Abstract
Objective To describe levels of physical activity (PA) in older adults with rheumatic and musculoskeletal diseases (RMDs) and study the association between PA level and patient-reported outcomes.
Methods Using data from FORWARD, a cross-sectional analysis was performed among adults aged 65 years and older with RMDs to assess the levels of PA. PA was categorized as high (vigorously active for at least 30 minutes, 3 times per week), moderate (moderately active for at least 3 times per week) or low (seldom active). We assessed the self-reported levels of PA among patients with different types of RMDs and assessed the association between levels of PA and PROs, including the 29-item Patient Reported Outcomes Measurement Information System (PROMIS-29) assessment.
Results Among the 3343 eligible participants, rheumatoid arthritis (68%) was the most common RMD. High PA was reported by 457 (13.6%) participants, and 1820 (54.4%) reported moderate activity. Overall, participants reported a median of 7 (IQR 0-15) days of moderate to vigorous level of PA for ≥ 30 min per month. Obese participants were significantly more likely to report low levels of activity (44% of obese compared to 25% of nonobese individuals). Participants with low PA levels had higher (worse) pain scores, higher (worse) Health Assessment Questionnaire–Disability Index scores, higher depression rates, and worse PROMIS-29 scores related to pain, sleep and fatigue.
Conclusion Among patients with RMDs, levels of high PA were relatively low among older patients. These observations, though descriptive, support a relationship between physical inactivity and obesity, depression, poor sleep, and fatigue in patients with RMDs.
Physical activity (PA) offers primary, secondary, and tertiary prevention of several chronic conditions, such as hypertension, obesity, and cardiovascular disease. Regular PA can extend years of active independent living, reduce disability, and improve the quality of life for older people.1 PA helps in the reduction of all-cause mortality by 30% in the general population, to as high as 51% in the older population.2,3 Despite the multiple benefits offered by PA, the proportion of older adults meeting PA guidelines is between 27% to 44%.4 Across all surveys, non-Hispanic White male individuals reported higher levels of PA, which declined with age, and functional limitation across all groups.4 Rheumatic and musculoskeletal diseases (RMDs), such as rheumatoid arthritis (RA), spondyloarthritis (SpA), systemic lupus erythematous (SLE), and osteoarthritis (OA), are a diverse group of multisystem diseases that commonly affect the joints. As older adults with RMDs can have significant functional limitation, it is important to understand the level of PA in this group.
The European Alliance of Associations for Rheumatology (EULAR) recommendations for people with inflammatory arthritis and OA state that PA is effective, feasible, safe, and should be an integral part of care.5 In the United States, moderate-intensity aerobic PA for a minimum of 30 minutes, 5 days per week, or vigorous-intensity aerobic activity for a minimum of 20 minutes, 3 days per week, is recommended by the Department of Health and Human Services guidelines for the general population.6 For adults aged ≥ 65 years who have good fitness and no chronic conditions, at least 150 minutes of moderate-intensity or 75 minutes a week of vigorous-intensity aerobic PA is recommended.7 Preferably, aerobic activity should be spread throughout the week. Older adults with chronic conditions should understand whether and how their conditions affect their ability to do regular PA safely, and they should be as physically active as their abilities and conditions allow.7,8 With advancing age, structural and functional deterioration occurs in most physiological systems, even in the absence of disease. This process is exacerbated in patients with rheumatic diseases (RDs) such as RA, SpA, and OA, who may experience joint pain, restricted mobility, and reduced muscle strength and endurance.9,10 The presence of chronic systemic inflammation might account for the substantially increased cardiovascular risk and associated comorbidities of muscle wasting, anemia, and accelerated atherosclerosis.11,12 Chronic inflammation can cause fatigue and decreased energy, and diminish the ability of patients to perform PA.
Historically, exercise was not routinely recommended in patients with RDs due to concerns that it might exacerbate joint damage. However, it is now known that exercise is safe for people with rheumatic conditions, and that PA is capable of reducing chronic inflammation by direct and indirect antiinflammatory effects and is important in the management of RDs.13-15 Aging is generally associated with a loss of both aerobic capacity and muscle mass, as well as an increase in fat mass. Thus, the maintenance of PA as one ages is an important potential tool to disrupt this cycle and prevent deterioration in health. Participation in PA has also been shown to improve patient-reported outcomes (PROs), including health-related quality of life, function, and fatigue in most rheumatic conditions.16
To understand how to intervene in PA among older patients with RDs, it is paramount to first define and describe the problem. The objective of this study was therefore to describe patient-reported levels of PA across different diagnoses as well as the association between activity level and PROs among a large and representative sample of older adults with RDs.
METHODS
Study sample. A cross-sectional study was performed within the FORWARD database/The National Databank (NDB) for Rheumatic Diseases (now called the Forward Databank), the largest patient-reported databank in the US. The FORWARD database/NDB is a patient-based multidisease registry, though the largest cohorts are patients with RA, SLE, fibromyalgia syndrome (FMS), SpA, and OA. All are patient-reported diagnoses, though most were also confirmed through a questionnaire to the provider. The Forward Databank enrolls patients from the community, follows up with questionnaires every 6 months, and validates key patient data using medical records.17 Data from this analysis were taken from a single questionnaire administered in 2019 that included relevant PA questions. Individuals were included in the current analysis if they completed the single questionnaire and were aged ≥ 65 years and had received a physician-confirmed diagnosis of RA, SpA (which includes axial SpA [axSpA] and psoriatic arthritis [PsA]), OA, SLE, or FMS. These specific RMDs were chosen as they were the most common RMDs in the FORWARD Databank.
PA. Self-reported level of PA across different diagnoses was the primary exposure of interest. Three validated questions about PA were added to the survey in 2019. Participants were asked the following questions about their PA: (1) Which of the following best describes your PA level? PA level was categorized as high (vigorously active for at least 30 min, 3 times per week), moderate (moderately active for at least 3 times per week) or low (seldom active). (2) In the past month, on how many days have you done a total of 30 minutes or more of PA that was enough to raise your breathing rate? This might include sports, exercise, and brisk walking or cycling for recreation or to get around, but should not include housework or PA that is part of your job. (3) Compared to other people your age, do you think you are: much more active, more active, about as active, less active, much less active. Each of these items have previously been established as a validated measure of PA.18-20
PROs. Patients in the Forward Databank complete a wide range of PROs (eg, Psoriatic Arthritis Impact of Disease Questionnaire, Clinical Health Assessment Questionnaire, EQ-5D, patient global assessment). We used the Health Assessment Questionnaire–Disability Index (HAQ-DI) and the 29-item Patient-Reported Outcomes Measurement Information System (PROMIS-29) in the analysis. Participants complete a survey every 6 months including information on medications used and healthcare utilization, and they are asked to fill out all questionnaires. The PROMIS was developed as a PRO measure to assess functioning and well-being across different domains. PROMIS-29 profile instrument assesses pain intensity using a single 0 to 10 numeric rating item and 7 health domains like physical function, using 4 items for each domain.21 The PROMIS-29 profile has been used to assess different domains in patients with RDs.22 Each item in the 7 health domains is scored on a scale from 1 to 5.
Covariates. Self-reported patient characteristics such as age, sex, disease duration, Rheumatic Disease Comorbidity Index, college education, obesity (defined as BMI ≥ 30 based on self-reported height and weight, calculated as weight in kilograms divided by height in meters squared), and depression (self-reported) were collected.23
Statistical analysis. Descriptive statistics defined the characteristics of the cohort. ANOVA with posthoc means comparisons, Kruskal-Wallis tests, or chi-square tests (for normally distributed, nonnormally distributed continuous outcomes, and categorical outcomes, respectively) were used to determine whether differences between those who were active or inactive were statistically significant. Finally, we utilized linear regression models to examine the association of PA and PROs, after adjustment for potential prehypothesized confounders (ie, age, sex, and obesity).
Ethics. All NDB procedures are approved by the Via Christi Institutional Review Board (Wichita, Kansas, FWA00001005). Informed consent was obtained from all study subjects prior to enrollment in the registry.
RESULTS
Among the 5335 persons enrolled in the FORWARD database/NDB who completed the questionnaire, 3343 (62.7%) were aged ≥ 65 years. Of these, there were 2278 (68.1%) participants with RA, 681 (20.4%) with OA, 161 (4.8%) with SLE, 137 (4.1%) with FMS, and 111 (3.3%) with SpA. Diagnoses are not mutually exclusive. The mean age (SD) of the group was 74.4 (6.6) years, and most of the patients were women (83%). Additional characteristics of the sample are also shown in Table 1. There were 457 (13.6%) respondents who reported a high level of PA, 1820 (54.4%) with moderate levels of PA, and 1091 (32.6%) reported seldom being active. Levels of PA varied by diagnosis; for example, only 9% of patients in the FMS group reported high PA compared to 14% in RA and SpA. The level of moderate PA in the FMS group was 50%, similar to participants with SpA but numerically lower than participants with RA, SLE, or OA (Figure; Table 2). Overall, participants reported a median of 7 (IQR 0-15; mean 9.3) days of moderate to vigorous level of PA for ≥ 30 minutes per month. Table 2 illustrates the number of patients with different levels of PA among key subgroups. Among female participants, 34% reported low levels of PA compared to 24% of men. There were only 4% of current smokers who had a high level of PA. Majority of obese participants reported either low or moderate levels of PA (44% and 50%, respectively). Similarly, among patients with depression, 48% reported a low level of activity, 45% moderate activity, and 7% with high PA (Table 2). In unadjusted analyses, participants with low PA activity had worse (higher) mean (SD) HAQ-DI scores compared to participants with higher level of PA (1.32 [0.68] vs 0.50 [0.55]; Table 3). When we looked at pain scores, participants with lower or moderate PA levels had numerically higher pain scores compared to participants with higher PA levels (4.86 [2.82] vs 3.44 [2.58] vs 2.53 [2.38]). Patients with the lowest level of PA had poor PROMIS-29 scores across the board (Table 3) and as the level of PA increased, participants reported better scores in all PROMIS-29 domains including pain, sleep, fatigue, social satisfaction, and physical function. This was true even after adjustment for age, sex, and obesity (Table 4). PROMIS-29 scores were not adjusted for individual diagnoses as there was significant overlap between various diagnoses among participants.
Patient demographics.
Physical activity level by diagnosis. FMS: fibromyalgia syndrome; OA: osteoarthritis; RA: rheumatoid arthritis; SLE: systemic lupus erythematosus; SpA: spondyloarthritis.
Participant characteristics by physical activity (PA).
Patient-reported outcomes by level of physical activity (PA)a.
Multivariable models examining the association between level of physical activity (PA) and patient-reported outcomes.
DISCUSSION
In our cohort of persons aged 65 years and older and a diagnosis of RD, the level of PA was far lower than the EULAR-recommended PA guidelines.5 A very small percentage of patients (< 15%) reported performing vigorous PA at least 3 times a week. As PA was self-reported, which is subject to recall and desirability bias, we expect that the actual percentage is even lower. This report of the low level of PA among patients aged ≥ 65 years with RDs reveals a clinical care gap. Though the reasons for lower level of PA activity in our cohort can be multifactorial, some of the potential factors related to clinical care are persistent disease activity, diagnostic delay leading to joint damage, and disability. This can be an excellent opportunity for providers to educate and promote PA among elderly individuals.
A number of studies have described PA in older adults from the general population. For example, a comparison of PA across 3 national surveys reported a significantly higher proportion of recommended aerobic PA among older adults compared to those levels identified in our study.4 In the National Health and Nutrition Examination Survey (NHANES), 27% of older adults reported being physically active compared to 36% in the National Health Institute Survey (NHIS) and 44% in the Behavioral Risk Factor Surveillance System (BRFSS).4 In the NHANES survey, participants were asked about the frequency and duration of vigorous- and moderate-intensity activities the past 30 days alone, whereas in the NHIS survey, participants were asked how often they did vigorous- or light/moderate-intensity activity per week and then the average duration in each intensity. In the BRFSS survey, participants reported the number of days per week and time per day they engaged in moderate and vigorous PA for at least 10 minutes.4 Our study had relatively similar definitions for PA but reported lower levels of PA among older adults with RDs.
In contrast, there are few studies examining the level of PA across different rheumatic diagnoses.24-26 A study comparing PA among patients with RA and healthy controls in New York City found that 48% of patients with RA did not meet the PA recommendations.27 In the Swedish RA registry, more than 50% of the patients did not meet the recommended PA guidelines, the number was even higher in older female patients.28 It is expected that patients with active disease will have lower PA; however, a US-based study enrolling mostly patients in low disease activity (60%) also found that only 29% of patients were participating in moderate to vigorous PA.29 Thus, disease activity alone does not explain the inability to exercise and other factors like inherent motivation, which is difficult to capture, might be playing a role. On the other hand, similar to the findings in this study, higher BMI was associated with lower levels of PA.30 Additionally, though exercise is recommended in FMS, patients with FMS were less physically active in our cohort, which was similar to prior studies.31
PA has benefits in patients with RA, SpA, and OA, and results in improvement across a variety of domains including fatigue, pain, depression, and physical function.32-35 A systematic literature review examining the role of PA as a conservative treatment option for OA showed that active exercise and sport are effective to improve pain and physical function.35 In our study, patients with lower PA had higher pain, depression, and fatigue, and those with higher PA had lower pain, depression, and fatigue. Although this study is cross-sectional, previous studies have demonstrated that PA improves pain, fatigue, and depression.36-41 Fatigue can have a tremendous effect on patients with RDs and adequate pharmacotherapy is often inadequate to improve fatigue.42 Wearable technology can help promote PA, and can increase PA and decrease fatigue.39,43 Similarly, a home-based exercise program in patients with SpA proved to be effective in improving physical fatigue, and can be considered as a strategy for the older population.37 However, long-term adherence to exercise can be difficult for older patients.44,45 A Swedish follow-up cohort study showed that older adults with RA who participated in an exercise intervention with person-centered guidance had increased PA after 4 years, which can be crucial for older adults.46 Such exercise programs may help not only increase PA but also improve PROs.
One of the strengths of our study is that it captured the level of PA in a large number of older adults with different RDs as well as PROs and symptoms. We examined the association between the level of PA with different domains of PROMIS-29, a set of validated measures with scoring that allows comparison with the general population. There are also limitations of our study, including the fact that this was a questionnaire-based study, which is prone to volunteer bias and recall bias. We also did not employ a complete PA questionnaire such as the International Physical Activity Questionnaire, which is longer. In particular, there may be differences in reporting of PA, particularly among those with lower PA levels. As patients were asked about their perceived PA, the study is prone to desirability bias. Similarly, the perceived level of PA is prone to bias in severely deconditioned participants. Next, we did not have physician-assessed specific disease activity measures and thus were unable to correlate the level of PA with disease activity. Patients with several conditions were pooled in the examination of levels of PA and symptoms as measured by the PROMIS-29, limiting the generalizability to any individual disease. Diagnoses were defined by patient-report of diagnosis (including FMS), although a large proportion of these patients had the diagnosis confirmed by a rheumatologist. Additionally, patients may have had more than one condition (eg, OA, PsA, and FMS). Given the large number of potential combinations, we examined outcomes by diagnosis and allowed for patients to contribute to more than one group; we also did not attempt to adjust for other diagnoses nor examine smaller subsets.47 Finally, this is a cross-sectional study, and we are unable to draw conclusions about causation or temporality about the association between PA and PROs.
In conclusion, despite multiple recommendations regarding PA from national and rheumatology-specific organizations, the level of PA overall is quite low in older adults with RDs in the US. The lower level of PA was associated with greater pain, fatigue, and sleep disturbances. This demonstrates an opportunity for improving outcomes for these patients. Activity trackers may be an effective technology to encourage PA among older adults. However, initial positive response to tracker use does not guarantee tracker use maintenance. Maintenance depends on recognizing the long-term benefits of tracker use, social support, and internal motivation.48 Further, additional efforts are needed to encourage rheumatology providers to counsel patients on the importance of PA. Innovative efforts to promote and sustain PA among older adults should be initiated as well as programs that help providers create meaningful change.41,49
Footnotes
JB has received consulting fees from BMS, Pfizer, Corrona, and Gilead. AO reports grants from AbbVie (to Penn), Novartis (to Penn), Pfizer (to Penn), Amgen (to FORWARD/NDB); consulting fees from AbbVie, Amgen, BMS, Celgene, CorEvitas, Eli Lilly, Gilead, GSK, Happify Health, Janssen, Novartis, Pfizer, and UCB. The remaining authors declare no conflicts of interest relevant to this article.
- Accepted for publication September 26, 2022.
- Copyright © 2023 by the Journal of Rheumatology
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