Objectives Research on effectiveness and cost‐effectiveness of longstanding exercise therapy in patients with axial SpondyloArthritis (axSpA) or Rheumatoid Arthritis (RA) is scarce, and mainly concerned patients with a relatively favorable health status. We aim to evaluate the effectiveness and cost‐effectiveness of longstanding exercise therapy compared to usual care in the subgroup of patients with axSpA or RA and severe limitations in functioning. Methods In two separate, parallel randomized controlled trials the effectiveness and cost‐effectiveness of longstanding, active exercise therapy (52 weeks) compared with usual care (1:1) will be evaluated. The longstanding, active exercise therapy will focus on improving individual limitations in daily activities and participation and will be given by a trained physical therapist in the vicinity of the participant. For each diagnosis, 215 patients with severe limitations in activities and participation will be included. Assessments are performed at baseline, 12, 26, and 52 weeks. The primary outcome measure of effectiveness is the individual level of functioning (activities and participation), as measured with the Patient‐Specific Complaints instrument at 52 weeks. For cost‐effectiveness analyses, the EuroQol (EQ‐5D‐5L) and questionnaires on healthcare use and productivity will be administered. The economic evaluation will be a cost‐utility analysis from a societal perspective. After 52 weeks, the patients in the usual care group are offered longstanding, active exercise therapy as well. Follow‐up assessments are done at 104, 156, and 208 weeks. Conclusion The results of these studies will provide insights in the effectiveness and cost‐effectiveness of longstanding exercise therapy in the subgroup of axSpA and RA patients with severe functional limitations.
Background:Axial SpondyloArthritis (axSpA) and Rheumatoid Arthritis (RA) are chronic rheumatic diseases with an often progressive course, defined by chronic inflammation. With respect to exercise therapy, in axSpA and RA, multiple systematic reviews concluded that supervised exercise therapy is an effective and safe treatment option, resulting in small to modest improvements in pain, disease activity, functional ability and axial mobility. In general, most of the studies included in these reviews concerned programs of a relatively short duration (<12 weeks) and the studies mostly concerned patients with stable disease, without co-morbid conditions and relatively favorable functional ability (1-5). The group of patients with active disease, irreversible joint damage, multiple joint replacements and/or severe comorbidity hampering participation in exercise therapy programs and in need for individualized, longstanding therapy is therefore likely to be underrepresented in research so far. Consequently, cost-effectiveness studies on longstanding physical therapy are also lacking in these specific subgroups.Objectives:We aim to evaluate the effectiveness and cost-effectiveness of longstanding exercise therapy compared to usual care in the subgroup of patients with axSpA or RA and severe limitations in functioning.Methods:In two separate, parallel randomized controlled trials, the effectiveness and cost-effectiveness of longstanding, active exercise therapy (52 weeks) compared with usual care (1:1) will be evaluated (Figure 1). The longstanding, active exercise therapy will focus on improving individual limitations in daily activities and participation, and will be given by a trained physical therapist in the vicinity of the participant. For each diagnosis, 215 patients with severe limitations in activities and participation will be included. Assessments are performed at baseline, 12, 26, and 52 weeks. The primary outcome measure of effectiveness is the individual level of functioning (activities and participation), as measured with the Patient-Specific Complaints instrument at 52 weeks. For cost-effectiveness analyses, the EuroQol (EQ-5D-5L) and questionnaires on healthcare use and productivity will be administered. The economic evaluation will be a cost-utility analysis from a societal perspective. After 52 weeks, the patients in the usual care group are offered longstanding, active exercise therapy as well. Follow-up assessments are done at 104, 156 and 208 weeks.Figure 1.Study flowchartResults:The results of these studies will provide insights in the effectiveness and cost-effectiveness of longstanding exercise therapy in the subgroup of axSpA and RA patients with severe functional limitations.References:[1]Mewes J, de Bekker P, Bossen D, Steuten L. 2016. Systematic review of supervised physical exercise therapy for patients with rheumatoid arthritis. Panaxea.[2]Mewes J, de Bekker P, Bossen D, Steuten L. 2016. Systematic review of supervised phyiscal exercise therapy for patients with ankylosing spondylitis. Panaxea.[3]Swardh E, Brodin N. 2016. Effects of aerobic and muscle strengthening exercise in adults with rheumatoid arthritis: a narrative review summarising a chapter in Physical activity in the prevention and treatment of disease (FYSS 2016). Br J Sports Med 50: 362-7.[4]Sveaas SH, Smedslund G, Hagen KB, Dagfinrud H. 2017. Effect of cardiorespiratory and strength exercises on disease activity in patients with inflammatory rheumatic diseases: a systematic review and meta-analysis. Br J Sports Med 51: 1065-72.[5]Regel A, Sepriano A, Baraliakos X, van der Heijde D, Braun J, Landewe R, Van den Bosch F, Falzon L, Ramiro S. 2017. Efficacy and safety of non-pharmacological and non-biological pharmacological treatment: a systematic literature review informing the 2016 update of the ASAS/EULAR recommendations for the management of axial spondyloarthritis. RMD Open 3: e000397.Disclosure of Interests:None declared
BackgroundIn national and international management guidelines physical therapy (PT) is a recommended treatment for people with inflammatory arthritis (IA). Based on multiple systematic reviews, concluding that supervised exercise therapy and exercise promotion is an effective and safe PT treatment option in patients with IA, recommendations in particular endorse active PT treatment. In order to monitor and enhance the quality of PT in clinical practice, knowledge about its delivery, including its active content, is needed.ObjectivesTo assess the use, frequency, duration and content of PT in patients with IA.MethodsIn this cross-sectional, national study a link to an electronic questionnaire addressing people with rheumatic and musculoskeletal diseases was published between December 2020-July 2021 by the Dutch Arthritis Foundation via their website, newsletter and various social media. It comprised questions on demographic and health characteristics, the EuroQol 5-Dimensions 5-Levels (EQ5D5L) and 29 questions on the usage of PT currently and/or in the past 12 months and, if applicable, the duration, frequency and content of the PT treatment. The content of PT was categorized into exercises (active aerobic, muscle strengthening, range of motion and/or functional exercises), manual treatment, physical modalities and counseling/education. Only data from patients self-identifying as diagnosed with rheumatoid arthritis (RA) and/or axial spondyloarthritis (axSpA) were used for the current study.ResultsA total of 267 people with RA (mean (SD) age 54 (12) years, 96% female) and 104 people with axSpA (age 47 (13) years, 88% female) (10 patients with both diagnoses) completed the questionnaire. More than 90% were treated by a rheumatologist; the mean (SD) EQ5D5L of people with RA was 0.62 (0.2) and of axSpA 0.59 (0.2). 172 RA respondents (64%) reported the use of PT related to their RA (162 individual PT, 1 group PT, 9 both individual and group PT). In axSpA, the rate was 87 (84%; 77 individual PT, 2 group PT, 8 both individual and group PT).Of those reporting individual PT treatment, the duration was long-term (> 3 months) in 134 (89%) and 70 (89%) of the respondents with RA and axSpA respectively, with a duration of more than 2 years in 67 (44%) and 38 (48%). In all users of individual PT, the mean frequency was once per week or less in 116 (77%) of the RA and 63 (80%) of the axSpA patients. Proportions were based on number of respondents to questions on individual PT.Concerning the content of individual PT, and taking into account both short-term and long-term use, for active exercises, the proportion of patients reporting aerobic, muscle strengthening, range of motion or functional exercises ranged from 40-66% in RA and 24-73% in axSpA patients. Regarding manual treatment, the proportions were 61% and 58%, in RA and 73% and 72% in axSpA for massage and passive mobilizations, respectively. With respect to physical modalities (passive), the modality most frequently mentioned were kinesiotaping and dry needling (40 and 25% and 43 and 32% in RA and axSpA). For counseling/education, exercises to perform at home (70 and 78%) and physical activity (PA) promotion (48 and 49%) were most often reported in both RA and AxSpA.ConclusionLong-term use of PT is common in patients with RA and AxSpA. Apart from active treatment modalities (exercises) and promoting recommended PA, passive treatment options appear to be relatively often used. The results must be interpreted with caution, as the respondents may not constitute a representative sample of the IA population, yet warrant further research.Acknowledgements:This work was supported by the Dutch Arthritis Society [ReumaNederland], the Royal Dutch Society for Physical Therapy [KNGF] and The Netherlands Organisation for Health Research and Development [ZonMw].Disclosure of InterestsNone declared
To assess the reporting quality of interventions aiming at promoting physical activity (PA) using a wearable activity tracker (WAT) in patients with inflammatory arthritis (IA) or hip/knee osteoarthritis (OA). A systematic search was performed in eight databases (including PubMed, Embase and Cochrane Library) for studies published between 2000 and 2022. Two reviewers independently selected studies and extracted data on study characteristics and the reporting of the PA intervention using a WAT using the Consensus on Exercise Reporting Template (CERT) (12 items) and Consolidated Standards of Reporting Trials (CONSORT) E-Health checklist (16 items). The reporting quality of each study was expressed as a percentage of reported items of the total CERT and CONSORT E-Health (50% or less = poor; 51–79% = moderate; and 80–100% = good reporting quality). Sixteen studies were included; three involved patients with IA and 13 with OA. Reporting quality was poor in 6/16 studies and moderate in 10/16 studies, according to the CERT and poor in 8/16 and moderate in 8/16 studies following the CONSORT E-Health checklist. Poorly reported checklist items included: the description of decision rule(s) for determining progression and the starting level, the number of adverse events and how adherence or fidelity was assessed. In clinical trials on PA interventions using a WAT in patients with IA or OA, the reporting quality of delivery process is moderate to poor. The poor reporting quality of the progression and tailoring of the PA programs makes replication difficult. Improvements in reporting quality are necessary.
BackgroundDespite the availability of effective medical treatment, there is still a subgroup of people with Rheumatoid Arthritis (RA) who have considerable functional limitations due to persistently high disease activity, joint destruction or deformities and/or comorbidities. More insight into the nature and severity of these functional limitations is important to provide adequate treatment matching the needs of this specific subgroup.ObjectivesTo describe the nature and severity of functional limitations in patients with RA and severe functional limitations, identified by the Health Assessment Questionnaire Disability Index (HAQ-DI).MethodsBaseline data from people with RA and severe limitations in physical functioning participating in a randomized controlled trial on the (cost-)effectiveness of longstanding physical therapy as compared to usual care [1] were used. Patients completed the HAQ-DI (Dutch version)[2, 3], a reliable, valid and widely used questionnaire reflecting problems in activities of daily living and consisting of 20 items divided over eight domains (Dressing and grooming, Arising, Eating, Walking, Personal hygiene, Reaching, Gripping and Usual activities). Each item is scored on a 4-point scale ranging from 0 to 3 (no difficulty - unable to perform), with the total HAQ-DI score ranging from 0 to 3 (no disability - severe disability). This preliminary data analysis does not yet take into account the use of assistance/assistive devices. Gender, age, sex and disease duration were recorded, and the EuroQol 5 Dimensions 5 Levels (EQ-5D-5L) administered for health related quality of life (HRQoL) (Single index score (-0.446-1.000), and visual analogue scale (EQ-VAS, 0-100), higher scores indicating better HRQoL).ResultsFrom 2020-2021, 215 people with RA were included (n=194; 90% women, mean age (standard deviation) of 58.8 (12.9) years and median disease duration (Interquartile Range (IQR)) of 19 (9-27) years (n=166)). The median EQ-5D-5L index and EQ-VAS were 0.6 (0.3-0.7) and 59 (41 -70), respectively. The median total HAQ-DI score was 1.5 (1.1-1.9). The majority (83%, n=179) had a total HAQ-DI score ≥1 indicating moderate to severe activity limitations. The mean HAQ-DI domain scores and the percentage of patients within each domain reporting no/some/much difficulty or inability to perform everyday activities are shown in Figure 1.The median number of domains with a score ≥1 was 8 (range 3-8, IQR 7-8, mean 7.1). More than half of the participants had a domain score ≥1 in all 8 domains (52%, n=111), almost a quarter in 7 domains (24%, n=52), 13% (n=28) in 6 domains and the minority (11%, n=24) in 5 or less domains. The highest proportion of patients with a maximum score of 3 were seen in the domains Personal hygiene (42%) and Reaching (28%), followed by Usual activities and Eating (15% and 14%, respectively). For Gripping, Arising, Walking and Dressing and grooming the proportions of patients with the maximum score was less than 8%.ConclusionIn a subgroup of patients with RA and severe functional disability, the majority had limitations in almost all the domains of the HAQ-DI. Most severe limitations were seen in Reaching and Personal hygiene and the least severe for Arising and Dressing and grooming. In daily clinical practice, a comprehensive assessment of all areas of daily activities in this subgroup of RA patients is necessary, and because the functional limitations are present and significant in all domains, extensive support from multiple healthcare professionals may be indicated.References[1]van Wissen MAT, et al. Physiother Res Int. 2021;e1933.[2]Fries JF, et al. Arthritis Rheum. 1980;23:137-45.[3]Boers M, et al. Ann Rheum Dis. 2007;66:132-3.Figure 1.Mean HAQ-DI scores for each HAQ-DI domain and the percentage of patients that reported to have either no/some/much difficulty or unable to perform everyday activities represented for each domain.AcknowledgementsThis project is financially supported by Netherlands Organization for Health Research and Development (ZonMw; 852004018), Ministry of Health, Welfare and Sport (VWS), the Royal Dutch Society for Physical Therapy (KNGF) and the Dutch Arthritis Society (ReumaNederland).Disclosure of InterestsNone Declared.
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