CRITICALLY APPRAISED PAPER (CAP) Breedland, I., Scheppingen, C. V., Leijsma, M., Verheij-Jansen, N. P., & Weert, E. V. (2011). Effects of a group-based exercise and educational program on physical performance and disease self-management in rheumatoid arthritis: A randomized controlled study. Physical Therapy, 91(6), 879 893. https://doi.org/10.2522/ptj.20090010 CLINICAL BOTTOM LINE Studies have shown that most people with rheumatoid arthritis (RA) tend to live a sedentary lifestyle and avoid physical activity because of their fear of pain exacerbation. This article revealed that creating an effective group therapy program, led by a multidisciplinary team, can positively affect individuals with RA. Helping individuals with chronic diseases manage their symptoms and engage in meaningful activities may lead to improved functional abilities and greater quality of life. In particular, this physical activity program significantly increased the aerobic capacity of the individuals who received the treatment, compared with those who did not. Increasing individuals aerobic capacity may also lead to an increase in their activity tolerance, which promotes their engagement in physical activity. In this way, occupational therapists can aid individuals with RA by helping them to participate in meaningful occupations. In addition to the intensive exercise program, the study intervention included an educational portion that addressed disease self-management. Although the results were not significant in the area of increased health status or self-efficacy levels, practitioners should consider including patients education on the importance of engaging in physical activity to increase patients knowledge of disease self-management. Because of the small number of participants, this study lacked the power to support any positive changes in muscle strength, self-management, and self-efficacy among patients with RA. However, the within-group positive changes in the intervention group indicate the potential for group therapy programs to positively affect patients with RA. RESEARCH OBJECTIVE(S) Examine the effects of a group-based exercise and educational program on aerobic capacity, muscle strength, self-reported health status, and self-efficacy among people with RA 1
DESIGN TYPE AND LEVEL OF EVIDENCE Level I: Randomized controlled trial PARTICIPANT SELECTION Participants were referred by a rheumatologist if they had complaints about their physical performance or if they had difficulties managing their illness. INCLUSION CRITERIA Medical diagnosis of RA (according to the American College of Rheumatology criteria) Living independently at home Age 18 66 years EXCLUSION CRITERIA Living in a nursing home Severe disease activity (Disease Activity Score > 5.1) Cardiac or pulmonary disease resulting in restrictions to participating in a physical exercise program Steinbrocker classification of functional capacity >3 No stable medication for the RA Intra-articular injections during the time of the study PARTICIPANT CHARACTERISTICS N= (Number of participants taking part in the study) 34 #/ (%) Male 10/(29.4%) #/ (%) Female 24/(70.6%) Ethnicity NR Disease/disability diagnosis Rheumatoid arthritis with 9.7 years mean duration of RA (SD = 14) for intervention group 5.9 years mean duration of RA (SD = 7.2) for waiting list control group INTERVENTION(S) AND CONTROL GROUPS Group 1: Intervention group Brief description of the intervention The FIT program intervention was a multidisciplinary group rehabilitation program consisting of a physical exercise portion and an educational portion. Physical exercise portion: muscle exercise circuit and bicycle training (once a week; 60 minutes), sports (once a week; 60 2
How many participants in the group? Where did the intervention take place? 19 minutes), and aqua jogging (twice a week; 30 minutes) Educational portion: A multidisciplinary team led a group discussion on how to manage symptoms of RA during weekly education sessions. Each specialist provided professional advice and knowledge on how to cope with the symptoms of RA, and patients were instructed to monitor their daily activities at home, with follow-up discussion in the following week. The primary goal of the educational portion was to increase participants knowledge of various aspects of their disease. Outpatient setting at the rehabilitation center of the University Medical Center Groningen Who Delivered? All physical exercises were supervised by physical therapists experienced in guiding patients with RA. A psychologist, physical therapist, occupational therapist, dietitian, and social worker facilitated the educational portion. How often? For how long? Exercise = 3 hours/week, 2 separate days Education = 1 hour/week, 1 day 8 weeks Group 2: Waiting list control group Brief description of the intervention How many participants in the group? Where did the intervention take place? Who Delivered? How often? For how long? No intervention was given during the study period, but participants were allowed to enter the FIT program once the study was completed. 15 8 weeks Intervention Biases: Check yes, no, or NR and explain, if needed. Contamination: Contamination was not addressed. The study did not report whether the control group was monitored or whether they were told not to engage in an exercise program. 3
Co-intervention: The study did not report whether the intervention group was directed not to exercise outside of the intervention sessions. Timing: NO Site: NO The site remained consistent and was described as an outpatient setting at the rehabilitation center of the University Medical Center Groningen. Use of different therapists to provide intervention: Although the therapists were described briefly, it was not made clear whether the same therapists conducted the interventions over the 8- week period. Physical therapists supervised the exercise portion, and a psychologist, physical therapist, occupational therapist, dietitian, and social worker supervised the educational portion of the interventions. The authors did not report which therapists conducted the outcome measures. MEASURES AND OUTCOMES Complete for each measure relevant to occupational therapy: Measure 1: Muscle strength Name/type of Handheld dynamometer (Microfet) Maximal voluntary isometric muscle strength of the elbow flexors, elbow extensors, knee flexors, and knee extensors YES YES To measure the amount of isometric muscle strength an individual is able to generate. Clinicians may use this tool to document and record the progress of their clients and to guide their treatment plans. 4
Measure 2: Aerobic capacity Name/type of Measure 3: Self-reported health status Name/type of Cycle ergometer Astrand-Rhyming ergometry test Maximum oxygen uptake (Vo 2 max, in ml/min/kg) YES YES This measure is the standard index used to measure cardiorespiratory fitness. Dutch version of the Arthritis Impact Measurement Scales 2 (Dutch AIMS2) Five dimensions of health status: physical functioning, psychological functioning, symptoms, social interaction, and role functioning YES YES Self-administered, used specifically for individuals with arthritis to record their perceived level of health Measure 4: Self-efficacy questionnaires Name/type of Dutch version of the Arthritis Self-Efficacy Scale Three subscales of self-efficacy: Self-Efficacy Pain, Self-Efficacy Function, and Self-Efficacy Other Symptoms YES YES To measure patients beliefs and attitudes about how they perform specific tasks or behaviors to cope with the consequences of their arthritis Measurement Biases: Check yes or no, and include a brief explanation Were the evaluators blind to treatment status? Check yes, no, or NR, and if no, explain. Recall or memory bias. Check yes, no, or NR, and if yes, explain. 5
YES A recall or memory bias could have occurred, because the selfefficacy scale asked the participants to recall how they previously performed. Others (list and explain): RESULTS List key findings based on study objectives Include statistical significance where appropriate (p<0.05) Include effect size if reported The significance level for all statistical tests was set at p <.05. There were highly significant differences in change of aerobic capacity in the intervention group, compared with the control group (Mann Whitney U test; p =.002). No significant differences were found in change for upper extremity muscle strength between the intervention and control groups. However, the intervention group showed within-group improvements in upper extremity strength over time, improving by 5.1%. The effect size of 0.15 indicates a trivial change. There were no significant differences in change for lower extremity muscle strength between the intervention and control groups. The intervention group showed within-group improvements in lower extremity strength over time, improving by 12.9%. The effect size of 0.43 indicates small positive change. There were no significant differences in change of self-reported health status: Effect size for physical health = 0.60; moderately positive change in the intervention group (a lower score indicates better health on the Dutch AIMS-2 manual) Effect size for psychological health = 0.20; small positive change in the intervention group (a lower score indicates better health on the Dutch AIMS-2 manual) Effect size for social interaction = 0.29 for the intervention group and 0.49 for the control group; small positive change for both groups (a lower score indicates better health on the Dutch AIMS-2 manual) There were no significant differences in change of self-efficacy. Effect size for self-efficacy pain = 0.46; small positive change in intervention group (a higher score indicates greater self-efficacy on the Dutch ASES manual) Effect size for self-efficacy function = 0.37; small positive change for intervention group (a higher score indicates greater self-efficacy on the Dutch ASES manual) Was this study adequately powered (large enough to show a difference)? Check yes, no, or NR, and if no, explain. NO The small number of participants in both the intervention group (n = 19) and the control group (n = 15) might have affected the lack of power in this study. A post hoc power analysis revealed that a group of 57 participants would be needed to yield a power of.8. 6
Were appropriate analytic methods used? Check yes, no, or NR, and if no, explain. YES Were statistics appropriately reported (in written or table format)? Check yes or no, and if no, explain. YES Was the percent/number of subjects/participants who dropped out of the study reported? YES Limitations: What are the overall study limitations? The main limitation of this study was the lack of power because of the small number of participants. CONCLUSIONS State the authors conclusions related to the research objectives. The authors hypothesis was partially confirmed. The FIT program produced significant improvements in aerobic capacity but no significant improvements in muscle strength, selfreported health status, or self-efficacy among patients with RA. Further studies should be conducted with a larger sample size to address the lack of power and to confirm the small effect sizes. This work is based on the evidence-based literature review completed by Grace Yi, OTS, and Colleen Maher, OTD, OTR/L, CHT, faculty advisor, University of the Sciences. CAP Worksheet adapted from Critical Review Form Quantitative Studies. Copyright 1998 by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, & M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: www.copyright.com 7