2022 American College of Rheumatology Guideline for Exercise, Rehabilitation, Diet, and Additional Integrative Interventions for Rheumatoid Arthritis.

OBJECTIVE: To develop initial American College of Rheumatology (ACR) guidelines on the use of exercise, rehabilitation, diet, and additional interventions in conjunction with disease-modifying antirheumatic drugs (DMARDs) as part of an integrative management approach for people with rheumatoid arthritis (RA). METHODS: An interprofessional guideline development group constructed clinically relevant Population, Intervention, Comparator, and Outcome (PICO) questions. A literature review team then completed a systematic literature review and applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate the certainty of evidence. An interprofessional Voting Panel (n = 20 participants) that included 3 individuals with RA achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS: The Voting Panel achieved consensus on 28 recommendations for the use of integrative interventions in conjunction with DMARDs for the management of RA. Consistent engagement in exercise received a strong recommendation. Of 27 conditional recommendations, 4 pertained to exercise, 13 to rehabilitation, 3 to diet, and 7 to additional integrative interventions. These recommendations are specific to RA management, recognizing that other medical indications and general health benefits may exist for many of these interventions. CONCLUSION: This guideline provides initial ACR recommendations on integrative interventions for the management of RA to accompany DMARD treatments. The broad range of interventions included in these recommendations illustrates the importance of an interprofessional, team-based approach to RA management. The conditional nature of most recommendations requires clinicians to engage persons with RA in shared decision-making when applying these recommendations.

2022 American College of Rheumatology Guideline for Exercise, Rehabilitation, Diet, and Additional Integrative Interventions for Rheumatoid Arthritis.

OBJECTIVE: To develop initial American College of Rheumatology (ACR) guidelines on the use of exercise, rehabilitation, diet, and additional interventions in conjunction with disease-modifying antirheumatic drugs (DMARDs) as part of an integrative management approach for people with rheumatoid arthritis (RA). METHODS: An interprofessional guideline development group constructed clinically relevant Population, Intervention, Comparator, and Outcome (PICO) questions. A literature review team then completed a systematic literature review and applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate the certainty of evidence. An interprofessional Voting Panel (n = 20 participants) that included 3 individuals with RA achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS: The Voting Panel achieved consensus on 28 recommendations for the use of integrative interventions in conjunction with DMARDs for the management of RA. Consistent engagement in exercise received a strong recommendation. Of 27 conditional recommendations, 4 pertained to exercise, 13 to rehabilitation, 3 to diet, and 7 to additional integrative interventions. These recommendations are specific to RA management, recognizing that other medical indications and general health benefits may exist for many of these interventions. CONCLUSION: This guideline provides initial ACR recommendations on integrative interventions for the management of RA to accompany DMARD treatments. The broad range of interventions included in these recommendations illustrates the importance of an interprofessional, team-based approach to RA management. The conditional nature of most recommendations requires clinicians to engage persons with RA in shared decision-making when applying these recommendations.

Voluntary Cooling during Exercise Is Augmented in People with Multiple Sclerosis Who Experience Heat Sensitivity.

INTRODUCTION: We tested the hypothesis that people with multiple sclerosis (MS) who experience heat sensitivity voluntarily engage in cool-seeking behavior during exercise to a greater extent than healthy controls. METHODS: In a 27.0°C ± 0.2°C, 41% ± 2% RH environment, seven participants with relapsing-remitting MS who exhibited heat sensitivity and seven healthy controls completed two randomized trials cycling for 40 min (EX) at 3.5 W·kg-1 metabolic heat production, followed by 30 min recovery (REC). In one trial, participants were restricted from engaging in cooling (CON). In the other trial, participants voluntarily pressed a button to receive 2 min of ~2°C water perfusing a top (COOL). Mean skin and core temperatures and mean skin wettedness were recorded continuously. Total time in cooling provided an index of cool-seeking behavior. RPE, total symptom scores (MS only), and subjective fatigue (MS only) were recorded every 10 min. RESULTS: Core temperature (+0.5°C ± 0.1°C) and skin wettedness (+0.53 ± 0.02 a.u.) increased but were not different between groups or trials at end exercise (P = 0.196) or end recovery (P = 0.342). Mean skin temperature was reduced in COOL compared with CON at end exercise (P ≤ 0.002), with no differences between groups (P ≥ 0.532). MS spent more total time in cooling during EX (MS, 13 ± 3 min; healthy, 7 ± 4 min; P < 0.001) but not REC (MS, 2 ± 1 min; healthy, 0 ± 1 min; P = 0.496). RPE was greater at end exercise in MS (P = 0.001). Total symptom scores increased during exercise (P = 0.005) but was not different between trials (P = 0.321), whereas subjective fatigue was not attenuated in the cooling trial (P = 0.065). CONCLUSION: Voluntary cooling is augmented in MS but does not consistently mitigate perceptions of heat-related symptoms or subjective fatigue.

Improving Sleep among Adults with Multiple Sclerosis using Mindfulness plus Sleep Education.

We explored the feasibility of a mindfulness plus sleep education intervention, SleepWell!, delivered via videoconference compared to onsite among adults with MS. A non-randomized wait-list control design was used. Participants wore actigraphy watches and kept sleep diaries for seven days pre- and post intervention. Questionnaires were completed pre-intervention, post-intervention, and three months post-intervention. One group was conducted onsite. Three groups participated via videoconference. Attrition among videoconference groups was 23% compared to 57% in the onsite group. Within group analysis showed moderate-to-large effect sizes on sleep efficiency (d=0.78) and total sleep time (d=0.54) in the videoconference groups. One-way repeated measures ANOVA post-hoc analysis suggested small-to-medium effect over three months on sleep quality (ηp2 =0.28), physical health quality of life (ηp2 =0.42), mental health quality of life (ηp2 =0.13), and mindfulness (ηp2 =0.29). Results indicate feasibility of providing our intervention via videoconferencing. Preliminary analysis suggests that SleepWell! improves sleep and mindfulness among adults with MS.

Impact of Physical Activities on Frailty in Community-Dwelling Older Women.

AIMS: The aim of the study was to determine whether increased physical activities (PA) affect frailty for old women, 75 years and older (OO), compared to 60-74 years old (YO). METHODS: This crosssectional study measured 19 frailty indicators (muscle strength and endurance, balance, gait characteristics, and function), using 46 community-dwelling women. PA were divided into three levels by caloric expenditure per week (<2,000 kcal/week, 2,000-3,999 kcal/week,>4,000 kcal/week). RESULTS: As PA level increased, a gap (=difference) between OO and YO narrowed for step length and function, but for quadriceps strength and endurance, a gap widened. CONCLUSIONS: Frailty progresses with aging but older women who engage in a high level of physical activity (>4,000 kcal/week) can increase mobility and functional capacity, but not for muscle strength and endurance. Starting regular resistance training activities early in the aging process is critical to improve or maintain muscle quality to offset age-related frailty.

Validity and Reliability of Four Clinical Gait Measures in Patients with Multiple Sclerosis.

BACKGROUND: The gold standards for assessing ambulation are the Expanded Disability Status Scale (EDSS) and the Timed 25-Foot Walk (T25FW) test. In relation with these measures, we assessed the reliability and validity of four clinical gait measures: the Timed Up and Go (TUG) test, the Dynamic Gait Index (DGI), the 2-Minute Walk Test (2MWT), and the 6-Minute Walk Test (6MWT). Patient self-report of gait was also assessed using the 12-item Multiple Sclerosis Walking Scale (MSWS-12). METHODS: Individuals 20 years or older with a diagnosis of multiple sclerosis (MS) and an EDSS score of 2.0 to 6.5 completed the MSWS-12, T25FW test, TUG test, DGI, 2MWT, and 6MWT. All the tests were repeated 2 weeks later at the same time of day to establish their reliability and concurrent validity. Predictive validity was established using the EDSS. RESULTS: Forty-two patients with MS were included. All measures showed high test-retest reliability. The TUG test, 2MWT, and 6MWT were significantly correlated with the T25FW test (Spearman ρ = -0.902, -0.919, and -0.905, respectively). The EDSS was also significantly correlated with all the walking tests. The MSWS-12 demonstrated the highest correlation to the EDSS (ρ = 0.788). CONCLUSIONS: The TUG test, the DGI, the 2MWT, and the 6MWT exhibited strong psychometric properties and were found to be significant predictors of the EDSS score. Use of these tests to prospectively monitor the effects of medical and rehabilitation treatment should be considered in the comprehensive care of patients with MS.

Measures of respiratory function correlate with fatigue in ambulatory persons with multiple sclerosis.

PURPOSE: This article examines the association between measures of respiratory muscle function and fatigue in individuals with mild-to-moderate disability multiple sclerosis (MS). METHODS: This was a cross-sectional study of 37 ambulatory volunteers with MS (28 F/9 M, 52.7 ± 10.2 years, Expanded Disability Status Scale [EDSS] = 3.5 ± 1.9). No patients withdrew from the study. Primary outcome variables included measures of respiratory function: maximal inspiratory (MIP) and expiratory pressures (MEP), forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), maximal voluntary ventilation (MVV12); and a self-reported measure of fatigue: the Modified Fatigue Impact Scale (MFIS). Secondary measures included 6-min walking test (6MWT), a timed stair climb, the Short Form (SF)-36, the Epworth Sleepiness Scale and the Physical Activity and Disability Scale (PADS). RESULTS: Significant correlations were shown between expiratory muscle strength (MEP) and the MFIS total (p < 0.03, r = -0.362) and between MEP and physical fatigue scores (p < 0.03, r = -0.360), as well as between MVV12 percent predicted (respiratory muscle endurance) and both the 6MWT (p = 0.045, r = 0.346) and the Epworth Sleepiness Scale (p = 0.006, r = 0.447). CONCLUSIONS: Respiratory muscle performance is correlated with perceived fatigue (MFIS), whereas respiratory endurance correlated to reductions in physical function and sleep quality among individuals with mild-to-moderate severity MS. Implications for Rehabilitation Multiple sclerosis (MS) results in peripheral and respiratory muscle weakness and affected individuals report fatigue as one of their most disabling symptoms. Expiratory muscle strength was correlated with self-reported physical fatigue, while respiratory muscle endurance was correlated with functional performance and sleepiness. Respiratory muscle strength was not correlated with lung spirometry testing. These findings highlight the importance of considering the effects of respiratory muscle weakness when evaluating causes of fatigue among individuals with mild-to-moderate MS.

A combined inspiratory and expiratory muscle training program improves respiratory muscle strength and fatigue in multiple sclerosis.

OBJECTIVE: To determine the effects of a short-duration, combined (inspiratory and expiratory), progressive resistance respiratory muscle training (RMT) protocol on respiratory muscle strength, fatigue, health-related quality of life, and functional performance in individuals with mild-to-moderate multiple sclerosis (MS). DESIGN: Quasi-experimental before-after trial. SETTING: University rehabilitation research laboratory. PARTICIPANTS: Volunteers with MS (N=21) were divided into 2 groups: RMT (n=11; 9 women, 2 men; mean age ± SD, 50.9 ± 5.7y, mean Expanded Disability Status Scale score ± SD, 3.2 ± 1.9) and a control group that did not train (n=10; 7 women, 3 men; mean age ± SD, 56.2 ± 8.8y, mean Expanded Disability Status Scale score ± SD, 4.4 ± 2.1). Expanded Disability Status Scale scores ranged from 1 to ≤6.5. No patients withdrew from the study. INTERVENTION: Training was a 5-week combined progressive resistance RMT program, 3d/wk, 30 minutes per session. MAIN OUTCOME MEASURES: The primary outcome measures were maximal inspiratory pressure and expiratory pressure and the Modified Fatigue Impact Scale. All subjects completed secondary measures of pulmonary function, the six-minute walk test, the timed stair climb, the Multiple Sclerosis Self-Efficacy Scale, the Medical Outcomes Study 36-Item Short-Form Health Survey, and the Physical Activity Disability Scale. RESULTS: Maximal inspiratory pressure and expiratory pressure (mean ± SD) increased 35% ± 22% (P<.001) and 26% ± 17% (P<.001), respectively, whereas no changes were noted in the control group (12% ± 23% and -4% ± 17%, respectively). RMT improved fatigue (Modified Fatigue Impact Scale, P<.029), with no change or worsening in the control group. No changes were noted in the six-minute walk test, stair climb, Multiple Sclerosis Self-Efficacy Scale, or Physical Activity Disability Scale in the RMT group. The control group had decreases in emotional well-being and general health (Medical Outcomes Study 36-Item Short-Form Health Survey). CONCLUSIONS: A short-duration, combined RMT program improved inspiratory and expiratory muscle strength and reduced fatigue in patients with mild to moderate MS.

Statin therapy depresses fat metabolism in older individuals.

OBJECTIVE: Statins (3-hydroxy-3-methylglutaryl coenzyme A [HMG CoA] reductase inhibitors) reduce blood lipoproteins and reduce the risk of cardiovascular events. However, they may reduce fat metabolism. This study tested the hypothesis that total body fat oxidation is reduced by statins in older subjects and the reduction is not due to substrate availability. METHODS: A total of 14 elderly patients (71 ± 6 years) on statin therapy were compared with 14 matched elderly controls (75 ± 7 years). Subjects were tested for respiratory exchange ratio (RER) during both maximal and submaximal sustained (70% Vo(2max)) exercise to voluntary exhaustion. Blood samples were drawn for lipoprotein analysis and substrate availability. RESULTS: RER was significantly higher in subjects taking statins during both the max and submax tests, indicating reduced fat oxidation. Blood lipoprotein levels after a fast were not different between the statin and control groups. Levels of glucose, lactate, or triglyceride were not different between groups; however, free fatty acid levels were elevated by exercise in the statin group. Fat oxidation was significantly reduced in older subjects taking statin drugs that were not associated with diet, exercise, and fitness, which were matched between groups, nor availability of fat from the blood, which was higher in the statin group. CONCLUSION: Although statin therapy normalizes blood lipoproteins, it reduced fat metabolism in older individuals, which cannot be a result of lower availability from blood.

Effects of a 6-week walking program on Taiwanese women newly diagnosed with early-stage breast cancer.

BACKGROUND: In Western culture, evidence has shown that in women with breast cancer exercise decreases fatigue and improves quality of life. However, only 1 pilot study about the effect of exercise has been examined in the Asian breast cancer population that indicated feasibility. Therefore, it is important to further study the effect of an exercise program for Taiwanese women with breast cancer. OBJECTIVE: The purpose of this study was to test the effects of a walking program on Taiwanese women newly diagnosed with early-stage breast cancer. METHODS: This was an experimental, longitudinal study with 4-time repeated measures based on Bandura's Self-efficacy Theory, with the aim of implementing interventions to boost exercise self-efficacy and to evaluate research outcomes. SPSS 17.0 with descriptive statistics using frequency, percentage, mean, and SD as well as inferential statistics such as t test, χ test, hierarchical linear model, repeated-measures analysis of variance, and analysis of covariance was used for data analysis. RESULTS: Results of this study indicated that subjects in the exercise group had significantly better quality of life, less fatigue, less sleep disturbances, higher exercise self-efficacy, more exercise behavior, and better exercise capacity compared with those in the usual-care group after the intervention. CONCLUSIONS: This program was effective and feasible, but more research studies with experimental, longitudinal design to verify the effects of this exercise program on Taiwanese women with breast cancer will be needed. IMPLICATIONS FOR PRACTICE: Nurses, depending on skill and knowledge, can encourage physical activity, refer patients to rehabilitation programs, and prescribe and monitor exercise in breast cancer population.

Effects of multidisciplinary Internet-based program on management of heart failure.

OBJECTIVES: To develop and test the effectiveness of an Internet-based self management program by multidisciplinary health care professionals for patients with heart failure (HF). METHODS: The comprehensive educational material for HF was created and posted on a website. A computer with Internet connection and computer training were provided first. A secure and simple web-based recording system of vital signs and health behaviors and a mechanism for feedback regarding each participant's record were developed. A randomized controlled trial with a one-year intervention was conducted using a total of 40 patients who were assessed three times in their homes. An intention-to-treat analysis used multivariate statistics. RESULTS: The treatment group had a high (85%) adherence to the intervention. Only the treatment group showed a significant improvement in the knowledge level (p < 0.001), amount of exercise (p = 0.001), and quality of life (p = 0.001), and reduction in HF related symptoms (dyspnea, p = 0.001; fatigue, p = 0.003; functional emotion, p < 0.001), blood pressure (systolic, p = 0.002; diastolic, p < 0.001), frequency of emergency room visit, and length of hospital stay (both p = 0.001). CONCLUSIONS: An effective program to change one's behaviors in managing HF takes a multidisciplinary approach to create and provide feedback regarding a patient's daily record, which can be accomplished through Internet use.

Phenotypic variability among first-degree relatives with carnitine palmitoyltransferase II deficiency.

Carnitine palmitoyltransferase (CPT) II deficiency disorders are clinically very variable. To examine the cause(s) of variable symptoms in first-degree relatives with CPT II deficiency, four sisters with various combinations of mutations and polymorphisms in the CPT2 gene were studied, together with 20 sedentary and 24 trained healthy female subjects. One sister, whose symptoms began at age 7 years, was more severely affected than her older sister, whose symptoms began at age 16 years; both were compound heterozygotes for the common S113L mutation and Q413fs, and for the common CPT2 polymorphisms, V3681 and M647V. A third sister became hypoglycemic with fasting, was heterozygous for the S113L mutation, and homozygous for the polymorphism variants. The fourth sister was asymptomatic, heterozygous for the Q413fs mutation, and homozygous for the normal polymorphisms. Residual CPT II activity in skeletal muscle and cultured skin fibroblasts from the two myopathic sisters, and palmitate oxidation in fibrobasts, were abnormally low; cellular and total body fat oxidation were also diminished. Muscle function and fat oxidation were nomal at rest, but a switch to carbohydrate utilization occurred at lower exercise intensities than in sedentary and trained individuals, respectively. Reliance on carbohydrates during stress and hormonal alterations may explain, in part, the variance in ages of onset and serverity of symptoms in myopathic patients.

Aerobic training and cardiovascular responses at rest and during exercise in older men and women.

PURPOSE: The effects of an intense 8-wk aerobic training program on cardiovascular responses at rest and during exercise, including heart rate variability (HRV) as an expression of autonomic modulation, were evaluated in subjects over 70 yr (mean: 73.9 +/- 3.5 yr). METHODS: Before and after training in 7 men and 8 women: a) heart rate (HR), blood pressures (BPs), pulse pressure (PP), and oxygen uptake were measured at rest, during, and after exhausting incremental exercise; b) HRV power spectra were calculated at rest in supine and sitting, and during and after two submaximal constant loads (5 min). Power in low-frequency (LF, 0.04-0.15 Hz) and high-frequency (HF, >0.15 Hz) bands were expressed as a percent of total power minus power < 0.04 Hz. RESULTS: After training: a) at rest HR and HRV parameters (in both body positions) were unchanged, whereas BPs decreased; b) peak cycle resistance and oxygen consumption increased by 25% and 18%, respectively, but no change in maximal HR and BPs were found; c) during submaximal loads HR was unchanged at the same metabolic demand, whereas SBP and DBP were lower than before at low loads whereas PP was unchanged. LF power decreased and HF increased at oxygen uptakes above about 0.7 L.min-1 similarly before and after training; and d) recovery of all parameters was similar to pretraining and complete after 10 min CONCLUSIONS: The increase in exercise capacity without changes in cardiovascular parameters suggests that 8 wk of aerobic training augmented peripheral gas exchange but not delivery to muscle. The lack of effect on HRV indicates that the improvements in aerobic power and cardiac autonomic modulation, at least in subjects over 70 yr, are dissociated. Moreover, the metabolic demand seems to be the main factor for the changes in HRV power spectra that occur during exercise.