Regular Physical Activity Erase Arthritis, Osteoarthritis

Recommendation 1: PA as integral part of standard care

Given the evidence for effectiveness, feasibility and safety, the PH recommendations for PA are applicable, and thus, PA should be an integral part of standard care for people with RA/SpA/HOA/KOA. PA according to PH recommendations2 is effective on PA level, physical fitness as well as disease-specific and general outcomes in people with RA/SpA/HOA/KOA (category l evidence16). Our MA including 16 RCTs26 35 36 42 43 50 54 56 57 61 70 showed that cardiovascular exercises have a moderate beneficial effect on cardiovascular fitness (evaluated in VO2 max) in all three conditions. Our MA including 25 RCTs25 28 31 34 38 39 44 47 49–51 59 62–66 72 75–78 81–83 85 86 88 90 91 showed that muscle strength exercises have a moderate beneficial effect for muscle strength in people with RA and HOA/KOA. Our MA including seven RCTs52 55 58 78 88 90 116 showed that combined exercises (aerobic or strength exercises plus flexibility exercises) had no effect on flexibility in people with SpA or HOA/KOA. However, exercise conditions, assessments and outcome measures varied greatly. There is no study comparing the effect of flexibility exercises alone versus no exercises. In one RCT[,48] the effect of a neuromotor-exercise programme on neuromotor performance was investigated in people with RA showing a positive effect. Eleven RCTs described the promotion of daily PA. Our MA including six RCTs[95 98 101 102 104 117]applying BCTs for the counselling intervention showed a small beneficial effect.

Feasibility of interventions can be captured by adherence to the intervention or the study protocol.[118] Adherence to interventions (number of sessions attended/total number of sessions) has been reported in 26 RCTs (35%) and the mean adherence was 69% in people with SpA, 71% in people with RA and 79% in people with HOA/KOA. However, the (self-) reported adherence to intervention might be overestimated due to recall bias or social desirability. In 68 RCTs (94%), protocol violations were reported, with approximately 10% of these being disease-related or intervention-related.

PH recommendations for PA can be considered safe. No detrimental effects were reported, rather beneficial effects on disease activity and symptoms in iA.7 Forty-four per cent of all included RCTs reported on adverse events (AE), of those 62% described no AE and 38% describe minor AE such as transitional exercise related joint or muscle pain.

Recommendation 2: Responsibility for PA promotion

All HCPs should have a responsibility for PA promotion and collaborative working that facilitate a close cooperation between different professions to support appropriate disease management. This statement was based on the finding that 66% of the included studies reported the profession of the HCP providing the intervention, of which 75% were PTs.However, the functions and responsibilities of HCPs vary across Europe.121 122 Therefore, the TF agreed that PA advice should be provided by all HCPs.

Recommendation 3: Delivery of PA

The delivery of interventions should be performed by HCPs competent in the field of PA principles and rheumatic conditions. The reporting of training on PA guidelines was rare. One study[59] described a ‘4 hours education session on cardiovascular training’, others described the instructing person as ‘trained’[25 ]or ‘experienced’.[31 49 76 77 88] Some studies with focus on the promotion of daily PA described training sessions on behaviour change skills like Motivational Interviewing.[94 96 104]

Recommendation 4: Evaluation of PA

The PA level (active or non-active) and the exercise domains (cardiorespiratory, muscle strength, flexibility and neuromotor) should be routinely assessed. Of 11 trials investigating the effect of PA promotion interventions, three RCTs[94 96 105 ]described baseline screening to distinguish between active and non-active persons before starting the tailored PA-intervention. Specific tools are needed to assess each domain.^{15,p. 68}

Recommendation 5: General and disease-specific contraindications

Tools for specific contraindications (CIs) were found;[15 94 124] however, available general or national guidelines defining absolute or relative CIs should be followed as a priority.

Recommendation 6: Personalised aims and evaluation

The PA-interventions should be based on individual aims, which should be regularly evaluated. This can be done by PA assessments and any other assessments related to the individual aims. As PA assessments, performance–based tests, patient-reported outcome measures (eg, SQUASH,104 PASE94) and self-monitoring tools (eg, wearables such as Fitbit,100 pedometer99 or accelerometer101) were identified. However, we did not evaluate the validity and reliability of the assessments applied.

Recommendation 7: General and disease-specific barriers and facilitators

General and disease-specific barriers (that are not CI per se) and facilitators should be addressed as described in 11 studies.11 107–115 125 Disease-specific barriers included lack of knowledge about the disease, lack of knowledge about safe exercising (both in people with iA/OA and HCPs) and symptoms like pain, fatigue, stiffness, reduced mobility, fear of flare-ups or causing damage. Disease-specific facilitators included positive impact of exercise in symptoms or disease control, information about disease and correct exercising, the use medication for pain prior to exercising, using self-regulation techniques, supportive, but not controlling encouragement from HCPs and a supportive social background.

Recommendation 8: Individual adaptations to PA following individualized assessment

Adaptations to PA should be made on a comprehensive individual assessment. However, no evidence on the necessity of general adaptations in people with RA/SpA/HOA/KOA was found. In some RA studies the ‘24 hour-rule’ was applied, that is, the exercise intensity was reduced when the increased pain persisted for more than 24 hours.23 40 50 ACSM provides adaptations to exercise testing in people with arthritis (eg, no high-intensity testing if acute inflammation) and training such as exercising when pain is typically least severe or to train carefully in order to reduce risk of associated injuries, although no clear evidence that high-impact activities cannot be engaged during active inflammation.^{15, pp. 298–301} Individual disease-related barriers (eg, symptoms) may determine these adaptations.

Recommendation 9: Behaviour change techniques

BCTs should be an integral component of PA-interventions. Several behaviour change theories were used in PA promotion interventions in the field of RA and HOA/KOA,4 126 but the reporting was poor. Future research based on theories in design, evaluation and interpretation of findings is needed.

A meta-analysis of six RCTs94 95 98 101 102 104 investigating the effects of a PA promotion intervention according to general PA recommendations2 and based on counselling interventions that apply BCTs showed a small beneficial effect on PA level.19Counselling interventions show a small beneficial effect if BCTs are applied.19

Recommendation 10: Modes of delivery

HCPs should consider the whole range of modes to deliver interventions. No evidence on the superiority of specific delivery modes was found. The delivery modes of PA-interventions vary considerably and are mostly described as ‘land-based and/or water-based’ and ‘supervised and individualised’, the latter usually applied to group settings. As booster strategies phone calls,36 96 98 105devices (eg, pedometer,98 99 wearable100 101), home visits,63 70 log book,36 51 76 98 web-based instructions,127 written material,51 54 103 visual instructions (eg, video103) were reported.

Research and education agendas

Based on the gaps identified in the literature, the TF discussed and proposed a research agenda (box 1) with the prioritised research topics and an education agenda (box 2) with topics for education and training in PA promotion for HCPs. Evidence on impact of (reducing) sedentary behaviour emerged as an important future research topic.