The European League Against Rheumatism (EULAR) has issued their 2018 recommendations for physical activity in patients with inflammatory arthritis and osteoarthritis (OA), emphasizing that physical activity should be an integral component of standard care throughout the course of these diseases. The recommendations were published in the Annals of the Rheumatic Diseases.

To create the guidelines, the researchers followed the EULAR standardized operating procedures for the development of recommendations. A task force consisting of rheumatologists, other medical specialists, physicians, health professionals, patient representatives, and methodologists from 16 countries met twice. During the first meeting, the task force identified and defined 13 research questions to support a systematic literature review. During the second meeting, the task force presented the evidence from the review and then formulated recommendations, research agenda, and education agenda.

The task force developed and agreed on 4 overarching principles and 10 recommendations for physical activity in people with inflammatory arthritis and OA.

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The 4 overarching principles are:

  • Physical activity is part of a larger system to optimize health-related quality of life.
  • Physical activity is beneficial to the health of patients with rheumatoid arthritis (RA), spondyloarthritis (SpA), hip OA, and knee OA.
  • General recommendations for physical activity including cardiorespiratory fitness, muscle strength, flexibility, and neuromotor performance are feasible and safe for patients with RA, OA, and SpA.
  • Healthcare providers and patients with RA, SpA, hip OA, and knee OA must work together to make decisions regarding physical activity, taking the patient’s preferences, capabilities, and resources into account.

A summary of the task force’s recommendations is as follows:

  • Encouraging physical activity for patients with RA, SpA, hip OA, and knee OA consistent with general physical activity recommendations is an integral part of care throughout the course of disease (strength of recommendation: A).
  • All clinicians should encourage physical activity in patients with RA, SpA, hip OA, knee OA, including making referrals (strength of recommendation: D).
  • Physical activity interventions should only be made by clinicians who are competent in their delivery to individuals with inflammatory arthritis and OA (strength of recommendation: D).
  • Clinicians should evaluate the type, intensity, frequency, and duration of a patient’s physical activity in order to identify what can be targeted for improvement (strength of recommendation: C).
  • Clinicians should take general and disease-specific contraindications for physical activity into account (strength of recommendation: D).
  • Physical activity interventions should have clear, personalized goals that should be evaluated over time through a combination of objective and subjective measures (strength of recommendation: D).
  • Clinicians and patients should identify and address general and disease-specific barriers to and facilitators for physical activity (strength of recommendation: C).
  • If a patient needs individual adaptations of general physical activity recommendations they should be based on an assessment of physical, social, and psychological factors (strength of recommendation: D).
  • Clinicians should plan and deliver physical activity interventions that include self-monitoring, goal setting, action planning, feedback, and problem solving (strength of recommendation: A).
  • Clinicians should consider different ways of delivering physical activity interventions to meet patient preferences (strength of recommendation: D).

In addition to the guidelines, the task force developed research and education agendas for physical activity in patients with inflammatory arthritis and OA.

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The research agenda includes 13 items:

  1. Evaluate long-term efficacy of physical activity of various intensity and types while monitoring adverse events.
  2. Evaluate links between physical activity and disease-specific outcomes.
  3. Evaluate the long-term efficacy of reducing sedentary behavior while monitoring adverse events.
  4. Evaluate links between sedentary behavior and disease-specific outcomes.
  5. Identify physical activity interventions that most effectively increase physical activity level and adherence in various patient subgroups.
  6. Identify markers of response and non-response to physical activity.
  7. Identify disease-specific contraindications for different exercise domains.
  8. Further develop and evaluate strategies to reduce and monitor changes in sedentary behavior.
  9. Develop physical activity interventions with a focus on feasibility that target all exercise dimensions.
  10. Evaluate and recommend physical activity assessments feasible for use in clinical practice.
  11. Study how to change physical activity behavior immediately after screening and how to address facilitators and barriers.
  12. Identify clinician barriers of applying physical activity recommendations.
  13. Perform long-term effectiveness trials on combined interventions that include other health behaviors.

The education agenda includes 6 items:

  1. Increase clinician and patient knowledge about physical activity.
  2. Increase clinicians’ skills in communicating the role of physical activity for the management of general health and disease-specific issues.
  3. Include knowledge and skills on physical activity promotion in undergraduate curricula for clinicians.
  4. Develop a EULAR training module on physical activity for clinicians and rheumatologists.
  5. Propose a session on physical activity at every EULAR congress.
  6. Develop educational materials for patients with inflammatory arthritis and OA.

“It is a clear ambition to implement these recommendations into daily clinical routine,” the researchers wrote. “Due to [different health systems], development and evaluation of target group and culture-specific implementation strategies are needed and should involve all stakeholders.”

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Osthoff AR, Niedermann K, Braun J, et al. 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis [published online July 11, 2018]. Ann Rheum Dis. doi:10.1136/ annrheumdis-2018-213585