Arja Häkkinen

A randomized two-year study of the effects of dynamic strength training on muscle strength, disease activity, functional capacity, and bone mineral density in early rheumatoid arthritis

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 bi-monthly) 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. RESULTS Sixty-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.

Physical inactivity in patients with rheumatoid arthritis: data from twenty-one countries in a cross-sectional, international study.

OBJECTIVE Regular physical activity is associated with decreased morbidity and mortality. Traditionally, patients with rheumatoid arthritis (RA) have been advised to limit physical exercise. We studied the prevalence of physical activity and associations with demographic and disease-related variables in patients with RA from 21 countries. METHODS The Questionnaires in Standard Monitoring of Patients with Rheumatoid Arthritis (QUEST-RA) is a cross-sectional study that includes a self-report questionnaire and clinical assessment of nonselected consecutive outpatients with RA who are receiving usual clinical care. Frequency of physical exercise (>or=30 minutes with at least some shortness of breath, sweating) is queried with 4 response options: >or=3 times weekly, 1-2 times weekly, 1-2 times monthly, and no exercise. RESULTS Between January 2005 and April 2007, a total of 5,235 patients from 58 sites in 21 countries were enrolled in QUEST-RA: 79% were women, >90% were white, mean age was 57 years, and mean disease duration was 11.6 years. Only 13.8% of all patients reported physical exercise>or=3 times weekly. The majority of the patients were physically inactive with no regular weekly exercise: >80% in 7 countries, 60-80% in 12 countries, and 45% and 29% in 2 countries, respectively. Physical inactivity was associated with female sex, older age, lower education, obesity, comorbidity, low functional capacity, and higher levels of disease activity, pain, and fatigue. CONCLUSION In many countries, a low proportion of patients with RA exercise. These data may alert rheumatologists to motivate their patients to increase physical activity levels.

Mixed-Methods Resistance Training Increases Power and Strength of Young and Older Men.

PURPOSE This study examined the effects of mixed-methods resistance training on young and older men to determine whether similar increases in muscle power were elicited. METHODS Effects of 10 wk of a periodized resistance-training program designed to increase muscle size, strength, and maximal power on isometric squat strength, time course of force development, muscle fiber characteristics, and muscle activation (iEMG), as well as force and power output during squat jumps, were compared in young (YM, 30 +/- 5 yr, N = 8) and older men (OM, 61 +/- 4 yr, N = 10). RESULTS Isometric squat strength was higher in the YM compared with OM at all testing occasions and increased over the training period by 23 +/- 15% and 40 +/- 42% for the YM and OM, respectively. The early phase of the force-time curve was shifted upward in both groups over the course of the training. During the squat jumps, the YM produced higher force and power at all test occasions and at all loads tested compared with the OM. The YM increased power output by 15 +/- 14%, 33 +/- 16%, and 26 +/- 12%, and the OM by 7 +/- 5%, 36 +/- 23%, and 25 +/- 16% for the 17 kg, and 30% and 60% 1RM loads, respectively. CONCLUSION Although the results of this study confirm age-related reductions in muscle strength and power, the older men did demonstrate similar capacity to young men for increases in these variables via an appropriate periodized resistance-training program that includes rapid, high-power exercises.

STRETCHING EXERCISES VS MANUAL THERAPY IN TREATMENT OF CHRONIC NECK PAIN: A RANDOMIZED, CONTROLLED CROSS-OVER TRIAL

OBJECTIVE To compare the effects of manual therapy and stretching exercise on neck pain and disability. DESIGN An examiner-blinded randomized cross-over trial. PATIENTS A total of 125 women with non-specific neck pain. METHODS PATIENTS were randomized into 2 groups. Group 1 received manual therapy twice weekly and Group 2 performed stretching exercises 5 times a week. After 4 weeks the treatments were changed. The follow-up times were after 4 and 12 weeks. Neck pain (visual analogue scale) and disability indices were measured. RESULTS Mean value (standard deviation) for neck pain was 50 mm (22) and 49 mm (19) at baseline in Group 1 and Group 2, respectively, and decreased during the first 4 weeks by 26 mm (95% Confidence Interval 20-33) and 19 mm (12-27), respectively. There was no significant difference between groups. Neck and shoulder pain and disability index decreased significantly more in Group 1 after manual therapy (p=0.01) as well as neck stiffness (p=0.01). CONCLUSION Both stretching exercise and manual therapy considerably decreased neck pain and disability in women with non-specific neck pain. The difference in effectiveness between the 2 treatments was minor. Low-cost stretching exercises can be recommended in the first instance as an appropriate therapy intervention to relieve pain, at least in the short-term.

Effects of Strength Training on Neuromuscular Function and Disease Activity in Patients with Recent-onset Inflammatory Arthritis

Thirty-nine consecutive patients with recent-onset rheumatoid or psoriatic arthritis were randomly allotted for six months period either to the experimental progressive dynamic strength training group (EG, 10 women and 11 men; 41 +/- 10 yrs), or to the control group (CG, 10 women and 8 men; 45 +/- 11 yrs) who just maintained their habitual physical activities. All patients received antirheumatic medication throughout the experimental period. During the study period significant improvements took place in the EG in maximal muscle strength of all examined muscle groups (31.5% for the knee extensors, p < 0.001; 14.8% and 10.7% for the trunk flexors and extensors, p < 0.01; 27.8% and 20.4% for grip strength, p < 0.001) as well as in erytrocyte sedimentation rate (p < 0.05). Ritchies articular index (RI) (p < 0.001) and HAQ (p < 0.01). In the CG only the decrease in RI was statistically significant (p < 0.05). Erosive changes in joints increased only slightly and less in the EG than in the CG. The present results suggest that dynamic strength training in early arthritis increases the neuromuscular performance without detrimental effects on disease activity or joint damage.

Effect of long‐term neck muscle training on pressure pain threshold: A randomized controlled trial

Muscle tenderness has been measured in several studies to evaluate effectiveness of treatment methods, but only short‐term results have been reported so far. The aim of the present study was to evaluate the long‐term effects of two different muscle training methods on the pressure pain threshold of neck muscles in women with neck pain.

Eight months of physical training in warm water improves physical and mental health in women with fibromyalgia: a randomized controlled trial.

OBJECTIVE To evaluate the feasibility of 8 months of supervised exercise therapy in warm water and its effects on the impact of fibromyalgia on physical and mental health and physical fitness in affected women. METHODS Thirty women with fibromyalgia were randomly assigned to an exercise therapy group (n = 15) or a control group (inactive) (n = 15). The impact of fibromyalgia on physical and mental health was assessed using the Fibromyalgia Impact Questionnaire and the anxiety state with State-Trait Anxiety Inventory. Physical fitness was measured using the following tests: Canadian Aerobic Fitness; hand-grip dynamometry; 10-metre walking; 10-step stair-climbing and blind 1-leg stance. RESULTS After 8 months of training, the exercise therapy group improved compared with the control group in terms of physical function (20%), pain (8%), stiffness (53%), anxiety (41%), depression (27%), Fibromyalgia Impact Questionnaire total scores (18%), State-Trait Anxiety Inventory score (22%), aerobic capacity (22%), balance (30%), functional capacity for walking (6%), stair-climbing with no extra weight (14%) and stair-climbing 10 kg-weighted (25%). CONCLUSION Eight months of supervised exercise in warm water was feasible and led to long-term improvements in physical and mental health in patients with fibromyalgia at a similar magnitude to those of shorter therapy programmes.

High prevalence of asymptomatic cervical spine subluxation in patients with rheumatoid arthritis waiting for orthopaedic surgery

Objective: To study the prevalence of cervical spine subluxation in patients with rheumatoid arthritis waiting for orthopaedic surgery, and symptoms that might be associated with the disorders. Methods: 194 patients with rheumatoid arthritis were referred for orthopaedic surgery at Jyväskylä Central Hospital, 154 (79%) of whom volunteered for the present study including clinical examination, laboratory tests, radiographs of the cervical spine, hands, and feet, and self report questionnaires. Definition of anterior atlantoaxial subluxation (aAAS) was >3 mm and of subaxial subluxation (SAS) ⩾3 mm. Atlantoaxial impaction (AAI) was analysed following to the Sakaguchi-Kauppi method. Results: 67 patients (44%) had cervical spine subluxation or previous surgical fusion. The prevalence of aAAS, AAI, SAS, or previous fusion was 27 (18%), 24 (16%), 29 (19%), and 8 (5%), respectively; 69% of patients with cervical spine subluxations (those with fusions excluded) reported neck pain, compared with 65% of patients without subluxations (p = 0.71). The prevalence of occipital, temporal, retro-orbital, and radicular pain in upper extremities was similar in patients with or without cervical spine subluxations (54% v 43%; 17% v 31%; 25% v 24%; 47% v 48%, respectively). However, patients with subluxations were older, had longer disease duration, more active disease, poorer function according to the Health Assessment Questionnaire, and had more often erosive disease. Conclusions: Asymptomatic cervical spine subluxation is common in patients with rheumatoid arthritis waiting for orthopaedic surgery. Regardless of symptoms, the possibility of cervical spine subluxation in patients with severe rheumatoid arthritis should be considered in preoperative evaluation.

Muscle hypertrophy, strength development, and serum hormones during strength training in elderly women with fibromyalgia

Objective: To examine the effects of strength training on maximal force, cross‐sectional area (CSA), and electromyographic (EMG) activity of muscles and serum hormone concentrations in elderly females with fibromyalgia (FM). Methods: Twenty‐six patients with FM were randomly assigned to a training (FMT; n = 13; mean age 60 years) or a control (FMC; n = 13; 59 years) group. FMT performed progressive strength training twice a week for 21 weeks. The measurements included maximal isometric and concentric leg extension forces, EMG activity of the vastus lateralis and medialis, CSA of the quadriceps femoris, and serum concentrations of testosterone (T), free testosterone (FT), growth hormone (GH), insulin‐like growth factor‐1 (IGF‐1), dehydroepiandrosterone sulfate (DHEAS), and cortisol. Subjectively perceived symptoms of FM were also assessed. Results: All patients were able to complete the training. In FMT strength training led to increases of 36% (p<0.001) and 33% (p<0.001) in maximal isometric and concentric forces, respectively. The CSA increased by 5% (p<0.001) and the EMG activity in isometric action by 47% (p<0.001) and in concentric action by 57% (p<0.001). Basal serum hormone concentrations remained unaltered during strength training. The subjective perceived symptoms showed a minor decreasing tendency (ns). No statistically significant changes occurred in any of these parameters in FMC. Conclusion: Progressive strength training increases strength, CSA, and voluntary activation of the trained muscles in elderly women with FM, while the measured basal serum hormone concentrations remain unaltered. Strength training benefits the overall physical fitness of the patients without adverse effects or any exacerbation of symptoms and should be included in the rehabilitation programmes of elderly patients with FM.

Reproducibility of imaging human knee cartilage by delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) at 1.5 Tesla

OBJECTIVE The purpose of this study was to investigate the day-to-day reproducibility of the delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) measurement at different knee joint surfaces in healthy subjects at 1.5 Tesla (T). METHODS The dGEMRIC experiment was repeated for 10 asymptomatic volunteers three times with an average interval of 5 days between scans. The measurement was performed from a single sagittal slice through the center of the lateral femoral condyle and from the center of the patella in the axial plane. Cartilage was manually segmented into superficial, deep and full-thickness regions of interests (ROIs) at different topographical locations of the femur, tibia and patella. The reproducibility was evaluated separately for each ROI as well as for the entire bulk cartilage in the slice of each joint surface. RESULTS The reproducibility at various ROIs expressed by root-mean-square average coefficient of variation (CV(RMS)) ranged between 4.7-12.9%. Thirty out of thirty-three ROIs showed a CV(RMS) less than 10%. Intraclass correlation coefficient (ICC) ranged between 0.45 and 0.98. The CV(RMS) and ICC for bulk dGEMRIC were 4.2% and 0.95 for femur, 5.5% and 0.87 for tibia, and 4.8% and 0.97 for patella. CONCLUSIONS The dGEMRIC technique showed good day-to-day reproducibility, on the average 8% for small deep or superficial segments, 7% for full-thickness ROIs and 5% for bulk ROIs covering all visible cartilage in a single joint surface. We conclude that dGEMRIC imaging at field strength 1.5 T can be used as a reliable instrument for the assessment of articular cartilage when staff has been carefully trained.