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Medizinische Fakultät der Martin-Luther-Universität Halle-Wittenberg
Institut für Rehabilitationsmedizin
Magdeburger Straße 8
06097 Halle

Dipl.-Psych. Kerstin Mattukat
Tel.: +49 (345) 557-7646
E-Mail:

 

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Rehab optimisation in patients with polyarthritis or spondyloarthritis through an individually agreed strength, endurance and coordination training program (KAKo training)

Project leader:
Prof. Dr. med. Wilfried Mau, Institut für Rehabilitationsmedizin, Medizinische Fakultät der Martin-Luther-Universität Halle-Wittenberg

 

Project implementation:
Dipl.‐Psych. Kerstin Mattukat, Institut für Rehabilitationsmedizin, MLU Halle‐Wittenberg

 

Cooperation:
Dr. Inge Ehlebracht‐König, Rehazentrum Bad Eilsen
Prof. Dr. Karin Kluge, Teufelsbad Fachklinik Blankenburg

 

Funding providers:
DRV Bund, DRV Braunschweig-Hannover (co-financing)

 

Funding code:
0421-FSCP-0536

 

Running time:
01.01.2008 - 31.03.2011 (39 months)

 

Background and current state of research:

Chronic polyarthritis (CP) and spondyloarthritis (SPA) are the most frequent chronic-inflammatory rheumatic diseases, with a high risk of impairments of activity and participation, including a reduction in capability to work (1). Around one million Germans are affected by the examined rheumatic diseases, which frequently show a chronic progression (2). Regular physical activities (above all aerobic strength and endurance training) are also associated for these patients with a multitude of health-related improvements (3, 4), and with correct implementation, there is little fear of increased joint damage or an increase in the disease activity (5). Nevertheless, an inactive lifestyle is particularly widespread here (6). After its short- and medium-term effectiveness was proven, the rehabilitation was adopted in evidence-based national and international recommendations for disease management for inflammatory-rheumatic diseases (7). To maintain the positive results of the rehabilitation, besides the prescription of physical activity-based aftercare services, following the rehabilitation, the patients were above all recommended to carry out physical activities independently. As, however, many rehabilitees are not successful in implementing the activity-related plans into everyday life (8), the realisation of physical activity after the end of rehab needs to be supported in a targeted manner.

 

Object and Aims:

Therefore, an intensive strength, endurance and coordination training program (KAKo training) following Jong et al. (9) was implemented in patients with cP or SpA in the routine clinical practice of the participating clinics and conducted during the three-week inpatient rehabilitation. These intensive training units in closed groups were supplemented by systematic motivation work against the background of the transtheoretical model (TTM). A therapeutic accompanying booklet in line with Sudeck (10) and the exercise planner introduced here acted as aids. In the framework of a participatory arrangement of care, the implementation of regular physical activities following the rehabilitation near the patient's home was prepared together with the rehabilitee and stipulated in writing in a training agreement at the end of rehab. An additional impetus to implement the planned physical activities ensued four weeks after discharge by a brief enquiry via letter or telephone from the rehabilitation clinic. The adoption and maintenance of independent physical activities was examined over the course of one year.

 

Method:

In the framework of the controlled, sequential study, rehabilitees with cP or SpA in the rehab centre Bad Eilsen and the Teifelsbad Fachklinik Blankenburg were surveyed at four (control group [CG]) and five (intervention group [IG]) time points, respectively. Of 555 rehabilitees who had been informed about the study in writing before commencing rehab, a total of 392 rehabilitees (71%) were recruited during the admission dialogue in the clinics. Of these, 1-year-progression data (T5) are available for 307 (78%). Sample at T1: age 47 [± 8] years, 62 % women, 70 % cP, 30 % SpA, illness duration 9 [± 8] years, 85 % in full- or part-time employment.

Compared to the control group (CG: n=156), improvements of the intervention group (IG: n=151) were examined with regard to the physical component of health-related quality of life (SF-36) as a primary dependent variable as well as the secondary dependent variables everyday functional capacity (FFbH), physical activity (energy consumption in Kcal/week; FFkA), pain (NRS), motivational exercise aspects (SSA), mental health (SF-36; anxiety and depression; HADS-D), employment as well as direct and indirect costs. As statistical procedures, Chi²- und t-tests, repeated-measures analyses of variance as well as multivariate analyses of covariance were implemented.

 

Results:

At the beginning of rehab (T1), no differences were apparent between the CG and IG in terms of health- and activity-related characteristics. At the end of rehab (T2), in both groups, the typical improvements compared to T1 could be observed in all examined health-related and motivational characteristics (time effects: p<.001). Compared to the CG, the IG additionally showed stronger improvements in motivational characteristics (sports-related self-efficacy and decision balance; interaction effects: p<.05). Furthermore, the participants of the IG rated their rehabilitation more positively in various areas (group effect; p<.05). There were no signs of overburden in either group. In the one-year progression, for the physical sum scale of the SF-36 as a primary dependent variable, an improvement was demonstrated in all rehabilitees (time effect: p<.01), but no superiority of the IG over the CG. Stable improvements of health-relevant characteristics spanning across groups were related to the reported pain (NRS), the emotional sum scale of the SF-36 (time effects: p<.01), depression and anxiety (HADS-D) (time effects: p<.001). No changes over time were apparent for the everyday functional capacity (FFbH) and disease activity (RADAI, BASDAI). The indirect sickness costs (above all due to periods of incapacity to work and restricted disability pensions), rose strongly over the course of one year (p<.001), whereby a stronger increase was recorded for the CG than for the IG (interaction effect: p<.05). From the direct costs of illness, in both groups, the hospital costs were reduced. In the remaining categories of medical treatment costs as well as in the costs of illness as a whole, no changes were apparent. In terms of employment, a more favourable tendency was observed for the IG (n.s.). In the area of physical activities, all participants were able to improve in the area of sport and general activities (FFkA; time effects: p<.01) as well as in terms of their sports-related self-efficacy (time effect: p<.001). Moreover, the IG showed stronger improvements regarding their physical everyday activity (interaction effect: p<.05). In line with recommendations on movement targets according to Paffenbarger et al. (at least 2,000 kcal/wk total activity) (11), at T5, 82% of participants of the IG were sufficiently active, while only 71% of the participants in the CG fulfilled this criterion (p<.05). The recommendations of the American College of Sports Medicine (at least 1,000 kcal/wk through training) (12) was fulfilled at T5 by 57% of the participants of the IG and only 42% of the participants of the CG (p<.05). Sub-group analyses demonstrate the activity-specific effectiveness of the intervention for both genders and disease groups as well as for younger and older patients. No changes were apparent over the course of one year for leisure activities and for sports-based decision balance. Only the "fear of injury", as a component of the perceived disadvantages of physical activity, was reduced in the overall sample (time effect: p<.01).

 

Summary and further steps:

The positive progression following conventional rheumatology rehabilitation is demonstrated through stable improvements spanning across groups in health-related characteristics at all follow-up time points compared to at the beginning of rehab. In addition, at the end of rehab, the IG had improved more strongly than the CG in terms of motivational characteristics. However, this effect was not retained in the course of one year. The data of the 12-month follow-up point to long-term positive effects of the intensive training with motivation work regarding increased independent physical activity and lower indirect costs through periods of work incapacity as well as restricted disability pensions. Currently, publications of the study results for academic journals are being prepared.

In the second funding phase, in a further project (boRN), the achievement of larger and more sustainable effects through (a) a screening of physical ability with allocation of rehabilitees to (b) a performance-based stepped training in closed, mixed diagnosis groups with (c) systematic motivation work and (d) individual aftercare, preferably through new media (SMS/E-Mail), will be strived for.

 

Literature:

  1. Mau W, Beyer W, Ehlebracht-König I, et al. Krankheitslast. Erste Routineberichterstattung zu sozialmedizinischen Folgen entzündlich-rheumatischer Erkrankungen in Deutschland. Z Rheumatol. 2008;67(2):157-64.
  2. Mau W, Zink A. Epidemiologie rheumatischer Erkrankungen. In: Assoziation für Orthopädische Rheumatologie (ARO), editor. Rheumaorthopädie. Darmstadt: Steinkopff; 2005. p. 12-20.
  3. Baillet A, Zeboulon N, Gossec L, et al. Efficacy of cardiorespiratory aerobic exercise in rheumatoid arthritis: meta-analysis of randomized controlled trials. Arthritis Care Res. 2010;62(7):984-92.
  4. Cooney JK, Law RJ, Matschke V, et al. Benefits of exercise in rheumatoid arthritis. J Aging Res. 2011;2011:681640.
  5. de Jong Z, Vliet Vlieland TP. Safety of exercise in patients with rheumatoid arthritis. Curr Opin Rheumatol. 2005;17(2):177-82.
  6. Sokka T, Häkkinen A, Kautiainen H, et al. Physical inactivity in patients with rheumatoid arthritis: Data from twenty-one countries in a cross-sectional, international study. Arthritis Rheum. 2008;59(1):42-50.
  7. Zochling J, van der Heijde D, Dougados M, Braun J. Current evidence for the management of ankylosing spondylitis: a systematic literature review for the ASAS/EULAR management recommendations in ankylosing spondylitis. Ann Rheum Dis. 2006;65(4):423-32.
  8. Morfeld M, Küch D, Greitemann B, et al. Multimodale Interventionsprogramme in der Rehabilitation von Patienten mit chronischen Rückenschmerzen – Ein Vergleich. Rehabilitation. 2010;49(02):66,79.
  9. de Jong Z, Munneke M, Zwinderman AH, et al. Is a long-term high-intensity exercise program effective and safe in patients with rheumatoid arthritis?: Results of a randomized controlled trial. Arthritis Rheum. 2003;48(9):2415-24.
  10. Sudeck G. Motivation und Volition in der Sport- und Bewegungstherapie. Konzeptualisierung und Evaluierung eines Interventionskonzepts zur Förderung von Sportaktivitäten im Alltag. Hamburg: Forum Sportwissenschaft, 2006.
  11. Paffenbarger RSJ, Hyde RT, Wing AL, Hsieh CC. Physical activity, all-cause mortality, and longevity of college alumni. N Engl J Med. 1986;314:605-13.
  12. American College of Sports Medicine. The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness in healthy adults. Medicine and Science in Sports and Exercise. 1990;22:265-74.



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