You are here

  • Home
  • Archive
  • Volume 10, Issue 1
  • Effect of high-intensity interval training in physiotherapy primary care for patients with inflammatory arthritis: the ExeHeart randomised controlled trial

Article Text

Article menu

Download PDFPDF

Inflammatory arthritis
Original research
Effect of high-intensity interval training in physiotherapy primary care for patients with inflammatory arthritis: the ExeHeart randomised controlled trial
  1. Kristine Røren Nordén1,2,
  2. Anne Grete Semb3,
  3. Hanne Dagfinrud1,2,
  4. Jonny Hisdal4,5,
  5. Joseph Sexton3,
  6. Camilla Fongen2,
  7. Emilie Bakke2,
  8. Sigrid Ødegård6,
  9. Jon Skandsen3,
  10. Thalita Blanck3,
  11. George S Metsios7 and
  12. Anne Therese Tveter2,8
  1. 1Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
  2. 2Center for treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Health Services Research and Innovation Unit, Diakonhjemmet Hospital, Oslo, Norway
  3. 3Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
  4. 4Department of Vascular Surgery, Oslo University Hospital, Oslo, Norway
  5. 5Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
  6. 6Norwegian National Unit for Rehabilitation for Rheumatic Patients with Special Needs, Diakonhjemmet Hospital, Oslo, Norway
  7. 7Department of Nutrition and Dietetics, University of Thessaly, Volos, Greece
  8. 8Faculty of Health Sciences, Institute of Rehabilitation Science and Health Technology, Oslo Metropolitan University, Oslo, Akershus, Norway
  1. Correspondence to Kristine Røren Nordén; kristineroren.norden{at}diakonsyk.no

Abstract

Objectives To assess the effect of high-intensity interval training (HIIT) delivered in physiotherapy primary care on the primary outcome of cardiorespiratory fitness (CRF) in patients with inflammatory arthritis (IA). Additionally, to explore the effects of HIIT on secondary outcomes, including cardiovascular disease (CVD) risk factors and disease activity.

Methods Single-blinded randomised controlled trial with 60 patients randomly assigned to either a control group receiving usual care or an exercise group receiving usual care and 12 weeks of individualised HIIT at 90%–95% peak heart rate. Outcomes were assessed at baseline, 3 months and 6 months post baseline and included CRF measured as peak oxygen uptake (VO2peak), classic CVD risk factors, disease activity, anthropometry and patient-reported physical activity, pain, fatigue, disease impact and exercise beliefs and self-efficacy.

Results Intention-to-treat analysis demonstrated a significant between-group difference in VO2peak at 3 months (2.5 mL/kg/min, 95% CI 0.9 to 4.0) and 6 months (2.6 mL/kg/min, 95% CI 0.8 to 4.3) in favour of the exercise group. A beneficial change in self-reported physical activity in favour of the exercise group was observed at 3 and 6 months. The HIIT intervention was well-tolerated with minimal adverse events and no apparent impact on disease activity. Differences in secondary outcomes related to CVD risk factors, disease impact, pain, fatigue and exercise beliefs and self-efficacy were generally small and non-significant.

Conclusion After 12 weeks of supervised HIIT delivered in physiotherapy primary care, patients with IA demonstrated a favourable improvement in CRF, with sustained effects at 6-month follow-up.

Trial registration number NCT04922840.

  • Spondylitis, Ankylosing
  • Physical Therapy Modalities
  • Cardiovascular Diseases
  • Arthritis, Psoriatic
  • Arthritis, Rheumatoid

Data availability statement

Data are available upon reasonable request.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/rmdopen-2023-003440

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • High-intensity interval training (HIIT) is known to enhance both cardiorespiratory fitness (CRF) and cardiovascular health, but its effectiveness as an intervention for patients with inflammatory arthritis (IA) in physiotherapy primary care is unknown.

    WHAT THIS STUDY ADDS

    • This study demonstrates that HIIT delivered in physiotherapy primary care for patients with IA can lead to a sustained increase in CRF without any adverse effects on disease activity.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • The results of this study support the implementation of HIIT in physiotherapy primary care as a way to increase CRF in patients with IA.

    Introduction

    Inflammatory arthritis (IA), including rheumatoid arthritis (RA), spondyloarthritis (SpA) and psoriatic arthritis (PsA), are autoimmune diseases characterised by joint inflammation, pain, fatigue and extra-articular manifestations. Patients with IA have an elevated risk of cardiovascular disease (CVD) driven by the proatherogenic effects of systemic inflammation on the vasculature, as well as a high prevalence of traditional CVD risk factors such as smoking, hypertension, adiposity and hypercholesterolemia.1–3 In addition to screening of traditional CVD risk factors, class 1a level evidence promotes habitual physical activity to optimise CVD risk management.4 Physical activity is of major influence to cardiorespiratory fitness (CRF), a renowned and clinically important measure of how well the body delivers oxygen to working muscles.5 6 CRF is an independent and modifiable risk factor of CVD,6 and modest increases in CRF associate with increased longevity and lower risk of cardiovascular events.7 8

    Exercise-induced adaptations in CRF are dose-dependent, and high-intensity interval training (HIIT) has been shown to elicit superior improvements in CRF compared with exercise at lower intensities.9 10 Empirical data further indicate favourable effects of HIIT on CVD risk factors related to haemodynamics, lipid parameters and body composition.11–13 Nonetheless, the sustainability of HIIT as a long-term exercise mode has been questioned.14

    There is growing support for the use of exercise to downregulate inflammatory pathways and alleviate symptom burden in IA.15 16 However, physical activity levels and CRF are reportedly lower in patients with IA compared with the general population,17 18 and patients with IA call for individualised exercise programmes tailored by health professionals.19 Despite awareness of increased CVD risk in IA and the beneficial effects of exercise on both CRF and disease activity, tailored exercise remains to be integrated in the cluster of CVD risk factors commonly addressed in IA care.20 Evidence on the effect of HIIT for patients with IA is derived from clinical trials that primarily focused on the effect of HIIT on disease activity.21 22 There is currently a limited number of studies designed to assess the cardioprotective effects of HIIT for patients with IA,23 as well as a lack of studies that evaluate the effect of HIIT delivered outside specialised healthcare settings.

    Therefore, the primary purpose of the ExeHeart randomised controlled trial (RCT) was to report on the effect of a 12-week HIIT intervention set in physiotherapy primary care on CRF in patients with IA. Additionally, we aimed to explore the impact of HIIT on classic CVD risk factors and disease activity in patients with IA, potential benefits of HIIT beyond the primary endpoint, and to assess safety of the HIIT intervention.

    Methods

    Trial design

    The ExeHeart study is an assessor-blinded, RCT comparing the effects of 12-week HIIT supervised by physiotherapists in primary care with usual care (control group) in a 1:1 ratio. The trial was prospectively registered (NCT04922840). A comprehensive study protocol has been previously published24 and is outlined below. Reporting is guided by Consolidated Standards of Reporting Trials statement for randomised trials of non-pharmacologic treatments,25 Consensus on Exercise Reporting Template26 and the Position Statement on Exercise Dosage in Rheumatic and Musculoskeletal Diseases (IMPACT-RMD toolkit).27

    Participants

    Patients meeting the eligibility criteria (table 1) were recruited from the Preventive Cardio-Rheuma Clinic at Diakonhjemmet Hospital, Oslo, Norway. Study enrolment was initiated in August 2021 and follow-up was completed primo March 2023.

    View this table:
    Table 1

    Eligibility criteria

    Intervention

    Regardless of group allocation, all patients received usual care at the Preventive Cardio-Rheuma Clinic, including CVD risk assessment, general lifestyle advice and relevant CVD medication. Between baseline and the 3-month follow-up, patients assigned to the intervention group were given a 12-week exercise programme, each week consisting of two face-to-face supervised HIIT sessions and one self-guided exercise session at moderate intensity. The first 2 weeks focused on a gradual increase in exercise load and familiarisation with the protocol. Exercise intensity was monitored by heart rate monitors and rating of perceived exertion (RPE) by the Borg 6–20 Scale.28 HIIT sessions were singly delivered and tailored to the following protocol: 10 min warm-up followed by 4×4 min high intensity exercise at 90%–95% of peak heart rate (HRpeak), RPE 16–18, interspersed by 2–3 min active recovery at 60%–70% HRpeak, RPE 11–13. Patients were recommended to use uphill walking or running, but other options such as cycling, rowing, and elliptical machines were also acceptable. Workload was individually adapted to ensure exercise intensity aligned with the prescribed HIIT protocol. Throughout the intervention period, absolute intensity was continuously adjusted to achieve the targeted relative intensity. Patients were also advised to perform a third weekly non-supervised exercise session at moderate intensity, consisting of a 10 min warm-up followed by 30 min at RPE 12–14.

    Four physiotherapists employed at three primary care clinics in Oslo, Norway, supervised the HIIT exercise sessions and advised patients on how to perform the third weekly, self-guided exercise session. While the physiotherapists were seasoned practitioners, they had limited prior experience with HIIT as a treatment modality and were not specialised in rheumatology. Prior to the study, they received educational sessions on how to prescribe and monitor the exercise protocol and were provided with treatment manuals and clinical checklists to use during HIIT sessions. Unblinded study personnel were available for on-demand consultation of any clinical issues that arose during the intervention period.

    After the study ended, control group participants were provided with a fitness watch and a single HIIT session tailored by a physiotherapist from the Norwegian National Unit for Rehabilitation for Rheumatic Patients with Special Needs, Diakonhjemmet Hospital, Oslo, Norway.

    Outcome assessments

    Outcomes were assessed at baseline, 3 months and 6 months post baseline and included questionnaires and clinical examinations. Medical background information regarding IA diagnosis and comorbidities were obtained from the patient’s medical record. Assessors blinded to group allocation conducted all examinations in the following order: blood samples, waist circumference, height and body composition, resting heart rate, blood pressure and arterial stiffness, tender and swollen joint count (if applicable), resting ECG, spirometry and a cardiopulmonary exercise test (CPET). Measurements taken at follow-up timepoints were carried out at the same time of day as the baseline measurements.

    Primary outcome measure and end criteria

    The primary outcome was change in CRF 3 months post baseline. CRF was quantified as peak oxygen uptake (VO2peak) in mL/kg/min by CPET. Respiratory gas exchange and ventilation were sampled over eight breaths and averaged over 30 s intervals. VO2peak was defined as the highest 30 s VO2 observed throughout the exercise test. A 12-lead ECG and percutaneous oxygen saturation were assessed continuously throughout the test, and blood pressure was measured every other minute. RPE was rated by Borg 0–10 Scale,28 and blood lactate was sampled within 60 s of test termination. Peak oxygen pulse, a surrogate of left ventricular stroke volume, was indexed as peak VO2 (mL/min) divided by HRpeak. To ensure validity of repeated CPETs and assess level of maximal exertion, commonly used end criteria were recorded, including respiratory exchange ratio, Borg RPE 0–10, HRpeak and postexercise blood lactate levels.29 30

    Secondary outcomes: clinical measures

    Secondary outcome data included CRF as absolute capacity (L/min) and adjusted to fat-free mass (FFM). Non-fasting blood samples were collected according to current procedures at the hospital laboratory and analysed for C reactive protein (CRP), erythrocyte sedimentation rate (ESR), total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol and triglycerides.

    Waist circumference was recorded as the mean of two attempts and height was measured by stadiometer. Body weight, total FFM, total fat mass and visceral fat indicator were measured by bioelectrical impedance analysis and body mass index was computed as height in cm/kg2.

    An ambulatory blood pressure monitor was used to measure systolic and diastolic blood pressure, mean arterial pressure, arterial stiffness (measured as pulse wave velocity and augmentation index) and resting heart rate. In the absence of statins and/or antihypertensives, Systemic Coronary Risk Estimation 2 (SCORE2) was estimated by the low-risk country algorithm,4 including a 1.5 multiplication factor for patients with RA.1 An increased CVD risk was categorised as use of statins and/or antihypertensives or SCORE2 ≥2.5%, ≥5% and ≥7.5% for ages<50 years, 50–69 years and ≥70 years, respectively.4

    Disease activity was classified as remission, low, moderate or high using disease-specific composite instruments: Disease Activity Score-28 Calculator for RA, Ankylosing Spondylitis Disease Activity Score for SpA and Disease Activity Index for PSoriatic Arthritis for PsA.24

    Secondary outcomes: patient reported

    Prior to all study visits, patients answered a digital questionnaire with the following items: demography, use of medication, healthcare services and cigarettes/snuff, pain and fatigue by Numerical Rating Scale 0–10 (0=best) and CVD history and symptoms. Exercise beliefs and exercise habits were indexed by 20 questions over four domains: exercise self-efficacy, barriers to exercise, benefits of exercise and impact of exercise on IA.31 Physical activity level was quantified by three questions regarding frequency, duration and intensity of habitual exercise.32 Self-reported burden of disease was evaluated according to IA entity: Rheumatoid Arthritis Impact of Disease for patients with RA, Bath Ankylosing Spondylitis Disease Activity Index for patients with SpA and Psoriatic Arthritis Impact of Disease for patients with PsA.24

    Registration of adherence and safety

    HIIT exercise sessions were logged by the physiotherapist in the patient’s personal training diaries and attendance was tallied as number of attended HIIT sessions over number of scheduled HIIT sessions. During HIIT sessions, heart rate and RPE 6–20 were recorded by the physiotherapist at the third minute of each interval bout. Patients self-recorded the moderate-intensity non-supervised exercise sessions and were instructed to register max and mean heart rate as well as overall RPE 6–20. Heart rate was further expressed as a percentage of the highest HRpeak recorded during CPET. Control group participants reported their exercise habits over the past 3 months retrospectively at 3-month follow-up, while all participants reported exercise habits retrospectively at 6-month follow-up. Measures of safety included absence of disease flares24 and reports of adverse events.

    Sample size

    Sample size was determined based on the primary outcome: change in VO2peak following the 12-week intervention. To detect an increase of 3.5 mL/kg/min in VO2peak, which has been associated with a significantly lower risk of CVD and all-cause mortality,8 33 a total of 60 patients was deemed adequate. This was calculated with allowance for a possible 20% dropout rate, a SD of 4.5 mL/kg/min,34 a power of 0.8 and an alpha of 0.05. The secondary outcomes were considered exploratory, and we did not conduct post hoc power calculations for these endpoints.35

    Randomisation and blinding

    A computer-generated randomisation sequence was used with gender-stratified permuted blocks of random sizes 4 and 6. A project member not involved in outcome assessments informed patients of group allocation, whereas all study personnel involved in outcome assessments were blinded to group allocation.

    Patient and public involvement

    Two patient representatives have participated in the ExeHeart project group from study inception. They have contributed with choice of outcome measures, trial implementation and interpretation of results.

    Statistical analysis

    Data are presented as means with SD, median with IQR and frequency with percentages. Intention-to-treat analysis was used, including all available data at the relevant time points. Missing data were assumed to be missing at random, and for the primary outcome, multiple imputation was used with 20 imputed sets for each missing entry. Analysis of covariance (ANCOVA) was applied to 3-month and 6-month follow-up data to assess mean group differences with age, gender and respective baseline value as covariates. ANCOVA model assumptions were assessed by homogeneity of variance (Levene’s test), linearity of relationships and normality of residuals. Bootstrap CIs with 10 000 replications were applied if residuals were skewed. Wilcoxon rank sum was used for outcome variables with less than 30 observations in the total sample (SCORE2 and measures of self-reported burden of disease). Change in disease activity category was generated using paired data (baseline to 3 months and baseline to 6 months) and all categorical data were analysed by χ2 tests.

    Prespecified per-protocol analysis for the primary outcome at 3-month follow-up was conducted including only patients in the exercise group that adhered to the HIIT intervention and patients in the control group that reported <1 endurance exercise session/week.24

    A p value of 0.05 was considered significant and CIs are presented at the 95% level with no adjustments for multiple testing. STATA V.16.1 was used for all statistical analyses.

    Results

    Participant flow and characteristics

    From August 2021 to August 2022, 113 patients were screened for eligibility, and ultimately 60 patients were enrolled in the ExeHeart trial. As shown in figure 1, a total of 55 patients (92%) completed all outcome measures at 3-month and 6-month follow-up. Among the enrolled participants, 27 (45%) had RA, 19 (32%) had SpA and 14 (23%) had PsA, while 49 (82%) patients were classified as having an increased CVD risk. Baseline characteristics are provided in table 2 and online supplemental table a.

    View this table:
    Table 2

    Baseline characteristics for all patients, the exercise group, and the control group

    Figure 1
    Figure 1

    Consolidated Standards of Reporting Trials flow diagram of study enrolment, allocation and follow-up in the ExeHeart trial. BMI, body mass index; CPET, cardiopulmonary exercise test; HIIT, high-intensity interval training; PT, physiotherapist; VO2peak, peak oxygen uptake.

    Adherence and safety

    In the exercise group, 27 training diaries were returned. On average, participants attended 18 (SD 5) out of 24 HIIT sessions, and 19 patients (70%) adhered to ≥70% of the scheduled sessions (≥17 out of 24 sessions). In the completed HIIT sessions, mean exercise intensity at the third minute of each interval bout was 92% (SD 1) of HRpeak and mean Borg RPE 6–20 was 16 (SD 1). Mean attendance to non-supervised exercise sessions at moderate intensity was 11 (SD 4) out of 12 sessions. During these sessions, mean intensity was recorded as 72% (SD 1) of HRpeak, with a mean Borg RPE 6–20 of 14 (SD 2).

    Throughout the study period, there were 18 cases of SARS-CoV-2 infection among patients from baseline to 3 months and an additional 14 cases from 3 months to 6 months, with no between-group difference in incidence (online supplemental table d). Two moderate adverse events were reported in the exercise group: One patient suffered from knee pain following exercise performed adjuvant to the HIIT protocol. One patient with a prior history of heart palpitations experienced irregular heart rate during two consecutive HIIT sessions. Said patient was offered an exercise ECG with unblinded study personnel. The test was deemed normal and the patient recommenced the HIIT intervention with no further complications. Within the control group, one serious and one moderate adverse event occurred, both unrelated to study visits: One patient in the control group experienced atrial flutter prior to study close-out and was hospitalised for further examinations, while the other patient suffered from a head concussion and waived further exercise tests.

    At 3-month follow-up, disease flares were observed in one patient in the exercise group and two patients in the control group.

    Efficacy on primary outcome

    Following 12 weeks of HIIT, the exercise group showed a 2.5 mL/kg/min (95% CI 0.9 to 4.0) difference in change in VO2peak at 3-month follow-up compared with the control group. The group difference in VO2peak in favour of the exercise group was maintained at 6-month follow-up, with a mean difference of 2.6 mL/kg/min (95% CI 0.8 to 4.3) (tables 3 and 4 and figure 2). Sensitivity analyses of complete case data showed similar results for the primary outcome (online supplemental tables b and c). Per-protocol analysis revealed a significant difference of 3.2 mL/kg/min (95% CI 1.7 to 4.8) in VO2peak at 3-month follow-up between the 19 (70%) exercise group patients who completed at ≥17/24 HIIT sessions versus the 20 (71%) control group participants who did not engage in regular aerobic exercise (online supplemental table b). No significant between-group changes were observed in end criteria for VO2peak at 3-month and 6-month follow-up (table 5). While a significant difference in peak ventilation (5.8 L/min, 95% CI 0.5 to 11.0) was observed in favour of the exercise group at 3 months, there was no corresponding difference between groups at 6 months.

    Figure 2
    Figure 2

    Mean VO2peak in mL/kg/min across groups and study visits. Error bars represent 95% CI of means adjusted by covariates from analysis of covariance; age, gender and baseline value. Control group is shown in grey and exercise group in blue. Between-group difference at 3 months was 2.5 mL/kg/min (95% CI 0.9 to 4.0, p<0.01) and at 6 months 2.6 mL/kg/min (95% CI 0.8 to 4.3, p<0.01). ITT, Intention to Treat; VO2peak, peak oxygen uptake in mL/kg/min.

    View this table:
    Table 3

    Efficacy results from baseline to 3-month follow-up

    View this table:
    Table 4

    Efficacy results from baseline to 6-month follow-up

    View this table:
    Table 5

    Ventilation and common VO2peak end criteria from cardiopulmonary exercise tests at baseline, 3 months and 6 months

    Efficacy on secondary outcomes

    Tables 3 and 4 present secondary outcomes at 3-month and 6-month follow-up, respectively. After HIIT, there were significant group differences in VO2peak measured as absolute capacity, VO2peak relative to FFM and oxygen pulse in favour of the exercise group at 3-month and 6-month follow-up. There were no significant group differences in anthropometry, resting heart rate, blood pressure and blood biochemistry at follow-up timepoints. The exercise group showed a higher proportion of patients being reclassified to lower disease activity category during follow-up compared with the control group. However, there were no significant group differences in change of disease activity category at 3-month (χ2=8.3, p=0.08) and 6-month follow-up (χ2=9.8, p=0.08). No significant differences were observed between the groups in terms of patient-reported pain, fatigue or exercise beliefs and self-efficacy at follow-up timepoints. Favourable changes in self-reported physical activity were observed in the exercise group compared with the control group at 3 months (7.0 points, 95% CI 3.3 to 10.7) and 6 months (4.7 points, 95% CI 0.1 to 9.4). At 6-month follow-up, a significant difference was found in self-reported exercise habits between the two groups. Specifically, 18 (64%) patients in the exercise group reported engaging in aerobic exercise≥1 per week in the past 3 months, while 8 (27%) patients in the control group reported the same (χ2=8.3, p<0.01, online supplemental table e).

    Discussion

    In this assessor-blinded RCT, a 12-week HIIT programme delivered in physiotherapy primary care improved CRF in patients with IA, with beneficial effects on oxygen uptake sustained at the 6-month follow-up. The impact on secondary outcomes appeared modest and did not reach statistical significance, and the exercise intervention demonstrated good tolerability with minimal adverse events and no increase in disease activity.

    Increasing CRF through consistent exercise has favourable clinical implications as it enhances cardiovascular function,6 and our study adds to the growing body of evidence demonstrating positive effects of HIIT on CRF in various clinical populations.13 36 Notably, there is a scarcity of RCTs that have explored the effects of HIIT on improving CRF among patients with IA. The few existing studies focused on disease activity as the main outcome measure,21 22 although one of these studies also reported on CRF as the primary outcome.37 Unlike the other RCTs on HIIT in IA conducted in specialised healthcare settings, our study delivered HIIT through physiotherapy primary care and illustrates the feasibility of HIIT as an effective exercise intervention that can be used in the management of IA in primary care settings. We found that the exercise group attained a 2.5 mL/kg/min higher VO2peak following the intervention, consistent with the 2.7 mL/kg/min improvement in estimated CRF reported in the ESpA trial.21 Compared with our results, Thomsen et al37 reported a higher increase in VO2peak following HIIT in patients with PsA. This difference could be attributed to the frequency of HIIT sessions, as the study by Thompson et al conducted three weekly HIIT sessions, whereas our study involved two weekly HIIT sessions and one session at moderate intensity. Moreover, two pilot studies using pre–post38 and cross-over39 designs support the beneficial effects of HIIT on CRF in the context of IA. While our estimate of effect falls short of the 3.5 mL/kg/min increase in CRF that is commonly associated with substantial risk reduction in epidemiological studies,8 it is important to recognise that even smaller improvements, such as 1 mL/kg/min, have been linked to notable health benefits and lower risk of CVD and all-cause mortality.7 40 Furthermore, our results demonstrate a significant increase in VO2peak measured in terms of absolute capacity and adjusted to FFM, indicating an improvement in CRF independent of changes in weight and body composition. Additionally, we observed a concurrent rise in oxygen pulse, serving as a surrogate marker for stroke volume, subsequent to HIIT. This aligns with the notion that the changes observed in VO2peak following HIIT are largely driven by enhancements in stroke volume.41 Given the elevated CVD risk faced by patients with IA, time-efficient HIIT interventions that promote CRF can play a vital role in mitigating this risk.

    Despite concerns about the long-term effects of HIIT, particularly the potential decline in CRF once the supervised exercise intervention is ceased,14 our study provides evidence to the contrary. We found that the beneficial increase in CRF remained consistently strong at 6-month follow-up. Furthermore, patients in the exercise group presented with higher physical activity indexes at follow-up as well as greater engagement in aerobic exercise between the 3-month and 6-month follow-up compared with those in the control group. This suggests a sustained adherence to an active lifestyle among the exercise group. Our findings align with a study conducted by Thomsen et al,37 which observed sustained effects of HIIT in patients with PsA at 9-month follow-up. These results underscore the potential of HIIT as a long-term strategy for enhancing CRF in individuals with IA.

    While our ITT analyses provide estimates that may reflect real-world conditions, the per-protocol analysis focuses on patients that adhered to the exercise plan and offers insights into the optimal treatment effects of HIIT on CRF.42 In our study, the per-protocol analysis revealed a notable increase of 3.2 mL/kg/min in CRF among patients who adhered to ≥70% of the HIIT sessions. This improvement closely approaches the 3.6 mL/kg/min reported in a smaller study by Haglo et al,43 which investigated the per-protocol effect of supervised versus app-based HIIT in patients with IA. These findings emphasise the importance of adhering to an exercise programme to maximise the benefits on CRF.

    Although HIIT has been established as beneficial for cardiometabolic health in the general population,13 there is a paucity of research examining the impact of HIIT on classic CVD risk factors in individuals with IA. In the present study, we observed no significant results in the secondary outcomes related to CVD risk factors, which aligns with the findings of two pilot studies conducted in patients with RA.39 44 However, other studies have reported favourable changes in body composition and waist circumference in patients with PsA37 and SpA21 following HIIT, and in patients with RA, a 6-month moderate intensity exercise programme improved blood pressure, lipid levels45 and endothelial function.46 It is important to highlight that although over 80% of the individuals in our study presented with an increased CVD risk, a considerable number of patients had prescribed antihypertensives and/or statins, and baseline levels of blood pressure and lipids were within recommended target levels. This efficient management of traditional CVD risk factors at the onset of the study may have limited the potential for further adaptation in response to exercise.

    There is some evidence indicating that appropriately prescribed exercise can improve disease activity in patients with IA,47 similar to the positive changes in inflammatory markers observed in healthy middle-aged and older individuals.16 HIIT has been found to improve disease activity in patients with SpA,21 while studies in patients with PsA22 and RA39 have reported no significant impact on disease activity. In the present study, we observed no significant effects of HIIT on serum inflammatory markers. However, baseline levels of inflammatory values were low, and this may have introduced a floor effect and limited the potential for substantial change. Despite the lack of significant group differences, a higher number of patients in the exercise group were reclassified to a lower disease activity category at follow-up timepoints. Although disease activity category is a coarse classification, it combines the patient’s subjective perception of disease activity along with objective clinical measures.48 Therefore, an improvement in disease activity category could be interpreted as an overall improvement in disease impact.

    Future research is needed to investigate the effects of HIIT on inflammatory markers and CVD risk factors, especially in patients not receiving CVD preventive medication. Considering the high prevalence of carotid plaque in our study sample and the potential of HIIT to reduce atheroma volume,49 studying the impact of HIIT on coronary plaque in individuals with IA may also be an interesting avenue for further research.

    Strengths and limitations

    Strengths of the current study include its randomised controlled design, assessor-blinded approach, intention-to-treat analyses and use of the CPET criterion method to measure CRF.

    Several limitations should be acknowledged. First, our study sample likely consisted of motivated individuals and a possible selection bias may limit the generalisability of our findings to the broader IA population. Second, our a priori power calculation was based on the primary outcome, potentially leading to insufficient power to detect differences in secondary outcomes. We recognise that despite employing an RCT design, chance imbalance between groups may arise, as indicated by the higher proportion of smokers and longer disease duration in the control group. However, considering the comparable spirometry values and self-reported measures of disease burden in both groups (online supplemental table a), we do not believe this had a substantial impact on study results. Despite no group differences in SARS-CoV-2 incidence, we cannot rule out the possibility that a SARS-CoV-2 infection could have blunted the response to HIIT in the exercise group. Moreover, lack of blinding among patients may have introduced bias in self-reported outcomes. Additionally, the therapeutic effect of several CPET sessions could have motivated the control group and influenced outcomes by triggering them to engage in vigorous exercise. Lastly, the use of bioelectrical impedance analysis has limitations in accuracy,50 which could affect the validity of measures of body composition.

    Conclusion

    This study demonstrates improvements in CRF, measured as peak oxygen uptake, in patients with IA following 12 weeks of supervised exercise at high intensity delivered in physiotherapy primary care, compared with usual care. The positive effects on oxygen uptake were maintained at 6-month follow-up. The HIIT intervention was well tolerated, with minimal adverse events and no negative impact on disease activity. These findings support the integration of HIIT as an effective and feasible physiotherapy intervention in primary care for patients with IA.

    Data availability statement

    Data are available upon reasonable request.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants and was approved by the Regional Committee for Medical and Health Research Ethics (201227) and the data protection officer at Diakonhjemmet Hospital (reg. no. 00397). Participants gave informed consent to participate in the study before taking part and study procedures aligned with the Declaration of Helsinki.

    Acknowledgments

    The authors express their gratitude to the patients who participated in the ExeHeart trial and to the Norwegian League against Rheumatism/Norwegian Rheumatism Association for collaboration in the planning of the study. The authors thank nurse Anne Stormyr Eirheim for training in measures of arterial stiffness and valuable assistance in patient enrolment and pharmacist Kirsten K Viktil for support on pharmaceutical issues. The authors acknowledge and commend the unwavering commitment and contribution to the ExeHeart trial by physiotherapist Henrik Gifstad at Atlet Fysio, physiotherapist Paal Drummond at Volvat and musculoskeletal physiotherapists Fred Hatlebrekke and Øyvind Erås at Hans & Olaf Fysioterapi AS. Lastly, the authors extend their gratitude to physiotherapists from the Norwegian National Unit for Rehabilitation for Rheumatic Patients with Special Needs, Diakonhjemmet Hospital, Oslo, Norway, for delivering HIIT sessions to control group participants on study completion.

    References

    1. ↵
      1. Agca R,
      2. Heslinga SC,
      3. Rollefstad S, et al
      . EULAR recommendations for cardiovascular disease risk management in patients with rheumatoid arthritis and other forms of inflammatory joint disorders: 2015/2016 update. Ann Rheum Dis 2017;76:17–28. doi:10.1136/annrheumdis-2016-209775
      OpenUrlAbstract/FREE Full Text
    2. ↵
      1. Conrad N,
      2. Verbeke G,
      3. Molenberghs G, et al
      . Autoimmune diseases and cardiovascular risk: a population-based study on 19 autoimmune diseases and 12 cardiovascular diseases in 22 million individuals in the UK. Lancet 2022;400:733–43. doi:10.1016/S0140-6736(22)01349-6
      OpenUrlCrossRefPubMed
    3. ↵
      1. Kerola AM,
      2. Kazemi A,
      3. Rollefstad S, et al
      . All-cause and cause-specific mortality in rheumatoid arthritis, psoriatic arthritis and axial spondyloarthritis: a nationwide Registry study. Rheumatology (Oxford) 2022;61:4656–66. doi:10.1093/rheumatology/keac210
      OpenUrl
    4. ↵
      1. Visseren FLJ,
      2. Mach F,
      3. Smulders YM, et al
      . ESC guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J 2021;42:3227–337. doi:10.1093/eurheartj/ehab484
      OpenUrlCrossRefPubMed
    5. ↵
      1. Wagner J,
      2. Knaier R,
      3. Infanger D, et al
      . Novel CPET reference values in healthy adults: associations with physical activity. Med Sci Sports Exerc 2021;53:26–37. doi:10.1249/MSS.0000000000002454
      OpenUrlCrossRef
    6. ↵
      1. Ross R,
      2. Blair SN,
      3. Arena R, et al
      . Importance of assessing cardiorespiratory fitness in clinical practice: a case for fitness as a clinical vital sign: a scientific statement from the American Heart Association. Circulation 2016;134:e653–99. doi:10.1161/CIR.0000000000000461
      OpenUrlAbstract/FREE Full Text
    7. ↵
      1. Imboden MT,
      2. Harber MP,
      3. Whaley MH, et al
      . The association between the change in directly measured cardiorespiratory fitness across time and mortality risk. Prog Cardiovasc Dis 2019;62:157–62. doi:10.1016/j.pcad.2018.12.003
      OpenUrlPubMed
    8. ↵
      1. Han M,
      2. Qie R,
      3. Shi X, et al
      . Cardiorespiratory fitness and mortality from all causes, cardiovascular disease and cancer: dose-response meta-analysis of cohort studies. Br J Sports Med 2022;56:733–9. doi:10.1136/bjsports-2021-104876
      OpenUrlAbstract/FREE Full Text
    9. ↵
      1. Poon ET-C,
      2. Wongpipit W,
      3. Ho RS-T, et al
      . Interval training versus moderate-intensity continuous training for cardiorespiratory fitness improvements in middle-aged and older adults: a systematic review and meta-analysis. J Sports Sci 2021;39:1996–2005. doi:10.1080/02640414.2021.1912453
      OpenUrl
    10. ↵
      1. Williams CJ,
      2. Gurd BJ,
      3. Bonafiglia JT, et al
      . A multi-center comparison of O2Peak trainability between interval training and moderate intensity continuous training. Front Physiol 2019;10:19. doi:10.3389/fphys.2019.00019
    11. ↵
      1. Maillard F,
      2. Pereira B,
      3. Boisseau N
      . Effect of high-intensity interval training on total, abdominal and visceral fat mass: a meta-analysis. Sports Med 2018;48:269–88. doi:10.1007/s40279-017-0807-y
      OpenUrlCrossRefPubMed
    12. ↵
      1. Leal JM,
      2. Galliano LM,
      3. Del Vecchio FB
      . Effectiveness of high-intensity interval training versus moderate-intensity continuous training in hypertensive patients: a systematic review and meta-analysis. Curr Hypertens Rep 2020;22:26. doi:10.1007/s11906-020-1030-z
    13. ↵
      1. Edwards JJ,
      2. Griffiths M,
      3. Deenmamode AHP, et al
      . High-intensity interval training and Cardiometabolic health in the general population: a systematic review and meta-analysis of randomised controlled trials. Sports Med 2023;53:1753–63. doi:10.1007/s40279-023-01863-8
      OpenUrl
    14. ↵
      1. Biddle SJH,
      2. Batterham AM
      . High-intensity interval exercise training for public health: a big HIT or shall we HIT it on the head Int J Behav Nutr Phys Act 2015;12:95. doi:10.1186/s12966-015-0254-9
    15. ↵
      1. Metsios GS,
      2. Moe RH,
      3. Kitas GD
      . Exercise and inflammation. Best Pract Res Clin Rheumatol 2020;34:101504. doi:10.1016/j.berh.2020.101504
      OpenUrlPubMed
    16. ↵
      1. Zheng G,
      2. Qiu P,
      3. Xia R, et al
      . Effect of aerobic exercise on inflammatory markers in healthy middle-aged and older adults: a systematic review and meta-analysis of randomized controlled trials. Front Aging Neurosci 2019;11:98. doi:10.3389/fnagi.2019.00098
    17. ↵
      1. Liff MH,
      2. Hoff M,
      3. Fremo T, et al
      . Cardiorespiratory fitness in patients with rheumatoid arthritis is associated with the patient global assessment but not with objective measurements of disease activity. RMD Open 2019;5:e000912. doi:10.1136/rmdopen-2019-000912
    18. ↵
      1. O’Dwyer T,
      2. O’Shea F,
      3. Wilson F
      . Decreased physical activity and cardiorespiratory fitness in adults with Ankylosing Spondylitis: a cross-sectional controlled study. Rheumatol Int 2015;35:1863–72. doi:10.1007/s00296-015-3339-5
      OpenUrlPubMed
    19. ↵
      1. Rausch Osthoff A-K,
      2. Niedermann K,
      3. Braun J, et al
      . EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis. Ann Rheum Dis 2018;77:1251–60. doi:10.1136/annrheumdis-2018-213585
      OpenUrlCrossRefPubMed
    20. ↵
      1. Semb AG,
      2. Ikdahl E,
      3. Wibetoe G, et al
      . Atherosclerotic cardiovascular disease prevention in rheumatoid arthritis. Nat Rev Rheumatol 2020;16:361–79. doi:10.1038/s41584-020-0428-y
      OpenUrlCrossRefPubMed
    21. ↵
      1. Sveaas SH,
      2. Bilberg A,
      3. Berg IJ, et al
      . High intensity exercise for 3 months reduces disease activity in axial Spondyloarthritis (axSpA): a multicentre randomised trial of 100 patients. Br J Sports Med 2020;54:292–7. doi:10.1136/bjsports-2018-099943
      OpenUrlAbstract/FREE Full Text
    22. ↵
      1. Thomsen RS,
      2. Nilsen TIL,
      3. Haugeberg G, et al
      . Impact of high-intensity interval training on disease activity and disease in patients with psoriatic arthritis: a randomized controlled trial. Arthritis Care Res (Hoboken) 2019;71:530–7. doi:10.1002/acr.23614
      OpenUrl
    23. ↵
      1. Metsios GS,
      2. Moe RH,
      3. van der Esch M, et al
      . The effects of exercise on cardiovascular disease risk factors and cardiovascular physiology in rheumatoid arthritis. Rheumatol Int 2020;40:347–57. doi:10.1007/s00296-019-04483-6
      OpenUrlPubMed
    24. ↵
      1. Nordén KR,
      2. Dagfinrud H,
      3. Semb AG, et al
      . Effect of high-intensity exercise on cardiorespiratory fitness, cardiovascular disease risk and disease activity in patients with inflammatory joint disease: protocol for the Exeheart randomised controlled trial. BMJ Open 2022;12:e058634. doi:10.1136/bmjopen-2021-058634
    25. ↵
      1. Boutron I,
      2. Altman DG,
      3. Moher D, et al
      . CONSORT statement for randomized trials of Nonpharmacologic treatments: a 2017 update and a CONSORT extension for nonpharmacologic trial abstracts. Ann Intern Med 2017;167:40–7. doi:10.7326/M17-0046
      OpenUrlCrossRefPubMed
    26. ↵
      1. Slade SC,
      2. Dionne CE,
      3. Underwood M, et al
      . Consensus on exercise reporting template (CERT): explanation and elaboration statement. Br J Sports Med 2016;50:1428–37. doi:10.1136/bjsports-2016-096651
      OpenUrlAbstract/FREE Full Text
    27. ↵
      1. Metsios GS,
      2. Brodin N,
      3. Vlieland TPMV, et al
      . Position statement on exercise dosage in rheumatic and musculoskeletal diseases: the role of the IMPACT-RMD Toolkit. Mediterr J Rheumatol 2021;32:378–85. doi:10.31138/mjr.32.4.378
      OpenUrl
    28. ↵
      1. Borg GAV
      . Psychophysical bases of perceived exertion. Medicine & Science in Sports & Exercise 1982;14:377 doi:10.1249/00005768-198205000-00012
      OpenUrl
    29. ↵
      1. Liguori G
      . ACSM’s guidelines for exercise testing and prescription. Lippincott Williams & Wilkins, 2020.
    30. ↵
      1. Pritchard A,
      2. Burns P,
      3. Correia J, et al
      . ARTP statement on cardiopulmonary exercise testing 2021. BMJ Open Respir Res 2021;8:e001121. doi:10.1136/bmjresp-2021-001121
    31. ↵
      1. Gecht MR,
      2. Connell KJ,
      3. Sinacore JM, et al
      . A survey of exercise beliefs and exercise habits among people with arthritis. Arthritis Care Res 1996;9:82–8. doi:10.1002/1529-0131(199604)9:2<82::aid-anr1790090203>3.0.co;2-t
      OpenUrlPubMedWeb of Science
    32. ↵
      1. Nes BM,
      2. Janszky I,
      3. Vatten LJ, et al
      . Estimating V.O 2Peak from a nonexercise prediction model: the HUNT study, Norway. Med Sci Sports Exerc 2011;43:2024–30. doi:10.1249/MSS.0b013e31821d3f6f
      OpenUrlCrossRefPubMed
    33. ↵
      1. Kodama S,
      2. Saito K,
      3. Tanaka S, et al
      . Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men and women: a meta-analysis. JAMA 2009;301:2024–35. doi:10.1001/jama.2009.681
      OpenUrlCrossRefPubMedWeb of Science
    34. ↵
      1. Decato TW,
      2. Bradley SM,
      3. Wilson EL, et al
      . Repeatability and meaningful change of CPET parameters in healthy subjects. Med Sci Sports Exerc 2018;50:589–95. doi:10.1249/MSS.0000000000001474
      OpenUrlCrossRefPubMed
    35. ↵
      1. Heckman MG,
      2. Davis JM,
      3. Crowson CS
      . Post hoc power calculations: an inappropriate method for interpreting the findings of a research study. J Rheumatol 2022;49:867–70. doi:10.3899/jrheum.211115
      OpenUrlAbstract/FREE Full Text
    36. ↵
      1. Cuenca-Martínez F,
      2. Sempere-Rubio N,
      3. Varangot-Reille C, et al
      . Effects of high-intensity interval training (HIIT) on patients with musculoskeletal disorders: a systematic review and meta-analysis with a meta-regression and mapping report. Diagnostics (Basel) 2022;12:2532. doi:10.3390/diagnostics12102532
    37. ↵
      1. Thomsen RS,
      2. Nilsen TIL,
      3. Haugeberg G, et al
      . Effect of high-intensity interval training on cardiovascular disease risk factors and body composition in psoriatic arthritis: a randomised controlled trial. RMD Open 2018;4:e000729. doi:10.1136/rmdopen-2018-000729
    38. ↵
      1. Bartlett DB,
      2. Willis LH,
      3. Slentz CA, et al
      . Ten weeks of high-intensity interval walk training is associated with reduced disease activity and improved innate immune function in older adults with rheumatoid arthritis: a pilot study. Arthritis Res Ther 2018;20:127. doi:10.1186/s13075-018-1624-x
    39. ↵
      1. Sandstad J,
      2. Stensvold D,
      3. Hoff M, et al
      . The effects of high intensity interval training in women with rheumatic disease: a pilot study. Eur J Appl Physiol 2015;115:2081–9. doi:10.1007/s00421-015-3186-9
      OpenUrl
    40. ↵
      1. Blackwell JEM,
      2. Doleman B,
      3. Herrod PJJ, et al
      . Short-term (<8 wk) high-intensity interval training in diseased cohorts. Med Sci Sports Exerc 2018;50:1740–9. doi:10.1249/MSS.0000000000001634
      OpenUrlPubMed
    41. ↵
      1. Astorino TA,
      2. Causer E,
      3. Hazell TJ, et al
      . Change in central cardiovascular function in response to intense interval training: a systematic review and meta-analysis. Med Sci Sports Exerc 2022;54:1991–2004. doi:10.1249/MSS.0000000000002993
      OpenUrl
    42. ↵
      1. Smith VA,
      2. Coffman CJ,
      3. Hudgens MG
      . Interpreting the results of intention-to-treat, per-protocol, and as-treated analyses of clinical trials. JAMA 2021;326:433–4. doi:10.1001/jama.2021.2825
      OpenUrlCrossRefPubMed
    43. ↵
      1. Haglo H,
      2. Wang E,
      3. Berg OK, et al
      . Smartphone-assisted high-intensity interval training in inflammatory rheumatic disease patients: randomized controlled trial. JMIR Mhealth Uhealth 2021;9:e28124. doi:10.2196/28124
    44. ↵
      1. Sobejana M,
      2. van den Hoek J,
      3. Metsios GS, et al
      . Exercise intervention on cardiorespiratory fitness in rheumatoid arthritis patients with high cardiovascular disease risk: a single-arm pilot study. Clin Rheumatol 2022;41:3725–34. doi:10.1007/s10067-022-06343-4
      OpenUrl
    45. ↵
      1. Stavropoulos-Kalinoglou A,
      2. Metsios GS,
      3. Veldhuijzen van Zanten JJJCS, et al
      . Individualised aerobic and resistance exercise training improves cardiorespiratory fitness and reduces cardiovascular risk in patients with rheumatoid arthritis. Ann Rheum Dis 2013;72:1819–25. doi:10.1136/annrheumdis-2012-202075
      OpenUrlAbstract/FREE Full Text
    46. ↵
      1. Metsios GS,
      2. Stavropoulos-Kalinoglou A,
      3. Veldhuijzen van Zanten JJCS, et al
      . Individualised exercise improves endothelial function in patients with rheumatoid arthritis. Ann Rheum Dis 2014;73:748–51. doi:10.1136/annrheumdis-2013-203291
      OpenUrlAbstract/FREE Full Text
    47. ↵
      1. Sveaas SH,
      2. Smedslund G,
      3. Hagen KB, et al
      . Effect of cardiorespiratory and strength exercises on disease activity in patients with inflammatory rheumatic diseases: a systematic review and meta-analysis. Br J Sports Med 2017;51:1065–72. doi:10.1136/bjsports-2016-097149
      OpenUrlAbstract/FREE Full Text
    48. ↵
      1. Wells GA,
      2. Tugwell P,
      3. Tomasson G, et al
      . Composite outcomes at OMERACT: multi-outcome domains and composite outcome domains. Semin Arthritis Rheum 2021;51:1370–7. doi:10.1016/j.semarthrit.2021.11.001
      OpenUrl
    49. ↵
      1. Vesterbekkmo EK,
      2. Aksetøy I-LA,
      3. Follestad T, et al
      . High intensity interval training induces beneficial effects on coronary atheromatous plaques - a randomized trial. Eur J Prev Cardiol 2023;30:384–92. doi:10.1093/eurjpc/zwac309
      OpenUrl
    50. ↵
      1. Marra M,
      2. Sammarco R,
      3. De Lorenzo A, et al
      . Assessment of body composition in health and disease using bioelectrical impedance analysis (BIA) and dual energy X-ray Absorptiometry (DXA): a critical overview. Contrast Media Mol Imaging 2019;2019:3548284. doi:10.1155/2019/3548284

    Supplementary materials

    • Supplementary Data

      This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    Footnotes

    • Presented at Data from the present study was accepted as a late-breaking oral presentation abstract at the EULAR 2023 Congress.

    • Contributors KRN contributed to study design, data acquisition, draft of manuscript and final approval of the manuscript. AGS contributed to study design, data acquisition, critical revision and final approval of the manuscript. CF and EB were involved in data acquisition, critical revision and final approval of the manuscript. ATT, HD, JH, SØ, GSM, JSexton, JSkandsen and TB contributed to study design, critical revision and final approval of the manuscript. ATT is the guarantor for this paper.

    • Funding The ExeHeart trial is supported by the Dam Foundation (grant number 2021/FO347439), REMEDY—Center for treatment of Rheumatic and Musculoskeletal Diseases (grant number 328657), Dr Trygve Gythfeldt and Wife's Research Fund (June 2021, no grant number), the Norwegian Rheumatism Association (November 2021, no grant number) and the Norwegian Health Association (grant number 25576). This work was further supported by a Research Voucher from the European Alliance of Associations for Rheumatology.

    • Competing interests KRN has received lecture honoraria from UCB. AGS has received lecture honoraria from Merck/Schering-Plough, BMS, UCB, Pfizer/Wyeth, Sanofi, Novartis, Pfizer and Lilly and is secretary of ESC Cardiovascular Pharmacotherapy working group.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.