EULAR: Docs Should Push Hard on Physical Activity for Arthritis Patients

Counseling patients with arthritis about the value of keeping physically active “should be an integral part of standard care throughout the course of disease,” according to an updated guideline from the European Alliance of Associations for Rheumatology (EULAR).

That’s the first of 11 recommendations included in the new document, authored by Anne-Kathrin Rausch Osthoff, PhD, MSc, of Zurich University of Applied Sciences in Switzerland, and colleagues, and published open-access in EULAR’s flagship journal, Annals of the Rheumatic Diseases.

The update expands on the organization’s initial guidance issued in 2018, incorporating research published in the intervening 8 years on the benefits and risks of specific types of physical activity and on interventions that get patients up and moving.

Inflammatory types of arthritis (e.g., rheumatoid arthritis) as well as osteoarthritis (OA) are covered in the guideline. More than 100 new studies (including 30 randomized controlled trials) helped inform the revision.

Overall, the document is meant to combat the arthritis patient’s worst enemy: sedentarism. While it’s understandable that people with painful joints may find it feels better to sit on the couch than walk around the block, research has established that, in the long run, they will end up feeling worse if they give up on physical activity.

Rausch Osthoff and colleagues emphasized that it’s not enough to suggest ways for patients to be more active — clinicians must also make a point of discouraging sedentary behaviors. “Although regular vigorous-intensity [physical activity] can mitigate some of the adverse effects of prolonged sitting, it may not eliminate the increased risk associated with high proportions of [sedentary behavior],” the guideline noted.

The recommendation to include counseling on physical activity as part of routine care was also first on the 2018 list, and a few others in the new edition are also repeats from 2018. But some are entirely novel and some, while addressing the same general concerns as before, are expressed in new ways intended to make clinicians’ advice more compelling for patients.

For example, the new version takes into account the burgeoning literature on movement trackers and other bits of wearable technology, urging clinicians to at least think about discussing them with patients. Studies on these innovations were still scarce when the 2018 guideline was developed, and wearables were discussed only in passing as, for example, a “booster strategy” described in some reports.

While both the old and new guidelines recommend that clinicians consider four different types of physical activity (cardiorespiratory fitness, muscle strength, flexibility, and neuromotor performance) in determining where an individual patient needs attention, the new one adds a firm direction to “define the frequency, intensity, time, type, volume, and progression of” physical activity.

One recommendation in 2018 did not carry over. It called for clinicians to look for “contraindications” to physical activity when developing management plans; Rausch Osthoff and colleagues determined that there really aren’t any, per se, although “of course, the intensity of physical activity needs to be adapted” to patients’ specific condition.

Novel in the new edition is that the recommendations come with numerical estimates of the potential impact and also of their feasibility, each rated on a 10-point scale. As one might expect, the anticipated impacts are all quite high — otherwise we might question their inclusion — ranging from 8.3 to 9.2. Feasibility was seen as more iffy, with ratings of 6.9 for a recommendation for clinicians to identify barriers to keeping active up to 8.4 for including physical activity counseling at routine visits.

But anyone hoping that EULAR would recommend specific interventions to encourage physical activity will be disappointed, as the guideline doesn’t go into that level of detail. In part that’s because it emphasizes that all counseling needs to be individualized; recommending a particular exercise regimen, or X minutes of high-intensity aerobics per week for patients with Y diagnosis, runs counter to that. Besides which, studies of particular activity programs have not been robust enough to warrant inclusion in formal guidelines.

Rausch Osthoff and colleagues did include an 11-point research agenda that, if followed through, could support more specifics in future updates. They called for trials to evaluate programs that, for example, combine exercise with dietary changes or with medications, and that seek to improve patient uptake and adherence. The panel also would like to see studies on long-term effectiveness of various types of interventions, including those aimed at reducing sedentarism as well as those promoting exercise.

The committee noted some limitations to the document. A disproportionate share of recent studies was devoted to physical activity among patients with knee OA, with many fewer related to hip OA or inflammatory forms of arthritis. Another problem, the group wrote, is that “overall, the inadequate reporting of interventions in many studies prevents the meaningful pooling of data or transfer into practice, thereby limiting the yield of research resources.”