Physical Activity In Rheumatoid Arthritis Research Articles

Promoting physical activity in rheumatoid arthritis through a physiotherapist led behaviour change-based intervention (PIPPRA): a feasibility randomised trial

Physical activity (PA) is recommended as a key component in the management of people with rheumatoid arthritis (RA). The objective of this study was to examine the feasibility of a physiotherapist led, behaviour change (BC) theory-informed, intervention to promote PA in people with RA who have low levels of current PA. A feasibility randomised trial (ClinicalTrials.gov NCT03644160) of people with RA over 18 years recruited from outpatient rheumatology clinics and classified as insufficiently physically active using the Godin−Shephard Leisure Time Physical Activity Questionnaire. Participants were randomised to intervention group (4 BC physiotherapy sessions in 8 weeks) delivered in person/virtually or control group (PA information leaflet only). Feasibility targets (eligibility, recruitment, and refusal), protocol adherence and acceptability were measured. Health care professionals (HCPs) involved in the study and patients in the intervention and control arms were interviewed to determine acceptability. Descriptive statistics were used to analyse the data with SPSS (v27) with interviews analysed using content analysis using NVivo (v14). Three hundred and twenty participants were identified as potentially eligible, with n = 183 (57%) eligible to participate, of which n = 58 (32%) consented to participate. The recruitment rate was 6.4 per month. Due to the impact of COVID-19 on the study, recruitment took place over two separate phases in 2020 and 2021. Of the 25 participants completing the full study, 23 were female (mean age 60 years (SD 11.5)), with n = 11 allocated to intervention group and n = 14 to control. Intervention group participants completed 100% of sessions 1 & 2, 88% of session 3 and 81% of session 4. The study design and intervention were acceptable overall to participants, with enhancements suggested. The PIPPRA study to improve promote physical activity in people with RA who have low PA levels was feasible, acceptable and safe. Despite the impact of COVID-19 on the recruitment and retention of patients, the study provides preliminary evidence that this physiotherapist led BC intervention is feasible and a full definitive intervention should be undertaken. Health care professionals involved in the study delivery and the patient participants described a number of positive aspects to the study with some suggestions to enhance the design. These findings hence inform the design of a future efficacy-focused clinical trial.

The impact of COVID-19 on clinical research: the PIPPRA and MEDRA experience.

Coronavirus disease 2019 (COVID-19) has had a significant impact on clinical research. This paper aims to provide an insight into how the COVID-19 pandemic, associated public health restrictions and international guidance on the conduct of clinical research impacted two clinical rheumatology research trials - the Physiotherapist-led Intervention to Promote Physical Activity in Rheumatoid Arthritis (PIPPRA) and the MEDiterranean diet in Rheumatoid Arthritis (MEDRA) projects. The March 2019 public health restrictions imposed to mitigate the risk of COVID-19 occurred at a time when PIPPRA was in the process of delivering assessment and intervention on a face-to-face basis (n=48) and MEDRA had commenced recruitment. Participants in PIPPRA and MEDRA had a diagnosis of rheumatoid arthritis, with some being immunosuppressed and thus at a higher risk for COVID-19. The decision-making processes of both trials is outlined to demonstrate the required amendments to continue in the context of the COVID-19 pandemic. Amendments to PIPPRA and MEDRA trial protocols were agreed and received ethical and funder approval. Both trials switched from a face-to-face delivery to a telehealth using online platforms. The PIPPRA study was paused for five months (April-August 2020), resulting in n=33 (60%) negative deviations from assessment protocol. MEDRA switched from face-to-face to online recruitment with 20% (n=35/44) negative deviations in recruitment. Of the n=18 participants who consented to participating in a face-to-face trial, just n=2 (11%) opted to engage with telehealth delivery of the intervention. MEDRA assessment and intervention deviations were 100% as no sessions were completed as planned in 2020. The COVID-19 pandemic has severely impacted the PIPPRA and MEDRA clinical trials. Moving face-to-face clinical research to telehealth delivery may not be the panacea it is purported to be. Our experiences may be of benefit to researchers, clinicians, and funders in seeking to continue clinical research during a global pandemic.

The impact of COVID-19 on clinical research: the PIPPRA and MEDRA experience

Background: Coronavirus disease 2019 (COVID-19) has had a significant impact on clinical research. This paper aims to provide an insight into how the COVID-19 pandemic, associated public health restrictions and international guidance on the conduct of clinical research impacted two clinical rheumatology research trials - the Physiotherapist-led Intervention to Promote Physical Activity in Rheumatoid Arthritis (PIPPRA) and the MEDiterranean diet in Rheumatoid Arthritis (MEDRA) projects. Methods: The March 2019 public health restrictions imposed to mitigate the risk of COVID-19 occurred at a time when PIPPRA was in the process of delivering assessment and intervention on a face-to-face basis (n=48) and MEDRA had commenced recruitment. Participants in PIPPRA and MEDRA had a diagnosis of rheumatoid arthritis, with some being immunosuppressed and thus at a higher risk for COVID-19. The decision-making processes of both trials is outlined to demonstrate the required amendments to continue in the context of the COVID-19 pandemic. Results: Amendments to PIPPRA and MEDRA trial protocols were agreed and received ethical and funder approval. Both trials switched from a face-to-face delivery to a telehealth using online platforms. The PIPPRA study was paused for five months (April-August 2020), resulting in n=33 (60%) deviations from assessment protocol. MEDRA switched from face-to-face to online recruitment with 20% (n=35/44) deviation in recruitment. Of the n=18 participants who consented to participating in a face-to-face trial, just n=2 (11%) opted to engage with telehealth delivery of the intervention. MEDRA assessment and intervention deviations were 100% as no sessions were completed as planned in 2020. Conclusions: The COVID-19 pandemic has severely impacted the PIPPRA and MEDRA clinical trials. Moving face-to-face clinical research to telehealth delivery may not be the panacea it is purported to be. Our experiences may be of benefit to researchers, clinicians, and funders in seeking to continue clinical research during a global pandemic.

Benefits and promotion of physical activity in rheumatoid arthritis.

The aim of this article is to describe the benefits of physical activity and exercise on rheumatoid arthritis disease activity, functioning, and symptoms; and offer recommendations for promotion of physical activity and exercise among people with rheumatoid arthritis. In addition to well-known benefits of exercise such as improving cardiovascular health and metabolic syndrome and reducing obesity, exercise has consistently shown rheumatoid arthritis-specific benefits. Exercise and increases in physical activity improve clinically measured disease activity, reduce symptoms such as fatigue and pain, and improve function and mental health. In spite of these benefits, most people with rheumatoid arthritis are inactive. Patient barriers to engaging in physical activity may include fears of joint damage, rheumatoid arthritis symptoms, and lack of understanding that physical activity improves the symptoms that may be barriers. However, the greatest barrier to healthy levels of physical activity among individuals with rheumatoid arthritis appears to be the lack of direction from healthcare providers. Exercise is safe and highly beneficial for people with rheumatoid arthritis. Because receiving recommendations from healthcare providers may be the factor most strongly associated with engaging in physical activity or exercise, providers are encouraged to give patients positive messages about the benefits of physical activity and the extremely low risks of harm.

The impact of lifestyle behaviours, physical activity and smoking on morbidity and mortality in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) is associated with pain, disability and increased risk of developing comorbidities and premature mortality. While these poor outcomes have improved in line with advances in the treatment of RA, they still persist to some degree today. Physical activity and smoking are two areas of patients' lives where changes may have a substantial impact on the poor outcomes associated with RA. Physical activity in RA has been well studied, with many randomised trials indicating the benefits of physical activity on pain and disability. A number of observational studies have assessed the impact of smoking on RA, also indicating the benefits of quitting smoking on RA-related outcomes, but with less consistent findings, potentially due to epidemiological challenges (e.g. collider bias, recall bias). There are also a number of barriers preventing patients making these positive lifestyle changes, such as lack of time and motivation, lack of knowledge and advice, as well as disease-specific barriers, such as pain and fatigue.

Physical activity in rheumatoid arthritis: relationship to cardiovascular risk factors, subclinical atherosclerosis, and disease activity

Objective: To investigate associations between physical activity and risk factors for cardiovascular disease (CVD), subclinical atherosclerosis, and disease activity in patients with early and long-standing rheumatoid arthritis (RA).Method: This cross-sectional study included 84 patients with early and 37 with long-standing RA (disease duration, mean ± sd: 1.4 ± 0.4 and 16.3 ± 2.3 years, respectively). Physical activity was measured using a combined accelerometer and heart-rate monitor. Further assessments were disease activity (erythrocyte sedimentation rate, Disease Activity Score in 28 joints), functional ability (Health Assessment Questionnaire), risk factors for CVD (blood lipids, i.e. triglycerides, high-density lipoprotein, low-density lipoprotein; blood glucose, blood pressure, sleeping heart rate, waist circumference, body mass index, and body fat), and subclinical atherosclerosis (pulse-wave velocity, augmentation index, and carotid intima–media thickness).Results: Physical activity variables did not differ between patients with early and long-standing RA. However, 37% of the patients with early and 43% of those with long-standing RA did not reach the World Health Organization’s recommended levels of moderate to vigorous physical activity (MVPA). In a final multiple regression model, adjusted for age, gender, disease duration, and activity monitor wear time, higher total physical activity was associated with lower body fat and higher functional ability. With the same adjustments, more time spent in MVPA was associated with lower high-density lipoprotein and lower sleeping heart rate.Conclusions: Physical activity was associated with more favourable risk factors for CVD. However, many patients were physically inactive, stressing the importance of promoting physical activity in RA.

Objective measurement of sedentary time and physical activity in people with rheumatoid arthritis: protocol for an accelerometer and activPALTM validation study.

Background:The accurate measurement of sedentary time and physical activity in Rheumatoid Arthritis (RA) is critical to identify important health consequences and determinants of these behaviours in this patient group. However, objective methods have not been well-validated for measurement of sedentary time and physical activity in RA.Aims:Specific objectives are to: 1) validate the ActiGraph GT3X+ accelerometer and activPAL3μTM against indirect calorimetry and direct observation respectively, and define RA-specific accelerometer cut-points, for measurement of sedentary time and physical activity in RA; 2) validate the RA-specific sedentary time accelerometer cut-points against the activPAL3μTM; 3) compare sedentary time and physical activity estimates in RA, using RA-specific vs. widely-used non-RA accelerometer cut-points.Methods:Objective 1: People with RA will wear an ActiGraph GT3X+, activPAL3μTM, heart rate monitor and indirect calorimeter, whilst being video-recorded undertaking 11 activities representative of sedentary behaviour, and light and moderate intensity physical activity. Objectives 2 and 3: People with RA will wear an ActiGraph GT3X+ and activPAL3μTM for 7 days to measure free-living sedentary time and physical activity.Discussion:This will be the first study to define RA-specific accelerometer cut-points, and represents the first validation of the ActiGraph accelerometer and activPALTM, for measurement of sedentary time and physical activity in RA. Findings will inform future RA studies employing these devices, ensuring more valid assessment of sedentary time and physical activity in this patient group.

The effect of interactive digital interventions on physical activity in people with inflammatory arthritis: a systematic review

The aim of this systematic review was to evaluate the evidence from randomised controlled trials (RCTs) evaluating the effectiveness of interactive digital interventions (IDIs) for physical activity (PA) and health related quality of life (HRQoL) in people with Inflammatory Arthritis [rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA) axial Spondyloarthritis (AS) and psoriatic arthritis (PsA)]. Seven electronic databases identified published and unpublished studies. Two reviewers conducted independent data extraction and quality assessment using the Cochrane risk of bias tool (RoB). The primary outcome was change in objective PA after the intervention; secondary outcomes included self-reported PA and HRQoL after the intervention and objective or self-reported PA at least 1 year later. Five manuscripts, reporting four RCTs (three high and one low RoB) representing 492 (459 RA, 33 JIA) participants were included. No trials studying PsA or AS met the inclusion criteria. Interventions ranged from 6 to 52 weeks and included 3–18 Behaviour Change Techniques. Due to heterogeneity of outcomes, a narrative synthesis was conducted. No trials reported any significant between group differences in objective PA at end of intervention. Only one low RoB trial found a significant between group difference in self-reported vigorous [MD Δ 0.9 days (95% CI 0.3, 1.5); p = 0.004], but not moderate, PA in people with RA but not JIA. There were no between group differences in any other secondary outcomes. There is very limited evidence for the effectiveness of IDIs on PA and HRQoL in RA and JIA and no evidence for their effectiveness in PsA or AS.

Theory-informed interventions to promote physical activity and reduce sedentary behaviour in rheumatoid arthritis: a critical review of the literature.

Moderate-intensity physical activity (PA) is recommended for the management of Rheumatoid Arthritis (RA). Recent evidence suggests that reducing sedentary behaviour (promoting ‘sedentary breaks’ and light intensity PA) may also offer potential for improving RA outcomes, independently of the benefits of moderate-intensity PA. Unfortunately, people living with RA engage in very little moderate-intensity PA, and the spend the majority of the day sedentary. Interventions to support PA and sedentary behaviour change in this population are therefore required. Psychological theory can provide a basis for the development and implementation of intervention strategies, and specify the cognitive processes or mechanisms assumed to result in behavioural change. Application of psychological theory to intervention development and evaluation, therefore, permits evaluation of “how things work”, helping to identify optimal intervention strategies, and eliminate ineffective components. In this review, we provide an overview of existing PA and sedentary behaviour change interventions in RA, illustrating the extent to which current interventions have been informed by psychological theories of behaviour change. Recommendations are provided for future interventional research in this domain, serving as a reference point to encourage proper application of behavioural theories into intervention design, implementation and appraisal.

Pain sensitivity at rest and during muscle contraction in persons with rheumatoid arthritis: a substudy within the Physical Activity in Rheumatoid Arthritis 2010 study

BackgroundWe aimed to explore pressure pain sensitivity and the function of segmental and plurisegmental exercise-induced hypoalgesia (EIH) in persons with rheumatoid arthritis (RA) compared with healthy control subjects (HC).MethodsForty-six participants with RA (43 female, 3 male) and 20 HC (16 female, 4 male) participated in the study. Pressure pain thresholds, suprathreshold pressure pain at rest, and segmental and plurisegmental EIH during standardised submaximal contractions were assessed by algometry. Assessments of EIH were made by performing algometry alternately at the contracting (30% of the individual maximum) right m. quadriceps and the resting left m. deltoideus.ResultsParticipants with RA had higher sensitivity to pressure pain (RA, 318 kPa; HC, 487 kPa; p < 0.001), suprathreshold pressure pain 4/10 (RA, 433 kPa; HC, 638 kPa; p = 0.001) and suprathreshold pressure pain 7/10 (RA, 620 kPa; HC, 851 kPa; p = 0.002) than HC. Segmental EIH (RA, 0.99 vs 1.27; p < 0.001; HC, 0.89 vs 1.10; p = 0.016) and plurisegmental EIH (RA, 0.95 vs 1.36; p < 0.001; HC, 0.87 vs 1.31; p < 0.001) increased significantly during static muscle contraction in both groups alike (p > 0.05).ConclusionsOur results indicate a generally increased pain sensitivity but normal function of EIH among persons with RA and offer one possible explanation for pain reduction observed in this group of patients following clinical exercise programmes.Trial registrationISRCTN registry, ISRCTN25539102. Retrospectively registered on 4 March 2011.

How Are Behavioral Theories Used in Interventions to Promote Physical Activity in Rheumatoid Arthritis? A Systematic Review.

To identify the use of behavioral theories in physical activity interventions in populations with rheumatoid arthritis (RA). This review includes articles published in English between January 1, 1980 and November 8, 2015 in MEDLINE, Cochrane, and CINAHL, identified by a strategic literature search. Included studies were published in international peer-reviewed journals, mentioned theory, evaluated a physical activity intervention for adults with RA, and had ≥1 physical activity variable as the outcome. References and reviews were also checked. Two investigators independently selected articles and extracted data using a validated scale, the theory coding scheme. Additional extracted data included author, sample characteristics, study design, physical activity outcomes, intervention type and duration, and control group. A total of 245 articles were identified, 211 articles and references were screened, and 29 articles were reviewed. Of these, 18 were excluded, leaving 11 articles with 1,472 participants (75% women). Ten studies (91%) were randomized controlled trials, 8 (73%) assessed physical activity plus self-management, and 3 (27%) physical activity only. Program durations ranged from 5 weeks to 1 year. Eight studies (73%) used a single theory, 7 studies (64%) linked at least 1 intervention technique to theory, 2 studies (18%) analyzed mediating effects of theoretical constructs, and 5 studies (45%) discussed results in relation to theory. Findings indicate that physical activity intervention studies claiming the use of behavioral theories use theory to a small extent. We suggest expanding theory use in design, evaluation, and interpretation of physical activity intervention results. Further, we recommend that future studies evaluate the most salient behavioral theories, interventions components, and delivery modes in RA populations.

Community-based intervention to promote physical activity in rheumatoid arthritis (CIPPA-RA): a study protocol for a pilot randomised control trial.

Rheumatoid arthritis (RA) is a chronic, inflammatory condition which may cause pain, stiffness and fatigue. People who have RA have reduced levels of physical activity due to these symptoms. Interventions targeting physical activity behaviour in this population have had limited efficacy. This paper describes a protocol for a pilot randomised controlled trial (RCT) of a theory-based intervention delivered in a community setting designed to promote physical activity in people who have RA. The aim of the pilot study is to assess the impact of the intervention on moderate-intensity physical activity in people with RA. The objectives are to obtain reliable estimates regarding recruitment rates; participant retention, protocol adherence and generate potential effect size estimates to inform sample size calculations for a main trial on physical activity participation. Semi-structured interviews will be conducted with a selected sample of participants to explore their experiences. Participants will be recruited from direct referrals from the rheumatology clinics in a public hospital. Participants meeting inclusion criteria will be randomised into a 6week physical activity intervention (four sessions delivered over a 6-week period by a trained physiotherapist) or a control group (physical activity information leaflet). Results of the pilot study will provide data to determine if a larger RCT is feasible. Qualitative data will inform intervention design and delivery. The findings will be disseminated to health professionals, in peer-reviewed journals and conference presentations.

Validity of the Nurses\u2019 health study physical activity questionnaire in estimating physical activity in adults with rheumatoid arthritis

BackgroundPatients with rheumatoid arthritis (RA) demonstrate reduced aerobic capacity, excess cardiovascular risk, mobility limitations and are less physically active than their healthy peers. Physical activity may decrease RA disease activity through its anti-inflammatory effects and psychological and health benefits. To successfully manage RA symptoms and reduce cardiovascular risks associated with RA through increased physical activity (PA), accurate physical activity assessments are critical. Accelerometry is an objective physical activity measure, but not widely used. Validity of the Nurses’ Health Study physical activity questionnaire II (NHSPAQ) has not been determined for estimation of physical activity in RA. This study examined NHSPAQ validity in adults with RA compared to accelerometry-based metabolic equivalents determined (METs) and results of performance tests. We hypothesized NHSPAQ scores would correlate moderately (0.4–0.5) with accelerometer physical activity estimates.MethodsThirty-five adults with RA (mean age [SD] 62 (Williams et. al, Health Qual Life Outcomes10:28, 2012) years, 28 females (80%) recruited from a hospital-based clinic registry participated in a one-week accelerometry trial. Medical data was compiled. Participants completed the NHSPAQ, a self-paced 20-m walk test, and modified timed step test. Participants wore an accelerometer for 7 consecutive days, then completed a physical activity log and another NHSPAQ. Metabolic equivalents (METs) were derived from NHSPAQ and accelerometers using standardized formulas. NHSPAQ METs were correlated with accelerometer METs and data from performance measures.ResultsAverage disease duration was 21 years (SD = 11), 63% patients took biologics. The average weekly METs reported were 29 (SD = 33) and accelerometer METs were 33 (SD = 22). NHSPAQ METs correlated moderately with accelerometer-derived METs (r = 0.48 95% CI (0.15–0.70). Self-reported PA correlated moderately with Step Test performance (r = 0.50 95% CI (0.18–0.72).ConclusionPatients with RA exhibit low physical activity levels. General fitness measures were moderately correlated with physical activity levels. A moderate significant correlation existed between NHSPAQ and accelerometry METs. These preliminary data suggest the NHSPAQ may be useful to describe physical activity levels in this population.

Sedentary behaviour is associated with increased long-term cardiovascular risk in patients with rheumatoid arthritis independently of moderate-to-vigorous physical activity

BackgroundRheumatoid Arthritis (RA) is associated with an increased risk of cardiovascular disease (CVD). The physical dysfunction symptomatic of RA means people living with this disease spend large periods of the day sedentary, which may further elevate their risk of CVD. The primary aim of this study was to investigate relationships between objectively assessed sedentary behaviour patterns and light physical activity (LPA) with 10-year risk of CVD. Secondary aims were to explore the role of sedentary behaviour patterns and LPA for individual CVD risk factors and functional disability in RA. The extent to which associations were independent of moderate-to-vigorous physical activity (MVPA) engagement was also examined.MethodsBaseline data from a subsample of participants recruited to the Physical Activity in Rheumatoid Arthritis (PARA) study were used to answer current research questions. Sixty-one patients with RA (mean age (± SD) = 54.92 ± 12.39 years) provided a fasted blood sample and underwent physical assessments to evaluate factors associated with their cardiovascular health. Sedentary behaviour patterns (sedentary time, sedentary bouts, sedentary breaks), LPA and MVPA were measured via 7-days of accelerometry. Ten-year CVD risk was computed (Q-risk-score2), and functional disability determined via questionnaire.ResultsRegressions revealed significant positive associations between sedentary time and the number of sedentary bouts per day ≥20 min with 10-year CVD risk, with the reverse true for LPA participation. Associations were independent of MVPA engagement.ConclusionsPromoting LPA participation and restricting sedentary bouts to <20 min may attenuate long-term CVD risk in RA, independent of MVPA engagement.Trial registrationISRCTN04121489 (retrospectively registered 19/10/2012).

Trajectories of Physical Activity Over Two Years in Persons With Rheumatoid Arthritis.

To identify and describe different trajectories of physical activity over 2 years and to identify baseline predictors for each trajectory within a large cohort of people with rheumatoid arthritis (RA). The sample included 2,752 people ages 18-75 years and independent in daily living. Data on sociodemographic, disease-related, and psychosocial variables and physical activity (total weekly hours of vigorously/moderately intense activity and walking) were collected from registers and by questionnaires at baseline, and at 14 and 26 months. K-means cluster analysis was used to identify different physical activity trajectories. Multinomial logistic regression was used to identify predictors of trajectory membership. Three trajectories were identified: 1 stable high (n = 272; with an average of 25 hours of physical activity/week), 1 decreasing (n = 564; changing from 22 to 8 hours), and 1 stable low (n = 1,916; with an average of 3 hours). Predictors of the stable high trajectory versus the other 2 were male sex and already established physical activity at baseline. Predictors of the stable high trajectory versus decreasing trajectory were lower age and less social support for exercise, while predictors of stable high versus the stable low trajectory were less activity limitation and higher exercise self-efficacy. The results indicate that distinct trajectories of physical activity over 2 years in people with RA exist, and that stable, high physical activity is mainly predicted by male sex and already established physical activity at baseline. Additional predictors, amenable to change, include activity limitation, social support, and self-efficacy for exercise, suggesting a wide perspective on maintained physical activity in RA.

If a joint is hot it’s not the time: health professionals’ views on developing an intervention to promote physical activity in rheumatoid arthritis

Purpose: The study aimed to explore the views of health professionals on (i) physical activity in people who have rheumatoid arthritis (RA) and (ii) the design of an intervention to promote physical activity in this population.Method: We used a qualitative methodology and conducted 14 interviews (rheumatologists n = 7, physiotherapist n = 4, clinical nurse specialists n = 3). Interviews were transcribed verbatim and analyzed using thematic analysis.Results: Three key themes were generated: “Personal opinions”, “Supporting physical activity” and “An ideal world”. Although health professionals viewed physical activity as important, recommending it to people who have RA was largely based on persons’ disease status rather than empirical evidence. Resources were highlight as a key challenge to interventions in clinical practice. Supporting physical activity through provision of information, goal setting and monitoring was also discussed.Conclusion: Health professionals believe physical activity is important for people who have RA, although there is uncertainty regarding physical activity recommendations for this population. Thus, there is scope to increase health professionals’ knowledge of recent evidence. Views varied on how an intervention to promote physical activity should be delivered, but consideration of barriers to delivery in clinical practice is important.Implications for RehabilitationPhysical activity is an important aspect of disease management for people who have rheumatoid arthritis.Health professionals need to acknowledge the “mixed messages” received by people who have RA about being physically active thus further education for health professionals is suggested to standardize physical activity advice in clinical practice.Health professionals may benefit from education about behavior change theory and techniques.When designing future physical activity interventions consideration of the practical challenges of implementing research in a clinical setting is necessary.

A Mobile Internet Service for Self-Management of Physical Activity in People With Rheumatoid Arthritis: Challenges in Advancing the Co-Design Process During the Requirements Specification Phase.

BackgroundUser involvement in the development of health care services is important for the viability, usability, and effectiveness of services. This study reports on the second step of the co-design process.ObjectiveThe aim was to explore the significant challenges in advancing the co-design process during the requirements specification phase of a mobile Internet service for the self-management of physical activity (PA) in rheumatoid arthritis (RA).MethodsA participatory action research design was used to involve lead users and stakeholders as co-designers. Lead users (n=5), a clinical physiotherapist (n=1), researchers (n=2) with knowledge in PA in RA and behavioral learning theories, an eHealth strategist (n=1), and an officer from the patient organization (n=1) collaborated in 4 workshops. Data-collection methods included video recordings and naturalistic observations.ResultsThe inductive qualitative video-based analysis resulted in 1 overarching theme, merging perspectives, and 2 subthemes reflecting different aspects of merging: (1) finding a common starting point and (2) deciding on design solutions. Seven categories illustrated the specific challenges: reaching shared understanding of goals, clarifying and handling the complexity of participants’ roles, clarifying terminology related to system development, establishing the rationale for features, negotiating features, transforming ideas into concrete features, and participants’ alignment with the agreed goal and task.ConclusionsCo-designing the system requirements of a mobile Internet service including multiple stakeholders was a complex and extensive collaborative decision-making process. Considering, valuing, counterbalancing, and integrating different perspectives into agreements and solutions (ie, the merging of participants’ perspectives) were crucial for moving the process forward and were considered the core challenges of co-design. Further research is needed to replicate the results and to increase knowledge on key factors for a successful co-design of health care services.

Behaviour change interventions to promote physical activity in rheumatoid arthritis: a systematic review.

Research has shown that people who have rheumatoid arthritis (RA) do not usually participate in enough physical activity to obtain the benefits of optimal physical activity levels, including quality of life, aerobic fitness and disease-related characteristics. Behaviour change theory underpins the promotion of physical activity. The aim of this systematic review was to explore behaviour change interventions which targeted physical activity behaviour in people who have RA, focusing on the theory underpinning the interventions and the behaviour change techniques utilised using specific behaviour change taxonomy. An electronic database search was conducted via EBSCOhost, PubMed, Cochrane Central Register of Controlled Trials and Web of Science databases in August 2014, using Medical Subject Headings and keywords. A manual search of reference lists was also conducted. Randomised control trials which used behaviour change techniques and targeted physical activity behaviour in adults who have RA were included. Two reviewers independently screened studies for inclusion. Methodological quality was assessed using the Cochrane risk of bias tool. Five studies with 784 participants were included in the review. Methodological quality of the studies was mixed. The studies consisted of behaviour change interventions or combined practical physical activity and behaviour change interventions and utilised a large variety of behaviour change techniques. Four studies reported increased physical activity behaviour. All studies used subjective methods of assessing physical activity with only one study utilising an objective measure. There has been varied success of behaviour change interventions in promoting physical activity behaviour in people who have RA. Further studies are required to develop and implement the optimal behaviour change intervention in this population.

Promoting physical activity in rheumatoid arthritis: a narrative review of behaviour change theories

Purpose: Despite physical activity having significant health benefits for people with rheumatoid arthritis (RA), current levels of physical activity in this population are suboptimal. Changing behaviour is challenging and interventions aimed at increasing physical activity in this context have had varying levels of success. This review provides an overview of common behaviour change theories used in interventions to promote physical activity and their application for promoting physical activity in people with RA. Method: A scoping, narrative review was conducted of English language literature, using the search terms “physical activity/exercise” and keywords, which are associated with behaviour change interventions. The theoretical basis of such interventions in people with RA was assessed using the “theory coding scheme”. Results: Six theories which have been used in physical activity research are discussed. Further, four studies which aimed to increase physical activity levels in people with RA are explored in detail. Conclusions: To date, behaviour change interventions conducted in RA populations to increase physical activity levels have not had a strong theoretical underpinning. It is proposed that an intervention utilising the theory of planned behaviour is developed with the aim of increasing physical activity in people with RA.Implications for RehabilitationInterventions to promote physical activity in the rheumatoid arthritis (RA) population have failed to change participants' behaviour.A small number of studies have used behaviour change theories in the development and delivery of interventions.The theory of planned behaviour is recommended as the theoretical basis for an intervention to promote physical activity in the RA population.

Fear-avoidance beliefs about physical activity in adults with rheumatoid arthritis

Objectives: The aim of this study was to describe fear-avoidance beliefs about physical activity and explore how these beliefs correlate with sociodemographic, disease-specific, and psychosocial factors in adults with rheumatoid arthritis (RA).Method: This cross-sectional study is part of the Physical Activity in Rheumatoid Arthritis (PARA) 2010 study. The study participants (n = 2351) were identified through the Swedish Rheumatology Quality (SRQ) registries from six rheumatology clinics in Sweden. Univariate and backwards stepwise logistic regressions were performed.Results: Stepwise logistic regressions showed that male gender [odds ratio (OR) 1.55, 95% confidence interval (CI) 1.26–1.91] and having a below average income (OR 1.35, 95% CI 1.12–1.63) were associated with an increased risk of high scores on the modified Fear Avoidance-Belief Questionnaire (mFABQ). The two disease-specific factors most indicative of high mFABQ scores were high level of pain (OR 1.99, 95% CI 1.40–2.84) and poor health (OR 1.59, 95% CI 1.10–2.29). With regard to psychosocial factors, low health-related quality of life (HRQoL; OR 0.44, 95% CI 0.35–0.55) and a low score on the Exercise Self-Efficacy Scale (ESES; OR 0.66, 95% CI 0.52–0.82) were significantly associated with a high mFABQ score. The model fit was 0.27 (Nagelkerke’s R2).Conclusions: High fear-avoidance beliefs about physical activity in patients with RA were found to be associated with being male and having a below average income, a high level of pain, poor health, a low HRQoL, and low ESES score. Additional research is warranted for adults with RA to capture the multiple potential correlates to fear-avoidance beliefs about physical activity.