Recreational Running with Low Disease Activity Rheumatoid Arthritis
Daniel Thomas, SPT
I love almost all forms of exercise, but endurance sports have always been a passion of mine. For years, running has been an outlet for me in pursuit of competition, mental health and physical and emotional well-being. Personally, I have seen patients filled with joy when accomplishing a task of their first 5k race or even being able to run a mile. I believe human movement is a gift and has the power to transform lives. Unfortunately, running is often demonized by preconceived notions that it is dangerous and leads destruction of joints and the body. I wanted to venture out to prove this wrong.
With the assistance of Dr. Thoma, she proposed the idea of exercise in relation to rheumatoid arthritis. After having discussions with rheumatologist and patients living with rheumatoid arthritis, she discovered there is a portion of this population that is wishing to run but simply didn’t know how or where to begin. Like all autoimmune diseases, the path is not straight forward, treatment can be complex and our knowledge of diseases processes and safety can be of crucial importance in being a guide to these patient populations. Together, Dr. Thoma and I felt the melding of my passion for running and ways to navigate exercise prescription and monitoring in those living with rheumatoid arthritis deserved a spotlight.
Statement of Need
Rheumatoid arthritis is a complex, immunological condition that effects a wide age range of patients from both genders. Presently, the research for engaging in exercise for those diagnosed with rheumatoid arthritis (RA) has stagnated in the previous decade or greater. Most of the literature commonly cited for exercise and rheumatoid arthritis is prior to the year 20101–7 with limited randomized control trials published in the last 5 years on the topic.8 However, the guidelines for both the treatment of rheumatoid arthritis and recommendations for exercise has consistently changed and advanced in recent years.9–11 Thus, the evidence that we as clinicians are basing our recommendations on may be outdated, and with treatments leading to low disease activity or remission becoming more common,9 patients can likely participate in exercise feats that were historically avoided.
For running, the evidence in populations living with rheumatoid arthritis is non-existent. However, this is not to say rheumatoid arthritis patients are not approaching clinicians with questions in how, and if, they can safely engage in running related activities. In fact, this has happened, and stories of those living with rheumatoid arthritis can be found throughout media.12–15
As human movement experts, we should have the knowledge and skills to be able to help our patients safely navigate the realm of running and mitigate the risk of any possible disease progression and/or injury.
The purpose of my capstone project was twofold. One, I set out to develop a narrative review that may eventually lead to publication to fill a void in the field and spark interest for future research. With it, my goal was to create and provide an evidence-informed approach to how clinicians may guide patients living with rheumatoid arthritis in beginning a running program. Furthermore, I wanted to provide methods for how to track and monitor patient symptoms and progress for safety. Second, I created presentation and VoiceThread materials as support to be used as possible education resources for student physical therapists throughout the doctor of physical therapy curriculum. With both the VoiceThread and narrative review, I hope to improve knowledge about the integration of exercise in the treatment of patients living with rheumatoid arthritis.
In order to address health literacy, suggestions from VoiceThread presentations in order to aide in formatting my PowerPoint were included. Although the materials are intended for entry level DPT students, some of the concepts in relation to running biomechanics data or rheumatoid arthritis disease processes could be complex. I attempted to simplify wording, reduce clutter and use charts or pictures were appropriate to solidify topics.16,17 In addition, my capstone committee members provided detailed feedback for strengthening the content of my narrative review for accuracy and understanding. Weekly communication took place with my capstone advisor in which I have received feedback on refining sentence structure to create an easier reading experience for those that may view my article during potential publication.
As for the creation of the PowerPoint, my aim was to create a VoiceThread for potential use in courses throughout the curriculum. Considering my PowerPoint/presentation would not have the same back-and-forth dialog as a live presentation, I instead implemented strategies to give clear direction to the information contained in the lecture. I applied straight forward and outlined objectives to guide the learner in what to expect, and I tried to limit unnecessary background material that may not apply to the students about more complex disease processes of rheumatoid arthritis.18 Furthermore, I attempted to implement many concepts to hold the viewer’s attention, such as consistent color scheme, limiting wording on slides, considering bullet points for only important concepts, limiting unnecessary data and graphs and spell checking. I also did not include any animations as I feel they are distracting during a presentation.19 Lastly, considering my presentation has multiple different concepts in it, such as osteoarthritis and running, rheumatoid arthritis and exercise, brief background information on rheumatoid arthritis, running biomechanics, symptom monitoring and running program application, I attempted to take the main concepts that I wanted to translate to the audience and simplify each category. Although my overall presentation may be 30 slides of information, I have made each category ~5 slides or less.20 With that, I hope that my PowerPoint is effectively straight to the point and carries my message that exercise for those living with low disease activity rheumatoid arthritis can be pursued safely and running should remain an exercise option for its vast health related benefits.
Products for clinicians/professionals
Recreational Running with Low Disease Activity Rheumatoid Arthritis is a PDF version of the narrative review for hopeful publication with a full reference list provided at the end of the document.
Running with Rheumatoid Arthritis is a PDF version of the slide deck that corresponds with the VoiceThread lecture with a full reference list at the completion of the presentation.
Running with Rheumatoid Arthritis is the link to the VoiceThread presentation covering basic background and medical treatment of rheumatoid arthritis, evidence of exercise in patients living with rheumatoid arthritis, outcomes of recreational running in relation to osteoarthritis, tools for examination and symptom monitoring and an example walk-run program for integration into clinical practice.
The primary form of evaluation in the development of the narrative review was through weekly meetings with my capstone advisor, Louise Thoma, PT, DPT, PhD. Prior to meetings I would attempt to implement corrections, research topics, review articles and develop questions for weekly meetings. When applicable, I would email preliminary work prior to our meetings to allow for more detailed weekly feedback. Capstone committee members were also contacted with questions or concerns and provided feedback via email communication in which I was able to response and ask further questions. In the end, I believe all have led to a well-developed product that is more informative and richer than I dreamed.
My personal learning objectives for my capstone were to increase knowledge of injury risks with running, discover ways to mitigate potential joint injury, develop my understanding of running biomechanics for future career growth and interests, increase my comprehension of rheumatoid arthritis and safe exercise prescription, improve my knowledge on the outcomes of running with osteoarthritis or risk of development and understanding how exercise processes effect those living with rheumatoid arthritis.
Through the process of developing the narrative review Running with Low Disease Activity Rheumatoid Arthritis, I believe I have thoroughly accomplished all of these personal goals. The review evolved over time and through feedback from my committee advisor, Louise Thoma, PT, DPT, PhD and committee members, Carla Hill, PT, DPT and Jean-Francois Esculier, PT, PhD the end product is more in depth than planned. This partially was due to an early accelerated timeline in order to receive feedback from one capstone committee member prior to being unavailable due to travel. Although this created some stress, it also allowed for substantial time to research topics in greater depth throughout the semester. This allowed for considerable growth in the narrative review which became the primary focus of my capstone.
I believe through the capstone I have utilized substantial time management skills to develop the review while balancing other coursework and being a husband and father. I have also been open to feedback throughout the process as I know I have much to learn and forever room to grow. The suggestions from my capstone advisor and committee have been crucial to advancement of the written review, but also to my own personal and professional growth. They have challenged my thinking and forced reflection of how my words may be received by others. This has changed the way I think which will inherently alter the way I communicate with others in clinical practice and during my professional career.
Throughout the process, literature on exercise and rheumatoid arthritis is extremely limited which obviously complicated my efforts. However, I found the most challenging component to actually be restructuring and amending materials that I had written. I was exceptionally open to feedback, but usually when I write, I write towards completion. Receiving feedback that challenged the way I create and structure materials to improve conceptual understanding to an outside reader was a new experience to me. It is something that I will take with me into the future, as I feel it has improved my abilities as a writer. The materials I have created for this capstone have solidified my knowledge in being able to treat those that are living with rheumatoid arthritis. It is an understudied area with much light that needs to be shed upon it. I am extremely proud of the review I have created, and the ability to still create a PowerPoint for future coursework use.
To Dr. Louise Thomas, PT, DPT, PhD: Your expertise helped shape and mold the final product that everyone now sees before them, and you offered tremendous guidance. However, I think this can be said of professors and capstone committee members on all projects. Where I really want to thank you is for challenging me, being supportive, open, honest and forcing self-reflection. You have foster tremendous personal and professional growth in me over such as short few months. I will carry what you have taught me and passed on for the remainder of my career and life. For that, I can’t thank you enough. Thank you for being an inspiration.
To Dr. Jean-Francois Esculier, PT, PhD: You opened my eyes to the vastness of biomechanical knowledge that is out there in relation to human movement and running. Several topics you shared throughout the course of this experience have strengthened my knowledge on subjects that are deep passions of mine and have sparked interest in considering where my future professional trajectory should aim. The strength of the final product has such depth and clinical application because of your insight, and I would not have been able to produce such a rich educational tool without you. Thank you.
To Dr. Carla Hill, PT, DPT: Your clinical experience and insight shown through every time you provided feedback. Your advice on use of language consistently made me aware of my words. I am still not perfect, but even in writing, I try to think always about the patient first and not their condition. Your influence will transpire through my future clinical practice, and I strongly believe that I will influence others causing a ripple effect over the years to come. Therefore, beyond the development of the paper and presentation laid before everyone, I must thank you for the personal growth you have encouraged.
- Munneke M, de Jong Z, Zwinderman AH, et al. Effect of a high-intensity weight-bearing exercise program on radiologic damage progression of the large joints in subgroups of patients with rheumatoid arthritis. Arthritis Rheum. 2005;53(3):410-417. doi:10.1002/art.21165
- Häkkinen A, Sokka T, Lietsalmi A-M, Kautiainen H, Hannonen P. Effects of dynamic strength training on physical function, Valpar 9 work sample test, and working capacity in patients with recent-onset rheumatoid arthritis. Arthritis Rheum. 2003;49(1):71-77. doi:10.1002/art.10902
- Häkkinen A, Sokka T, Kotaniemi A, Hannonen P. A randomized two-year study of the effects of dynamic strength training on muscle strength, disease activity, functional capacity, and bone mineral density in early rheumatoid arthritis. Arthritis Rheum. 2001;44(3):515-522. doi:10.1002/1529-0131(200103)44:3<515::AID-ANR98>3.0.CO;2-5
- Lemmey AB, Marcora SM, Chester K, Wilson S, Casanova F, Maddison PJ. Effects of high-intensity resistance training in patients with rheumatoid arthritis: a randomized controlled trial. Arthritis Rheum. 2009;61(12):1726-1734. doi:10.1002/art.24891
- Flint-Wagner HG, Lisse J, Lohman TG, et al. Assessment of a sixteen-week training program on strength, pain, and function in rheumatoid arthritis patients. J Clin Rheumatol. 2009;15(4):165-171. doi:10.1097/RHU.0b013e318190f95f
- Hurkmans E, van der Giesen FJ, Vliet Vlieland TP, Schoones J, Van den Ende ECHM. Dynamic exercise programs (aerobic capacity and/or muscle strength training) in patients with rheumatoid arthritis. Cochrane Database Syst Rev. 2009;(4):CD006853. doi:10.1002/14651858.CD006853.pub2
- van den Ende CH, Hazes JM, le Cessie S, et al. Comparison of high and low intensity training in well controlled rheumatoid arthritis. Results of a randomised clinical trial. Ann Rheum Dis. 1996;55(11):798-805. doi:10.1136/ard.55.11.798
- Lourenzi FM, Jones A, Pereira DF, Santos JHCAD, Furtado RNV, Natour J. Effectiveness of an overall progressive resistance strength program for improving the functional capacity of patients with rheumatoid arthritis: a randomized controlled trial. Clin Rehabil. 2017;31(11):1482-1491. doi:10.1177/0269215517698732
- Aletaha D, Smolen JS. Diagnosis and management of rheumatoid arthritis: A review. JAMA. 2018;320(13):1360-1372. doi:10.1001/jama.2018.13103
- Singh JA, Saag KG, Bridges SL, et al. 2015 american college of rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Rheumatol. 2016;68(1):1-26. doi:10.1002/art.39480
- Fraenkel L, Bathon JM, England BR, et al. 2021 american college of rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken). 2021;73(7):924-939. doi:10.1002/acr.24596
- Taking the Long Way Home: Running with RA. Accessed April 16, 2022. https://www.takinglongwayhome.com/p/running-with-ra.html
- Marathon Runner Manages Rheumatoid Arthritis – Sharp Health News. Accessed April 16, 2022. https://www.sharp.com/health-news/overcoming-obstacles-1-mile-at-a-time.cfm
- Can I Run with Rheumatoid Arthritis? | Runner’s World. Accessed April 16, 2022. https://www.runnersworld.com/health-injuries/a20844331/can-i-run-with-rheumatoid-arthritis/
- Levine H. “It’s my church”: 3 women with chronic pain on the unlikely activity that helps relieve it. Yahoo.com. May 28, 2018. Accessed April 16, 2022. https://www.yahoo.com/now/3-women-share-dont-let-joint-pain-stiffness-stop-running-definitely-serves-therapy-church-100002199.html
- McCulloch, PT, PhD, MS, FAPTA, NCS(E) K. Health Literacy – Sample Patient Brochure. Presented at the: Health Literacy- Sample Patient Brochure; March 11, 2022; Online VoiceThread.
- McCulloch, PT, PhD, MS, FAPTA, NCS(E) K. Health Literacy 101: Defining the Problem and What We Can Do About It. Presented at the: Health Literacy Basic Concepts; February 5, 2022; Online VoiceThread.
- Plack PT EdD M, Driscoll PhD PT M. Teaching and Learning in Physical Therapy: From Classroom to Clinic. 1st ed. Slack Incorporated; 2011:288.
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