EULAR Asserts Physical Activity Integral to Care Plan in RA

A special task force established by the European League Against Rheumatism (EULAR) has developed 4 overall principles and 10 specific recommendations to ensure that physical activity (PA) is a part of the standard of care among patients diagnosed with rheumatoid arthritis (RA), spondyloarthritis (SpA), and osteoarthritis (OA) in Europe.

Although the World Health Organization and the American College of Sports Medicine (ACSM) have developed general guidance for PA among healthy adults, uptake among individuals with rheumatic diseases is less, likely due to a fear of joint damage or flare-ups among both patients and their care providers. While existing EULAR guidelines¹ and those by ACSM recommend exercise or PA, they lack in specifics on the type and dose of exercise.

The EULAR task force—composed of 22 European PA experts, 1 orthopedic surgeon, 9 physiotherapists, 1 psychologist, 1 occupational therapy nurse, and 1 human movement specialist—was therefore commissioned to:²

• Evaluate if the public health recommendations for PA are applicable for people with inflammatory arthritis and OA
• Develop evidence-based recommendations on PA promotion and delivery in the management of people with inflammatory arthritis and OA
• Formulate an educational and research agenda

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ACSM’s position stand was followed and the group kicked off the process by agreeing on the definitions of exercise and PA. The group conducted 2 systematic literature searches and meta-analyzed studies that measured efficacy of PA interventions. Results from here were used to develop the overarching principles as well as the specific recommendations during a face-to-face meeting, followed by independent and anonymous voting by the task force members to establish the level of agreement on these recommendations. The objective was to understand the barriers and facilitators of PA intervention in the said patient population.

The 4 overarching principles state that:

• PA is part of a general concept to optimize health-related quality of life.
• PA has health benefits for people with RA/SpA/OA.
• General PA recommendations, including the 4 domains (cardiorespiratory fitness, muscle strength, flexibility, and neuromotor performance), are applicable (feasible and safe) to people with RA/OA/SpA.
• The planning of PA requires a shared decision between healthcare providers and people with RA/SpA/OA, which takes people’s preferences, capabilities, and resources into account.

Specific recommendations by the task force include:

• PA as an integral part of standard care. The task force recommended that PA should be integral to the standard of care for individuals with RA/SpA/OA. With cardiovascular benefits and improved muscle strength, randomized clinical trials have shown that combined exercises (aerobic/strength exercises plus flexibility exercises) did not impact flexibility among people with SpA/OA—although exercise conditions, assessments, and outcome measures were variable. PA can be considered safe, with beneficial effects observed in disease activity and symptoms in RA and OA, with no detrimental effects reported.
• Responsibility for PA promotion. This is expected to fall on all healthcare providers, with close collaboration recommended for appropriate disease management. Because functions and responsibilities of healthcare providers vary across Europe, PA advice should be provided by all healthcare providers.
• Delivery of PA. This burden rests on the shoulders of healthcare providers competent in the field of PA principles and rheumatic conditions.
• Evaluation of PA. The PA level (active/nonactive) and exercise domains (cardiorespiratory, muscle strength, flexibility, and neuromotor) should be routinely assessed using specific tools.
• General and disease-specific contradictions. General/national guidelines defining absolute or relative contraindications should be followed.
• Personalized aims and evaluations. PA interventions should be assessed based on the individual aims. Assessment tools include performance-based tests, patient-reported outcomes measures, and self-monitoring tools, including pedometers or Fitbits.
• General and disease-specific barriers and facilitators. Disease-specific barriers, including lack of knowledge on the disease or about safe exercising and symptoms like fatigue, reduced mobility, or stiffness. Facilitators include positive impact of exercise on symptom or disease control, information on disease and correct exercising, and medication for pain prior to exercising, among others.
• Behavior change techniques. These should be integral to PA interventions, according to the task force. Alluding to poor reporting in clinical trials, they recommend future research based on theories in design, evaluation, and interpretation of findings.
• Modes of delivery. Healthcare providers should get creative with the mode of delivery, but there is no clear evidence on one mode being superior to another. Land-based/water-based and supervised/individualized modes of delivery of PA intervention are available. Additionally, booster strategies are recommended, including home visits, phone calls, devices, and web-based instructions.

The guidelines have been developed for care providers, patient advocacy groups, and policy makers.

References

1. Agca R, Heslinga SC, Rollefstad S, et al. EULAR recommendations for cardiovascular disease risk management in patients with rheumatoid arthritis and other forms of inflammatory joint disorders: 2015/2016 update. Ann Rheum Dis. 2017;76(1):17-28. doi: 10.1136/annrheumdis-2016-209775.
2. Rausch Osthoff AK, Niedermann K, et al. 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis. Ann Rheum Dis. 2018;77(9):1251-1260. doi: 10.1136/annrheumdis-2018-213585.