Bilberg (2005) Moderately intensive exercise in a temperate pool for patients with rheumatoid arthritis- a randomized controlled study.

Background: Increased physical activity is associated with better physical andmental well-being. In postmenopausal women, land-based exercise has a modesteffect on bone strength which is predominantly reflected in the spatial distribution(geometry) of bone mineral at the skeletal sites targeted by the exercise. However, the risks and benefits of exercise for women with osteoporotic vertebralfracture (VFs) who are at high risk for future fracture are not known. Women withestablished osteoporosis may prefer exercising in water where compressiveloads are reduced. However, it is not known if the reduced compressive loadingis detrimental to bone health. Also contributing to this evidence gap is the limitedmethods available for measuring vertebral bone geometry which may beexpected to respond to exercises targeting the trunk. Bone geometry can bemeasured using computed tomography scans but this involves exposure to asubstantial dose of radiation. Semi-automated analyses of dual energy X-rayabsorptiometry (DXA) vertebral fracture assessment (VFA) scans providemeasures of vertebral height (VH); however, the measurement properties of thisoutcome have not been established. Measures of mechanical bone strength andvolumetric density also provide insight into bone adaptations to exercise. Noresearch has yet investigated the effect of exercising in water on bone geometryin women with osteoporotic VFs.

Purpose: The overall purpose of this thesis was to investigate methods ofmeasuring bone geometry in women with osteoporotic VFs that could be used ina future clinical trial to determine the effect of water exercises on bone in womenwith VFs. The first objective was to determine the relative and absolute intra-raterreliability of VHs in postmenopausal women with and without VFs. In the secondstudy, protocols for recruitment of postmenopausal women with osteoporotic VFsfor a 6 month water exercise intervention and protocols for assessing proposedoutcome measures were piloted to determine the recruitment, adherence to theintervention, adherence to the assessment protocol, safety of the intervention andassessment and retention.

Methods: To address the first objective, DXA VFA scans were acquired for 32women [mean (SD) age 70(7)] and analyzed on 2 occasions, 4 weeks apart, by asingle rater using a predetermined protocol. Semi-automated software derivedmeasures of anterior, middle, and posterior VH. Intra-rater relative reliability wasestimated using the intraclass correlation coefficient (ICC) with 95% confidenceintervals (95% CI). Absolute reliability was estimated using standard error ofmeasurement (SEM) with 95% CI. To address the second objective, women 60years and older with one or more VF were recruited through two osteoporosisclinics and poster advertisements over two months. Feasibility of recruitment wassummarized using the CONSORT flow diagram. Adherence to the six monthcommunity-based aquatic exercise program (74 sessions) was evaluated bypercentage of sessions attended. Adherence to the assessment protocol wasevaluated based on the number of data points lost. The safety was assessedbased on the occurrence of adverse events that were documented as major andminor. Retention was assessed as number of participants returning for follow-up.

Results: DXA-based VH intra-rater reliability could be estimated from T9 to L4,with reduced visibility from T4 to T8. The ICCs were > 0.80 and the SEM wasless than 1.17 mm for all VH except for the posterior aspect of T9 (ICC = 0.62(0.15, 0.84), SEM = 0.92 mm). For the feasibility study, 10 participants wererecruited in 10 weeks by expanding the inclusion criteria. The average adherenceto the intervention was 68%. No measures of VH were obtained for twoparticipants. Movement during acquisition and unanticipated protocol changesresulted in loss of 46% of pQCT scans and 10% of physical performancemeasurement data. There was one major adverse event (fracture). Retention was100% at 6 months and 89% at 12 months.Conclusion: Intra-rater reliability was acceptable for VH between T10 and L4.Further study is needed to assess other measurement properties of DXA-basedVH measures and to identify methods for assessing more proximal vertebrallevels. Further study is needed to determine feasible protocols for recruitmentand assessment of outcome measures. Screening tests for falls risk and protocolfor implementing suitable safety precautions are recommended.

Rheumatology 2005;44:502508 doi:10.1093rheumatologykeh528
Advance Access publication 22 February 2005
Moderately intensive exercise in a temperate pool for
patients with rheumatoid arthritis: a randomized
controlled study
A. Bilberg, M. Ahlme
n1and K. Mannerkorpi1
Objectives.The aim of this study was to evaluate the effects of moderately intensive pool exercise therapy on patients with
rheumatoid arthritis (RA).
Methods.Forty-six patients with chronic RA were randomly assigned to a treatment group and a control group. The treatment
group (n20) exercised in a temperate pool twice a week for 12 weeks. The control group (n23) continued with their
previous activities. Aerobic capacity, measured by means of a submaximum bicycle test, and the physical component of the
SF-36 were chosen as the primary outcome measures. Two tests of muscle endurance were chosen as the secondary outcome
measure. Additional functional tests and instruments were included.
Results.No signicant differences between the groups were found for the primary outcome measures. Signicant improvements
in the following aspects of muscular function (P0.05) were found in the treatment group when their performance was
compared with that of the control group: isometric shoulder endurance, grip force, dynamic endurance of lower extremities
(chair test) and muscle function of lower extremities. Signicant improvements were also found for vitality (SF-36) compared
with the control group. The improvements in the training group were maintained for 3 months.
Conclusions. Pool exercise therapy of moderate intensity signicantly improved muscle endurance in the upper and lower
extremities in patients with RA, while no impact on aerobic capacity was found. However, the study population was small and
there is a need for further studies with larger populations.
KEY WORDS:Pool exercise training, Rheumatoid arthritis, Physical therapy, Aerobic capacity, Muscle endurance, SF-36, Function.
Rheumatoid arthritis (RA) is a chronic syndrome characterized
by non-specic, symmetric inammation of the peripheral joints,
potentially resulting in the progressive destruction of articular and
peri-articular structures, with or without generalized manifesta-
tions 14. The clinical picture of RA is dominated by pain,
fatigue, stiffness, reduced range of motion in the joints and muscle
weakness. A combination of these symptoms, together with
deterioration in physical condition, often leads to difculty in the
activities of daily living and poor quality of life 5.
A reduced level of physical performance has been found to be
associated with RA. Patients with RA have been shown to have
reduced muscle strength 6, 7 and aerobic capacity 69. A
reduction in muscle strength and endurance can be due to several
factors, such as the intra-articular and extra-articular inamma-
tory process, side-effects of medication, inactivity, reex inhibition
due to pain and joint swelling, reduced proprioception and the loss
of mechanical stability around the joint. However, studies indicate
that patients with RA engaging in physical exercise can improve
their physical ability, aerobic endurance and muscle strength
without worsening the inammatory process 10, 11. Several
studies have documented improvements in aerobic capacity 1214
and one study reported a reduction in disease activity after an
exercise period 15.
Exercise in a temperate pool is a common mode of treatment for
patients with RA. Physical properties such as buoyancy and
temperature facilitate training in water 16 and reduce a subjective
feeling of stiffness and the load on the joints. Patients with RAparticipating in pool exercise usually say that their function
improves during a treatment period, but only two randomized,
controlled studies evaluating the effects for patients with RA were
found 17, 18. A signicant reduction in joint tenderness after
intervention was found in one of these studies 17, while an
improvement in active joint count and erythrocyte sedimentation
rate (ESR) was found in the other 18. Two uncontrolled studies
reported improvements in grip strength, physical activity 19 and
muscle strength 20. It has been suggested that patient-relevant
outcome measures should also be applied in further studies 21, 22.
The purpose of this study was to evaluate the effects of pool
exercise on patients with RA. We hypothesized that pool exercise
for 3 months would improve their aerobic capacity, functional
ability and perception of physical health.
Patients and methods
Patients
A total of 91 patients with RA 23 at the Department of
Rheumatology at Sahlgrenska University Hospital in Go
teborg
were invited by mail and 47 patients (42 women and ve men)
accepted. They all fullled the criteria for inclusion and were
included in the study. The criteria for inclusion were: duration of
RA ranging from 1 to 5 yr, stable medication for the past 3 months,
functional class I, II or III 8 and age ranging between 20
Correspondence to: A. Bilberg, Department of Physical Therapy, Sahlgrenska University Hospital, Go
teborg, SE-413 45 Go
teborg, Sweden. E-mail:
Annelie.Bilberg@vgregion.se
Department of Physical Therapy, Sahlgrenska University Hospital and1Department of Rheumatology and Inammation Research, Sahlgrenska Academy,
Go
teborg University, Go
teborg, Sweden.
Submitted 27 May 2004; revised version accepted 19 November 2004.
Rheumatology Vol. 44 No. 4British Society for Rheumatology 2005; all rights reserved 502

and 65 yr. The criteria for exclusion were other severe diseases or
functional limitations that would make pool training impossible.
The patients were randomly assigned 24 to the training group
or the control group using optimal allocation with a computer
programme for a minimization procedure to balance for the
background variables age, disease duration, DAS 28 and aerobic
capacity. All the patients were asked to maintain the type and
dosage of pre-entry medication and not to start any other
treatment (pool exercise or strength training), as far as was
ethically possible during the study period. The study was approved
by the ethics committee at the Sahlgrenska Academy, Go
teborg
University. Written and oral information was given to all the
patients, but no informed consent was required at that time and
thus was not obtained for this study.
Treatment programme
The treatment group exercised twice a week for 12 weeks in groups
of eight or nine patients in a temperate pool. Each session was
45 min long and of moderate aerobic intensity. It comprised
exercises for aerobic capacity, dynamic (eccentric and concentric)
and static muscle strength, and muscle endurance in the upper
and lower extremities, exibility, coordination and relaxation. The
pace of the exercises was guided by music. The sessions were led by
two alternating physiotherapists, who gave individual instructions
to each patient if needed. The mean attendance rate at the sessions
was 78%. The patients in the control group continued their daily
activities, which included the home exercise programme introduced
to them on admission to the clinic. Two patients in the training
group and two in the control group dropped out, one before the
start of the study and the other after seven pool sessions. The
reasons for dropping out were lack of time due to commitments
relating to work. Two patients in the control group started
exercising in other pool groups and were excluded. As a result,
20 patients in the training group and 23 in the control group
completed the study. The median age of the patients was 49 yr
(range 3262 in the training group) and 46 yr (range 2165) in the
control group. The mean duration was 31 months (
S.D. 15.8) and
35 months (S.D. 17.1) respectively. Only one patient in the study
population consulted a physiotherapist during the study period,
because of knee pain.
Outcome measures
A physiotherapist blinded to group membership during the whole
study conducted the examinations. Aerobic capacity, estimated
using a submaximum ergometer cycle 25, and the physical
component of the SF-36 26 were chosen as the primary outcome
measures. Two tests of muscle endurance, one for the lower
extremities and another for the upper extremities, were chosen
as the secondary outcome measurements; they were the chair test
and the shoulder endurance test 27, 28. Additional functional
tests assessing limitations in the upper and lower extremities
were included, as well as self-administered generic and disease-
specic instruments assessing quality of life, disease activity and
disabilities.
The outcome measurements were applied at baseline and
directly at post-treatment for the training patients (3 months)
and after the control period (3 months) for the control patients.
The patients in the training group were also followed up 6 months
after the start of the study.
Self-administered instruments
The SF-36 26 is a generic, multidimensional, health status
instrument comprising eight subscales ranging from 0 to 100.
The instrument gives an index for a physical component and amental component. The SF-36 has been validated for Swedish
populations 29.
The Arthritis Impact Measurement Scales (AIMS 2) 30 is a
multidimensional health status instrument designed for patients
with arthritis. The instrument comprises 12 subscales ranging from
0 to 10. The physical dimension, including the subscales of
mobility, physical activity, dexterity, household activity, activities
of daily living and pain, was applied. The AIMS 2 has been
validated for Swedish arthritis patients 31.
The Health Assessment Questionnaire (HAQ) 32 is a disease-
specic instrument that measures disability with scores ranging
from 0 to 3. The instrument possesses satisfactory reliability and
validity and sensitivity to change in long-term studies for patients
with RA 33.
Performance-based tests and clinical investigation
The performance-based tests used in this study have been shown
to possess satisfactory reliability in arthritis populations 25, 27,
28, 3438 and they are described in the order in which they were
performed.
Aerobic capacity was estimated by means of a submaximum
test according to A
strands principle 25. An ergometric bicycle
(Monark) was used. The heart rate was measured using Polar
Electro Oy, Kempele, Finland. The examiner recorded the patients
heart rate once a minute. The patient estimated his or her exertion
using Borgs exertion scale 39.
Active forward and lateral elevation of the shoulder were
recorded in degrees using a universal full-circle goniometer 34.
Functional arm movementshand to neck and hand to back
27, 28were rated on a scale of 04, where 0 represented the best
and 4 the most decreased function.
Isometric endurance of the shoulder abductor muscles 27, 28
was measured as the maximum time a person was able to hold
hisher arm at 90
abduction with a 1-kg cuff attached proximally
to the wrist joint.
Muscle endurance for the lower extremities (chair test) 27, 28
was assessed by counting the maximum number of times the
patient was able to get up from a chair during 1 min.
The Index of Muscle Function (IMF) 35, 36 comprises 11 tests
for the lower extremities, including tests of muscle strength,
balance, coordination and endurance. The IMF ranges from 0 to
40 and the highest score represents serious disability.
Hand grip force (N) 37, 38 was measured as the maximum and
mean strength using an electronic instrument (Grippit). The best
performance of three was recorded.
DAS 28 (disease activity score) 40, an index based on 28-joint
status, the ESR and the patients assessment of global health, was
used to determine RA disease activity. The examination was
conducted by a trained physiotherapist under the supervision of a
rheumatologist.
Statistical methods
Fishers non-parametric permutation test was used to compare
changes between the two groups, while Fishers non-parametric
permutation test for matched pairs was used to analyse changes
within groups over time 41. The following two null hypotheses
were tested: no changes will be found between the two groups or
over time within the groups. Fishers exact test was used to
compare proportions between the groups. In the follow-up study,
two null hypotheses were tested: no changes will be found
between the baseline and the follow-up values, or between the
post-test and the follow-up values. The signicance level was set
at 0.05. Moderately intensive pool exercise for RA patients503

Results
Baseline data
The means and standard deviations at baseline are shown in
Table 1. There were no signicant baseline differences between
the two groups in terms of age, duration of RA, disease-specic
measures, such as DAS 28, and the total HAQ score. Nor were
there any signicant baseline differences between the two groups in
the functional tests or in the self-administered instruments.
Missing values
Twenty-two patients in the control group and 19 patients in the
training group fully completed the SF-36 on both test occasions.
Twenty-one patients in the control group and 20 patients in the
training group fully completed the AIMS 2. Twenty-one patients in
the control group and 18 in the training group completed the HAQ.
All 43 patients completed the shoulder range of motion, the
functional arm movements test, the isometric endurance of the
shoulder abductor muscles test, the IMF and the hand grip force
test. Twenty-two patients in the control group and 19 in the training
group performed the bicycle test (missing data due to knee pain).
Twenty-two patients in the control group and 20 patients in the
training group performed the chair test. The data analysis was done
by protocol, implying that when data were missing for any test or
subscale for patient, these patients were removed from the analysis.
Between-group differences, 03 months
The differences between the post-treatment and baseline values are
shown in Tables 2 and 3. No signicant differences between the
groups in medication or injections occurred during the study
period. No signicant changes were found for the primary outcome
measuresthe aerobic capacity and the physical component of the
SF-36. All the secondary outcome variables, measuring muscle
endurance the chair test (P0.005), and the isometric shoulder
endurance of the left and the right arm (P0.001) increased
signicantly in the training group compared with the control
group. The maximum and mean grip strength of the left hand
(P0.001) increased signicantly in the training group compared
with the control group. The IMF score (P0.006) increasedsignicantly for the patients in the training group compared with
the control group. The active lateral shoulder elevation for the left
(P0.009) and right (P0.047) arms, and the active forward
elevation of the left arm (P0.03) increased signicantly in the
training group compared with the control group (Table 3).
Within-group differences in the training group, 03 months
Signicant within-group changes are marked with asterisks in
Tables 2 and 3. The following scores on the SF-36 improved: the
SF-36 physical function (P0.0001), bodily pain (P0.003),
vitality (P0.004) and the physical component (P0.01). The
chair test (P0.008), the AIMS 2 physical dimension (P0.007)
and the HAQ score (P0.04) also improved. The lateral elevation
of the left arm (P0.04), the shoulder endurance of the right and
left arm (P0.001), Grippit maximum force of the left side
(P0.001) and IMF score (P0.007) also improved.
Within-group differences in the control group, 03 months
Signicant within-group changes are marked with asterisks
in Tables 2 and 3.At the post-treatment examination, the
maximum (P0.04) and mean force (P0.03) in the left hand
was found to have decreased and the SF-36 bodily pain (P0.03)
had increased.
Follow-up for the training group, 06 months
The differences between the follow-up and the baseline values for
the training group are shown in Tables 4 and 5. No signicant
differences in medication or injection occurred during the period
of 6 months for the training group. For the primary outcome
measures, the aerobic capacity did not change, while the SF-36
physical component revealed signicant improvements compared
with baseline values (Table 4). The secondary outcome measures,
the chair test and the shoulder endurance test, also displayed
signicant improvements at follow-up. Moreover, 10 of the 13
functional measures had improved signicantly (P0.05) at
follow-up (shoulder forward elevation and shoulder lateral eleva-
tion for both arms, hand to neck and hand to scapula for the right
TABLE1. Demographic data at study entry
Treatment group (n20) Control group (n23)
Median Range Median Range
Age (yr) 49 (3262) 46 (2165)
Mean (
S.D.) Mean (S.D.)
RA duration (months) 31 (15.8) 35 (17.1)
DAS 28 4.1 (1.5) 4.0 (1.3)
Tender joints (n) 6 (5.2) 6 (6.0)
Swollen joints (n) 5 (3.7) 5 (14.4)
ESR (mmh) 16 (13.1) 19 (19.0)
Haemoglobin (gl) 138 (10.4) 136 (14.9)
Patient global assessment (VAS) 45.5 (25.0) 39.4 (26.6)
n(%)n(%)
Sick leave
Full time 7 (35) 3 (23)
Part time 3 (15) 9 (23)
Retirement pension 4 (20) 5 (25)
Drugs
Analgesic 13 (65) 10 (43)
DMARD 18 (75) 20 (87)
Oral steroids 3 (15) 4 (17)
504A. Bilberget al.

arm, IMF score, the Grippit maximum force for the left hand and
the Grippit mean force for both hands) (Table 5). Seven of the
eight subscales on the SF-36 showed signicant improvements
(P0.05) (physical functioning, role physical, bodily pain, social
functioning, mental health, role emotional, vitality and the mental
component). In addition, the AIMS 2 physical dimension and
the HAQ score displayed signicant improvements (Table 4).
No signicant deterioration was found for any variables when
compared with the post-treatment values (Tables 4 and 5).Discussion
The purpose of this study was to evaluate the effects of temperate
pool exercise on patients with RA. We were not able to conrm our
hypotheses that aerobic capacity and the SF-36 physical compo-
nent would improve signicantly when the training group was
compared with the control group. However, a signicant improve-
ment in the treatment group was found for all measures of muscle
endurance and exibility.
TABLE3. Functional tests at baseline and the post-test in the training and control group
Training group (n20) Control group (n23)
Baseline Post-testDifference
within
the group Baseline Post-testDifference
within
the groupDifferences
between
the groups
Mean (
S.D.) Mean (S.D.) Mean (S.D.) Mean (S.D.) Mean (S.D.) Mean (S.D.)P-value
Vo2 ml(kgmin) 34.0 (10.9) 33.8 (10.0)0.26 (5.4) 34.2 (6.7) 32.4 (7.3)1.8 (5.0) NS
Forward shoulder elevation (
)
Right 156.0 (29.8) 165.0 (26.3) 9.0 (28.8) 161.5 (25.4) 158.9 (27.2)2.6 (15.1) NS
Left 156.8 (28.7) 166.0 (19.6) 9.3 (23.7) 166.1 (19.0) 161.5 (19.8)4.6 (15.6) 0.027
Lateral shoulder elevation (
)
Right 148.8 (34.7) 160.5 (35.9) 11.8 (35.4) 159.1 (31.0) 154.4 (30.4)4.8 (14.8) 0.047
Left 142.8 (38.8) 158.5 (38.2) 15.8 (31.1)* 160.9 (28.6) 155.0 (31.9)5.9 (21.7) 0.009
Hand to neck (04)
Right 0.3 (0.5) 0.4 (0.8) 0.0 (0.7) 0.2 (0.5) 0.3 (0.7) 0.1 (0.4) NS
Left 0.2 (0.4) 0.2 (0.4)0.10 (0.45) 0.3 (0.8) 0.2 (0.5)0.09 (0.7) NS
Hand to scapula (04)
Right 0.6 (0.9) 0.2 0.6)0.4 (0.8) 0.4 (0.9) 0.4 (0.9)0.04 (0.4) NS
Left 0.6 (0.7) 0.3 (0.7)0.3 (0.6) 0.2 (0.5) 0.1 (0.5)0.1 (0.3) NS
Shoulder endurance (s)
Right 59.8 (54.1) 90.3 (52.2) 30.5 (26.0)*** 70.9 (40.4) 58.2 (35.4)12.7 (31.4) 0.001
Left 54.8 (51.6) 80.5 (54.6) 25.8 (23.6) 65.4 (34.3) 59.8 (32.4)5.7 (27.3) 0.001
IMF score 5.4 (7.3) 2.2 (3.6)3.2 (5.2)** 2.3 (2.8) 2.2 (3.5) 0.3 (2.6) 0.006
Chair test 20.6 (6.6) 23.7 (7.0) 3.2 (4.5)** 24.3 (6.4) 23.7 (62)0.7 (3.6) 0.005
Grippit, max. (N)
Right 179.0 (115.2) 181.1 (91.0) 2.1 (48.4) 178.7 (109.6) 180.7 (103.3) 2.0 (36.0) NS
Left 152.4 (106.7) 182.8 (116.7) 30.3 (34.5)*** 188.5 (105.3) 172.6 (88.4)15.9 (34.6)* 0.001
Grippit, mean (N)
Right 140.5 (96.5) 139.0 (72.7)1.6 (41.9) 145.1 (89.8) 142.0 (86.7)3.1 (30.3) NS
Left 114.3 (89.4) 142.9 (100.4) 28.6 (33.5)*** 153.6 (87.3) 137.6 (70.2)15.9 (32.8)* 0.001
Mean and
S.D. for the ratings and the differences within and between the groups are given.
*P0.05; **P0.01; ***P0.001.
TABLE2. Instruments assessing health at baseline and the post-test in the training and control group
Training group (n20) Control group (n23)
Baseline Post-testDifference within
the group Baseline Post-testDifference within
the groupDifferences between
the groups
Mean (
S.D.) Mean (S.D.) Mean (S.D.) Mean (S.D.) Mean (S.D.) Mean (S.D.)P-value
SF-36
Physical functioning 56.0 (20.9) 64.7 (20.0) 9.5 (10.6)*** 60.7 (18.8) 64.9 (21.4) 4.2 (11.8) NS
Role physical 20.2 (40.9) 39.5 (37.6) 17.1 (44.1) 48.9 (41.6) 48.9 (38.0) 0.0 (40.6) NS
Bodily pain 40.7 (21.0) 50.8 (23.4) 10.7 (15.0)** 45.9 (22.3) 50.9 (21.0) 5.0 (10.0)* NS
Social functioning 68.1 (29.1) 73.7 (22.4) 6.6 (21.8) 72.3 (23.2) 71.2 (21.1)1.1 (18.4) NS
Mental health 68.4 (23.5) 72.4 (15.9) 5.5 (19.5) 76.9 (18.6) 72.7 (16.9)3.3 (19.9) NS
Role emotional 48.3 (43.9) 69.6 (36.1) 10.5 (45.9) 60.9 (46.7) 69.6 (36.1) 8.7 (36.5) NS
Vitality 41.5 (23.9) 51.8 (22.6) 12.1 (17.6)** 51.8 (22.1) 49.1 (17.6)1.6 (18.8) 0.021
General health 46.0 (26.3) 49.8 (19.3) 6.3 (17.8) 59.8 (19.6) 59.3 (16.1)0.5 (16.0) NS
Physical component 33.0 (9.6) 37.1 (10.5) 4.8 (7.1)** 37.1 (8.9) 38.3 (9.6) 1.5 (7.5) NS
Mental component 43.1 (13.7) 45.1 (11.5) 2.8 (11.8) 47.6 (12.5) 46.2 (10.8)0.6 (12.6) NS
AIMS 2
Physical 2.6 (1.5) 2.1 (1.4)0.6 (1.0)** 2.2 (1.3) 2.1 (1.2)0.2 (0.7) NS
HAQ score 0.9 (0.5) 0.7 (0.5)0.2 (0.3)* 0.7 (0.5) 0.8 (0.6) 0.0 (0.2) 0.045
Mean and
S.D. for the ratings and the differences within and between the groups are given.
*P0.05; **P0.01; ***P0.001.
Moderately intensive pool exercise for RA patients505

The aerobic exercise part of the training programme had been
designed to achieve and maintain a target heart rate of 70% of the
maximum heart rate, which is considered to improve aerobic
capacity 25. We measured the heart rate at two training sessions
to ensure the exercise intensity. It is possible that the exercise
intensity should have been monitored more frequently to ensure
that it was maintained throughout the study period. Also, this
study population, with fairly good pretreatment aerobic capacity
(Table 3), might have needed a higher training intensity to attain
improvement in aerobic capacity. The frequency of the sessions
might have been at the lower limit to improve aerobic capacity.However, the failure to improve aerobic capacity found in this
study is in line with the results reported in a previous study of pool
exercise for patients with RA 18.
The other primary outcome measure, the physical component
index of the SF-36, revealed no signicant difference in the
between-group analyses, but it improved signicantly in the
within-group analysis of the training group. No improvements in
the primary outcome measures were found in the control group.
Both muscle endurance tests selected as secondary outcome
measures, the chair test and shoulder endurance test, revealed a
signicant improvement in the treatment group when compared
TABLE5. Functional tests at baseline and at the 6-month follow-up for the training group
n20
Baselinen18
Follow-up Difference within the group
Mean (
S.D.) Mean (S.D.) Mean (S.D.)
Vo2 ml(kgmin) 34.0 (10.9) 30.8 (10.1)2.7 (7.8)
Forward shoulder elevation (
)
Right 156.0 (29.8) 171.0 (13.1) 17.2 (28.4)*
Left 156.8 (28.7) 169.7 (22.7) 15.0 (24.7)*
Lateral shoulder elevation (
)
Right 148.8 (34.7) 168.6 (20.1) 20.6 (32.2)*
Left 142.8 (38.8) 166.1 (30.1) 22.5 (30.2)**
Hand to neck (04)
Right 0.3 (0.5) 0.0 (0.0)0.3 (0.5)*
Left 0.2 (0.4) 0.1 (0.5)0.7 (0.5)
Hand to scapula (04)
Right 0.6 (0.9) 0.1 (0.3)0.6 (0.8)*
Left 0.6 (0.7) 0.2 (0.7)0.4 (0.7)
Shoulder endurance (s)
Right 59.8 (54.1) 88.1 (59.9) 29.3 (40.2)**
Left 54.8 (51.6) 76.5 (56.0) 28.4 (39.3)*
IMF
Total score 5.4 (7.3) 2.9 (5.5)2.4 (4.0)**
Chair test 20.6 (6.6) 25.2 (6.4) 4.4 (5.3)**
Grippit, max. (N)
Right 179.0 (115.2) 190.4 (107.9) 20.2 (51.1)
Left 152.4 (106.7) 191.8 (120.8) 44.2 (42.5)***
Grippit, mean. (N)
Right 140.5 (96.5) 170.3 (121.8) 37.8 (75.6)**
Left 114.3 (89.4) 162.1 (111.1) 50.4 (63.4)***
Mean and
S.D. for the ratings and the differences in changes within the group are given.
*P0.05; **P0.01; ***P0.001.
TABLE4. Baseline and 6-month follow-up data for the generic and disease-specic instruments in the training group
n20
Baselinen18
Follow-up Difference within the group
Mean (
S.D.) Mean (S.D.) Mean (S.D.)
SF-36
Physical functioning 56.0 (20.9) 65.6 (20.5) 9.7 (14.2)*
Role physical 20.2 (40.9) 54.4 (46.1) 35.3 (46.0)**
Bodily pain 40.7 (21.0) 55.3 (18.7) 17.8 (15.7)***
Social functioning 68.1 (29.1) 82.4 (17.2) 16.2 (22.4)**
Mental health 68.4 (23.5) 77.5 (17.6) 10.2 (16.1)**
Role emotional 48.3 (43.9) 66.7 (42.5) 21.6 (37.2)*
Vitality 41.5 (23.9) 58.5 (22.1) 19.1 (19.4)***
General health 46.0 (26.3) 51.5 (22.3) 6.4 (19.0)
Physical component 33.0 (9.6) 38.4 (10.2) 6.4 (8.0)**
Mental component 43.1 (13.7) 49.0 (10.0) 6.7 (8.6)**
AIMS 2
Physical 2.6 (1.5) 1.9 (1.5)0.8 (1.3)*
HAQ
Score 0.9 (0.5) 0.7 (0.5)0.3 (0.5)*
Mean and
S.D. for the ratings and the differences within the group are given.
*P0.05; **P0.01; ***P0.001.
506A. Bilberget al.

with the control group, as did the additional endurance tests, the
Grippit and IMF. These ndings support previous reports of
increased muscle strength after pool exercise therapy in patients
with RA 10, 11, 18, 19. The results of improved endurance
in upper and lower extremities were probably produced by the
resistance exercises included in the training program comprising
both eccentric and concentric exercises for the muscles in upper
and lower extremities. Recent studies indicate that patients with
impaired muscle function can improve their muscle endurance also
by low impact programmes 42, 43.
Moreover, shoulder range of motion showed an improvement.
The between-group differences were supported by several within-
group improvements in the treatment group.
Two self-administered, disease-specic instruments (the AIMS 2
physical dimension and the HAQ), focusing on physical function,
indicated that the patients perceptions of their function improved
signicantly in the training group. The generic health instrument
(SF-36) revealed a signicant improvement in vitality for the
training group compared with the control group, which is in line
with previous pool exercise studies 44.
A follow-up study was conducted 3 months after the patients
had completed the training programme. Eighteen of the total of 20
patients in the training group participated in the follow-up
examinations. The SF-36 index physical component, one of the
primary outcome measures, revealed signicant improvements at
this follow-up, while the aerobic capacity did not, when compared
with the baseline values. Interestingly, seven of the total of eight
SF-36 subscales now showed signicant improvements in the
training group, together with the AIMS 2 physical dimension and
the total score for the HAQ. The results indicate that changes in
quality of life and disability measures may take a longer time to
attain than changes in functional tests. The measures of muscle
endurance still showed signicant improvements.
When the patients included in this study were admitted to the
clinic, they had been offered a home exercise programme
comprising range of motion and isometric muscle exercises. No
patient reported any strength or aerobic training at the inclusion
or at the end of the study period, except that the training group
reported pool training at the end of the period. At the 6 months
follow-up, nine of the total of 18 training group patients reported
habitual physical exercise being pool training (n8), twice a week,
and group training on land (n1) once a week. This might partly
explain why the health status of the patients improved during the
follow-up period.In this study, we compared the treatment group
attending the pool sessions with the control group, which
continued with their previous activities and exercise. We cannot
exclude the possibility that the interaction between the physio-
therapists and the patients in the training group during the
treatment period may have inuenced some of the outcomes, as
it is known that health can be improved as a result of both specic
and non-specic effects of treatment. These non-specic effects can
be related to a therapists attention and interaction skills andor a
patients expectations, motivation and experience of the mean-
ingfulness of the treatment 45. However, we did not monitor the
adherence of the home training programme. The dropout rate in
this study was low, as only four patients, two in the training group
and two in the control group, did not participate in the post-test
analysis. As a result, 91% of the patients in the training group
and 92% of the control group completed the study. The main
limitations of this study are the small number of patients and the
lack of a control group in the follow-up study. For ethical reasons,
no long-term control group was available at the follow-up, because
the patients initially randomized to the control group were offered
a similar treatment programme directly after they had completed
their control period.
To conclude, exercise in a temperate pool twice a week
signicantly improved muscle endurance in the upper and lower
extremities of patients with RA, while aerobic capacity did not
improve. However, studies with larger populations are neededto obtain more knowledge about the effects of pool exercise
therapy.
Acknowledgements
The statistical advisor was Nils-Gunnar Pehrsson, and Christina
Finsba
ck did the examinations. This work was supported by
grants from the Swedish Rheumatism Association and Rune and
Ulla Amlo
vs Foundation.
The authors have declared no conflicts of interest.
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