Rebecca-Jane Law

Benefits of exercise in Rheumatoid Arthritis.

This paper aims to highlight the importance of exercise in patients with rheumatoid arthritis (RA) and to demonstrate the multitude of beneficial effects that properly designed exercise training has in this population. RA is a chronic, systemic, autoimmune disease characterised by decrements to joint health including joint pain and inflammation, fatigue, increased incidence and progression of cardiovascular disease, and accelerated loss of muscle mass, that is, “rheumatoid cachexia”. These factors contribute to functional limitation, disability, comorbidities, and reduced quality of life. Exercise training for RA patients has been shown to be efficacious in reversing cachexia and substantially improving function without exacerbating disease activity and is likely to reduce cardiovascular risk. Thus, all RA patients should be encouraged to include aerobic and resistance exercise training as part of routine care. Understanding the perceptions of RA patients and health professionals to exercise is key to patients initiating and adhering to effective exercise training.

Perceptions of the effects of exercise on joint health in rheumatoid arthritis patients

OBJECTIVESnExercise is important in RA management. However, RA patients are less active than the general population. This qualitative study explores the perceptions of patients regarding the effects of exercise on joint health.nnnMETHODSnA purposive sample of 12 female and 6 male RA outpatients [age: 23-76 years; disease duration: 2.5 months to 33 years; HAQ score: 0-2.13] participated in four moderated focus groups. The main questions addressed were: (i) How do you feel exercise affects your joints?; and (ii) What affects your exercise behaviour? Transcriptions were independently analysed with 455 meaning units identified. An inductive, thematic analysis was conducted using established techniques. Discussion with a third analyst contributed to consensus validation.nnnRESULTSnSixteen constructs emerged, clustering into five themes, reflecting the issues relating to exercise and joint health in RA patients. Emergent themes were: health professionals showing a lack of exercise knowledge, not knowing what exercise should be done, worry about causing harm to joints, not wanting to exercise as joints hurt and having to exercise because it is helpful.nnnCONCLUSIONSnRA patients demonstrated awareness of the advantages of exercise for their joints, both experientially and through education. However, they perceived that health professionals lacked certainty and clarity regarding specific exercise recommendations and the occurrence of joint damage. Thus, to enhance patient-centred exercise prescription in the RA population, uncertainties surrounding joint health, pain symptoms and exercise specificity need to be addressed, alongside continual emphasis of exercise benefits.

Perceptions of Issues Relating to Exercise and Joint Health in Rheumatoid Arthritis: A UK-Based Questionnaire Study

OBJECTIVESnThis questionnaire study investigated the perceptions of rheumatoid arthritis (RA) patients across the UK in relation to exercise and joint health. The validity of the measure was also assessed.nnnMETHODSnMembers of the National Rheumatoid Arthritis Society (NRAS) with self-reported RA completed the questionnaire online. Items related to five factors that emerged from previous qualitative research. Participants responded using a five-point Likert-style scale (strongly disagree to strongly agree). The International Physical Activity Questionnaire (IPAQ) assessed physical activity. The model was tested using confirmatory factor analysis (LISREL 8.8); statistical analyses were conducted using the Statistical Package for the Social Sciences (SPSS).nnnRESULTSnA total of 247 responses were collected over 47 days (88% females; age: 18-77 years; disease duration: <1-51 years). Acceptable factorial validity was revealed (Satorra-Bentler χ(2) u2009=u2009774.47, dfu2009=u2009454, pu2009<u20090.001, root mean squared error of approximation (RMSEA)u2009=u20090.05, 90% confidence interval RMSEAu2009=u20090.05-0.06, comparative fit indexu2009=u20090.94, standardized root mean square residualu2009=u20090.09), with the following factor endorsements: Health professionals show exercise knowledge (19%); Knowing what exercise should be done (43%); Having to exercise because it is helpful (72%); Worry about causing harm to joints (44%); and Not wanting to exercise as joints hurt (52%). Patient concerns about joint pain, joint harm and how to exercise were significantly associated with lower physical activity (pu2009<u20090.05).nnnCONCLUSIONSnThese results confirm that patients perceive exercise as beneficial. However, concerns about how to exercise, joint pain, causing harm to joints and a perceived lack of exercise knowledge among health professionals remain. Addressing these concerns may have implications for increasing physical activity within the RA population.

The Effects of Aerobic and Resistance Exercise on Markers of Large Joint Health in Stable Rheumatoid Arthritis Patients: A Pilot Study.

OBJECTIVEnExercise is beneficial for people with rheumatoid arthritis (RA). However, patients and health professionals have expressed concern about the possible detrimental effects of exercise on joint health. The present study investigated the acute and chronic effects of high-intensity, low-impact aerobic and resistance exercise on markers of large joint health in RA.nnnMETHODSnEight RA patients and eight healthy, matched control (CTL) participants performed 30 minutes high-intensity, low-impact aerobic and lower-body resistance exercise, one week apart. Primary outcome measures assessing joint health were serum cartilage oligomeric matrix protein (sCOMP) and knee joint synovial inflammation (Doppler ultrasound colour fraction; CF). These measures were taken at baseline, immediately after and 0.5, one, two, six and 24 hours post-exercise. In a separate study, nine RA patients completed eight weeks of progressive exercise training. The same outcome measures were reassessed at baseline, and at one hour post-exercise of training weeks 0, 1, 4 and 8.nnnRESULTSnRA patients showed higher overall sCOMP [RA: 1,347 ± 421, CTL: 1,189 ± 562 ng/mL; p < 0.05; effect size (ES) = 0.32] and CF when scanned longitudinally (RA: 0.489 ± 0.30 × 10(-3) , CTL: 0.101 ± 0.13 × 10(-3) ; p < 0.01; ES = 1.73) and transversely (RA: 0.938 ± 0.69 × 10(-3) , CTL: 0.199 ± 0.36 × 10(-3) ; p < 0.01; ES = 1.33) than CTL. However, no acute effects on joint health were observed post-exercise. Similarly, no chronic effects were observed over eight weeks of combined aerobic and resistance training in RA, with positive effects on physical fitness and function.nnnCONCLUSIONSnRA patients on stable treatment with low disease activity were able to perform an individually prescribed high-intensity, low-impact aerobic and resistance exercise without changes in markers of large joint health. Copyright

Health Professionals' Perceptions of the Effects of Exercise on Joint Health in Rheumatoid Arthritis Patients.

OBJECTIVESnAlthough exercise is an important factor in the management of rheumatoid arthritis (RA), research indicates that patients perceive that health professionals (HPs) are uncertain about the place of exercise in treatment and its relationship with joint damage. The present study investigated the perceptions of HPs regarding the effects of exercise on joint health in RA patients.nnnMETHODSnA questionnaire investigating perceptions of exercise and joint health was distributed via professional networks and websites. Confirmatory factor analysis (CFA) was used to analyse questionnaire data and develop a focus group interview guide. Focus groups were conducted with multidisciplinary teams (MDTs) of rheumatology HPs and analysed using framework analysis.nnnRESULTSnA total of 137 rheumatology HPs (95 female; 27-65 years of age) completed questionnaires. CFA showed that a four-factor model provided a marginally acceptable fit. Analysis of four focus groups (nu2009=u200924; 19 female; 30-60 years of age) identified five themes relating to HPs perceptions of exercise and joint health in RA patients: Exercise is beneficial, Concerns about damage to joints, Patients have barriers to exercise, HP knowledge differs and Patients may think service delivery is vague.nnnCONCLUSIONSnHPs were highly aware of the benefits and importance of exercise for RA patients. However, to remove the patient perception that HPs lack certainty and clarity regarding exercise it is important to ensure: (i) consistent promotion of exercise across the whole MDT; (ii) clear provision of information regarding rest, joint protection and exercise; (iii) HP education to ensure consistent, accurate knowledge, and understanding of the potential for conflicting advice when promoting exercise as part of an MDT. Copy

Patient perspectives on delays in diagnosis and treatment of cancer: a qualitative analysis of free-text data.

BACKGROUNDnEarlier cancer diagnosis is crucial in improving cancer survival. The International Cancer Benchmarking Partnership Module 4 (ICBP4) is a quantitative survey study that explores the reasons for delays in diagnosis and treatment of breast, colorectal, lung, and ovarian cancer. To further understand the associated diagnostic processes, it is also important to explore the patient perspectives expressed in the free-text comments.nnnAIMnTo use the free-text data provided by patients completing the ICBP4 survey to augment the understanding of patients perspectives of their diagnostic journey.nnnDESIGN AND SETTINGnQualitative analysis of the free-text data collected in Wales between October 2013 and December 2014 as part of the ICBP4 survey. Newly-diagnosed patients with either breast, ovarian, colorectal, or lung cancer were identified from registry data and then invited by their GPs to participate in the survey.nnnMETHODnA thematic framework was used to analyse the free-text comments provided at the end of the ICBP4 survey. Of the 905 patients who returned a questionnaire, 530 included comments.nnnRESULTSnThe free-text data provided information about patients perspectives of the diagnostic journey. Analysis identified factors that acted as either barriers or facilitators at different stages of the diagnostic process. Some factors, such as screening, doctor-patient familiarity, and private treatment, acted as both barriers and facilitators depending on the context.nnnCONCLUSIONnFactors identified in this study help to explain how existing models of cancer diagnosis (for example, the Pathways to Treatment Model) work in practice. It is important that clinicians are aware of how these factors may interact with individual clinical cases and either facilitate, or act as a barrier to, subsequent cancer diagnosis. Understanding and implementing this knowledge into clinical practice may result in quicker cancer diagnoses.

Development of an intervention to expedite cancer diagnosis through primary care: a protocol

Background GPs can play an important role in achieving earlier cancer diagnosis to improve patient outcomes, for example through prompt use of the urgent suspected cancer referral pathway. Barriers to early diagnosis include individual practitioner variation in knowledge, attitudes, beliefs, professional expectations, and norms. Aim This programme of work (Wales Interventions and Cancer Knowledge about Early Diagnosis [WICKED]) will develop a behaviour change intervention to expedite diagnosis through primary care and contribute to improved cancer outcomes. Design & setting Non-experimental mixed-method study with GPs and primary care practice teams from Wales. Method Four work packages will inform the development of the behaviour change intervention. Work package 1 will identify relevant evidence-based interventions (systematic review of reviews) and will determine why interventions do or do not work, for whom, and in what circumstances (realist review). Work package 2 will assess cancer knowledge, attitudes, and behaviour of GPs, as well as primary care teams’ perspectives on cancer referral and investigation (GP survey, discrete choice experiment [DCE], interviews, and focus groups). Work package 3 will synthesise findings from earlier work packages using the behaviour change wheel as an overarching theoretical framework to guide intervention development. Work package 4 will test the feasibility and acceptability of the intervention, and determine methods for measuring costs and effects of subsequent behaviour change in a randomised feasibility trial. Results The findings will inform the design of a future effectiveness trial, with concurrent economic evaluation, aimed at earlier diagnosis. Conclusion This comprehensive, evidence-based programme will develop a complex GP behaviour change intervention to expedite the diagnosis of symptomatic cancer, and may be applicable to countries with similar healthcare systems.

Perceptions Relating to Exercise in Rheumatoid Arthritis

Historically, the recommendation of exercise for patients with rheumatoid arthritis (RA) has been avoided by clinicians due to fears that such activity may contribute to joint damage and result in worsening of disease. Hence, previous treatment of active RA has included bed rest and splinting of the affected joints (Partridge & Duthie, 1962). Over recent decades however, the numerous physiological advantages of exercise have become well-established and include improved cardiovascular health, increased muscular hypertrophy and increased bone mineral density. Enhanced physical function and psychosocial advantages have also been shown in followers of a continued exercise programme (Baillet et al., 2009; Bilberg et al., 2005; de Jong et al, 2003, 2004; Hakkinen et al., 2001; Lemmey et al., 2009; Marcora et al., 2005; Melikoglu et al., 2006; Van Den Berg et al., 2006; van den Ende et al., 1996, 2000). Importantly, it has also been found that high-intensity exercise training is of superior effectiveness, with no detrimental effect on disease activity. This has been confirmed in patients with controlled (Ekdahl et al., 1990; Lemmey et al., 2009; van den Ende et al., 1996) and active RA (van den Ende et al., 2000). Furthermore, as advances in pharmacological treatment work to effectively control disease, this patient group are now able to tolerate regular, progressive and intensive exercise (Lemmey, 2011). A recent systematic review also provides further information as to the benefits, effectiveness and safety of exercise in RA (Hurkmans et al., 2009). Patients with RA are also at an increased risk for cardiovascular disease (Metsios et al., 2008), cachexia (Walsmith & Roubenoff, 2002) and osteoporotic fracture (Van Staa et al., 2006). Therefore, the aforementioned improvements associated with exercise are vital in limiting the negative consequences inherent to the disease. Furthermore, physical activity has been found to be a significant predictor of the number of hospital admissions and the length of hospitalisation in RA (Metsios et al., 2011). In light of this evidence, exercise is now considered an essential component within the management of this condition. However, despite this it is apparent that RA patients are less physically active than the general population (Sokka et al., 2008), and greater medical costs are coupled with this inactivity (Wang et al., 2001). Therefore it is important for those involved in the care of RA patients to be aware of factors that may positively and negatively affect the uptake and maintenance of an exercise prescription for this patient group.