**4. Fundamentals of PRT prescription for RA patients**

"The key factor to successful resistance training at any level of fitness or age is appropriate program design" (Kraemer & Ratamess, 2004); and this requires that specific needs and goals are addressed. For RA patients generally, the needs a PRT program should address are: counteracting rheumatoid cachexia by restoring muscle mass and reducing adiposity (especially central stores); augmenting strength and thus improving physical function and the ability to perform ADL's; and lowering osteoporotic fracture risk by stabilizing or increasing bone mass and reducing the likelihood of falling by enhancing strength and balance. In specifying these aims, the intention is not to ignore the numerous generic benefits of exercise training such as reduced CVD risk, improved insulin-sensitivity, decreased risk of specific cancers, enhanced mood and mental health etc., but to concentrate on those aspects of RA-specific health for which PRT is particularly appropriate. Additionally, individuals may also have personal goals and these should be taken into account when designing the training program. Since untrained individuals readily respond physiologically to most protocols, it is unnecessary to devise complicated or advanced programs.

To maximise the health and performance benefits, and to best ensure safety, it is important that appropriately qualified professionals are involved in designing the PRT program and, for the initial weeks at least, in supervising training. The following training recommendations are all consistent with guidelines provided by the ACR (2022, 2006), EULAR (Combe et al., 2007), ACSM (1998, 2010a-e) and AHA (Williams et al., 2007) either for RA specifically or for the co-morbid conditions common in RA, and by the WHO (2008) "for promoting and maintaining health" in the general population. As with most exercise programs, these guidelines are based on the FITT principle: frequency, intensity, time (or volume), and type (or modality) (ACSM, 2010e).

#### **4.1 Frequency**

296 Rheumatoid Arthritis – Treatment

years) for 32 weeks of HI PRT in which they performed 3 sets of 8 repetitions at 75-80% of 1 repetition maximum (1-RM, i.e. the maximum load that can be correctly lifted for a given exercise) for each exercise. As anticipated, this high intensity PRT resulted in substantial, and correlated, improvements in strength and balance. More importantly, it also proved to be well tolerated and safe with no compression fractures or other training related injuries

For many years, intensive weight-bearing exercise was considered inappropriate for RA patients due to concern that this unaccustomed stress on the joints would exacerbate inflammation, pain, and joint damage (e.g. Sutej & Hadler, 1991). Even today, many rheumatologists and their multidisciplinary teams retain these anachronistic beliefs and advise patients to avoid strenuous physical pursuits in order to protect their joints and conserve their energy (i.e. the strategy of "pacing") (for further discussion on this see Metsios et al., 2007; Munneke et al., 2004). This is despite the unanimity of research findings that exercise training, including resistance training (Table 1), irrespective of the intensity employed, is safe in RA patients. In fact, although most studies report no changes in disease activity following resistance training, findings of improvements are not uncommon; e.g. reductions in: erythrocyte sedimentation rate (ESR; Hakkinen et al., 1994, 1997, 1999), morning stiffness (Ekdahl et al., 1990), number of tender and swollen joints (Ritchie articular index; Ekdahl et al., 1990; Hakkinen et al., 1994, 1997; van den Ende et al., 1996), self-reported joint count (Komatireddy et al., 1997), pain (Komatireddy et al., 1997; McMeeken et al., 1999; Rall et al., 1996b), and Disease Activity Score (DAS28, DAS4; Hakkinen et al., 1999, 2001, 2004a). High-intensity exercise even appears to be safe in patients with active disease; van den Ende et al. (2000) randomly allocated RA patients admitted to hospital for RA flares to perform either HI exercise (isokinetic and isometric strength training) or LI exercise (ROM and isometric exercises). After 24 weeks of training (3x's/week), improvements in DAS were observed for both groups with a trend toward

Adherence to PRT over prolonged periods also provides no cause for concern. Hakkinen et al. (2001) in an RCT comparing 2 years of strength training to conventional physiotherapy (ROM exercises), found that although DAS28 improved significantly for both groups, the strength training group enjoyed greater benefit. Similarly, de Jong et al. (2003) in their 2 year RCT (the RAPIT trial) also identified reductions in disease activity (DAS4) in their HI exercise (including strength training) group; albeit, this time with no difference between the

In a broader investigation of immune responses to PRT in RA patients, Rall et al. (1996c) detected no effects of 12 weeks HI training on peripheral blood mononuclear (PBMC) subpopulations, or stimulated proliferation of TNF-α, interleukin (IL)-1β, IL-2, IL-6, or

Although reassuring effects on joint counts, systemic inflammation, pain, and more generalised disease activity are provided by studies of strength training interventions in RA patients, relatively few studies have assessed the effects of training on radiographic joint damage. An exception to this was the RAPIT trial. Initially, reports from this investigation (de Jong et al., 2003; Munneke et al., 2005) raised concerns by suggesting that high intensity

observed.

**3.6 Safety of PRT for RA patients** 

greater improvement in the HI patients.

exercise and control ("usual care") groups.

prostaglandin E2, or delayed type hypersensitivity skin response.

It is generally recommended that strength training is performed 2-3 days a week with at least 48 hours rest between sessions (Evans, 1999; Hass et al., 2001; Kraemer & Ratamess, 2004). Training on alternate days allows adequate time for recovery and adaptation, and this

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

occurrences of training related injuries or dropouts from the program.

individual, and vary again within an individual for each exercise performed.

these will certainly produce beneficial responses (Hass et al., 2001).

**4.3 Time (volume)** 

al., 2009; Marcora et al., 2005a).

Rheumatoid Cachexia, and Osteoporosis; and Recommendations for Prescription 299

repetitions per set) for weeks 4-6. Before finally progressing to 8 repetitions per set at 80% 1- RM for weeks 7-24 (note: to ensure maintenance of relative intensities, 1-RM's were reassessed every 4 weeks). By adhering to this protocol substantial training benefits were gained (e.g. increased LM and improvements of 119% in training specific strength), with no

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

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

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,

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

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 dropping out of exercise programs (Dishman, 1994).

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

#### **4.2 Intensity**

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; Kerr et al., 1996).

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

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 repetitions per set) for weeks 4-6. Before finally progressing to 8 repetitions per set at 80% 1- RM for weeks 7-24 (note: to ensure maintenance of relative intensities, 1-RM's were reassessed every 4 weeks). By adhering to this protocol substantial training benefits were gained (e.g. increased LM and improvements of 119% in training specific strength), with no occurrences of training related injuries or dropouts from the program.
