Updated exercise guidelines for adults with arthritis

Counseling patients with inflammatory arthritis (iA) or osteoarthritis (OA) of the hip or knee about the benefits of physical activity (PA) should be standard of care in clinical practice, new recommendations from the European League Against Rheumatism (EULAR) indicate. The authors emphasize that public health recommendations for PA apply as much to those with arthritic diseases as they do for the general public.

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Pam Harrison, Medscape July 19, 2018

“People with iA and OA may be reluctant towards engaging in PA, fearing flare-up or joint damage by exercising,” Anne-Kathrin Rausch Osthoff MSc, from the Institute of Physiotherapy at Zurich University of Applied Sciences in Winterthur, Switzerland, and colleagues write. “Given the evidence for its effectiveness, feasibility and safety, PA is advocated as [an] integral part of standard care throughout the course of these diseases… It is advised that these recommendations should be implemented considering individual needs and national health systems.”

The recommendations were published online July 11 in the Annals of the Rheumatic Diseases.

The 2018 EULAR Task Force based their recommendations on a quantitative analysis of data from 11 studies. Task force members considered patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA), as well as OA involving either the hip or knee.

Overall, the task force members found that cardiovascular exercises “have a moderate beneficial effect on cardiovascular fitness (evaluated in VO2 max) in all three conditions,” they write.

Similarly, the analysis showed a moderate benefit from strength training exercises in RA and OA. In contrast, the combination or aerobic exercise plus strength training, along with exercises to improve flexibility, were not found to be beneficial in patients with either SpA or OA.

The authors also point out that standard public health recommendations for PA are safe. “No detrimental effects were reported, rather beneficial effects on disease activity and symptoms in iA,” they state.

Public health recommendations for PA from the American College of Sports Medicine and the American Heart Association include the following:

  • Adults 18 to 65 years of age should engage in either moderate-intensity aerobic PA for a minimum of 30 minutes 5 days a week or vigorous-intensity aerobic activity for a minimum of either 20 minutes on 3 days a week or a combination of both.
  • This amount of moderate-intensity aerobic activity can be accumulated by doing bouts of exercise lasting at least 10 minutes each to reach the recommended total of 30 minutes a day.
  • Adults need to engage in any activity that maintains or increases muscle strength and endurance on at least 2 days a week.
  • Anyone who wants to improve their level of fitness, reduce the risk for chronic disease and disabilities, or prevent unhealthy weight gain may exceed the minimum recommended PA levels.

Increase Promotion, Task Force Emphasizes
Task force members also emphasize that all healthcare professionals need to increase their promotion of PA for patients with iA and OA and, if necessary, collaborate with different professions to better meet these goals.

In fact, the authors recommend that interventions aimed at improving PA among patients with iA and OA should be undertaken by healthcare professionals who are competent in both the principles of PA, as well as rheumatic diseases. “The PA level (active or non-active) and the exercise domains (cardiorespiratory, muscle strength, flexibility and neuromotor) should [also] be routinely assessed,” they suggest.

Specific contraindications to PA, in contrast, do exist, and healthcare professionals need to follow general or national guidelines regarding any type of contraindication closely. As is true for the general public, any recommendation for PA needs to be tailored to a patient’s individual goals, which should be regularly assessed, as goals may change. Disease-specific as well as general barriers to PA also need to be factored into counseling patients on PA recommendations, they note.

Information about the benefits exercise can have on symptoms or on disease control should be shared with patients to encourage their participation in PA. Healthcare professionals should also be prepared to discuss the use of pain medications before exercising to improve tolerability. “Adaptations to PA should be made on a comprehensive individual assessment,” the task force members add, even though they found no evidence that patients with any of the arthritic diseases under consideration require adaptation when it comes to PA recommendations.

Importantly, motivation is a major driver of engagement in PA, and healthcare professionals need to discuss strategies that will help patients change their behavior and help them stay motivated to achieve recommended PA levels.

Also, healthcare professionals need to consider the ways in which patients may achieve recommended PA targets, including whether the intervention is “land-based” or “water-based,” “supervised” or “individualized.” Several cheerleader strategies to get people up and moving include a simple telephone call, the use of wearable devices such as a pedometer or Fitbit, a log book, web-based instructions, or the use of videos.

CDC Guidelines Soon Updated
Asked by Medscape Medical News to comment on the new PA recommendations, Jennifer Hootman PhD, epidemiologist, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, indicated that the 2008 guidelines developed at the CDC are in the process of being updated and will likely be released before the end of the year. In the meantime, PA guidelines for adults with arthritis are the same as for all US adults, she stressed.

“Most people with arthritis can do physical activity safely,” Hootman said. There are individual patients who may have a contraindication to PA, but that needs to be determined on an individual basis.

Joint-friendly activities include walking, swimming, cycling, and some exercise classes, Hootman points out. Similar to the new EULAR recommendations, the CDC also recommends that adults with arthritis engage in muscle strengthening activities at least 2 days a week.

The biggest hurdle that physicians have in counseling patients with arthritis is time and, at least for some, a feeling they don’t know enough about PA requirements to confidently recommend it, Hootman suggests.

At the very least, “physicians need to ask patients what kind of activity they are doing, and then counsel them if they are not doing anything to do at least something, or if they are doing something, perhaps they can be encouraged to increase their PA levels somewhat,” Hootman said.

For the select few who are meeting recommended PA levels, “just support them to keep it up,” she added.

Patients may also be referred to recommended exercise programs for patients with arthritis, which can be found on the CDC’s web site.

2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis, Anne-Kathrin Rausch Osthoff, Karin Niedermann, Jürgen Braun, Jo Adams, Nina Brodin, Hanne Dagfinrud, Tuncay Duruoz, Bente Appel Esbensen, Klaus-Peter Günther, Emailie Hurkmans, Carsten Bogh Juhl, Norelee Kennedy, Uta Kiltz, Keegan Knittle, Michael Nurmohamed, Sandra Pais, Guy Severijns, Thijs Willem Swinnen, Irene A Pitsillidou, Louise Warburton, Zhivko Yankov, Theodora PM Vliet Vlieland. Annals of the Rheumatic Diseases. Published Online First: 11 July 2018. doi: 10.1136/annrheumdis-2018-213585 PDF

Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association, Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, Franklin BA, Macera CA, Heath GW, Thompson PD, Bauman A. Med Sci Sports Exerc. 2007 Aug;39(8):1423-34.

Source Medscape

Poor replicability of recommended exercise interventions for knee osteoarthritis: a descriptive analysis of evidence informing current guidelines and recommendations, Bartholdy C, Nielsen SM, Warming S, Hunter DJ, Christensen R, Henriksen M. Osteoarthritis Cartilage. 2018 Sep 22. pii: S1063-4584(18)31470-5. doi: 10.1016/j.joca.2018.06.018. [Epub ahead of print] Review.

Also see
EULAR recommends physical activity as part of standard care for inflammatory arthritis, OA in Healio
Guidelines for exercise in knee OA unusable: study in Pharmacy News

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