Its not that often that a paper comes along that changes my practice but this particular one will. I have known for a number of years that Rheumatoid Arthritis patients are at risk of muscle loss due to the systemic nature of the inflammatory process this is similar to Diabetics and other conditions. This paper provides more detail and I will outline that as well as the change to practice I propose in this blog.
Mike and I also recorded a longer podcast on the subject!
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The paper in question (reference at the bottom of the page) was interesting and clever in its design. The numbers used were quite small but then it was quite a logistical undertaking with each patient. The researchers split them into groups, newly diagnosed RA, active RA, remission RA and controls. The definitions of these don’t really matter for our purposes and are self explanatory.
The researchers measured strength of knee extension, knee flexion and grip. They also used quantitative MRI to look at muscle bulk in the groups. The aim was to find out if there were between group differences.
This is particularly interesting because I suspect many outside the sphere of Rheumatology think RA is purely a joint related problem and the results of this paper highlight the widespread systemic nature of the disease. We need to think much more broadly as therapists to treat multiple areas of concern. Joint disease and muscle strength will affect function, further afield RA affects the cardiovascular system and we need to consider this in our treatment plans and referrals.
The researchers showed (admittedly with the small numbers) that muscle volume and strength was lower than controls in all the categories. This was lower than controls even in the New RA group suggesting this process begins very early into disease.
Muscle volume and strength does improve once in clinical remission however does not reach the levels of the controls.
Clinical relevance for Therapists
Muscle volume and strength can be the domain of Therapists to improve and may well be a necessity as clinical remission is not sufficient enough to return these measures to normal. I would advise that ALL RA patients regardless of disease activity receive a personalised exercise/loading/activity program to help address these likely deficits.
Further to this ALL people suspected of having RA (and I would add any inflammatory arthritis) should be encouraged to maintain activity as far as able to limit the loss of muscle volume and strength and / or have a concurrent referral for an exercise/loading/activity program while awaiting diagnosis to try and get ahead of the curve.
It might also be appropriate to discuss protein intake as a way of mitigating muscle volume and strength loss this can be done by the Therapist if they are confident or by appropriate referral.
It may be argued that this is excessive but I would disagree. I don’t believe it would take much resources to implement and maintaining or even increasing muscle volume could have a significant effect on many health and functional outcomes.
I hope similar studies are conducted in this fashion. One where they compare those who went through an exercise program and those that didn’t would be awesome if there are any researchers reading this…
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Matthew Farrow, John Biglands, Steven Tanner, Elizabeth M A Hensor, Maya H Buch, Paul Emery, Ai Lyn Tan, Muscle deterioration due to rheumatoid arthritis: assessment by quantitative MRI and strength testing, Rheumatology, , keaa364, https://doi.org/10.1093/rheumatology/keaa364