**4.3 Time (volume)**

298 Rheumatoid Arthritis – Treatment

is particularly important for untrained and/or elderly individuals (Hakkinen, 1995). Whilst there are benefits for highly trained individuals in training more frequently (e.g. daily), for the previously untrained there is insufficient additional training gain to justify the reduction in the recovery period and the additional time commitment (ACSM, 1998; Demichele et al., 1997). For example, Demichele et al. (1997) found that training twice a week elicited 80-90% of the strength gain achieved when training more frequently. In addition to facilitating recovery, limiting PRT sessions to 2-3 times per week should also enhance adherence to the training program, as "insufficient time" is a common reason for not commencing or

In healthy individuals it appears that once the training effects of PRT have been established (after 8-12 weeks training), that training once per week, perhaps even once fortnightly is sufficient to maintain these benefits (Graves et al., 1990). A similar maintenance training frequency seems to be appropriate for RA patients, as in the RAPIT study (de Jong et al., 2009), strength gains following 2 years of twice weekly HI training (including strength training) were maintained by patients who continued exercising once/week for the

To maximise improvements in strength and muscle hypertrophy, it is necessary to recruit the maximal number of motor unit; and since the high-threshold motor units may not be activated by light-to-moderate loads, it is essential to use heavy loads to ensure activation of all motor units. Thus, maximal or near maximal loads elicit the greatest gains in strength and muscle mass (Fleck & Kraemer, 1997). Additionally, as mentioned previously bone also responds most favourably to heavy loading (e.g. Chamay & Tschantz, 1972;

In resistance training, intensity is determined by the percentage of the 1-RM a load (weight) corresponds to. Although improvements in strength and muscle mass in previously untrained subjects have been demonstrated following training with loads of 50% 1-RM, multiple studies have shown that loads of ≥ 80% 1-RM are optimal for increasing strength and inducing muscle hypertrophy (e.g. ACSM, 1998; Evans, 1999; Hass et al., 2001; Kraemer & Ratamess, 2004). For untrained subjects and clinical populations aiming to enhance strength and muscle mass, an intensity of 80% 1-RM is generally prescribed, with higher intensities usually the preserve of competition athletes. For 80% 1-RM, 6-12 repetitions or lifts are usually possible. If less than 6 repetitions can be performed then the weight is too heavy, and if more than 12 repetitions can be achieved then the weight is too light. It should be noted that even when the relative intensity is fixed (e.g. 80% 1-RM), the maximum number of repetitions that can be performed varies both between individuals and for a

It is absolutely crucial that for untrained individuals, intensity at the commencement of PRT, should start low and progress slowly to allow the musculo-skeletal system sufficient time to adapt to the (unaccustomed) demands of training. For example, in our RCT (Lemmey et al., 2009), although the aim was for patients to eventually perform 3 sets of 8-12 repetitions at 80% 1-RM, (primarily to reduce muscle soreness) training was initially performed at much lower intensities. Thus, one set of 15 repetitions at 60% 1-RM was performed for each exercise in the first week, increasing to 2 sets at the same intensity in the second week and 3 sets at the same intensity in the third week. Intensity then increased to 70% 1-RM (12

subsequent 18 months, but completely lost by those who stopped exercising. .

given individual performing different exercises (Hoeger et al., 1987).

dropping out of exercise programs (Dishman, 1994).

**4.2 Intensity** 

Kerr et al., 1996).

With PRT, training volume is defined as the product of: number of exercises x number of sets per exercise x number of repetitions per set. Thus, training volume can be manipulated by altering any of these variables. It needs to be stated that there is no "magic number" for any of these variables; and if there was it would no doubt vary from individual to individual, and vary again within an individual for each exercise performed.

With regard to the number of exercises; to maximise muscle hypertrophy and to facilitate improvement in the performance of ADL's, resistance training should involve the wholebody. Thus, 6-10 exercises each involving large muscle groups are usually prescribed (e.g. 1) leg press; 2) chest press; 3) leg extension; 4) seated rowing; 5) leg curl; 6) triceps extensions; 7) abdominal crunches/curls; 8) standing calf raises; 9) bicep curl (Lemmey et al., 2009; Marcora et al., 2005a).

Numerous studies have tried to determine the optimal number of sets per exercise, with comparisons of all permutations from one to 6 sets made, but no single number has consistently emerged as the best (e.g. Campos et al., 2002; Kraemer, 1997). When enhanced health and general function is the principle aim of training, for both healthy and clinical populations, 2 or 3 sets are usually prescribed (e.g. ACR, 2002, 2006; ACSM, 2010a-d; Combe et al., 2007; WHO, 2008, Williams et al., 2007). And for novice trainers, both 2 and 3 sets are very effective in eliciting training effects, with controversy persisting as to whether performing 3 sets delivers substantially better returns than performing 2 sets (Ostrowski et al., 1997). Of recent interest is the efficacy of single-set programs. In a number of studies one set of 8-12 repetitions performed to voluntary failure has, in previously untrained subjects, produced training gains comparable to those of conventional multiple set programs (ACSM, 1998); although there is disagreement with this finding (Paulsen et al., 2003), particularly in trained individuals (Kraemer, 1997). Even if single-set protocols are marginally less effective than multi-set programs, the time efficiency of the former may result in better training compliance, as programs that require in excess of 1 hour per session have higher dropout rates (Pollock, 1988). Thus, if time constraint is an important consideration, and especially if the patient wants to additionally perform aerobic training, the use of single-set protocols should be considered as, provided the intensity is sufficient, these will certainly produce beneficial responses (Hass et al., 2001).

Another variable that can be manipulated is the duration of the rest period between sets. Researchers have found that short rest periods (≤1 min) elicit more pronounced muscle hypertrophy (Kraemer, 1997) whilst longer rest periods (2-5 min) produce greater strength gains (ACSM, 2002). These differing effects have been attributed to the extent of ATP-PC (phosphagen system) repletion (Kraemer & Ratamess, 2004); hence, for maximal strength gains complete restoration of ATP-PC is required to enable maximal lifts, whereas incomplete restoration results in metabolic, hormonal, and CV responses that facilitate hypertrophy (Kraemer, 1997; Kraemer et al., 1987, 1991). Not surprisingly, body builders

Resistance Training for Patients with Rheumatoid Arthritis: Effects on Disability,

challenged by an unfamiliar training stimulus.

capacity (McCartney et al., 1993).

**5. Conclusion** 

advice with regard to exercise should be sought.

compliance was similar to that expected of healthy individuals.

**4.6 Exclusion criteria and further recommendations** 

Rheumatoid Cachexia, and Osteoporosis; and Recommendations for Prescription 301

situation is to manipulate the training program variables (types of exercises, training intensity, number of sets and/or repetitions, rest period between sets), so that the body is

As discussed previously, appropriately designed PRT is safe, and well tolerated by males and females of all ages and most conditions, including RA (ACSM, 1998). In the recommendations made by the AHA regarding resistance training for patients with and without CVD (Pollock et al., 2000), the contraindications to PRT are: unstable angina, uncontrolled hypertension (≥160/100 mm Hg), recent and untreated episodes of congestive heart failure, uncontrolled dysrhythmias, severe stenotic or regurgitant valvular disease, and hypertrophic cardiomyopathy. Additionally, for low to moderate risk cardiac patients wanting to participate in PRT programs, they suggest preliminary aerobic exercise training for 2-4 weeks (Pollock et al., 2000). Overall, however, they concluded that "resistance training exercise is strongly recommended for implementation in primary and secondary cardiovascular disease-prevention programs" and "…is particularly beneficial for improving the function of most cardiac, frail, and elderly patients"( Pollock et al., 2000). In part, this is because increased strength reduces the myocardial demands (i.e. heart rate and BP) when patients perform ADL's because the task requires a lower percentage of functional

Caution must be taken when prescribing PRT to severely osteoporotic patients, with highintensity exercise to be avoided (ACSM, 2010a). In the case of these patients, specialist

Despite the apparently beneficial consequences of training during acute flares shown by Van den Ende et al. (2000), we discourage training during flares. Similarly, as healthy individuals should be advised, we also discourage training during illness (e.g. colds, influenza etc), and tell patients to only resume training when health is restored. Upon resumption of training, loads should be adjusted to account for loss of strength due to detraining. Under these circumstances, pre-illness strength levels are usually rapidly regained. To underline the safety of and tolerance to PRT for RA patients, in our high intensity PRT intervention studies (Lemmey et al., 2009; Marcora et al., 2005a), mean compliance to training sessions (i.e. sessions attended as a % of those scheduled) was around 80%. Thus, even when advised to avoid training when unwell, patients training

This chapter has described important consequences of RA which are usually untreated (i.e. diminished muscle mass and high fat mass, particularly central obesity; rheumatoid cachexia) or are still prevalent despite enhanced pharmaceutical treatment (disability, CVD, osteoporotic fractures), and then reviewed the research into the efficacy and safety of PRT in treating these conditions. The evidence indicates that PRT is an appropriate adjunct therapy for RA patients. In particular, its efficacy in positively affecting body composition and physical function is almost unique, particularly when accessibility and the lack of negative side effects are considered. As such, rheumatologists and allied health professionals overseeing the management of RA patients should be encouraging them to undertake PRT, ideally in conjunction with aerobic training. To better inform clinicians in their exercise

favour programs which feature short rest periods, whilst strength and power athletes generally employ longer rest intervals. Whether these differential effects of rest period duration also operate in middle-aged and elderly previously untrained exercisers is unclear. As such, and given that training benefit is unlikely to be significantly compromised but training time will be markedly reduced if short rest periods are preferred to long rest periods, allocation of 1-2 min rest between sets appears optimal.
