Strength training benefits maintained in early RA patients

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Strength training benefits maintained in early RA patients

Rheumawire

Aug 10, 2004

Mann

Jyvaskyla, Finland - Regular strength-building exercise provides greater

long-term benefits for patients with early rheumatoid arthritis (RA)

than range-of-motion exercise, according to a new study in the August

2004 issue of the ls of the Rheumatic Diseases [1].

" Individually tailored and regularly conducted physical exercises

provide long-term benefits for patients with early RA, " conclude the

researchers, led by Dr A Häkkinen (Jyvaskyla Central Hospital, Finland).

" Structural joint damage remained low and clinical disease activity

decreased during the whole 5-year follow-up, indicating that patients

actively treated with disease-modifying antirheumatic drugs (DMARDs) can

safely carry out the applied individually tailored, moderate-intensity

physical activity. "

The 5-year study of 70 patients looked at whether an initial 2-year

home-based, strength-training program had sustained effects on muscle

strength, bone-mineral density (BMD), structural joint damage, and

disease activity in patients with early RA. To this end, patients either

participated in a home-based strength training with weights loaded to

50% to 70% of the patient's repetition maximum (experimental group [EG])

or range-of-motion exercises (control group [CG]). The strength training

included exercises for all groups: biceps curl, lateral pull-down, and

forward single up-rise for the arms/knee extension; flexion, hip

extension and abduction, and squats for the legs; abdominal crunches and

leg lifts while patients lay on their backs; and back hyperextensions in

prone position for the back. These were done using rubber bands and

dumbbells as resistance. Subjects exercised twice a week, doing 2 sets

for each exercise and 8 to 12 repetitions for each set. Both groups were

also encouraged to take part in aerobic activities 2 to 3 times a week.

Exercise training by both groups was monitored over the first 24 months

of the study, and patients were again assessed at the 5-year mark.

Maximal muscle strength of different muscle groups was measured by

dynamometers. BMD at the femoral neck and lumbar spine were measured by

dual x-ray densitometry. Disease activity was assessed by the 28-joint

disease activity score (DAS28), and joint damage by x-ray findings.

Of the patients, 62 completed 2 years of training (31 in each group) and

59 completed the trial to 5 years (29 in EG, 30 in CG). Of the 29 EG

patients, 10 continued their strength training during the entire 5

years. None of the 30 control-group patients continued their

range-of-motion exercises beyond the first 2 years.

In the first 2 years, maximum muscle strength increased by a mean 68 kg

in EG patients vs 35 kg in controls. At 5 years, these gains were

largely maintained: 59 kg in EG vs 30 kg in controls.

Patients in the resistance-training group also used strikingly less

prednisolone over the 5-year period than those in the control group. EG

patients used prednisolone for an average of 8.0 months vs 30.2 months

for control patients, for a cumulative prednisolone dosage of 0.76 g vs

3.25 g (p=0.0005.)

Despite substantial training effects in muscle strength, BMD values

remained relatively constant. Femoral and spinal BMD both increased in

the EG group at 2 years while decreasing in the control group, but these

differences were not significant when corrected for age, sex, DAS, use

of prednisolone, and drug treatment for osteoporosis and were not

significant at 5 years.

To address concerns that this type of exercise might increase damage to

inflamed joints, the investigators compared changes in DAS, Larsen

scores, pain scores, and health-assessment questionnaire (HAQ) scores at

2 and 5 years. These measures showed not only that patients in the

strength-training group did not have faster joint deterioration but also

that they had significant improvements in disease activity, pain, and

quality of life during the 2-year monitored training period.

Mean DAS scores improved by about 2 points in both groups at 2 years and

remained about the same or improved slightly at the 5-year point. Pain

scores improved at the 2-year point by 67% in the EG group and by 3% in

the control group (p=0.03) but were not significantly different at 5

years. Similarly, HAQ scores improved significantly more in the EG group

at 2 years than in the control group but were not significantly

different at 5 years. Radiographic damage remained low even at 5 years,

the researchers concluded.

Study participants had RA lasting for <24 months at inclusion and had

not been treated with prednisolone or DMARDs before inclusion in the

study. After initial assessment, patients were put on sulfasalazine as

the first drug (with a few exceptions). At the 6-month and 2-year visit,

24% and 50% were taking MTX or a combination of DMARDS including MTX,

respectively. At the 5-year visit, 70% were taking DMARDs.

" The effect of exercise on the outcome of patients with rheumatoid

arthritis has always been debated, and all of the studies have been

short term, " Dr Jan Bergman ( Hospital, Ridley Park, PA)

tells rheumawire. " In general, most rheumatologists probably use the

same rules today that I was taught 20 years ago: 'if it is hot and

angry, rest it . . . if it's stiff, move it,' but there is no basis for

this other than 'that's the way it was done.' "

Bergman says that with regard to RA, there has been a concern that

vigorous strength-training exercise might lead to increased damage of

the already-inflamed joint. " In this paper, despite the fact that there

ultimately was little difference between the 2 treatment arms, there was

convincing evidence that having patients exercise, including

strengthening exercise, did not cause any increased harm. This should be

reassuring both to physicians who encourage exercise and to patients who

are concerned about the exercise hurting and doing damage, " Bergman

says. " This finding is the most important point of the study. "

Source

Häkkinen A, Sokka T, Kautiainen H, Kotaniemi A, and

Hannonen P. Sustained maintenance of exercise induced muscle strength

gains and normal bone mineral density in patients with early rheumatoid

arthritis: a 5-year follow-up. Ann Rheum Dis 2004; 63:910-916.

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Mayo Clinic in Rochester

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