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Dynamic exercise therapy for rheumatoid arthritis

Clinical bottom line:

Dynamic exercise therapy (aerobic exercise) appears to be effective in improving physical capacity (aerobic capacity, muscle strength and joint mobility) but less effective in improving functional ability when compared with other forms of exercise or no exercise. Based on small patient numbers, dynamic exercise therapy does not increase pain. It does not appear to exacerbate disease activity or radiological progression, but there is currently insufficient evidence to draw a firm conclusion.


Exercise therapy has traditionally been used for patients with rheumatoid arthritis to preserve joint mobility and maintain muscle strength. Interventions have often been designed to put limited stress on joints, with non-weight-bearing, isometric exercise. One rational for this has been that a more intense intervention might cause pain and damage joints or cause increased disease activity.

Systematic review

Van den Ende CHM et al, Dynamic exercise therapy in rheumatoid arthritis: a systematic review. Br J Rheumatol 1998; 37:677-687.

Inclusion criteria were randomised controlled trials of dynamic exercise therapy for rheumatoid arthritis; other exercise or no exercise control groups; full length articles including unpublished; intervention sufficient to improve aerobic function; outcome measures standardised or accepted in measuring symptom changes in rheumatoid arthritis; English, Dutch, French or German language articles.

Appropriate exercise interventions were defined as exercise frequency at least twice a week with each session of at least 20 minutes, exercises likely to increase heart rate to exceed 60% of maximal heart rate, and duration of exercise programme at least six weeks.

Mean data with standard deviations were extracted, together with (where possible) mean changes from baseline with standard deviations. Data pooling was not possible because trials were not similar enough, so conclusions from original reports were summarised.

Findings

Disease duration was for a minimum of seven years, and patients were predominantly on stable medication with non-active to moderately active disease and mildly restricted daily functioning. Mean ages ranged from 48 to 67. Length of exercise intervention ranged from eight weeks to two years.

Efficacy

The results from the six trials suggest that dynamic exercise therapy is effective in improving physical capacity (aerobic capacity, muscle strength and joint mobility) but less effective in improving functional ability. Details of findings are given in the review.

Adverse effects

This review specifically set out to answer the question of whether dynamic exercise therapy had any deleterious effects. This was assessed by measuring pain, disease activity and radiological progression.

Pain Worse?

Changes in pain were used to assess whether pain was exacerbated by exercise. In three of three trials there was no significant difference between dynamic exercise and control group on measures of pain. Controls were no exercise (2) and ROM exercise (1).

No detrimental effects of exercise were observed for disease activity or radiological progression, but reviewers point out that this is based on very limited data.

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