Development of a safe, effective and accessible physical activity intervention for people with rheumatoid arthritis

This thesis focuses on physical activity among people with Rheumatoid Arthritis (PwRA). Despite proposed functional benefits, adherence to regular physical activity remains difficult for PwRA. There have been few systematic approaches investigating types of physical activity that would be most feasible for PwRA, and the frequency and duration of physical activity that would be acceptable. The first part of this thesis comprised a systematic review which revealed that previous randomised controlled trials (RCTs) of physical activity interventions for PwRA have investigated supervised rather than independent exercise regimes. Furthermore, there were no indications of what aspect of such programs (whether it be the duration or type of training) resulted in significant changes to self-report and observer measured functional outcome measures. No previous RCT has investigated walking as a physical activity intervention for PwRA, and walking is therefore the primary focus of this thesis. Walking is a low cost and low impact (to the joints) activity requiring little supervision or specialist training, and is inherently a clinically meaningful outcome measure of independence. In line with the UK Medical Research Council (MRC) framework for developing complex interventions, a qualitative study with eight PwRA was first conducted to investigate what might be acceptable for frequency and type of exercise, and to identify barriers and facilitators to exercise. Based on these results, safe and enjoyable walking routes were identified, developed, and tested by healthy adult volunteers (n=17). Thirty three PwRA were then recruited from a rheumatology outpatient clinic into a RCT feasibility study. Participants were randomly allocated to intervention (n=11) or control group (n=22). Participants in the control group received an attention-matched nutrition information session, and those in the intervention group were asked to use the walking route three to four times a week. Both groups were tested at baseline and 6 weeks later for functional measures of walking speed, score for a timed step up test, and patient recorded functional measures of disability, quality of life, self-efficacy for physical activity, daily pedometer readings, and daily pain (secondary outcomes). There were no adverse effects (significant increase in pain) for participants across the intervention group. There was a positive trend towards higher self-efficacy for physical activity and improved quality of life in the treatment group compared to the control group. However, these changes did not reach statistical significance, but indicate the sample size required to power future RCTs. Walking appears to be a feasible and acceptable intervention for a PwRA; however, a major consideration for future trials would be to tailor level of walking route difficulty to the ability of each participant