Exercise therapy

Exercise is the cornerstone of the non-pharmacological treatment of RA; its main function is to improve muscle strength, endurance and GWB (Hurkmans et al., 2009; Vliet Vlieland & Van den Ende, 2011). Terms such as physical activity and exercise can describe different concepts (Caspersen et al., 1985). These terms are sometimes used interchangeably and they are often difficult to distinguish between (Caspersen et al., 1985). In this thesis, physical activity is referred to in the context of: any body movement generated by skeletal muscles, resulting in energy expenditure, such as activities of daily life in terms of occupational, sport conditioning and household (Caspersen et al., 1985). Exercise is referred to as a division of physical activity that is planned, structured, and repetitive, and has a target for the improvement or maintenance of physical fitness (Caspersen et al., 1985). Patients with RA experience severe pain and stiffness because of joint inflammation, the consequences of which may lead to loss of joint motion, loss of muscle strength, muscle atrophy and contractures. This, in turn, leads to decreased joint stability and further increased fatigue (Hurley et al., 2002; Schur &

Moreland, 2011).

60 In RA patients, one of the most important points is to strike a balance between rest and exercise, which can be tailored and modified depending on the clinical condition (Frank, 2010). A variety of exercises may be considered as beneficial to RA patients in helping improve range of movement, strength and endurance.

These may include isometric, isotonic, isokinetic, walking, swimming and cycling (Beardmore, 2008; Hurley et al., 2002; Schur & Moreland, 2011). One question that needs to be asked, however, is whether or not some interventions that are aimed principally at improving other variables also reduce fatigue. For instance, pharmacological interventions were prescribed to reduce inflammation, exercise interventions administered to improve physical activity and psychological behavioural therapy indicated to improve psychological distress and all these treatment modalities might reduce fatigue in RA (Hewlett et al., 2011; Hewlett et al., 2008).

Recent evidence suggests that exercise has a positive effect on joints, and has no harmful effect on the patient in relation to disease activity or pain. A systematic review by Van den Ende et al. (2007) emphasised that there were no detrimental effects on RA patients of dynamic exercise therapy, but rather that there was a positive effect from exercise.

Hydrotherapy

Hydrotherapy is a combination of therapeutic exercises and immersion in warm water (Beardmore, 2008). ‘Hydrotherapy’, otherwise known as ‘aquatic exercise’

or ‘aquatic therapy’, is defined as the controlled exercise in warm water using the buoyancy, assistance and resistance of warm water to relieve pain, induce muscle

61 relaxation and promote more effective exercise (Ahern et al., 1995). It is now called ‘aquatic physiotherapy’ and is highly valued as an excellent exercise for patients with arthritis (HyDAT Team, 2009).

The main aim of hydrotherapy is to relieve pain, improve joint motion, promote feelings of comfort, and consequently improve function and QoL (Ahern et al., 1995; Foley et al., 2003). Hydrotherapy is advocated as a safe and efficient medium for achieving exercise-related goals, and it is commonly used for patients with rheumatic disease (Beardmore, 2008; Rintala et al., 1996). The difference between aquatic exercise and exercise on land is that floating in water has been found useful in relaxing the muscles. Some exercises are made easier due to the buoyancy of the water; some are made more difficult due to the resistance provided by the water (Foley et al., 2003; Rintala et al., 1996).

Immersion in the thermo-neutral water temperature has a soothing effect and plays an important role providing an optimum environment for exercise (Eversden et al., 2007; Verhagen et al., 2008). Water is an appropriate environment for treating RA patients because it helps relax tense muscles and increases blood flow to the tissues (Bood et al., 2007; Kjellgren et al., 2001; Melzack & Wall, 1967). It also has a sedative effect on nerve endings, and therefore reduces pain and discomfort (Bood et al., 2007; Kjellgren et al., 2001; Melzack & Wall, 1967). It is suggested that this form of treatment helps RA patients manage their disease independently for longer, preventing or reducing hospital admissions and enabling a speedy return to occupations, which therefore reduces the cost impact on employers and society.

62 2.9.2.2.3 Heat and cold therapy

The use of hot and cold water has been commonly indicated for centuries in most musculoskeletal illnesses and impairments, especially in acute injury (Beardmore, 2008; Hurley et al., 2002). Heat and cold are used to reduce pain and decrease stiffness in many rheumatic and musculoskeletal conditions such as OA (Hurley et al., 2002). This treatment is easy to use, is low-cost, and can be used in the home, outpatient clinic and private office (Beardmore, 2008). A Cochrane review in 2002 by Robinson et al. supported also by Welch et al. (2011), found that heat and cold had no effects on the objective measures of disease activity, and no harmful effects of thermotherapy were reported (Robinson et al., 2002; Welch et al., 2011).

Heat therapy can be applied as hot packs, water baths, paraffin wax, or thermal packs. Water baths or Whirlpools can be combined with active or passive motion of exercises to increase the range of joint movement (Beardmore, 2008; Hurley et al., 2002; Welch et al., 2011). Thermal packs contain chemical agents, which produce heat through the occurrence of an exothermic reaction upon activation (Beardmore, 2008; Hurley et al., 2002; Welch et al., 2011). Heat therapy is contraindicated in the absence of normal sensation or impairment or diminished blood supply, mainly in people with diabetes (Beardmore, 2008; Hurley et al., 2002; Welch et al., 2011).

Application of cold is used for immediate care after musculoskeletal injury because it causes vasospasm and is associated with reduction in tissue inflammation and oedema; therefore, it reduces pain, muscle spasm and

63 circulation (Beardmore, 2008). This type of treatment should be applied locally for up to 30 minutes, but deep cooling is reliant on application time and soft tissue depth (Beardmore, 2008).

2.9.2.2.4 Electrotherapy

There are many types of electrotherapy such as transcutaneous electrical nerve stimulation (TENS), interferential and laser, all of which may be used to relieve pain in non-inflammatory chronic conditions such as back pain, knee pain, chronic shoulder pain or other joint pain (Beardmore, 2008). The evidence for effectiveness of these treatments in RA is uncertain and poorly evaluated (Beardmore, 2008; Hurley et al., 2002; Minor & Sanford, 1993).

2.9.2.2.5 Joint protection, the provision of adaptive devices and walking aids