Introduction
Rheumatoid arthritis (RA) is characterized by symptoms that can interfere with regular engagement in exercise and physical activity (PA). PA is defined as any bodily movement produced by skeletal muscles that requires energy expenditure, whereas exercise is a subgroup of PA that includes planned, structured and repetitive activities, which aims to improve or maintain one or more components of physical fitness [
1]. In addition to well-known health benefits on aerobic capacity and cardiovascular health [
2,
3], PA has also been shown to reduce pain and fatigue and improve physical function and quality of life in patients with RA [
2,
4‐
7]. However, the literature also shows that a majority of patients with RA are physically inactive, i.e., fewer meeting PA recommendations compared to the general population [
8]. Barriers involve fear of joint damage, pain, fatigue and lack of knowledge that PA may in fact improve symptoms [
9]. However, a recent review argued that a significant barrier may be that patients lack specific and adequate guidance from health professionals (HPRs) [
10]. This is supported by a cross-sectional study [
11] demonstrating that only 49% of 1061 Swedish patients with RA recalled having discussions on PA and exercise in the rheumatology clinic. Still, HPRs in rheumatology believe that PA is important for patients and an important aspect to discuss, although they also experience uncertainty about the specific guidance [
12]. If receiving guidance from HPRs has an influence on motivation and engagement in PA in patients with RA, it seems obvious that this should be an integral part of rheumatology clinic. While the literature offers perspectives on PA guidance from the HPRs’ point of view, the patient perspective on this remains largely unexplored. Thus, to improve a possible integration of PA guidance as part of rheumatology clinic, the present study aimed to explore daily PA levels and perspectives on the current and future PA guidance from HPRs in patients with RA.
Discussion
The purpose of this qualitative study was to explore daily PA levels and perspectives on clinic-based PA guidance in patients with RA. Our analysis revealed that patients may need to accept their arthritis as part of life before adjusting PA levels to new physical capabilities. It was apparent that integrating PA and daily movement into everyday life was more natural for those participants considering PA as an inherent value. Central barriers to engaging in PA were related to the arthritis and to co-morbidities. Finally, the analysis suggested that PA guidance in the rheumatology clinic was often a low-prioritized and rather inconsistent subject in the consultations. The participants called for PA guidance to be an integrated part of the rheumatology clinic, preferably a certain time after diagnosis, as an individually tailored continuing service with the same nurse throughout.
Our results depict several aspects in the lives of patients with RA that influence the patients’ daily PA behaviours. In the following we address some of the identified barriers. It is well-established knowledge that PA levels decrease after being diagnosed with arthritis, and patients report lack of motivation, fatigue, pain and functional limitations as barriers to PA and exercise [
9,
21,
22]. This is supported by our study. However, a notable finding in our study was how acceptance of the arthritis was described as a significant mental step in performing and matching activities to new capabilities. The patients, who had struggled to come to terms with the arthritis diagnosis, described how they had fought to retain the same life roles and activities up to 9 years after diagnosis, and often had failed in this attempt. This is in line with an earlier qualitative interview study exploring disease acceptance in patients with RA [
23]. Here, a five-stage acceptance process was introduced, including a ‘resistance phase’, where patients would be reluctant to accept the imposed limitations on daily activities, keep on doing the same activities, and in many cases give up on it. The process [
23] also includes an ‘integration phase’, in which patients would begin using practical strategies to change daily routines to respect new limitations. This is in accordance with our findings, where patients explained how they had accepted the need to adjust their exercise and PA habits to the capability of their muscles, joints and mental well-being. As such, if acceptance of the arthritis plays a major role in PA and exercise behaviour in patients with RA, identifying whether the patient has reached some sort of acceptance of life circumstances may need to be considered by HPRs in promoting PA in patients.
Another potential barrier we need to address is the lack of consistent PA guidance from HPRs. No participants in our study described PA guidance as part of a standard offer in the rheumatology clinic. Rather, the topics of PA and exercise were addressed sporadically and mostly as per request from the individual patient. Noteworthy, it was the younger part of our participants, who requested information and discussions about lifestyle, including PA, with the rheumatology HPRs. This implies that in future PA guidance HPRs should be particularly attentive to the older group of patients and take the initiative to inquire about PA. The lack of systematic PA guidance was also reported by patients with inflammatory arthritis from the United States in a cross-sectional study, where only few respondents reported that exercise recommendations were addressed by HPRs [
21]. In our study, the participants experienced the quality of the guidance as varied; from feeling supported and met with competent advice to a more insecure and deficient guidance from the HPRs. Insecurity especially arose in relation to the specific PA recommendations for patients with arthritis or to the safety of joints during high-intensity exercise. From the HPR’s point of view, similar uncertainties were indicated by rheumatologists, nurses and physiotherapists in a Dutch cross-sectional study about general attitudes towards PA and guiding patients with RA [
24]. Here, more than half of the HPRs expressed a need for further education on the promotion of PA [
24], which is in line with other evidence documenting lack of knowledge and confidence in PA promotion, and thus, educational needs among rheumatology HPRs [
25,
26]. For instance, while 52% of physiotherapists from a recent cross-sectional study reported advising patients with RA to engage in PA, up to 62% never recommended the appropriate PA guidelines [
26]. As such, and supported by a recent review about PA promotion in RA [
10], an essential barrier to engaging in PA and exercise in patients with RA, may be the lack of consistent and specific directions from HPRs. However, as indicated in the recent review [
10] and in the present study, sufficient PA guidance may not only be a matter of providing patients with knowledge about general PA recommendations and the health benefits of engaging in PA. Most patients with RA understand the health benefits but may need validation of their PA behaviour and specific guidance from HPRs regarding frequency, intensity and types of activities matching their individual needs.
In continuation, participants in our study gave us insight into their specific wishes and preferences for PA guidance in the future. Overall, the participants acknowledged that addressing PA and exercise should be integrated as part of treatment in rheumatology clinic. Furthermore, they suggested to tailor the PA promotion to the life circumstances of the individual patient, as a continuing service with the same nurse over time. Though, we need to acknowledge that the preference for a continuing, individually tailored service was especially expressed by those of our participants who had lived with and managed RA for over 10 years. There may be different needs among patients who have been recently diagnosed. The specific suggestions from study participants are integrated in a current implementation of individual PA guidance in four rheumatology outpatient clinics in the Capital Region of Denmark. In addition to results from our own research [
13,
14], this implementation effort is based on accumulated evidence of PA and exercise on health benefits in patients with inflammatory arthritis [
3], and is inspired by a proposed implementation model for facilitating long-term sustainability of PA in patients with RA [
27]. The model includes training of HPRs to deliver brief PA advising during routine patient visits based on specific guidelines and current PA recommendations [
27]. As such, supporting HPRs to embed PA guidance in rheumatology clinic may be an important approach in reducing physical inactivity and promoting health in patients with inflammatory arthritis [
28]. This is not a new notion in the rheumatology community. In light of the vast evidence on PA and inflammatory arthritis and suggested frameworks for implementation, a recent editorial from
Rheumatology Advances in Practice (2023) stated that ‘it is time to push the change’ to optimize the delivery and use of PA as an efficient management strategy in rheumatic diseases [
29].
Addressing some methodological considerations of our findings is needed. First, there are several strengths. The study examines the patient perspective on current practitioner-led PA guidance through qualitative methods, which ensured rich and deepened descriptions of patient experiences. In addition, the study included a national sample of patients with RA from five Danish rheumatology outpatient clinics, which strengthens the transferability of our findings. Another strength is the research team’s combined background covering both a MD, a physiotherapist, a nurse and an occupational therapist with extensive clinical and research experience in medical treatment, disability, PA and self-management in rheumatology. This allowed for nuanced interpretations of data.
Second, there are important limitations that must be acknowledged as well. Although we initially instructed nurses in the rheumatology outpatient clinics about the inclusion criteria (age, education, smoking status, PA levels, co-morbidities), we cannot be certain how these criteria were interpreted in the actual clinics. Thus, the sample may not be that varied as aimed for. For instance, the sample includes a higher proportion of participants with a relatively low educational level. Another limitation related to selection and inclusion of participants is that the nurses, who informed and invited patients to the study may have invited those patients with whom they had the best communication and contact. Linked to this notion, we recognized many descriptions during data analysis that were related to the value of a good contact with the rheumatology nurse. A final limitation is that 14 of 20 interviews were conducted as a telephone interview including an inability to observe body language and facial expressions. In addition, we did not test the interview guide before the first interview.
In conclusion, this qualitative study expands our understanding of motivation and barriers of engaging in PA and exercise in patients with RA. The study also gives insight into current experiences and wishes for future PA promotion in the rheumatology clinic from a patient perspective. Patients specified that PA guidelines are not used consistently in rheumatology clinic and HPRs seem to lack knowledge of the central concepts and recommendations for PA in patients with RA. This calls for further efforts for improving and implementing PA as part of rheumatology clinic, including building up capacities in HPRs. It is time to push the change indeed!
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