**2. Patient perceptions relating to exercise in RA**

Understanding the perceptions of people with RA regarding exercise is vital to assist in the initiation of and adherence to effective exercise training (Cooney et al., 2011). Primarily, a positive mindset regarding exercise prescription is necessary in order to challenge the longstanding opinion that exercise exacerbates disease (Gecht et al., 1996). However, many patients harbour concerns relating to the potential detrimental effects of exercise and perceive specific barriers to uptake and participation. Furthermore, due to uncertainties about which exercises to do and how to do them without causing harm, many patients feel they are unable to exercise at all. Encouragingly however, qualitative research has revealed that patients with arthritis believe exercise to be an important factor in treatment (Lambert et al., 2000; Law et al., 2010).

Qualitative research methods, including the analysis of focus group discussions and one-toone interviews, have been successfully utilised in the clinical setting. These methods allow the researcher to gather rich, plentiful data and enable an in-depth description of experiences, thought-processes and beliefs (Kitzinger, 1995; Ong & Coady, 2006). In patients with osteoarthritis, a qualitative study following the onset of disease revealed a subgroup of patients who had previously exercised but had stopped because of their symptoms and because they believed exercise was damaging their joints (Hendry et al., 2006). As may be expected of a condition that presents with similar symptoms (i.e. joint pain, swelling and stiffness), comparable perceptions have been confirmed in RA patients (Law et al., 2010). This study involved four moderated focus groups of RA patients (n = 18) and included both males and females of varied ages and disease duration, thus incorporating a broad range of experiences. Systematic content analysis of the discussion transcripts formed the basic meaning units for analysis. These quotes were then categorized, smaller constructs or subthemes were grouped, and the following main themes were identified: 'Health professionals showing a lack of exercise knowledge', 'Not knowing what exercise should be done', 'Not wanting to exercise as joints hurt', 'Worry about causing harm to joints' and 'Having to exercise because it is helpful'. Following discussion and comprehensive data interrogation, an analytical model was then developed (Figure 1). These themes were then used to develop a questionnaire to collect analogous quantitative data. Preliminary results (n = 247) from this questionnaire offer confirmatory findings of the prevalence of these issues in a larger population (Law et al., manuscript in preparation).

#### **2.1 Perceived benefits of exercise**

Although RA patients appear to be insufficiently active (Sokka et al., 2008), research suggests they are aware that exercise is a beneficial and necessary aspect of their disease management (Lambert et al., 2000, Law et al., 2010). This notion is reflected in the theme that emerged from focus group research; **'Having to exercise because it is helpful'**, indicating

332 Rheumatoid Arthritis – Treatment

This chapter will discuss the perceptions of patients and health professionals in relation to exercising with RA, alongside the implications and recommendations for patient care. Many of these issues have been highlighted as part of our continuing research and it is the findings from these novel investigations, alongside others, which form the basis of this chapter. Illustrative quotes from patients and practitioners have been included to facilitate

Understanding the perceptions of people with RA regarding exercise is vital to assist in the initiation of and adherence to effective exercise training (Cooney et al., 2011). Primarily, a positive mindset regarding exercise prescription is necessary in order to challenge the longstanding opinion that exercise exacerbates disease (Gecht et al., 1996). However, many patients harbour concerns relating to the potential detrimental effects of exercise and perceive specific barriers to uptake and participation. Furthermore, due to uncertainties about which exercises to do and how to do them without causing harm, many patients feel they are unable to exercise at all. Encouragingly however, qualitative research has revealed that patients with arthritis believe exercise to be an important factor in treatment (Lambert

Qualitative research methods, including the analysis of focus group discussions and one-toone interviews, have been successfully utilised in the clinical setting. These methods allow the researcher to gather rich, plentiful data and enable an in-depth description of experiences, thought-processes and beliefs (Kitzinger, 1995; Ong & Coady, 2006). In patients with osteoarthritis, a qualitative study following the onset of disease revealed a subgroup of patients who had previously exercised but had stopped because of their symptoms and because they believed exercise was damaging their joints (Hendry et al., 2006). As may be expected of a condition that presents with similar symptoms (i.e. joint pain, swelling and stiffness), comparable perceptions have been confirmed in RA patients (Law et al., 2010). This study involved four moderated focus groups of RA patients (n = 18) and included both males and females of varied ages and disease duration, thus incorporating a broad range of experiences. Systematic content analysis of the discussion transcripts formed the basic meaning units for analysis. These quotes were then categorized, smaller constructs or subthemes were grouped, and the following main themes were identified: 'Health professionals showing a lack of exercise knowledge', 'Not knowing what exercise should be done', 'Not wanting to exercise as joints hurt', 'Worry about causing harm to joints' and 'Having to exercise because it is helpful'. Following discussion and comprehensive data interrogation, an analytical model was then developed (Figure 1). These themes were then used to develop a questionnaire to collect analogous quantitative data. Preliminary results (n = 247) from this questionnaire offer confirmatory findings of the prevalence of these issues in a

Although RA patients appear to be insufficiently active (Sokka et al., 2008), research suggests they are aware that exercise is a beneficial and necessary aspect of their disease management (Lambert et al., 2000, Law et al., 2010). This notion is reflected in the theme that emerged from focus group research; **'Having to exercise because it is helpful'**, indicating

description of these issues.

et al., 2000; Law et al., 2010).

**2. Patient perceptions relating to exercise in RA** 

larger population (Law et al., manuscript in preparation).

**2.1 Perceived benefits of exercise** 

Fig. 1. Analytical model of the issues relating to exercise and joint health in RA patients (Law et al., 2010).

*'Even on days when I do have time, I think I'd rather be doing something else'* (65 year old

*'You want something there [somewhere to exercise], something you can access easily.'* (58 year old

*'...you get very tired with this. Sometimes in a week you might feel exhausted, doing nothing'.* (46

**exercise** Lack of time Lack of encouragement **No arthritis-**

**Lack of acknowledgement of arthritis** 

Lack of information from healthcare provider

Nobody to exercise

responsibilities

**Social Environmental** 

with Transportation

**specific facilities** 

Weather/surfaces

Cost

female)

female)

year old female)

**Pain before** 

**Pain during** 

**Pain after** 

**Impaired** 

**Co-morbid** 

**Joint swelling/**

**Muscle/joint pain** 

to arthritis are shown in bold.

**Physical Psychological/** 

**exercise** Lack of enjoyment

**exercise** Not a priority

**conditions Fear of a flare-up** 

**stiffness** Stress

**Fatigue** Feeling that 'physically

**behavioural** 

can't'

Perceived negative outcomes Perceived lack of positive outcomes **Worry about putting health at risk** 

**mobility** Lacking in skills Competing roles and

Table 1. Summary of barriers 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;). Those specific

This summary table has been created based upon our focus group research and the work of four other groups exploring barriers to exercise in patients with arthritis. Wilcox et al., (2006) conducted twelve focus groups including 68 adults with arthritis and described differences in barriers to exercise between 'exercisers' and 'non-exercisers'. Various barriers to exercise were identified, many of which were similar to those that have been described by the general population (Trost et al., 2002). However, as shown in bold in Table 1, others were unique to people with a chronic disease such as arthritis. Those patients who were already exercising indicated barriers similar to those who were not, but these did not

that patients felt they needed to exercise in order for strength, mobility, pain relief and functional benefits to occur. Example quotes are shown below:

*'I only do it [exercise] because I know it benefits me. I don't do it because I enjoy it.'* (65 year old female)

*'If you're strong where the muscles are, it helps to take the weight off the joint.'* (74 year old male)

 *'....it [the exercise] improved the pain and it improved the mobility.'* (65 year old female)

 *'I'm frightened that if I don't get up every morning, if I stay in bed it will become progressive.'* (66 year old female)

Additionally, the notion of having to exercise because it is helpful was upheld in our questionnaire study. Over two thirds of patients either agreed or strongly agreed with items relating to this theme. These items included statements such as 'Exercise helps to keep my joints moving' and 'I feel exercise relieves joint pain'.

However, it is important to note that not all patients considered exercise as advantageous and some felt that exercise is not 'helpful' as it causes pain or makes their condition worse. This is shown by the following quotes:

*'…you come back to this exercise business and you come back, exercise is painful…'* (67 year old male)

 *'I actually find if you push yourself it makes it [RA] worse.'* (56 year old female)

These negative perceptions, alongside other barriers, will be discussed in more detail throughout this chapter. Overall however, it is apparent that patients do perceive that exercise will be of benefit. Yet, if the perception that exercise as a positive feature of RA treatment is to supersede any negative connotations, continual emphasis and education of the benefits is critical (de Jong et al., 2004, Gecht et al., 1996; Neuberger et al., 2007).

#### **2.2 Barriers to exercise**

Within the general population, numerous barriers to exercise have been shown to exist (Trost et al., 2002). These barriers are broad and also affect the RA population. However, there are additional barriers that exist within the RA population, arising as a result of the local and systemic characteristics of the disease. Psychosocial aspects also make significant contribution. Concerns relating to joint health and limitations in exercise prescription are also key issues and are discussed in following sections.

Specific barriers to exercise in the RA population include musculoskeletal pain and fatigue. Medications and physical capabilities have also been highlighted as factors affecting patients' exercise behaviour, alongside complications associated with additional comorbidities. Time constraints brought about by lifestyle and other commitments are factors common to both the general and RA patient population, often further compounded by the distance necessary to travel to an exercise facility, alongside limited methods of transportation. Barriers such as a lack of enjoyment, motivation and confidence have also been identified, and especially for those on a limited income, concerns about cost and a lack of adequate insurance are also prevalent amongst non-exercisers (Gyursik et al., 2009; Hutton et al., 2010; Law et al., 2010; Neuberger et al., 2007; Shutzer & Graves, 2004; Wilcox et al., 2006). Table 1 displays a summary of these barriers, highlighting in bold those that are specific to arthritis. Examples relating to enjoyment, access and fatigue are provided here; quotes relating to pain will be provided later:

that patients felt they needed to exercise in order for strength, mobility, pain relief and

*'I only do it [exercise] because I know it benefits me. I don't do it because I enjoy it.'* (65 year old

*'If you're strong where the muscles are, it helps to take the weight off the joint.'* (74 year old male)

 *'I'm frightened that if I don't get up every morning, if I stay in bed it will become progressive.'* (66

Additionally, the notion of having to exercise because it is helpful was upheld in our questionnaire study. Over two thirds of patients either agreed or strongly agreed with items relating to this theme. These items included statements such as 'Exercise helps to keep my

However, it is important to note that not all patients considered exercise as advantageous and some felt that exercise is not 'helpful' as it causes pain or makes their condition worse.

*'…you come back to this exercise business and you come back, exercise is painful…'* (67 year old

These negative perceptions, alongside other barriers, will be discussed in more detail throughout this chapter. Overall however, it is apparent that patients do perceive that exercise will be of benefit. Yet, if the perception that exercise as a positive feature of RA treatment is to supersede any negative connotations, continual emphasis and education of

Within the general population, numerous barriers to exercise have been shown to exist (Trost et al., 2002). These barriers are broad and also affect the RA population. However, there are additional barriers that exist within the RA population, arising as a result of the local and systemic characteristics of the disease. Psychosocial aspects also make significant contribution. Concerns relating to joint health and limitations in exercise prescription are

Specific barriers to exercise in the RA population include musculoskeletal pain and fatigue. Medications and physical capabilities have also been highlighted as factors affecting patients' exercise behaviour, alongside complications associated with additional comorbidities. Time constraints brought about by lifestyle and other commitments are factors common to both the general and RA patient population, often further compounded by the distance necessary to travel to an exercise facility, alongside limited methods of transportation. Barriers such as a lack of enjoyment, motivation and confidence have also been identified, and especially for those on a limited income, concerns about cost and a lack of adequate insurance are also prevalent amongst non-exercisers (Gyursik et al., 2009; Hutton et al., 2010; Law et al., 2010; Neuberger et al., 2007; Shutzer & Graves, 2004; Wilcox et al., 2006). Table 1 displays a summary of these barriers, highlighting in bold those that are specific to arthritis. Examples relating to enjoyment, access and fatigue are provided here;

 *'I actually find if you push yourself it makes it [RA] worse.'* (56 year old female)

the benefits is critical (de Jong et al., 2004, Gecht et al., 1996; Neuberger et al., 2007).

 *'....it [the exercise] improved the pain and it improved the mobility.'* (65 year old female)

functional benefits to occur. Example quotes are shown below:

joints moving' and 'I feel exercise relieves joint pain'.

also key issues and are discussed in following sections.

quotes relating to pain will be provided later:

This is shown by the following quotes:

**2.2 Barriers to exercise** 

female)

male)

year old female)

*'Even on days when I do have time, I think I'd rather be doing something else'* (65 year old female)

*'You want something there [somewhere to exercise], something you can access easily.'* (58 year old female)

*'...you get very tired with this. Sometimes in a week you might feel exhausted, doing nothing'.* (46 year old female)


Table 1. Summary of barriers 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;). Those specific to arthritis are shown in bold.

This summary table has been created based upon our focus group research and the work of four other groups exploring barriers to exercise in patients with arthritis. Wilcox et al., (2006) conducted twelve focus groups including 68 adults with arthritis and described differences in barriers to exercise between 'exercisers' and 'non-exercisers'. Various barriers to exercise were identified, many of which were similar to those that have been described by the general population (Trost et al., 2002). However, as shown in bold in Table 1, others were unique to people with a chronic disease such as arthritis. Those patients who were already exercising indicated barriers similar to those who were not, but these did not

et al., 2006; Gyursik et al., 2009; Hutton et al., 2010; Wilcox et al., 2006;). The negative influence of pain on patients' exercise behaviour was also described during our focus groups, forming the theme '**Not wanting to exercise as joints hurt'.** This was discussed in terms of disease-related pain before, during and after exercise. Example quotes are shown

*'There's only one word that affects my exercise behaviour and that's pain.'* (66 year old female)  *'I mean you can't exercise if you are in pain can you. You can't really do anything.'* (57 year old

This patient described how she felt in terms of her RA in the days after exercising:

indicated in our focus group research, as shown by the following quote:

 *'Immediately it would ache for a bit, then ease off and then the day after, it would still be, I know that* 

An interesting contrast is also provided with regards to this theme, with some patients (especially those who had previously been involved in exercise), suggesting that they would continue exercising even if it was painful as they felt it was *'worth the risk'* (69 year old male). Furthermore and as previously mentioned, perceptions indicating that patients have experienced feelings of reduced pain have been noted (Wilcox et al., 2006). This was also

*best way to relieve pain is to do something and it [exercise] seems to soothe it and it goes away.'* 

As became clear in our focus group study, it is evident that patients with RA have concerns about the effects of exercise on joint health. Empirical evidence from a randomised controlled trial investigating the effects of a 2 year, high-intensity exercise programme also brought attention to this issue (de Jong & Vliet Vlieland, 2005). Whilst there was no evidence of further damage to the small joints of the hands and feet (de Jong et al., 2003), radiological evidence from a subgroup of exercisers indicated accelerated progression in large joints which had extensive, pre-existing damage (Munneke et al., 2005). However, the authors have since retracted this conclusion after a follow-up study at eighteen months was not able to confirm this trend (de Jong et al., 2009). Nonetheless, apprehension felt by patients in our focus groups regarding joint damage as a consequence of exercise was reflected in the theme

As highlighted in the following quotes, it also became clear that previous damage and pain

*'You can do all the exercises out, it won't affect what's at the back of your head saying, if I do that,* 

*'…if you do something and it's that painful, it must be doing your joints some damage.'* (66 year

**'Worry about causing harm to joints'**. The dialogue below provides an example:

*'The worry is whether you are damaging yourself really.'* (66 year old male)

*will I do any damage to what's already been damaged?'* (67 year old male)

*'Am I going to be worse as a result of it?'* (73 year old male) *'That's a significant anxiety for me.'* (66 year old male)

 *'…if it hurts you don't want to move.'* (46 year old female)

*was what aggravated it.'* (40 year old female)

below:

female)

*'*…

(67 year old male)

*'Yeah.'* (44 year old female)

provoked additional concern:

old female)

prevent them from exercising. This was mainly because they felt able to make modifications and accommodate physical limitations.

Research by der Anian et al., (2006) also investigated barriers to exercise amongst individuals with arthritis and included a subgroup of patients who were defined as 'insufficiently active'. These patients felt that they could not perform any more exercise because of their pain and because they did not know which exercises were safe or appropriate to do. In addition, they appeared to lack the knowledge necessary to modify exercise routines. It was also more common for these 'insufficiently active' individuals to express the need for more detailed advice.

The Obstacles to Action study (New Zealand) (Hutton et al., 2010) used a questionnaire to investigate factors influencing exercise participation for individuals with self-reported arthritis. These authors also compared participants defined as 'active' with those who were 'insufficiently active'. Arthritis, fatigue, and discomfort were ranked by both groups as the top three barriers. Further confirming the findings by Wilcox et al., (2006), the active participants reported significantly lower impact scores for these barriers than the inactive group, with these findings persisting after adjustments for occupational status, body mass index, and co-morbidities. They also revealed that active people with arthritis believed more strongly in the benefits of physical activity, reported significantly higher levels of encouragement from others, and had greater overall levels of self-efficacy when compared with the less active participants.

Gyursik et al., (2009) used a web-based survey to explore the frequency of barrier occurrence and extent of limitation brought about by barriers to exercise. Arthritis-specific personal barriers such as pain (reported by 50% of the sample) and fatigue (reported by nearly 40% of the sample), were more commonly reported than generic barriers (e.g. lack of time, bad weather). Interestingly, barrier frequency did not predict physical activity, further suggesting that it is the individual perception of the impact of the particular barriers and the ability to overcome these that is important. Coping strategies, such as thinking about the disease-specific health benefits and activity modification, were also reported in this study.

The barriers to exercise that exist in the general population also affect individuals with RA. However, our qualitative research highlighted further barriers specific to this patient group, including those relating to joint health, limited exercise prescription and pain. Similar to that of previous researchers, it appears that those patients who were attendees of a specialised exercise class perceived these barriers to exercise as less of a hindrance (Law et al., 2010). Nevertheless, and especially for those patients with no prior exercise experience, methods of overcoming these barriers are essential to ascertain and implement. This will be discussed in later sections.

### **2.3 Perceptions relating to exercise and joint health**

RA is often associated with impaired joint health, including joint inflammation, pain and damage, and it appears that these physical manifestations create additional barriers to exercise for RA patients. Corresponding with this, the perception that exercise may have detrimental effects on joint health has been found to exist in many patients with RA (Law et al., 2010). In particular, joint pain has been highlighted as a definitive barrier and has also been perceived as a prominent factor in determining patients' exercise behaviour (der Anian

prevent them from exercising. This was mainly because they felt able to make modifications

Research by der Anian et al., (2006) also investigated barriers to exercise amongst individuals with arthritis and included a subgroup of patients who were defined as 'insufficiently active'. These patients felt that they could not perform any more exercise because of their pain and because they did not know which exercises were safe or appropriate to do. In addition, they appeared to lack the knowledge necessary to modify exercise routines. It was also more common for these 'insufficiently active' individuals to

The Obstacles to Action study (New Zealand) (Hutton et al., 2010) used a questionnaire to investigate factors influencing exercise participation for individuals with self-reported arthritis. These authors also compared participants defined as 'active' with those who were 'insufficiently active'. Arthritis, fatigue, and discomfort were ranked by both groups as the top three barriers. Further confirming the findings by Wilcox et al., (2006), the active participants reported significantly lower impact scores for these barriers than the inactive group, with these findings persisting after adjustments for occupational status, body mass index, and co-morbidities. They also revealed that active people with arthritis believed more strongly in the benefits of physical activity, reported significantly higher levels of encouragement from others, and had greater overall levels of self-efficacy when compared

Gyursik et al., (2009) used a web-based survey to explore the frequency of barrier occurrence and extent of limitation brought about by barriers to exercise. Arthritis-specific personal barriers such as pain (reported by 50% of the sample) and fatigue (reported by nearly 40% of the sample), were more commonly reported than generic barriers (e.g. lack of time, bad weather). Interestingly, barrier frequency did not predict physical activity, further suggesting that it is the individual perception of the impact of the particular barriers and the ability to overcome these that is important. Coping strategies, such as thinking about the disease-specific health benefits and activity modification, were also

The barriers to exercise that exist in the general population also affect individuals with RA. However, our qualitative research highlighted further barriers specific to this patient group, including those relating to joint health, limited exercise prescription and pain. Similar to that of previous researchers, it appears that those patients who were attendees of a specialised exercise class perceived these barriers to exercise as less of a hindrance (Law et al., 2010). Nevertheless, and especially for those patients with no prior exercise experience, methods of overcoming these barriers are essential to ascertain and implement. This will be discussed in

RA is often associated with impaired joint health, including joint inflammation, pain and damage, and it appears that these physical manifestations create additional barriers to exercise for RA patients. Corresponding with this, the perception that exercise may have detrimental effects on joint health has been found to exist in many patients with RA (Law et al., 2010). In particular, joint pain has been highlighted as a definitive barrier and has also been perceived as a prominent factor in determining patients' exercise behaviour (der Anian

and accommodate physical limitations.

express the need for more detailed advice.

with the less active participants.

reported in this study.

later sections.

**2.3 Perceptions relating to exercise and joint health** 

et al., 2006; Gyursik et al., 2009; Hutton et al., 2010; Wilcox et al., 2006;). The negative influence of pain on patients' exercise behaviour was also described during our focus groups, forming the theme '**Not wanting to exercise as joints hurt'.** This was discussed in terms of disease-related pain before, during and after exercise. Example quotes are shown below:

*'There's only one word that affects my exercise behaviour and that's pain.'* (66 year old female)

 *'I mean you can't exercise if you are in pain can you. You can't really do anything.'* (57 year old female)

 *'…if it hurts you don't want to move.'* (46 year old female)

This patient described how she felt in terms of her RA in the days after exercising:

 *'Immediately it would ache for a bit, then ease off and then the day after, it would still be, I know that was what aggravated it.'* (40 year old female)

An interesting contrast is also provided with regards to this theme, with some patients (especially those who had previously been involved in exercise), suggesting that they would continue exercising even if it was painful as they felt it was *'worth the risk'* (69 year old male). Furthermore and as previously mentioned, perceptions indicating that patients have experienced feelings of reduced pain have been noted (Wilcox et al., 2006). This was also indicated in our focus group research, as shown by the following quote:

*'*…*best way to relieve pain is to do something and it [exercise] seems to soothe it and it goes away.'*  (67 year old male)

As became clear in our focus group study, it is evident that patients with RA have concerns about the effects of exercise on joint health. Empirical evidence from a randomised controlled trial investigating the effects of a 2 year, high-intensity exercise programme also brought attention to this issue (de Jong & Vliet Vlieland, 2005). Whilst there was no evidence of further damage to the small joints of the hands and feet (de Jong et al., 2003), radiological evidence from a subgroup of exercisers indicated accelerated progression in large joints which had extensive, pre-existing damage (Munneke et al., 2005). However, the authors have since retracted this conclusion after a follow-up study at eighteen months was not able to confirm this trend (de Jong et al., 2009). Nonetheless, apprehension felt by patients in our focus groups regarding joint damage as a consequence of exercise was reflected in the theme **'Worry about causing harm to joints'**. The dialogue below provides an example:

*'The worry is whether you are damaging yourself really.'* (66 year old male)

*'Yeah.'* (44 year old female)

*'Am I going to be worse as a result of it?'* (73 year old male)

*'That's a significant anxiety for me.'* (66 year old male)

As highlighted in the following quotes, it also became clear that previous damage and pain provoked additional concern:

*'You can do all the exercises out, it won't affect what's at the back of your head saying, if I do that, will I do any damage to what's already been damaged?'* (67 year old male)

*'…if you do something and it's that painful, it must be doing your joints some damage.'* (66 year old female)

*'It's difficult to know where to draw the line between 'oh for goodness sake, give it a bit of effort'…or* 

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

Furthermore, repetitive, impact-based exercise and pain provoked additional concern as

*'….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

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

*'…if I do that sort of thing and I get pain, I can go on doing it, now my next question [to a health* 

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

*'you know this is harmful, it's time to stop.'* (57 year old female)

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

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

be attainable for at least half of their patient group.

health. These views are demonstrated in the following extract:

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

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

*professional] is am I doing myself harm if I get pain?* (66 year old male)

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

female)

shown in the quotes below:

*'...mmmm'* (73 year old male) *'Yeah'* (44 year old female)

'*Nobody knows'* (66 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; Law et al., 2010). This is demonstrated by the quote below:

*'...it helps to keep them lubricated doesn't it. It helps keep you moving, exercise. If you don't they seize up...'* (65 year old female)

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 effects for joint health or disease activity.
