**2.4 Perceptions relating to exercise prescription**

The pharmacological treatment of RA involves a clear and specific prescription for medication. However, despite recommendations by the British Society for Rheumatology (BSR; Luqmani et al., 2006; 2009), National Institute of Health and Clinical Excellence (NICE, 2009), European League Against Rheumatism (EULAR; Combe et al., 2007) and the American College of Sports Medicine (ACSM; Nelson et al., 2007), that exercise should be incorporated into the treatment of people with RA, specific recommendations are less clear. Corresponding with this limited clarity, research suggests that a perceived uncertainty about which exercises to do, and how to do them, may be inhibiting patients from participating in regular exercise (Lambert et al. 2000, Law et al. 2010). Emerging from our focus group research, the theme '**Not knowing what exercise should be done'** reflects patients' concerns about not knowing enough about exercise with respect to their disease. Patients discussed doubts about the best forms of exercise to undertake and were unclear how much exercise they should do. Discussion relating to sufficient exercise intensity and heart rate also took place, with questions arising as to whether fast walking would be enough, and how breathless they should feel. Example quotes are provided below:

*'If you do it fast it does raise your heart rate. And how much do you need to raise your heart rate, you don't know how much. Do you raise your heart rate until you can't breathe?'* (65 year old female)

*'...It's just the type of exercise that you do. Obviously not something too strenuous, but sometimes you need reassurance as well before you do something. You think well, is that good for me or is that bad for me?'* (23 year old female)

*'Do you think you have to do different exercises for muscle to joints?'* (65 year old female)

*'Do you know, I haven't got a clue'* (56 year old female)

Furthermore, patients also showed concern about the possibility that they might do something wrong. This is demonstrated by the following quotes:

*'Yeah, it's, what is the exercise about. How do I do it, will it affect my worse little bits. You've got to go through the bit about it, you've got to read what the exercise is, you've got to look at what the exercise is, will I be alright with it … '* (67 year old male)

On the other hand, qualitative research has revealed that some patients *feel* that their joints benefit from exercise, with quotes indicating the view that joints are 'lubricated' as a result of movement and patients have expressed that they feel more agile (Kamwendo et al., 1999;

*'...it helps to keep them lubricated doesn't it. It helps keep you moving, exercise. If you don't they seize* 

Overall, however, as factors salient to individual beliefs regarding the effects of exercise, patient perceptions relating to joint health, pain and damage are important to consider when addressing the issue of exercise for this population. Moreover, just under half of the patients involved in our follow-up questionnaire study indicated agreement with items relating to the themes 'worry about causing harm to joints' and 'not wanting to exercise as joints hurt' (Law et al., manuscript in preparation). Therefore, it is evident that RA patients need continued reassurance and encouragement that exercise is a vital part of disease management and that the aforementioned benefits are achievable *without* unfavourable

The pharmacological treatment of RA involves a clear and specific prescription for medication. However, despite recommendations by the British Society for Rheumatology (BSR; Luqmani et al., 2006; 2009), National Institute of Health and Clinical Excellence (NICE, 2009), European League Against Rheumatism (EULAR; Combe et al., 2007) and the American College of Sports Medicine (ACSM; Nelson et al., 2007), that exercise should be incorporated into the treatment of people with RA, specific recommendations are less clear. Corresponding with this limited clarity, research suggests that a perceived uncertainty about which exercises to do, and how to do them, may be inhibiting patients from participating in regular exercise (Lambert et al. 2000, Law et al. 2010). Emerging from our focus group research, the theme '**Not knowing what exercise should be done'** reflects patients' concerns about not knowing enough about exercise with respect to their disease. Patients discussed doubts about the best forms of exercise to undertake and were unclear how much exercise they should do. Discussion relating to sufficient exercise intensity and heart rate also took place, with questions arising as to whether fast walking would be

enough, and how breathless they should feel. Example quotes are provided below:

*'Do you think you have to do different exercises for muscle to joints?'* (65 year old female)

*'If you do it fast it does raise your heart rate. And how much do you need to raise your heart rate, you don't know how much. Do you raise your heart rate until you can't breathe?'* (65 year old female) *'...It's just the type of exercise that you do. Obviously not something too strenuous, but sometimes you need reassurance as well before you do something. You think well, is that good for me or is that* 

Furthermore, patients also showed concern about the possibility that they might do

*'Yeah, it's, what is the exercise about. How do I do it, will it affect my worse little bits. You've got to go through the bit about it, you've got to read what the exercise is, you've got to look at what the* 

Law et al., 2010). This is demonstrated by the quote below:

*up...'* (65 year old female)

effects for joint health or disease activity.

*bad for me?'* (23 year old female)

*'Do you know, I haven't got a clue'* (56 year old female)

*exercise is, will I be alright with it … '* (67 year old male)

something wrong. This is demonstrated by the following quotes:

**2.4 Perceptions relating to exercise prescription** 

*'It's difficult to know where to draw the line between 'oh for goodness sake, give it a bit of effort'…or 'you know this is harmful, it's time to stop.'* (57 year old female)

*'Only if you do too much I think.'* (62 year old male)

*'Or if you do the wrong thing as well, I think you could easily do the wrong thing.'* (46 year old female)

Furthermore, repetitive, impact-based exercise and pain provoked additional concern as shown in the quotes below:

*'….got to be careful of a repetitive move.'* (58 year old female)

*'I think impact is really disastrous…'* (66 year old female)

*'….I don't think weight impact, I don't think that would be very helpful.'* (62 year old male)

As previously mentioned, high-intensity exercise is now considered to provide the greatest benefit. However, in a study by Munneke et al., (2003), the outcome expectations of patients for a high-intensity exercise programme were found to be significantly less positive when compared to a conventional exercise programme. In this study, conventional exercise was described as 'calmly performed exercises for the joints not leading to tiredness, e.g. bending and stretching of the arm' and high-intensity exercise as 'individually tailored and supervised physical fitness and strength training exercises for the whole body leading to tiredness'. As will be discussed later, it was found that health professionals also held the view that conventional exercise was preferable for a patient with RA. Despite this however, the majority of patients indicated that they thought an intensive exercise programme would be attainable for at least half of their patient group.

An additional theme that emerged from our focus groups offered further insight into patient perceptions relating to exercise prescription. The theme **'Health professionals showing a lack of exercise knowledge'** reflected patient perceptions that, while health professionals advocated exercise, there were uncertainties regarding the specifics of exercise prescription. Furthermore, when exploring this issue on a larger scale, our questionnaire study revealed that less than 20% of patients agreed that health professionals showed exercise knowledge. Patients were also unsure whether or not current disease state (i.e. pain and fatigue levels) affected the overall benefit of exercise. As previously mentioned, further uncertainties were perceived in relation to concerns within the health profession about exercise and joint health. These views are demonstrated in the following extract:

*'…if I do that sort of thing and I get pain, I can go on doing it, now my next question [to a health professional] is am I doing myself harm if I get pain?* (66 year old male)

*'...mmmm'* (73 year old male)

*'Yeah'* (44 year old female)

*'[The health professional] can't tell me, right'* (66 year old male)

*'No, that's what worries me'* (65 year old female)

'*Nobody knows'* (66 year old male)

These perceptions relating to exercise prescription suggest that patients require education to include specific exercise recommendations that are of sufficient intensity to provide

about exercise were four times more likely to occur when the rheumatologist initiated exercise discussion (Iversen et al., 2004a). These findings draw attention to the significance of health professionals and the influence they have on the exercise

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

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

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

*'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)

perceptions of this patient group.

**3.1 Perceptions of health professionals** 

appropriate exercises (Iversen et al., 2004b).

patients (Munneke et al., 2004).

prescription to individuals with RA.

beneficial effects. Furthermore, there is a perception amongst patients that health professionals lack clarity and certainty regarding exercise, especially in relation to joint health. This perception of health professionals is also an important area to explore in order to determine if and where uncertainties exist, alongside the best way to deliver a clear and consistent message to the patient population. It may be that a firm and assertive approach to recommending exercise is important when prescribing exercise to people with RA.
