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Background
Rheumatoid Arthritis Rheumatoid Arthritis (RA) is one of the most costly chronic inflammatory auto immune disease in which is characterised by joint swelling, stiffness, and severe pain which results in a severe disability and in some cases deformity of the joint. The inflammation mainly affects synovial membranes of multiple joints in which causes that severe pain and deformity generally resulting is a decreased quality of life1. Rheumatoid Arthritis has affected more than three million Australians where 50% of the risk for the development of it is attributable to genetic factors. The disorder is known to affect mostly women (17.7% women compared with males at 11.8%)2 and the elderly3. Those with Rheumatoid Arthritis suffer from sarcopenia (loss of muscle and reduced muscular strength) resulting in damage to the musculoskeletal system, with increased energy expenditure for the individual3.

Treatments
When it comes to treatment, unfortunately there is no cure for RA. It is however it can be managed and is suggested that a rehabilitative approach may be useful in reversing the loss of muscle and strength, in which a structured exercise program may offer an effective method of successfully achieving this4. Research has looked into the effects of strength and endurance training in patients with RA3

Exercise as a treatment
There is evidence to suggest that a combined strength training and endurance training regime can be seen as an effective treatment option. The evidence was published in the study conducted by Strasser, B Et al3. The study was published in 2011 in the Journal of the International League of Associations for Rheumatology and is a quantitative simple randomised study, which is one of the most powerful tools in clinical research5. The study investigated the effects of combined strength and endurance training on disease activity and functional ability as well as investigated the benefits of a six month program on muscle strength, cardiorespiratory fitness and body composition with RA patients3.

Method
The study involved forty patients with diagnosed Rheumatoid Arthritis between the ages on 41-73 who were recruited from the Rheumatology Unit at Wilhelminen Hospital, Vienna. The duration of the patients symptoms were greater than two years at the beginning of the study and all patients received stable drug therapy during the preceding three months and all patients continued their current medications throughout the study.

Twenty patients (19 females, one male) underwent the 6 month training program and twenty patients (17 females and three males) served as the control group. Before commencing the study, each patient was clinically examined by a rheumatologist to assess their clinical status (functional ability, cardiorespiratory fitness and maximum muscle strength), anthropometric measurements were also obtained for baseline measures.

The participants were to complete 2 strength training session (non consecutive days) a week. A brief 10 minute warm up consisting of stretching exercises was to be completed at the beginning of each session

Weeks 1 to 2 of the strength training program the weight was kept low in order for the patients to learn appropriate technique of the exercises and to prevent muscle soreness, any joint pain and to allow their muscles to adapt to the new training program. From week 3, the main goal was to achieve hypertrophy where 2 sets of exercises per muscle group were completed each week. Repetitions were kept between 10 -15 (equivalent to 70% 1RM). Training load was monitored for each individual and adapted to keep within the rep range (maintaining progressive overload). Every 6 weeks the number of sets for each muscle group was increased from 2 through to 4 at the end of the program. All strength training programs were individualised and consisted of exercises in which targeted major muscle groups.

The endurance training was conducted on a cycle ergometer. For weeks 1-4 patients were to complete 2 sessions of ET training a week for 15 minutes each session. From week 5 the time was increased by 5 minutes every 4 weeks. Heart rate was continuously monitored throughout each session. The total time spent training per week during the last 4 weeks was 80 minutes.

The patients who completed the combined strength and endurance training were compared to 20 patients control patients who were instructed to complete 2 sessions a week of stretching, but no exercise intervention.

The methodology was an effective way of measuring the changed in the two groups, as the only different between them was the structured program. Each group were able to continue normal medications and any other normal daily activities therefore any differences in the groups would be as a result of the program.

Basic results
After the 6 month combined strength and endurance training program the patients in the group showed improvements in: -	Pain (p=0.05) -	General health (30% increase, p=0.04) -	Maximum workload (10% increase) -	Cardiorespiratory endurance -	Weight (1.6kg average, p=0.01) -	Body fat (8.2% decrease, p=0.02) -	Functional capacity (16% increase)

The research has not over emphasised the findings in anyway as it goes on to discuss that patients who suffer from RA start with an unconditioned status, therefore more general adaptations will occur in these individuals as they are initially untrained and progress is influenced by baseline damage.

What conclusions should be taken away from this research
When is comes to RA patients, decreased muscle strength is a major important factor and is considered a major impairment among patients with RA so it seems reasonable to advise both cardio-respiratory fitness as well as muscle strength programs to these patients. The strength training component improves muscle strength due to better synchronisation and the endurance training improves capillarisation of the heart and skeletal muscles by increasing the absolute number of capillaries and the capillary density. This study, along with other reviewed studies reported no negative outcomes with the use of the combined program

Implications of this research
The implications of this research was there were a limited number of participants involved with a lack of a follow up period.

This research has shown that combined strength and endurance training could be an effective intervention strategy to help manage RA. Although in order for this to be successful, patients would need to commit to a training regime and any expenses that may come with that (memberships and fees). Patients would also need to work closely with their rheumatologist and qualified health professionals to ensure an individualised program is designed and technique is appropriate for that particular patient

Further Information
http://www.arthritisaustralia.com.au/