EULAR's Updated Exercise Guidelines for Adults With Arthritis

Evidence-based recommendations from the European League Against Rheumatism (EULAR) which appear in the journal Annals of the Rheumatic Diseases indicate that the counseling patients with inflammatory arthritis (iA) or osteoarthritis (OA) of the hip or knee about the benefits of physical activity (PA) should be an integral part standard of care in clinical practice.

A task force (TF) developed and agreed on four overarching principles and 10 recommendations for physical activity(PA0 in people with iA and OA. It is advised that these recommendations should be implemented considering individual needs and national health systems.

Ten Recommendations:

Recommendation 1: PA as an integral part of standard care

PA according to public health (PH) recommendations is effective on PA level, physical fitness as well as disease-specific and general outcomes in people with RA/SpA/HOA/KOA. A meta-analysis (MA) including 16 RCTs showed that cardiovascular exercises have a moderately beneficial effect on cardiovascular fitness in all three conditions. MA including 25 RCTs showed that muscle strength exercises have a moderate beneficial effect for muscle strength in people with RA and HOA/KOA. MA including seven RCTs showed that combined exercises (aerobic or strength exercises plus flexibility exercises) had no effect on flexibility in people with SpA or HOA/KOA. Eleven RCTs described the promotion of daily PA.

PH recommendations for PA can be considered safe. No detrimental effects were reported, rather beneficial effects on disease activity and symptoms in iA. Forty-four percent of all included RCTs reported on adverse events (AE), of that 62 % described no AE and 38% describe minor AE such as transitional exercise related joint or muscle pain.

Recommendation 2: Responsibility for PA promotion

All HCPs should have a responsibility for PA promotion and collaborative working that facilitate a close cooperation between different professions to support appropriate disease management. This statement was based on the finding that 66% of the included studies reported the profession of the HCP providing the intervention, of which 75% were PTs

Recommendation 3: Delivery of PA

The delivery of interventions should be performed by HCPs competent in the field of PA principles and rheumatic conditions. One study described a ‘4 hours education session on cardiovascular training’, others described the instructing person as ‘trained’ or ‘experienced’. Some studies with a focus on the promotion of daily PA described training sessions on behavior change skills like Motivational Interviewing.

Recommendation 4: Evaluation of PA

The PA level (active or non-active) and the exercise domains (cardiorespiratory, muscle strength, flexibility and neuromotor) should be routinely assessed. Of 11 trials investigating the effect of PA promotion interventions, three RCTs described baseline screening to distinguish between active and non-active persons before starting the tailored PA-intervention. Specific tools are needed to assess each domain.

Recommendation 5: General and disease-specific contraindications

Tools for specific contraindications (CIs) were found; however, available general or national guidelines defining absolute or relative CIs should be followed as a priority.

Recommendation 6: Personalised aims and evaluation

The PA-interventions should be based on individual aims, which should be regularly evaluated. This can be done by PA assessments and any other assessments related to the individual aims. As PA assessments, performance-based tests, patient-reported outcome measures (eg, SQUASH, PASE) and self-monitoring tools (eg, wearables such as Fitbit, pedometer or accelerometer) were identified. However, we did not evaluate the validity and reliability of the assessments applied.

Recommendation 7: General and disease-specific barriers and facilitators

General and disease-specific barriers (that are not CI per se) and facilitators should be addressed as described in 11 studies. Disease-specific barriers included lack of knowledge about the disease, lack of knowledge about safe exercising (both in people with iA/OA and HCPs) and symptoms like pain, fatigue, stiffness, reduced mobility, fear of flare-ups or causing damage. Disease-specific facilitators included the positive impact of exercise in symptoms or disease control, information about the disease and correct exercising, the use medication for pain prior to exercising, using self-regulation techniques, supportive, but not controlling encouragement from HCPs and a supportive social background.

Recommendation 8: Individual adaptations to PA following the individualized assessment

Adaptations to PA should be made on a comprehensive individual assessment. However, no evidence of the necessity of general adaptations in people with RA/SpA/HOA/KOA was found. In some RA studies the ‘24 hour-rule’ was applied, that is, the exercise intensity was reduced when the increased pain persisted for more than 24 hours. ACSM provides adaptations to exercise testing in people with arthritis (eg, no high-intensity testing if acute inflammation) and training such as exercising when pain is typically least severe or to train carefully in order to reduce the risk of associated injuries, although no clear evidence that high-impact activities cannot be engaged during active inflammation. Individual disease-related barriers (eg, symptoms) may determine these adaptations.

Recommendation 9: Behaviour change techniques

BCTs should be an integral component of PA-interventions. Behavior change theories were used in PA promotion interventions in the field of RA and HOA/KOA, but the reporting was poor. Future research based on theories in the design, evaluation, and interpretation of findings is needed.

A meta-analysis of six RCTs investigating the effects of a PA promotion intervention according to general PA recommendations and based on counseling interventions that apply BCTs showed a small beneficial effect on PA level. Counseling interventions show a small beneficial effect if BCTs are applied.

Recommendation 10: Modes of delivery

HCPs should consider the whole range of modes to deliver interventions. No evidence on the superiority of specific delivery modes was found. The delivery modes of PA-interventions vary considerably and are mostly described as ‘land-based and/or water-based’ and ‘supervised and individualized’, the latter usually applied to group settings. As booster strategies phone calls, devices (eg, pedometer, wearable), home visits, log book, web-based instructions, written material, visual instructions (eg, video) were reported.

For reference log on to http://dx.doi.org/10.1136/annrheumdis-2018-213585