Tight control of disease activity fails to improve body composition or physical function in rheumatoid arthritis patients.

OBJECTIVE: RA typically features rheumatoid cachexia [loss of muscle mass (MM) and excessive total fat mass (TFM), especially trunk FM], which contributes to physical disability. Since rheumatoid cachexia is driven by inflammation, it would be anticipated that the success of tight control of disease activity, such as treat-to-target (T2T), in attenuating inflammation would benefit body composition and physical function. This aim of this cross-sectional study was to assess the impact of T2T on body composition and objectively assessed function in RA patients. METHODS: A total of 82 RA patients exclusively treated by T2T, were compared with 85 matched sedentary healthy controls (HCs). Body composition was estimated by DXA, with appendicular lean mass the surrogate measure of total MM. Physical function was assessed by knee extensor strength, handgrip strength, 30 s sit-to-stands, 8' up and go, and 50' walk (tests which reflect the ability to perform activities of daily living). RESULTS: Although generally well treated (mean DAS28 = 2.8, with 49% in remission), RA patients had ∼10% proportionally less appendicular lean mass and were considerably fatter (by ∼27%), particularly in the trunk (∼32%), than HCs. All measures of function were 24-34% poorer in the RA patients relative to HC. CONCLUSIONS: Despite marked improvements in disease control (most patients achieving or approaching remission), the relative loss of MM and increased adiposity in RA patients compared with matched HCs was similar to that observed pre-T2T. Additionally, performance of objective function tests was unchanged from that reported by our group for pre-T2T RA patients. Thus T2T, even in responsive RA patients, did not attenuate rheumatoid cachexia or improve objectively assessed function.

Patellar tendon properties and lower limb function in rheumatoid arthritis and ankylosing spondylitis versus healthy controls: a cross-sectional study.

OBJECTIVE: Rheumatoid arthritis (RA) and ankylosing spondylitis (AS) lead to inflammation in tendons and peritendinous tissues, but effects on biomechanical tendon function are unknown. This study investigated patellar tendon (PT) properties in stable, established RA and AS patients. METHODS: We compared 18 RA patients (13 women, 59.0 ± 2.8 years, mean ± SEM) with 18 age- and sex-matched healthy controls (58.2 ± 3.2 years), and 12 AS patients (4 women, 52.9 ± 3.4 years) with 12 matched controls (54.5 ± 4.7 years). Assessments with electromyography, isokinetic dynamometry, and ultrasound included quadriceps muscle force and cross-sectional area (CSA), PT stiffness, and PT CSA. Additionally, measures of physical function and disease activity were performed. RESULTS: PT stiffness and physical function were lower in RA and AS patients compared to healthy controls, without a significant difference in force production. PT CSA was significantly larger leading to reduction in Young's modulus (YM) in AS, but not in RA. CONCLUSION: The adverse changes in PT properties in RA and AS may contribute to their impaired physical function. AS, but not RA, leads to PT thickening without increasing PT stiffness, suggesting that PT thickening in AS is a disorganised repair process. Longitudinal studies need to investigate the time course of these changes and their response to exercise training.

The 8-foot up and go test is the best way to assess physical function in the rheumatoid arthritis clinic.

OBJECTIVES: RA is characterized by poor physical function, which compromises patients' quality of life and outcome. Clinical assessment of function is usually performed using self-reported questionnaires, such as the Multi-Dimensional HAQ (MDHAQ) and the Short Form-36 (physical component) (SF36-PC). However, such subjective measures may not accurately reflect real functional status. This study aimed to determine: (i) which clinically practicable objective test best represents overall physical function; and (ii) the extent to which self-reported subjective functional measures reflect objectively assessed function. METHODS: Objective [isometric knee extensor strength, handgrip strength, sit-to-stands in 30 s, 8-foot up and go (8'UG), 50-foot walk (50'W) and estimated aerobic capacity (V̇O2max)] and subjective (MDHAQ and SF36-PC) measures of function were correlated with one another to determine the best overall test of functional status in 82 well-controlled RA patients (DAS28 (s.d.) = 2.8 (1.0)). RESULTS: In rank order of size, averaged correlations (r) to the other outcome measures were as follows: 8'UG: 0.650; 50'W: 0.636; isometric knee extensor strength: 0.502; handgrip strength: 0.449; sit-to-stands in 30 s: 0.432; and estimated V̇O2max: 0.358. The MDHAQ was weakly (0.361) and the SF36-PC moderately correlated (0.415) with objective measures. CONCLUSION: Our results show that the most appropriate measure of objective physical function in RA patients is the 8'UG, followed by the 50'W. We found discordance between objectively and subjectively measured function. In clinical practice, an objective measure that is simple and quick to perform, such as the 8'UG, is advocated for assessing real functional status.

Muscle loss following a single high-dose intramuscular injection of corticosteroids to treat disease flare in patients with rheumatoid arthritis.

OBJECTIVE: Adverse changes in body composition, specifically decreased muscle mass (MM) and increased fat mass, characterize rheumatoid arthritis (RA). These changes, termed rheumatoid cachexia (RC), are important contributors to the disability and elevated co-morbidity risk of RA. Recently, we observed substantial muscle loss (~2 kg) in a patient with RA following a single intramuscular (IM) corticosteroid (CS) injection to treat a disease flare. The aim of the current study is to determine whether this apparent iatrogenic effect of IM CS is typical, i.e., does this routine, recommended treatment contribute to RC? METHODS: Body composition was assessed by dual-energy X-ray absorptiometry (DXA) in eight patients with established RA who received a 120 mg IM methylprednisolone injection to treat a disease flare. DXA scans estimated appendicular lean mass (ALM; a surrogate measure of MM), total lean mass (LM), and total and regional adiposity at baseline (injection day) and 4 weeks and 6-9 months post-injection. Statistical analysis was performed using one-way ANOVA. RESULTS: There was significant loss of ALM (-0.93 kg, p=0.001, 95% CI [-0.49, -1.36]) and a trend toward reduced LM (-1.10 kg, p=0.165, 95% CI [0.58, -2.79]) at 4 weeks relative to baseline. At 6-9 months despite control of inflammation and disease activity, these losses remained. CONCLUSION: Substantial muscle loss occurred in patients with RA following IM CS injection to treat a disease flare. Thus, this recommended treatment appears to exacerbate RC, thereby potentially increasing disability and co-morbidity risk. If this effect is confirmed by larger studies, the role of one-off high-dose CS in the treatment of RA should be reviewed.

Health Professionals' Perceptions of the Effects of Exercise on Joint Health in Rheumatoid Arthritis Patients.

OBJECTIVES: Although exercise is an important factor in the management of rheumatoid arthritis (RA), research indicates that patients perceive that health professionals (HPs) are uncertain about the place of exercise in treatment and its relationship with joint damage. The present study investigated the perceptions of HPs regarding the effects of exercise on joint health in RA patients. METHODS: A questionnaire investigating perceptions of exercise and joint health was distributed via professional networks and websites. Confirmatory factor analysis (CFA) was used to analyse questionnaire data and develop a focus group interview guide. Focus groups were conducted with multidisciplinary teams (MDTs) of rheumatology HPs and analysed using framework analysis. RESULTS: A total of 137 rheumatology HPs (95 female; 27-65 years of age) completed questionnaires. CFA showed that a four-factor model provided a marginally acceptable fit. Analysis of four focus groups (n = 24; 19 female; 30-60 years of age) identified five themes relating to HPs' perceptions of exercise and joint health in RA patients: 'Exercise is beneficial', 'Concerns about damage to joints', 'Patients have barriers to exercise', 'HP knowledge differs' and 'Patients may think service delivery is vague'. CONCLUSIONS: HPs were highly aware of the benefits and importance of exercise for RA patients. However, to remove the patient perception that HPs lack certainty and clarity regarding exercise it is important to ensure: (i) consistent promotion of exercise across the whole MDT; (ii) clear provision of information regarding rest, joint protection and exercise; (iii) HP education to ensure consistent, accurate knowledge, and understanding of the potential for conflicting advice when promoting exercise as part of an MDT. Copy © 2016 John Wiley & Sons, Ltd.

Can Creatine Supplementation Improve Body Composition and Objective Physical Function in Rheumatoid Arthritis Patients? A Randomized Controlled Trial.

OBJECTIVE: Rheumatoid cachexia (muscle wasting) in rheumatoid arthritis (RA) patients contributes to substantial reductions in strength and impaired physical function. The objective of this randomized controlled trial was to investigate the effectiveness of oral creatine (Cr) supplementation in increasing lean mass and improving strength and physical function in RA patients. METHODS: In a double-blind design, 40 RA patients were randomized to either 12 weeks' supplementation of Cr or placebo. Body composition (dual x-ray absorptiometry and bioelectrical impedance spectroscopy [BIS]), strength, and objectively assessed physical function were measured at baseline, day 6, week 12, and week 24. Data analysis was performed by analysis of covariance. RESULTS: Cr supplementation increased appendicular lean mass (ALM; a surrogate measure of muscle mass) by mean ± SE 0.52 ± 0.13 kg (P = 0.004 versus placebo), and total LM by 0.60 ± 0.37 kg (P = 0.158). The change in LM concurred with the gain in intracellular water (0.64 ± 0.22 liters; P = 0.035) measured by BIS. Despite increasing ALM, Cr supplementation, relative to placebo, failed to improve isometric knee extensor strength (P = 0.408), handgrip strength (P = 0.833), or objectively assessed physical function (P = 0.335-0.764). CONCLUSION: In patients with RA, Cr supplementation increased muscle mass, but not strength or objective physical function. No treatment-related adverse effects were reported, suggesting that Cr supplementation may offer a safe and acceptable adjunct treatment for attenuating muscle loss; this treatment may be beneficial for patients experiencing severe rheumatoid cachexia.

Perceptions of issues relating to exercise and joint health in rheumatoid arthritis: a UK-based questionnaire study.

OBJECTIVES: This questionnaire study investigated the perceptions of rheumatoid arthritis (RA) patients across the UK in relation to exercise and joint health. The validity of the measure was also assessed. METHODS: Members of the National Rheumatoid Arthritis Society (NRAS) with self-reported RA completed the questionnaire online. Items related to five factors that emerged from previous qualitative research. Participants responded using a five-point Likert-style scale (strongly disagree to strongly agree). The International Physical Activity Questionnaire (IPAQ) assessed physical activity. The model was tested using confirmatory factor analysis (LISREL 8.8); statistical analyses were conducted using the Statistical Package for the Social Sciences (SPSS). RESULTS: A total of 247 responses were collected over 47 days (88% females; age: 18-77 years; disease duration: <1-51 years). Acceptable factorial validity was revealed (Satorra-Bentler χ(2) = 774.47, df = 454, p < 0.001, root mean squared error of approximation (RMSEA) = 0.05, 90% confidence interval RMSEA = 0.05-0.06, comparative fit index = 0.94, standardized root mean square residual = 0.09), with the following factor endorsements: 'Health professionals show exercise knowledge' (19%); 'Knowing what exercise should be done' (43%); 'Having to exercise because it is helpful' (72%); 'Worry about causing harm to joints' (44%); and 'Not wanting to exercise as joints hurt' (52%). Patient concerns about joint pain, joint harm and how to exercise were significantly associated with lower physical activity (p < 0.05). CONCLUSIONS: These results confirm that patients perceive exercise as beneficial. However, concerns about how to exercise, joint pain, causing harm to joints and a perceived lack of exercise knowledge among health professionals remain. Addressing these concerns may have implications for increasing physical activity within the RA population.

A simple step test to estimate cardio-respiratory fitness levels of rheumatoid arthritis patients in a clinical setting.

Purpose. Exercise tests represent an important clinical tool to evaluate cardio-respiratory fitness and to predict future adverse cardiovascular events. However, use of such tests in patients with rheumatoid arthritis (RA) is relatively uncommon despite well-established evidence that low exercise capacity and high CVD mortality are features of this disease. Therefore, this study examined the validity and reliability of a sub-maximal step test for use in RA patients. Methods. Thirty patients (24 females) (mean ± SD age 53 ± 10 years) performed a sub-maximal step test on two occasions to estimate the criterion measure of cardio-respiratory fitness ([Formula: see text]). A further maximal cycling test provided a direct fitness measurement ([Formula: see text]). Pearson correlation coefficient, intraclass correlation coefficient (ICC), Bland and Altman plots, and 95% limits of agreement (LOA) were used to determine the validity and reliability of the sub-maximal test. Results. Estimated [Formula: see text] correlated well with directly measured [Formula: see text] (r = 0.79, LoA ±5.7 mL·kg(-1) ·min(-1)). Test-retest reproducibility for estimated [Formula: see text] was excellent (ICC = 0.97, LoA ±2.2 mL·kg(-1) ·min(-1)). Conclusion. The sub-maximal step test studied here represents a valid and reproducible method to estimate cardio-respiratory fitness in RA patients. This test may be useful for the assessment and management of CVD risk in a clinical setting.

Benefits of exercise in rheumatoid arthritis.

This paper aims to highlight the importance of exercise in patients with rheumatoid arthritis (RA) and to demonstrate the multitude of beneficial effects that properly designed exercise training has in this population. RA is a chronic, systemic, autoimmune disease characterised by decrements to joint health including joint pain and inflammation, fatigue, increased incidence and progression of cardiovascular disease, and accelerated loss of muscle mass, that is, "rheumatoid cachexia". These factors contribute to functional limitation, disability, comorbidities, and reduced quality of life. Exercise training for RA patients has been shown to be efficacious in reversing cachexia and substantially improving function without exacerbating disease activity and is likely to reduce cardiovascular risk. Thus, all RA patients should be encouraged to include aerobic and resistance exercise training as part of routine care. Understanding the perceptions of RA patients and health professionals to exercise is key to patients initiating and adhering to effective exercise training.