Promoting physical activity in patients with rheumatoid arthritis
Berg, M.H. van den
Citation
Berg, M. H. van den. (2007, May 31). Promoting physical activity in patients with
rheumatoid arthritis. Department of Rheumatology, C1-R, Leiden University Medical
Center (LUMC), Faculty of Medicine, Leiden University. Retrieved from
https://hdl.handle.net/1887/11997
Version: Corrected Publisher’s Version
License: Licence agreement concerning inclusion of doctoral thesis in the
Institutional Repository of the University of Leiden
Downloaded from: https://hdl.handle.net/1887/11997
Note: To cite this publication please use the final published version (if applicable).
Ch C ha ap pt te er r 3 3
Leisure-time physical activity and exercise in rheumatoid
arthritis: patients’ participation and preferences
M.H. van den Berg I.G. de Boer S. le Cessie F.C. Breedveld T.P.M. Vliet Vlieland Accepted: Australian Journal of Physiotherapy
Participation and preferences regarding physical activity
35.
Abstract
Objective. To describe the participation and preferences regarding various types of leisure-time physical activity and exercise in patients with rheumatoid arthritis (RA).
Methods. A sample of 400 RA patients were sent a questionnaire comprising questions about patients' participation in various types of physical activity and exercise over the past 12 months, their preferences and perceived barriers for physical activity.
Results. 252 patients returned the questionnaire (response 63%). 201 (80%) patients participated in any type of physical activity or exercise. Significantly more inactive patients were male, were less educated, and were older than the active patients. Of the active patients, 45 (22%) exclusively participated in supervised activities, 72 (36%) in unsupervised activities and 84 patients (42%) combined supervised and unsupervised activities. Cycling and walking were the two unsupervised activities patients most often performed. Supervised group exercise therapy and unsupervised individual physical activity were reported as most favourite activities. Furthermore, significantly more patients preferred being physically active under expert supervision than without supervision and preferred water-based activities above land-based activities. Most frequently mentioned barriers included lack of energy, pain, lack of motivation, lack of information and fear of joint damage.
Conclusions. The majority of RA patients participated in any type of physical activity or exercise, with about two-thirds of them being active under supervision. Preferences for various types of activity varied, underpinning the need for delivering a variety of physical activity interventions for patients with RA.
Introduction
Over the past decades, a number of physical activity and exercise interventions for people with arthritis have been developed and evaluated, resulting in a large body of evidence about their health benefits (1-3). However, the literature suggests that in daily practice there is underusage of physical activity or exercise programs (4;5) as well as there are unmet demands regarding allied health care including physical therapy among RA patients (6;7). It could therefore be hypothesised that the current supply of physical activity interventions does not completely match with RA patients’ needs and preferences. This is an undesirable situation, as it has been previously demonstrated that interventions aimed at promoting physical activity and exercise are likely to be most effective if they address the needs and interests of the people involved (8).
Moreover, the literature on what patients with arthritis actually prefer with respect to participation in various types of physical activity and exercise is scanty.
The aim of this study was therefore to gain more insight into RA patients’ actual usage and preferences regarding physical activity or exercise interventions in daily practice.
Materials and Methods
Study design and patients
Data for this cross-sectional study were collected by means of a survey conducted in April 2004 in the Leiden University Medical Center (LUMC) in the Netherlands. A random sample was obtained from a registry of 1500 patients with a verified diagnosis of RA (9) who had been visiting the LUMC rheumatology outpatient clinic in the past 15 months. The registry was sorted in ascending order by the date of their forthcoming visit to the outpatient clinic and the first 400 patients were selected. Besides the diagnosis RA no other selection criteria were used. All eligible patients received a postal questionnaire, an information letter and a response envelope. Patients who did not respond within 4 weeks were contacted by telephone. The study was judged to be no medical research in the sense of the Medical Research Involving Human Subjects Act (in Dutch:
WMO) by the Medical Ethics Review Committee of the LUMC so that no individual informed consent was obtained (patients were free to either fill in the questionnaire or not).
Participation and preferences regarding physical activity
37.
Measurements
Sociodemographic and lifestyle-related data. Sociodemographic variables included age, sex, educational level (low, medium, high), living status (living alone yes/no) and paid employment (yes/no). Moreover, smoking habits (active smoker defined as smoking one or more cigarettes per day) and height and weight were recorded. From the latter the Body Mass Index (BMI = weight in kilograms/height in meters2) was determined and categorised as overweight (BMI ≥ 25.0) or not (BMI < 25.0).
Participation in physical activity or exercise. Physical activity is defined as any bodily movement that results in energy expenditure, with activities that are not related to work or household activities being referred to as leisure-time physical activity (10). Exercise is a subset of physical activity that is structured, planned and repetitive, and is performed with a fitness goal in mind (10).
Patients' participation regarding leisure-time physical activity and exercise was measured with a newly developed questionnaire. Patients were asked to fill in whether or not they were currently or in the previous 12 months engaged in 11 predefined activities (with examples) or any other leisure-physical activities or exercises which they could fill in themselves. These activities were categorised into supervised and unsupervised activities. Supervised activities included both individual and group exercise therapy and both water-based (hydrotherapy, aqua-jogging or aquatic exercise) and land-based activities. Unsupervised activities comprised individual and group activities.
Preferences physical activity and exercise. Patients' preferences were measured by asking patients to compose a personal 'top three' of their favourite physical activities, to be selected from the above-mentioned list of activities. Moreover, patients were asked to state their preferences regarding two 'opposite' attributes of physical activity. For example, individual versus group therapy, at home or in a gym, with or without supervision. All questions regarding these attributes about physical activity could also be answered with 'none of these two'.
Attitudes and perceived barriers. The last part of the questionnaire comprised 13 statements about physical activity for patients with rheumatic diseases. The first 3 statements evaluated the patients' opinions about to what extent people with arthritis should get specific help from professionals to adopt and maintain a physically active lifestyle. The other 10 statements dealt with patients' barriers for physical activity. All statements could be answered on a four point
Likert scale (1, fully disagree/ absolutely not applicable to me; 4, fully agree/ totally applicable to me).
Statistical analysis
The average proportion of RA patients participating in some type of physical activity or exercise was estimated to be about 80% (11;12). It was required for this estimate to be no more than 5 percentage points (0.05) of the true percentage with 95% confidence. This requires a sample size of at least 246 patients, since then the standard error of the estimate is less than 2.5%. Assuming a response rate of about 65% (13), we planned to send 400 questionnaires.
Descriptive statistics were used to summarise demographic characteristics and frequencies of the concerning variables. An independent samples t-test, a Pearson Chi-square test or a Fisher's Exact test was used to test whether there were significant differences between responders versus non-responders, active versus inactive patients and males versus females. A one sample Chi- square test was used to test whether the proportion of patients choosing between two alternatives regarding physical activity differed significantly from 50%. A p-value of less than 0.05 was adopted as the criterion for statistical significance.
All analyses were performed using the Statistical Package for the Social Sciences (SPSS 12.0 for Windows, Chicago IL, USA].
Results
Of the 400 patients who received the questionnaire, 204 patients returned it within 4 weeks.
From the 196 patients who were contacted by phone, 53 could not be reached after trying at least 2 times on different days of the week, 79 said they did not want or were not able to fill in the questionnaire, 4 patients had moved, and 60 patients said they would still return the questionnaire. Finally, 252 patients (63%) returned the questionnaire. The non-responders were slightly older than the responders (mean age (SD): 62.4 (14.7) and 60.5 (11.5) respectively) and were less often female (number (%): 104 (70) and 182 (72) respectively), but these differences did not reach statistical significance (p=0.17 and p=0.68, respectively). The characteristics of the participants are summarised in Table 1.
Participation and preferences regarding leisure-time physical activity
Table 1. Socio-demographic and lifestyle-related characteristics of the 252 study participants and physical activity participation rates of the 201 patients with RA reporting to participate in any type of physical activity or exercise (= active patients)
Active patients (n=201)
Inactive patients (n=51)
Total (n=252)
P-value active vs. inactive pts#
Socio-demographic and lifestyle-related characteristics
Age, years; mean (SD) 58.7 (11.3) 67.4 (9.8) 60.5 (11.5) <0.001*
Female 151 (75) 31 (61) 182 (72) 0.04*
Education level†
Low Medium High
90 (45) 80 (40) 31 (15)
34 (67) 14 (28) 3 (6)
124 (49) 94 (37) 34 (14)
0.02*
Overweight‡ 112 (56) 32 (65) 144 (58) 0.25
Current smoker 40 (20) 10 (20) 50 (20) 0.99
Living alone 33 (17) 13 (26) 46 (18) 0.14
Employed 58 (29) 9 (18) 67 (27) 0.13
Participation in supervised activity or exercise Individual exercise therapy
Group exercise therapy
− Hydrotherapy
− Land-based exercise therapy
n=129 91 (71) 71 (55) 29 (23) 60 (47) Participation in unsupervised activity or exercise
Individual physical activity or sports
− Cycling
− Walking
− Swimming
− Other (e.g. home exercise, aerobics, gardening) Group physical activity or sports
n=156 153 (98)
103 (67) 90 (59) 27 (18) 10 (7) 29 (19)
Values are the number (%) of patients, unless indicated otherwise. # Differences were analysed using an independent samples t-test, Chi-square test or Fisher's Exact test where appropriate. † Educational level: low = up to and including lower technical and vocational training or primary school; medium = up to and including secondary technical and vocational training; high = up to and including higher technical and vocational training and university.
‡ Overweight = BMI ≥ 25.0 (BMI = Body Mass Index = weight in kilograms/height in meters2).
* P<0.05
Participation in physical activity or exercise
Table 1 shows that 201 (80%) patients participated in any type of physical activity or exercise in the past 12 months. Inactive patients (n=51) were more often male, had a lower education level, and were older than active patients.
Of the 201 physically active patients, 45 (22%) exclusively participated in supervised activities or exercise, 84 (42%) patients combined these activities with unsupervised activities and 72 (36%) patients exclusively participated in unsupervised activities.
Of the 129 patients who participated in supervised activities, 58 patients (45%) participated exclusively in individual supervised activities, 38 patients (30%) exclusively in group supervised activities and 33 patients (26%) in a combination of individual and group activities. Of the 71 patients participating in any type of supervised group activities, 42 patients (59%) did this in a gym, 11 patients (16%) in warm water and 18 patients (25%) both in gyms and in water.
With respect to the 156 patients participating in unsupervised activities, the majority (127 patients, 81%) exclusively participated in unsupervised individual activities, 26 (17%) patients combined these activities with unsupervised group activities and 3 patients (2%) exclusively participated in unsupervised group activities. Furthermore, cycling and walking were the two unsupervised activities patients most often performed.
Preferences regarding physical activity or exercise
Table 2 reports the numbers of patients reporting the various physical activity categories as their top favourite (1st place) category, compared with the numbers of patients who indeed participate in those activity categories. It appeared that supervised group exercise therapy is most often mentioned as the top favourite activity and almost half of these patients indeed participated in this type of activity. Unsupervised individual physical activity was the second most frequently mentioned favourite activity. It appeared that the corresponding participation rate was high: 83%
of the patients actually performed this type of activity.
Table 3 shows that significantly more patients preferred to be physically active under expert supervision than without this supervision. In addition, the proportion of patients that preferred to be physically active together with other arthritis patients was significantly greater than the proportion that preferred to do this together with healthy people and significantly more patients preferred activities in water rather than land-based activities.
Participation and preferences regarding physical activity
41.
Table 2. Number (%) of patients reporting the various physical activity categories as their top favourite category, compared with the number (%) of these patients who indeed participate in this category*
* Values are number (%) of patients.
Table 3. Number of patients (%) expressing an explicit preference regarding two opposite attributes of physical activity
Activity attribute n (%) P-value#
Supervision
With vs. without supervision 142 (78) vs. 41 (22) <0.001*
Supervisor being physically present vs. distant supervision 119 (88) vs. 16 (12) <0.001*
Telephone vs. e-mail supervision 24 (34) vs. 46 (66) 0.01*
Type of activity
Individual vs. group activities 83 (51) vs. 81 (49) 0.85
Activities together with people with arthritis vs. activities together with healthy people
100 (65) vs. 55 (35) <0.001*
Activities in water vs. activities on land 124 (69) vs. 55 (31) <0.001*
Setting of activity
Indoor vs. outdoor activities 75 (44) vs. 97 (56) 0.09
Activities at home vs. activities at another place 63 (38) vs. 103 (62) 0.002*
# Differences between two opposite attributes of physical activity were analysed using a one sample Chi-square test.
† Differences between males and females were analysed using a Chi-square test.
* P<0.05
Reported as top favourite activity
(n=212)
Indeed participating in favourite activity Supervised activity or exercise
Individual exercise therapy
Group exercise therapy 31 (15)
89 (42) 22 (71)
41 (46) Unsupervised activity or exercise
Individual physical activity or sports
Group physical activity or sports 80 (38)
12 (6) 66 (83)
7 (58)
Attitudes and perceived barriers
The large majority of the patients (238/250, 95%) agreed or fully agreed with the statement that people with arthritis themselves are, just like healthy people, responsible for being sufficiently physically active. Furthermore, 175/249 patients (70%) did not agree with the statement that people with arthritis can only be physically active when they are being supervised by an expert in the field of rheumatic diseases. The same proportion of patients (180/244, 74 %) agreed or fully agreed with the statement that people with arthritis should get more assistance from professionals in making decisions about which activities or exercise to participate in.
Table 4 shows the proportions of patients reporting several barriers for not or not sufficiently being physically active. For both the active patients as well as the inactive patients lack of energy, pain, lack of motivation and fear of damaging joints were barriers that were often mentioned.
Analysis of the differences between the active and inactive patients revealed no significant differences.
Table 4. Number (%) of physically active and inactive patients reporting barriers for not or not sufficiently being physically active
Barrier Active patients
(n=201)
Inactive patients (n=51)
P-value#
Lack of energy 111 (56) 34 (71) 0.06
Pain 111 (56) 28 (60) 0.64
Lack of motivation 91 (46) 25 (52) 0.43
Lack of information 81 (41) 22 (47) 0.46
Fear of damaging joints 72 (36) 24 (51) 0.06
Too expensive 54 (27) 11 (23) 0.58
No appropriate physical activity or exercise interventions available in neighbourhood
44 (23) 13 (27) 0.52
Lack of time 35 (18) 9 (19) 0.85
# Differences between active and inactive patients were analysed using a Pearson Chi-square test.
Discussion
Our study showed that, over a period of one year, 80% of the RA patients currently or in the past 12 months participated in some type of physical activity or exercise. Furthermore, the majority of
Participation and preferences regarding physical activity
43.
the patients preferred to be physically active under expert supervision, they preferred to do this together with other arthritis patients and favoured water-based activities above land-based activities. Pain, lack of energy, motivation or information and fear of joint damage were the main barriers for physical activity.
Regarding the proportion of patients participating in any type of physical activity, our results are similar to those of other studies, where proportions varied between 56% and 83% (11;12;14-16).
Since we did not evaluate the frequency or intensity of the activities, we can not determine whether or not these were performed at a health-enhancing level.
Our observation that significantly more men than women were inactive stands in contrast with other reports (17-20), whereas the finding that inactive patients were significantly older and had a lower level of education than active patients is consistent with prior reports on sociodemographic factors associated with physical activity in people with arthritis (17;18;20;21).
These results suggests that promoting physical activity for specific patient groups such as the elderly and the less educated patients remains a matter of utmost importance.
It was found that more patients participated in supervised individual exercise therapy than in supervised group activities, whereas the preference for group activities appeared to be stronger than for individual therapy. This discrepancy may have been caused by a limited availability of group exercise therapy in the region where the study was conducted or by insufficient knowledge on the availability and accessibility of group programs for people with arthritis. Furthermore, it could also be hypothesised that health care providers refer patients more or less automatically to individual therapy, perhaps because they are not sufficiently informed about alternatives, such as group exercises.
In our study, cycling and walking were the two most common unsupervised individual activities.
High participation rates in walking have been reported in other studies concerning patients with arthritis as well (14;15). The high proportion of patients engaged in cycling could probably be explained by the fact that riding a bicycle is a rather common means of transportation in the Netherlands.
With respect to perceived barriers for physical activity, our results are concordant with those of other studies showing that fear of pain or joint damage, fatigue, lack of motivation, lack of perceived benefits or self-efficacy were reasons for non-participation (11;22-27). Other, more general barriers to be taken into account include financial resources (28), local facility access or neighbourhood safety (29). To accomplish sustained behavioural changes, health professionals
engaged in the promotion of physical activity in RA may need additional education, including skills such as providing feedback (30), setting and monitoring patients’ goals (31), and counselling patients according to their stage of change (32;33).
Our study was not designed to investigate the differences in effectiveness or costs between various types and attributes of physical activity interventions for people with RA. Future research should further explore these topics, as appropriate decision making is still hampered by a lack of knowledge regarding the optimal timing, duration, intensity and extent and mode of supervision of exercise and physical activity among RA patients. It is conceivable that in the future increasing knowledge on perceived health benefits obtained by various forms of physical activity and exercise might influence patients’ preferences.
A limitation of our study is that it pertained to a selection of RA patients, all living in a specific region in the Netherlands. The availability, accessibility of facilities, as well as the general functionality of the neighbourhood (e.g. the presence of sidewalks, traffic conditions) highly influence people‘s physical activity behaviour (34). Therefore, our results probably cannot be generalised to other regions or countries Future research should include more regions or may even be set up as a nation-wide or international study. Moreover, the patients who did not send back their questionnaire were slightly older than the responders group, and it is conceivable that this group was less physically active. In addition, our outcomes were exclusively based on self report measures, which could be subject to memory error and a tendency towards overestimation (35). Finally, this study did not compare the types of activities RA patients were engaged in with those of the general Dutch population. For that purpose, an additional survey among age and sex-matched people from the general population would be needed.
The results of our study imply that with respect to supervised physical activity, there is a need to investigate whether the supply of aquatic, supervised group programs is sufficient, and whether all stakeholders (patients, providers, referring rheumatologists and health insurance companies) have enough knowledge about their potential benefits and accessibility. However, nowadays many persons prefer to engage in physical activity outside structured settings (36) and in the literature the promotion of physical activity that is integrated in daily life is more and more advocated (37- 39). Consequently, the concept of traditional structured exercise prescription has been broadened and encompasses the promotion of moderate daily physical activities (40). Therefore, it is important for health care providers to develop physical activity promotion efforts matching those activities that people already perform in daily life and to focus on how these activities can
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be modified in such a way that they are performed at a health-enhancing level. In the Netherlands for example, cycling and (nordic) walking are currently popular activities; individual or group interventions should preferably fit these preferences. In other countries or cultures perhaps different interventions should be developed, as the key activities performed in daily life may differ.
In conclusion, this study shows that the majority of the RA patients living in the Leiden region in the Netherlands participated in some type of physical activity or exercise. In addition, their preferences regarding types of physical activity or exercise varied, stressing the need for a broad offer of activity and exercise interventions. Information about which type of activities are performed by patients with RA and learning more about their preferences are important issues for health care professionals to obtain an appropriate match with the supply of interventions by for example physical therapists or organizations such as patient social leagues. The information is also important for other stakeholders, such as referring rheumatologists, clinical nurse specialists and health insurance companies. Helping patients with arthritis to adopt or maintain an enjoyable, physically active lifestyle remains a challenge for all health care professionals dealing with patients with arthritis.
Acknowledgements
We would like to thank all patients who participated in this study. This study was financially supported by 'Stichting Vrienden van Sole Mio' (Foundation Friends of Sole Mio), Leiden, the Netherlands.
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