The effect of exercise training on the autonomic function, disease activity and functional capacity in females suffering from rheumatoid arthritis

Introduction: Rheumatoid arthritis (RA) is a chronic disease and one of the more common auto-immune diseases. Patients with RA rely almost solely on pharmaceutical intervention to manage the disease. Autonomic impairment has been proven in previous studies on patients with RA. The positive effect of exercise on autonomic impairment has also previously been demonstrated, but not in the RA population. The purpose of this study was firstly to confirm autonomic impairment in a South African based female population with RA and secondly to evaluate the effect of exercise on the autonomic cardiac function (as measured by short-term heart rate variability), disease activity and functional capacity. Methods: The study was conducted at the University of Pretoria during 2009 and 2010. In the first phase of the study female RA patients were recruited from all rheumatology practices in Pretoria and healthy controls were recruited from family and friends of the research team and of the RA group. Cardiac autonomic function was compared between the two groups by means of short-term heart rate variability. Three techniques were used: time domain, frequency domain and Poincare plot analysis. In the second phase of the study, females with confirmed RA were randomly assigned to an exercise group and a control group. The exercise group was requested to train under supervision two to three times per week for a period of twelve weeks, while the control group continued with their sedentary lifestyle. At study completion the two groups were compared for the effect of exercise intervention on the following three aspects: Autonomic function (as measured by heart rate variability) Disease activity (as measured by Disease Activity Score, Visual Analogue Scale and Health Activity Questionnaire) Functional capacity (as measured by strength, flexibility and aerobic capacity) Results: In the first phase of the study comparing females with RA (n=45) to healthy females (n=39), the basal heart rate was significantly higher in the RA group. In the supine position significant differences existed between the RA group and the control group (p ≤ 0.01). Indicators of parasympathetic activity showed significantly lower variation in the RA group [RMSSD=14.70, pNN50=0.50, SD1=10.50, HF(ms2)=31] compared to the control group [RMSSD=29.40, pNN50=7.8, SD1=20.9, HF(ms2)=141.00]. Indicators of sympathetic variation were also significantly lower in the RA Group [SD2=36.70, LF(ms2)=65) compared to the Control group (SD2=49.50, LF(ms2)=175]. In the standing position 8 variables indicated autonomic impairment by significant differences (p≤0.01) between the 2 groups. The response of the RA Group to an orthostatic stressor showed less vagal withdrawal, [p-values for RMSSD=0.038, pNN50=0.022, SD1=0.043 and HF(ms2)=0.008 respectively]; and lower sympathetic response [p-values for SD2=0.001 and LF(ms2)<0.001] when compared to the Control group. In the second phase of the study, comparing an RA exercise group to a RA sedentary group, three aspects were evaluated: 1. Heart rate variability At baseline the control group (n=18) had significantly higher variability compared to the exercise group (n=19) for most heart rate variability (HRV) indicators. At study completion the variables showing significant changes (p=0.01 to 0.05) favoured the exercise group in all instances. Wilcoxon signed rank tests were performed to assess changes within groups from start to end. The exercise group showed significant improvement for most of the standing variables, including measurements of combined autonomic influence e.g. SDRR (p=0.002) and variables indicating only vagal influence e.g. pNN50 (p=0.014). The control group mostly deteriorated with emphasis on variables measuring vagal influence [RMSSD, pNN50, SD1 and HF(ms2)]. 2. Disease activity At baseline the two groups were comparable. At the end of the intervention, the exercise group had significant improvement for the tender joint count (p=0.015), swollen joint count (p=<0.001), physician global assessment (p=0.003) and DAS score (p=0.003) compared to the control group. To assess changes that happened within each group from start to end, Wilcoxon signed rank tests were performed. The exercise group improved significantly with regards to tender joint count (p=0.002), swollen joint count (p=0.001), physician global assessment (p=0.001), DAS score (0.001) and the visual analogue scale (p=0.032). The sedentary group improved significantly only in the health assessment questionnaire (p=0.032). 3. Functional capacity Comparing the groups at baseline the exercise group had better knee- and hip flexion on the left hand side but it took them longer to complete the arm curl test. At study completion the exercise group was mostly favoured with regards to flexibility (significant p-values ranging between 0.001 – 0.049), strength (handgrip right p<0.001, leg strength p=0.035, arm curl test p=0.010, sit to stand test p=0.025) and aerobic fitness (1 mile walk test p<0.001 and VO2 max p=0.007). Changes within each group were assessed by Wilcoxon signed rank tests. The exercise groups showed significant changes for many parameters in the three categories, i.e. flexibility (8 of 18), strength (5 of 5), and aerobic fitness (4 of 8). The control group mostly deteriorated in flexibility, while their strength also improved, but not to the same extent as for the exercise group. Their aerobic fitness did not change. Discussion: In the first phase of this study, using standardised methods to measure short-term HRV, females with RA showed less variability compared to a healthy age- and sex matched control group. An inability of the autonomic nervous system to efficiently compensate to internal and external environmental changes may predispose RA patients to arrhythmias thereby increasing cardiovascular mortality. All 3 methods used showed the same outcome, implying decreased HRV and thus an increased risk for arrhythmias in RA patients. Evaluating the autonomic nervous system might be critical in planning management of RA. In the second phase study results indicated that twelve weeks of exercise intervention, had a positive effect on cardiac autonomic function as measured by short-term HRV, in females with RA. Several of the standing variables indicated improved vagal influence on the heart rate. Exercise can thus potentially be used as an instrument to improve cardiac health in a patient group known for increased cardiac morbidity. The exercise programme was also effective in decreasing perception of pain as well as disease activity in female RA patients. Given our findings it seems warranted to include physical exercise as part of the treatment prescription of patients with class I and II RA. Lastly this research has shown that regular, controlled exercise for RA patients with controlled disease can decrease joint stiffness and improve joint mobility, strength and aerobic capacity without exacerbating pain or disease activity. Also, if one observes the decline in the sedentary group for many parameters, it is important to note that this happened over a relative short time period and that even a small change may have a detrimental impact on the RA patient. The current report supports previous literature on autonomic impairment in patients suffering from RA as well as the meaningful positive effect of exercise on disease activity and functional capacity. It is the only study on the effect of an exercise intervention on the cardiac autonomic function of RA patients. Future research in this field should aim for larger study samples, longer intervention periods and perhaps add analysis of blood pressure variability to support results obtained by HRV analysis.Thesis (MD)--University of Pretoria, 2012.Internal Medicineunrestricte

Keep moving : overcoming physical, mental and pandemic challenges to stay active

There is little argument against the benefits of physical activity for most cohorts: healthy individuals, patients with non-communicable disease and auto-immune conditions, and patients with cancer - all experience improved health outcomes from regular physical activity. However, the physical activity requirements and the challenges to fulfil these vary for different populations. Athletes overcome many challenges to reach their goals. Recently, a major hurdle to fulfilling physical activity requirements was COVID-19. To represent this conquering spirit, we have Michaela Whitebooi on the cover of this edition. Michaela is a multiple African Senior Judo Champion (under 48 kg category) who has overcome injuries and personal factors to reach not only her sporting goals as a 2020 Tokyo Olympian, but also her academic goals through obtaining an Honours degree in Internal Auditing and a Postgraduate Diploma in Entrepreneurship.http://bjsm.bmj.comhj2023Sports Medicin

Exercise prescription in the management of rheumatoid arthritis

BACKGROUND: Over the last few years, the types of exercises prescribed for patients with rheumatoid arthritis (RA) have changed. There is also increasing knowledge on the physical status and physical activity levels of these patients. This article aims to give an overview of the physical status, physical activity levels and appropriate exercise prescription for patients with RA. METHOD: A literature search was conducted of scientific journals and text, including Medline and PubMed (1980-2012). Literature was selected for its in-depth data and well researched information. Key search terms included "RA and exercise therapy", as well as "physical activity levels and physical status of patients with RA". RESULTS: The literature indicated that RA has a major impact on physical and psychological health. Over the past decade, there has been growing evidence of the health benefits of physical activity for patients with RA. Despite this evidence, patients with RA are less physically active than the general population. The types of exercises prescribed for patients with RA have changed from the traditionally prescribed isometric and range-of-motion exercises. However, proper choice and appropriate utilisation of exercise is essential in order to provide a therapeutic effect. CONCLUSION: Although pharmacological interventions have largely improved RA management, exercise therapy remains an important part of treatment. Despite the known benefits of physical activity and exercise, patients with RA are less physically active than the general population.www.safpj.co.zaam201

Primary spontaneous pneumothorax in a recreational athlete

Primary spontaneous pneumothorax (PSP) is relatively uncommon in the athletic population. Because of the subtle nature of the symptoms, the diagnosis is easily missed, which can lead to unnecessary prolonged discomfort and recovery time for the athlete. ere is currently a lack of evidence in the literature concerning treatment and return-to-play protocols referring specifically to PSP within the athletic community. is case report highlights the predisposing and important factors in the history of a 34-year-old recreational male athlete who developed PSP. According to the knowledge of the authors, this report of PSP in a recreational athlete is the first of its kind described in South Africa. Owing to the possibility of life-threatening complications, it is important for sports physicians to be familiar with the important points in the history and to be made aware of the predisposing factors that may lead to PSP.http://sajsm.org.za/index.php/sajsmam201

No time to waste : necessary health support for retired professional rugby players

There has been increasing scrutiny of professional rugby following the concern that retired players might face several negative health conditions. Currently, support measures addressing the health of retired professional rugby players are not systematically implemented. This is unusual as professional rugby stakeholders have the duty of care to protect and promote the long-term health of retired players. Professional football has a health programme for retired players that is implemented globally. This programme formed the basis for the After Rugby Career Consultation (ARCC) which was developed to empower the sustainable health and quality of life of retired professional rugby players. The ARCC relies on information from three sources: (1) educational material, (2) medical examination, and (3) guidance, referral and/or monitoring. The South African rugby stakeholders have connected to pilot the ARCC as there is no time to waste: a step towards necessary health support for retired professional rugby players is needed.http://sajsm.org.za/index.php/sajsmhj2021Sports Medicin

Practical tips to manage travel fatigue and jet lag in athletes

Travel forms an integral part of modern-day athletes lives. The interrelated effects of travel fatigue, jet lag and increased risk of illness, are likely to affect performance unless managed appropriately.http://bjsm.bmj.comhj2020Sports Medicin

Clay-shoveler fracture in a paddler : a case report

Clay-shoveler fracture is a fracture of the spinous process of lower cervical and upper thoracic vertebrae. It has only rarely been reported as being caused by an overuse sports injury. This case report describes the first reported clay-shoveler fracture in a paddler. A 51-year-old male paddler, preparing for a paddling adventure over 630 km, felt a click and a sharp pain paravertebrally on the level of the upper thoracic vertebrae while paddling. Sonar investigation did not reveal any muscular injury but computed tomography revealed a fracture of the spinous process of T1. In this case, it is a stress injury due to excessive paddling over a short period of time. This fracture causes debilitating pain in the acute phase and is mainly treated conservativelyhttp://journals.lww.com/cjsportsmed2017-05-31hb2016Internal MedicineSports Medicin

Acute obturator internus muscle strain in a rugby player : a case report

A 28-year-old male rugby player presented with severe onset of right hip pain when he fell awkward after a ruck during an international match. A rare case of an acute strain of the obturator internus muscle, a deep muscle of the hip joint, is reported, which resolved completely after a period of rest and intense active physical therapy.http://www.minervamedica.it/en/journals/sports-med-physical-fitness2016-09-30hb2016Sports Medicin

Iliopsoas haematoma in a rugby player

Traumatic iliopsoas haematoma is a serious complication of haemorrhage disorders rarely seen in young healthy athletes. It is mostly described in patients on anticoagulant therapy and commonly associated with various degrees of femoral nerve palsy. A 22-year-old male rugby player presented with severe onset of pain in the lower back, right hip flexor/pelvic area following a tackle during a rugby match. Magnetic resonance imaging identified a distinct, hyperechoic heterogeneous mass within the right iliopsoas muscle, confirming a diagnosis of iliopsoas haematoma. The case resolved completely after conservative medical treatment in addition to a period of rest and intense active physical therapy. This case study reports the rare diagnosis of an uncomplicated iliopsoas haematoma following a sports injury in a young athlete.http://sajsm.org.za/index.php/sajsmam2016Sports Medicin

Shouldering the blame for impingement : the rotator cuff continuum

The aim of this article was to summarise recent research on shoulder impingement and rotator cuff pathology. A continuum model of rotator cuff pathology is described, and the challenges of accurate clinical diagnosis, imaging and best management discussed.http://www.tandfonline.com/ojfpam2016Sports Medicin