**3.1 Perceptions of health professionals**

When working towards a successful exercise prescription, it is important to consider the perceptions of health professionals involved in the care of people with RA. Common barriers cited for a lack of exercise-based intervention have included a lack of time during the patient visit, limited reimbursement, lack of training and perceived ineffectiveness as a behavioural counsellor (Calfas et al., 1996). In the study by Iversen et al. (1999), many rheumatologists felt that exercise prescription would take more time than they had available and also doubted their patients' interest in and ability to comply with an exercise programme. Further research by this group indicated that only 51% of rheumatologists reported feeling confident that they knew *when* exercises were appropriate for their patients with RA with only 22% reporting that they felt confident to instruct patients as to appropriate exercises (Iversen et al., 2004b).

The perceptions of health professionals in relation to exercise type may also be limiting recommendation and consequent uptake of exercise. Rheumatologists have reported negative attitudes towards aerobic exercise, with 29% of the belief that aerobic exercises were *rarely* useful in the management of RA (Iversen et al., 1999; 2004a). Furthermore and as previously mentioned, the outcome expectations of rheumatologists and physiotherapists for high intensity exercise have been found to be significantly less positive than those for a conventional exercise programme. Despite this, the majority of rheumatologists (and patients) felt that a high-intensity exercise programme would be attainable. Interestingly, the physiotherapists in this study were even more conservative than rheumatologists regarding high-intensity exercise with only a minority of physiotherapists of the view that intensive exercise would be attainable for half of all RA patients (Munneke et al., 2004).

Limitations within the existing literature may partially explain these perceptions as reservations regarding exercise and joint health were in existence (Munneke et al., 2005). However, as previously discussed, the most recent study by de Jong and colleagues (2009) refuted this, offering further substantiation of the earlier studies that showed no exacerbation of joint damage with prolonged, high-intensity exercise (Hakkinen et al., 1994; 2001; 2004; Nordemar et al., 1981;). Consequently, it may be that supplementary education for health professionals involved in the treatment of patients with RA is necessary to ensure they are sufficiently informed with respect to current scientific evidence (Munneke et al., 2004). Furthermore, it appears that further research and information dissemination, with the aim of addressing deficiencies in knowledge of specific exercise prescription for this population is required. As shown in the quotes below, our ongoing research investigating the perceptions of health professionals with regards to exercise has given an initial insight into the difficulties of providing an exercise prescription to individuals with RA.

*'I don't know specific recommendations for aerobic exercise in RA because journal articles on this never specify or describe exactly what exercise was prescribed…'* (Rheumatologist)

Enjoyment of exercising with others

someone to exercise with

> Want others to approve

**Social Environmental** 

Encouragement Programmes for

Water exercise

people with arthritis

Low cost

Available equipment

**Physical Psychological/** 

Reduced pain Increased

Reduced stiffness Experiencing

Improved mobility and function

Easier activities of daily living

Improved strength and flexibility

Increasing muscle mass, reducing fat mass

2010; Wilcox et al., 2006).

our focus group research:

year old female)

response to this:

**behavioural** 

independence

positive emotion

Increased energy Increased enjoyment Motivated by

Goal-setting/selfmotivation

Making exercise a priority

Table 2. Summary of benefits and factors encouraging a patient to exercise in arthritis (adapted from der Anian et al., 2006; Gyursik et al., 2009; Hutton et al., 2010; Law et al.,

Factors encouraging patients to exercise are also important considerations. Low cost, easy access, and weight reduction have been highlighted, alongside receiving assistance from instructors and the opportunity for social interaction. Examples quotes are provided from

*'...that for me was the secret. Was to find a good instructor and be in the company of others...'* (58

It is also evident from our research that difficulties arise as a result of incomplete information being provided, with health professionals advising exercise but lacking a definitive explanation of how to do so. It is also important that efforts are made to ensure that a consistent message is given. For example, during our focus group study, patients were introduced to the quote 'Many people are afraid to exercise because they believe that it will cause further damage to their joints'. The discussion extract below was from a patient in

*'...a symptom of misinformation and no information. That's why people believe that. They are not educated on Day 1 to believe that things are possible with the right help…'* (58 year old female).

*'...there's a lot of people at the moment complaining of the cost...'* (65 year old female)

*'That's another thing it [exercise] does, it helps you to keep the weight off.'* (62 year old male)

*'…patients are given a lot of conflicting advice and I am not sure how good the evidence is for advising exercise or exercise avoidance. It would be good to have clear advice/evidence/guidelines…exercise is good for RA patients especially when inflammation is controlled but I expect that it is much more difficult when disease is activ*e' (Rheumatologist)

*'…never prescribe, often recommend.'* (Rheumatologist)

The following quote demonstrates some of the considerations when deciding how to approach an exercise prescription for this patient group:

*'…The amount of pain a patient is in, whether synovitis is present and if there is joint damage will all affect the type, duration and number of 'reps' of exercise I would prescribe.'* (Physiotherapist)

Despite the superior effectiveness of intensive exercise (de Jong et al., 2003; Ekdahl et al., 1990; Hakkinen et al., 2001; Lemmey, 2009; van den Ende et al., 1996, 2000;) and a lack of detrimental consequences for disease activity and progression (deJong et al., 2003; Hakkinen et al., 2001; Lemmey et al., 2009; Strenstrom & Minor, 2003), it appears that health professionals may still struggle with the concept of recommending high-intensity exercise to patient with RA. Considering the increased risks to this population in terms of cardiovascular health, bone mineral density and rheumatoid cachexia, it is important to foster positive perceptions for both strength and aerobic-based exercise amongst health professionals. Thus, improved education is necessary to overcome any existing negative perceptions and enhance overall confidence to make a worthwhile exercise recommendation for health.
