No matter what setting you work in, we’re all well acquainted with rheumatoid arthritis (RA). Osteoarthritis’ sluttier cousin that likes to get around to several joints versus just one or two choice locations. Due to the widespread inflammation and its secondary effects, patients with RA are more at risk for comorbidities. Cardiovascular disease, diabetes, and congestive heart failure are some just to name a few. Patients with RA also have trouble participating in regular physical activity due to their widespread joint pain. This only puts them at more risk for secondary conditions. Given this, it begs the question – What exercise may work for RA patients to help improve their cardiorespiratory and physical fitness?
A study by Annelie Bilberg and colleagues may have at least one solution for us – high intensity interval training (HIIT). Read on to learn what they found out in the newest research highlight.
Annelie Bilberg ,Kaisa Mannerkorpi, Mats Borjesson, Sara Svedlund, Jenny Sivertsson, Eva Klingberg, Jan Bjersing
The Run Down
A quick summary on what they did in this study. The researchers took 87 patients (mostly female) and randomly assigned them to one of two groups. The first group was treated for 12 weeks using HIIT, supervised strength training, and non-supervised aerobic exercise. Table 1 of the article as A VERY detailed protocol of this. The second group only received education and recommendations on moderate intensity exercise which they also completed for 12 weeks.
The primary outcome measure was VO2max, but the researchers looked at several other secondary measures. These included O2 pulse, 1 min STS test, handgrip strength, waist circumference, patient-rated overall health (VAS), pain (VAS), and changes in symptoms (Patient Global Impression of Change (PGIC) questionnaires).
I hadn’t heard of the PGIC questionnaire before reading this article, but to be honest it’s one I may start using. The questionnaire asks patients to rate if their condition has worsened or improved since a certain period of time. For example, since they started PT. Or in the case of this research, since they started their 12-week program (HIIT or general activity). Here’s an example of what one might look like.
Definitely useful for the clinic! If we take a look at the results, we’ll find it was pretty useful for this study too.
Results of the Study
The authors found a significant improvement in the VO2 max of the HIIT group. This was the primary outcome of the study, but as stated before they looked at several secondary outcomes. The group treated with HIIT also saw improvements in waist circumference, overall health rating, hand grip strength, 1 minute STS test, and PGIC rating.
Key Takeaways
The researchers found some good results, but there’s plenty of other food for thought here. You may notice the HIIT exercise group did NOT have any changes in overall pain. Some may look at that as a big L for this study, but I would disagree.
Yes it would be ideal for several reasons if the HIIT group had decreased pain. What they found was NO change in pain. So while HIIT didn’t make it better, it also didn’t make it worse. Many patients suffering from chronic joint pain want to be able to exercise. However, they’re scared to because they’re not sure what they’ll tolerate. The fact there was no change in pain says something about the likelihood RA patients will tolerate this kind of exercise and hopefully be able to keep it up long-term.
This makes us wonder if HIIT may be a good option for patients suffering from similar musculoskeletal pain and conditions. Could HIIT be beneficial for things like OA or fibromyalgia? Anyone seen any good research for HIIT with these populations? I’d be interested to read it so share in the comments section or DM me on Instagram @the_pt_page.
One thing I had mixed feelings on in this study was the fact that the control group had a very hands-off approach compared to the treatment group. The treatment group had guided HIIT and strength training. All the control group got was some general education on recommended exercise guidelines.
The reason I didn’t like this is it made me wonder what the results would have been if the control group would have at least had guided strength training. To me that would have been a more fair comparison. Yes, people reported adhering to the exercise guidelines but subjective reports can be wildly inaccurate. You like to think the difference was the HIIT training for the sake of the study, but is it possible the difference was just the face-to-face time with PTs?
And for this reason, I love it! I’m not sure if it was intentional, but they demonstrated the need for skilled PT visits in order to get results. The treatment group having better outcomes than the control would lead one to think the routine PT is a big part of this as well. Obviously, I’m conflicted on this. What do you think? Do you think it’s good that the control group didn’t regularly see a PT to demo the need for our skill or do you think it cheapened the results too much? Drop your opinion in the comments.
One thing I definitely didn’t have mixed feelings about that I LOVED about this study is its investigation of utilizing preventative PT. While many of their outcomes were strength, function, pain, etc – all the things we like to measure as PTs, it wasn’t their main reason or purpose.
In the beginning of the article the authors clearly state patients with RA are more at risk for secondary cardiovascular conditions. That’s why VO2max was the primary outcome. They wanted to have a measurable number to indicate how useful HIIT may be in PREVENTING those secondary conditions. If you read the blog post I wrote about the possibility of preventative PT then you know this is how I dream of PT being used. So I love that they took this approach to the study.
Now the biggest question when it comes to any research. How do we implement it? The results of this study are fairly straightforward since HIIT is pretty easy to use. It doesn’t require any wild or expensive equipment and the patient can even implement it outside the clinic.
This study used a stationary bike for their HIIT exercise, but this could change depending on the patient. You could use nustep, elliptical, or even no equipment at all. Walking or jogging at different paces is a form of HIIT. The biggest thing is keeping intensity up high enough in order to be therapeutic. The researchers used 90-95% of HRmax for their high intensity intervals and 70% HRmax for the recovery periods. If you need a reminder, HRmax is found by using this formula:
220 – Age = HRmax.
Thanks to smart watch technology, once patients know their HR max, us or they themselves can easily keep track of target heart rate during HIIT.
If the patient doesn’t have a smart watch they can use RPE when outside the clinic. I do think some education would be needed here from the PT during in-person sessions. The PT would need to ask for the patient’s RPE during HIIT and then educate the patient on the goal of reproducing this intensity on their own. For example, if in the clinic during the HIIT they rate RPE around a 7/10, they’d want to be at least a 7 when they did it on their own. There is some information on corresponding HRmax to the Borg RPE, however I find the Borg tends to confuse patients versus the simple 0-10 scale.
Bottom line, HIIT is at least worth considering when treating patients with RA. It may be useful for other inflammatory conditions as well! Do you use HIIT in your PT practice? What do you think about the results of this study? What else have you found helpful when treating patients with RA? Drop it in the comments! I hope you enjoyed this research highlight! Have a research article you’d like to see discussed on The PT Page? Message me using the contact page or DM me on Instagram @the_pt_page. Don’t forget to subscribe below to get all new blog posts directly to your inbox and stay up to date on all things PT!
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