 months' duration and long-term as greater than 3 months. After a search of the literature to December 2008 of various databases, the reviewers updated a previous 1998 Cochrane review and categorized the different forms of dynamic exercise programs.

Inclusion criteria were randomized controlled trials in which participants had a supervised exercise program lasting more than 6 weeks, conducted at least twice weekly for more than 20 minutes, with aerobic exercise intensity greater than 55% of the maximal heart rate and/or muscle-strengthening exercises starting at 30% to 50% of 1 repetition maximum. To be included, the randomized controlled trial also had to have at least one of the following outcome measures: functional ability, aerobic capacity, muscle strength, pain, disease activity, or radiologic damage.

Trials meeting inclusion criteria were independently identified by 2 authors, who also rated the methodologic quality and extracted data. They performed a qualitative analysis or best-evidence synthesis and also determined pooled effect sizes for quantitative data analysis of suitable trials.

This updated review identified 4 different dynamic exercise programs and included 8 studies, enrolling a total of 575 patients. Two of these studies were added since the previous review. At least 8 of 10 methodologic criteria were met by 4 of the 8 studies. No adverse effects of exercise were found in any of the included studies.

Studies of short-term, land-based aerobic capacity training showed moderate evidence for a positive effect on aerobic capacity (pooled effect size, 0.99; 95% confidence interval [CI], 0.29 - 1.68). For short-term, land-based aerobic capacity and muscle strength training, there was moderate evidence for a positive effect on aerobic capacity and muscle strength (pooled effect size, 0.47; 95% CI, 0.01 - 0.93). In studies of short-term, water-based aerobic capacity training, evidence was limited for a positive effect on functional ability and aerobic capacity. Long-term, land-based aerobic capacity and muscle strength training were associated with moderate evidence for a positive effect on aerobic capacity and muscle strength.

"One important omission from this study is evidence for long term follow-up effects, so without further studies we can't rule out that the obtained effects vanish if exercise programs are not continued over long periods," Dr. Hurkmans said. "There are also other types of exercise that weren't included in our review, such as flexibility and stability training, and it would be interesting to find out whether these also have positive effects."

Limitations of this study are that only 8 studies were included, 6 of which were published more than 10 years ago. In addition, the populations studied in the included trials consisted mainly of women with a low to medium level of disease activity and an average disease duration of 5 to 14 years, limiting generalizability.

"Based on the evidence, aerobic capacity training combined with muscle strength training is recommended as routine practice in patients with RA," the study authors write. "The optimal duration of the intervention, mode of delivery, and extent of supervision need to be further investigated."

Cochrane Database Syst Rev. Published online October 7, 2009.