**4. Recommendations for improving patient perceptions**

It is evident that perceptions relating to exercise need to be improved in order to increase physical activity levels amongst RA patients and enhance the success of exercise recommendations. At present however, overall exercise education is insufficient and further support is required to overcome the physical, psychological, social and environmental barriers common to this patient group. The model previously discussed (Figure 1) presents the issues indicated by patients in relation to exercising with RA and Table 1 summarises the barriers to exercise for this patient group. On the other hand, Table 2 summarises the and factors that could be used encourage patients with arthritis to exercise. In addition to the pivotal role of the rheumatologist in influencing exercise prescription (Iversen et al., 1999; 2004a and 2004b), these implications are also relevant to other health professionals involved in the treatment of RA patients (i.e. nurse specialists, physiotherapists, occupational therapists).

Continual emphasis and communication of the known benefits of exercise for RA patients is necessary. It is also important to acknowledge the challenges that are faced by patients when attempting to exercise appropriately. For example, especially at the onset of their disease, it is important for patients to understand and feel able to make decisions about how to modify their exercise according to their fluctuating symptoms (Iversen et al., 1999). It is also important to consider methods of overcoming potential barriers when promoting the maintenance of an exercise programme. For example, working towards strengthening patient beliefs that they are able to continue exercise outside of the healthcare environment may be valuable (Swardh et al., 2008).

*'…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* 

The following quote demonstrates some of the considerations when deciding how to

*'…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

It is evident that perceptions relating to exercise need to be improved in order to increase physical activity levels amongst RA patients and enhance the success of exercise recommendations. At present however, overall exercise education is insufficient and further support is required to overcome the physical, psychological, social and environmental barriers common to this patient group. The model previously discussed (Figure 1) presents the issues indicated by patients in relation to exercising with RA and Table 1 summarises the barriers to exercise for this patient group. On the other hand, Table 2 summarises the and factors that could be used encourage patients with arthritis to exercise. In addition to the pivotal role of the rheumatologist in influencing exercise prescription (Iversen et al., 1999; 2004a and 2004b), these implications are also relevant to other health professionals involved in the treatment of RA patients (i.e. nurse specialists, physiotherapists,

Continual emphasis and communication of the known benefits of exercise for RA patients is necessary. It is also important to acknowledge the challenges that are faced by patients when attempting to exercise appropriately. For example, especially at the onset of their disease, it is important for patients to understand and feel able to make decisions about how to modify their exercise according to their fluctuating symptoms (Iversen et al., 1999). It is also important to consider methods of overcoming potential barriers when promoting the maintenance of an exercise programme. For example, working towards strengthening patient beliefs that they are able to continue exercise outside of the healthcare environment

*difficult when disease is activ*e' (Rheumatologist)

for health.

occupational therapists).

may be valuable (Swardh et al., 2008).

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

approach an exercise prescription for this patient group:

**4. Recommendations for improving patient perceptions** 


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., 2010; Wilcox et al., 2006).

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 our focus group research:

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

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 response to this:

*'...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).

alongside a motivational and assertive approach to exercise prescription is also important to

Further research and use of evidence-based practice within the health profession will address limitations in current exercise knowledge. The most effective method of enhancing transfer of this information and educating patients and health professionals in this area needs to be utilised, an area which may also require further investigation. With more specific exercise information and an effectual method of education and delivery, exercise can become akin to a medical prescription. Working to build upon perceptions that exercise is an essential part of disease management and lifelong health promotion will facilitate this

The authors would like to thank Dr. Jeremy Jones, Mrs. Anne Breslin, Dr. Emily Oliver,

Baillet, A, Payraud, E, Niderprim, V-A, Nissen, MJ, Allenet, B, Francois, P, Grange, L, Casez,

Bilberg, A, Ahlmen, M, Mannerkorpi, K. (2005). Moderately intensive exercise in a

Calfas KJ, Long BJ, Sallis JF, Wooten, WJ, Pratt, M & Patrick, K. (1996). A controlled trial of

Combe, B, Landewe, R, Lukas, C, Bolosiu, HD, Breedveld, F, Dougados, M, Emery, P,

Cooney, JK., Law, R-J, Matschke, V, Lemmey, AB, Moore, JP, Ahmad, Y, Jones, JG,

de Jong Z & Vliet Vlieland TPM. (2005). Safety of exercise in patients with rheumatoid

de Jong, Z, Munneke, M, Jansen, LM, Ronday, K, van Schaardenburg, DJ, Brand, R, van den

arthritis. *Current Opinion in Rheumatology*, Vol. 17, pp. 177-182.

P, Juvin R & Gaudin, P. (2009). A dynamic exercise programme to improve patients' disability in rheumatoid arthritis: a prospective randomized controlled

temperate pool for patients with rheumatoid arthritis: a randomized controlled

physician counseling to promote the adoption of physical activity. *Preventative* 

Ferraccioli, G, Hazes, JMW, Klareskog, L, Machold, K, Martin-Mola, E, Nielsen, H, Silman, A, Smolen, J & Yazici H. (2007). EULAR recommendations for the management of early arthritis: report of a task force of the European Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT).

Maddison, P & Thom, J. (2011). Benefits of Exercise in Rheumatoid Arthritis. *Journal* 

Ende, CHM, Vliet Vlieland, TPM, Zuijderduin, WM & Hazes, JMW. (2004). Differences between participants and nonparticipants in an exercise trial for adults with rheumatoid arthritis. *Arthritis Care & Research*, vol. 51, No. 4, pp. 593-600. de Jong, Z, Munneke, M, Kroon, HM, van Schaardenburg, D, Dijkmans, BAC, Hazes, JMW

& Vliet Vlieland, TPM. (2009). Long-term follow-up of a high-intensity exercise

Lauren Mawn and Serena Halls for their valued contributions.

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implement.

process.

**6. Acknowledgment** 

**7. References** 

This highlights the importance of emphasising the benefits of exercise and giving specific exercise recommendations early in treatment. Furthermore, within the Obstacles to Action study (Hutton et al., 2010) 'insufficient advice from a healthcare provider' was a theme for the insufficiently active individuals, with queries relating to the type, frequency, and intensity of appropriate exercise. These correspond with recommendations by the American College of Sports Medicine, who describe exercise prescription using the 'FITT' principle (Swain, 2010). This incorporates the following: how often per week the patient should exercise (Frequency), how energetically or vigorously the patient should exercise (Intensity), how long the patient should exercise to obtain benefits (Time) and what type of exercises should be prescribed to the patient (Type) (Tancred & Tancred, 1996). This acronym offers a useful and simple framework upon which to base an exercise prescription.

An interesting point also stems from the quote below, indicating that means of continuing assessment and feedback may benefit patients.

*'...I would love to have some measurement that shows me that it's doing me some good.'* (66 year old male)

However, whilst working to develop these areas would be worthwhile, barriers for the health professional also exist. As previously mentioned, limited knowledge may hinder their ability and confidence to discuss the topic of exercise. Moreover, the time constraint of a standard appointment often means that medication and symptom control is prioritised (Calfas et al., 1996). In a study by Podl et al. (1999) involving family physicians, it was highlighted that an average of 45 seconds of consultation time involved conversation about exercise. This lack of consultation time was confirmed by Iversen et al., (1999) who found that when a medical regime was more complicated, there was less talk about exercise. Therefore, quick and effective means of prescribing exercise and providing continual followup and feedback would be of benefit. Future direction could also include referral to a trained clinical exercise physiologist, who would possess the skills to make physiological assessments and prescribe exercise. Additionally, as local communities vary widely in the availability of resources and programmes for individuals with arthritis (Wilcox et al., 2006), incorporating home-based recommendations may be of value.

In summary, clear exercise guidelines and prescription advice is necessary to address the fact that RA patients are often faced with ambiguous and incomplete information. This may mean that further information for those health professionals involved in the care of this patient group is necessary to instil the confidence and allegiance required to positively shape the perceptions of this patient group.

#### **5. Conclusions**

The benefits of continued, regular exercise of a sufficient intensity for RA patients are clear. Furthermore, it appears that many patients are aware that exercise forms an advantageous part of their disease management. However, negative perceptions relating to joint health, pain and the clarity of exercise prescription for this patient group add to the barriers to exercise uptake that already exist in the general population. Therefore, to improve patient perceptions, the benefits require continual emphasis and the additional concerns regarding joint health, pain symptoms the specificity of exercise recommendations need to be acknowledged and addressed. Initiation of exercise discussion by the health professional alongside a motivational and assertive approach to exercise prescription is also important to implement.

Further research and use of evidence-based practice within the health profession will address limitations in current exercise knowledge. The most effective method of enhancing transfer of this information and educating patients and health professionals in this area needs to be utilised, an area which may also require further investigation. With more specific exercise information and an effectual method of education and delivery, exercise can become akin to a medical prescription. Working to build upon perceptions that exercise is an essential part of disease management and lifelong health promotion will facilitate this process.
