Tailoring Strength Training Prescriptions for People with Rheumatoid Arthritis: A Scoping Review

Introduction: Prescribing strength training (ST) for people with rheumatoid arthritis (RA) is complicated by factors (barriers and facilitators) that affect participation. It is unclear whether guidelines include recommendations beyond prescription parameters (frequency, intensity, time, type, volume, and progression) and adequately incorporate participation factors tailored to people with RA. Objective: To summarize available recommendations to aid in the tailoring of ST prescriptions for people with RA. Methods: Medline, Embase, and CINAHL databases and gray literature were searched for guidelines, recommendations, and review articles containing ST prescription recommendations for RA. Article screening and data extraction were performed in duplicate by two reviewers. Results: Twenty-seven articles met the inclusion criteria. The recommendations address RA-specific ST participation factors including: knowledge gaps (of equipment, ST benefits, disease), memory problems, the management of joint deformity, comorbidity, the fluctuating nature of the disease and symptoms (pain, stiffness, flares), fear avoidance, motivation, need for referral to other professionals, and provision of RA-specific resources. Conclusion: This review summarizes recommendations for tailoring ST prescriptions for people with RA. Future research is required to understand how pain, symptom assessment, and unaddressed ST participation factors like sleep and medication side effects can be addressed to support ST participation amongst people with RA.


Introduction
Rheumatoid arthritis (RA) is an autoimmune inflammatory disease affecting 1% of the Canadian adult population. 1,2Pathological immune processes lead to dysregulated inflammation of the synovial membrane, resulting in structural joint damage and joint pain. 1 The systemic inflammation associated with RA often leads to other secondary complications including changes in body composition (e.g., rheumatoid cachexia with increased fatty infiltration into muscle), declines in functional ability, cognitive dysfunction, fatigue, as well as co-morbidities such as depression, cardiovascular disease, hypertension, dyslipidemia, and secondary osteoarthritis. 1,3trength training is a safe intervention that can address many sequelae of RA.Strength training is done by sustaining or repeating muscular action with a goal to increase muscle strength and muscle mass. 4It can be done with the use of one's body weight, elastic resistance bands, household items, machines, or free weights. 5In addition to increasing muscular strength, strength training has been shown to reduce pain, 6 lower inflammatory markers, 7 improve body composition (i.e., decreased fat mass, increased muscle mass), 8,9 increase functional ability (e.g, walking performance), 6,7 and lower cardiovascular and other comorbidity risk among individuals with RA. 10,11 In addition to these benefits, even high intensity strength training has been found to be well tolerated by people with RA with no evidence of worsening disease activity nor radiological joint damage. 7,12In 2018, The European League Against Rheumatism (EULAR) published physical activity recommendations supporting strength training as an integral part of standard care in RA.Specifically, they provide strength training prescription recommendations (frequency, intensity, time, type, volume, progression; FITT-VP) and advise participation in strength training at least twice per week. 13espite its broad benefits, only 1-14% of people with RA engage in regular strength training. 14,15rriers to participation in strength training identified in people with RA include challenges with recall of exercise technique, knowing how to adapt the exercise routine during a flare, knowing how to distinguish RA-related joint pain from delayed onset muscle soreness, and fearing that exercise may trigger symptoms. 16Further, healthcare professionals including rheumatologists, nurses, and physical therapists acknowledge the importance of physical activity but the majority of those surveyed were uncertain on how to prescribe strength training to individuals with RA. 17,18 While there is a focus on how to prescribe strength training based on FITT-VP parameters, 7,13,19,20 it is equally important to highlight strategies that may facilitate the delivery of strength training prescriptions. 21,22The 2018 EULAR recommendations note that while the FITT-VP recommendations are well established, their feasibility amongst people with RA is not as well studied.Therefore, the purpose of this scoping review is to summarize current available recommendations from clinical practice guidelines, review articles, and recommendation papers that address participation factors to aid in the tailoring of strength training prescriptions for individuals with RA.

Materials and Methods
The scoping review methodology was based on the Arksey and O'Malley (2005) framework 23 which was updated by Levac et al. 24  (2010).Reporting was guided by the Preferred Reporting Items for Systematic Reviews and Meta Analyses-Scoping Review (PRISMA-ScR) checklist. 25Scoping review methodologies are recommended for addressing exploratory research questions by "mapping" evidence to synthesize knowledge and determine gaps in the research area. 23,24,26Given the broad nature of the research question, a scoping review was conducted as opposed to a systematic review, which may be more suited towards answering a specific question addressing outcome measures of a certain treatment or practice. 27Furthermore, the Arksey and O'Malley (2005) 23 scoping review framework includes an optional step in which stakeholders are consulted to offer their perspective on methodology and preliminary findings.We used an integrated knowledge translation approach, 28 whereby patient and healthcare professional partners were engaged in the scoping review process.Specifically, seven patient partners with arthritis, recruited from Arthritis Research Canada's Arthritis Patient Advisory Board, 1 codeveloped the research question, data extraction sheet, interpreted the data, and contributed to manuscript writing.The details of their involvement are described within each phase of the methods.The scoping review protocol was uploaded to Open Science Framework on July 10 2020 (https:// osf.io/n4ygx/?view_only= 8cbeb4acb6034 606bb757e97ceb5f1c3at).

Identifying the Research Question
This scoping review addressed the broad question, "what are the available recommendations for tailoring strength training prescriptions for people with RA?" Seven patient partners, two of whom are physical therapists, codeveloped the research questions and identified specific subquestions to guide the scope of the research question. 29The specific objective was to identify recommendations for tailoring strength training prescriptions for people with RA.

Identifying Relevant Studies
A medical librarian was consulted to develop the search strategy.The search was completed in May 2020.MEDLINE (OVID), Embase, and CINAHL were searched using the following keywords: (1)   31 The full data extraction sheet can be found in Supplemental Material 3.

Quality Appraisal
All guidelines (including expert recommendations, evidence-based guidelines, and consensus-based guidelines) were assessed using the Appraisal of Guidelines for Research and Evaluation Instrument (AGREE II). 32It contains 23 items encompassing 6 domains including scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. 33The quality of systematic reviews was evaluated using the 16-item AMSTAR 2 tool (A Measurement Tool to Assess systematic Reviews). 34arrative reviews were not evaluated with AMSTAR 2. AMSTAR 2 has yielded evidence of acceptable inter-rater agreement for most items when tested on a sample of 54 systematic reviews across 3 pairs of raters. 34AGREE II and AMSTAR 2 scoring was done independently by JM and MW, and discrepancies were resolved through discussion.LL acted as a third reviewer to resolve discrepancies.While not appraised for quality, recommendations that were supported by sources other than guidelines or systematic reviews (e.g., non-systematic reviews) were flagged as limitations in the discussion.

Summarizing and Reporting the Findings
Descriptive analysis was conducted on article characteristics.Key findings and recommendations were categorized into factors that affect strength training participation by the core research team (MW, JM, and LL).These recommendations and their categorizations were presented to patient and healthcare professional partners to ensure relevance to end-users.

Characteristics of Included Studies
The search strategy retrieved 266 articles, 160 of which were screened for title and abstract.Of those, 101 were excluded with 59 articles proceeding to full text review.32 full text articles were not eligible, leaving 27 articles eligible for review (Figure 1).Articles included in this scoping review were published between 1996 and 2019, with the majority (n = 15) published in 2010 or later (Table 1).Of the 27 articles, there were 12 narrative reviews, 5 systematic reviews, 5 consensus-based guidelines, 4 expert recommendations, and 1 evidence-based guideline.The majority of articles were targeted towards healthcare professionals (n = 20).Our full data extraction sheet is found in Supplemental Material 3.

Recommendations for Tailoring Strength Training Prescriptions for People with RA
Several participation factors were addressed in the tailoring of strength training prescriptions for people with RA and are summarized in Table 2.These included knowledge gaps (of equipment, strength training benefits, disease), memory problems, the management of joint deformity, comorbidity, the fluctuating nature of the disease and symptoms (pain, stiffness, flares), fear avoidance, motivation, need for referral to other healthcare and exercise professionals, and provision of RA-specific resources.Specific prescription recommendations based on individual characteristics of age, RA disease activity, strength training experience, and performing strength training during a flare were also identified (Table 3).Tables 2 and 3   11).Four of the five appraised articles provided some account for RoB when framing and discussing the results of the review (Question 13).Finally, two of the three meta-analyses investigated publication bias and discussed its impact on the results of the review (Question 15).Critical domain scores for the 5 appraised review articles are shown in Table 5.

Recommendations for Tailoring Strength Training Prescriptions for People with RA
This review highlights available recommendations for tailoring strength training prescriptions for people with RA.Findings span recommendations that address an individuals' capability, opportunity, and motivation to participate in strength training. 56While the scope of recommendations to address participation factors (e.g., barriers and facilitators) was diverse, no single article addresses the full range of factors that affect strength training participation among people with RA.This is supported by the finding that "applicability" of the reviewed literature, which considers the extent that articles provide tools for application and discuss practical considerations such as barriers to implementation, was the lowestscored AGREE II domain. 33urthermore, many participation factors (e.g., sleep, fatigue, medication side effects, mental health status) lack evidence for recommendations that adequately target these in the context of strength training.

Clarifying Pain Recommendations
Recommendations regarding pain monitoring were at times conflicting.Pain duration was recommended to be monitored with both 2 hours 42,43   Increased functional ability through improvement in walking, greater ease rising from a seated position, or reduced risk of falls Pain can be of a nociceptive character as a result of the inflammatory tissue process, but can also be neurogenic or widespread 40,52,53   Joint instability is the result of elongated/lax tendons, ligaments and joint capsules 40 Fatigue associated with RA is proposed to be related to pain, cerebral inflammation, and physical inactivity and/or lack of sleep and 24 hours suggested as a threshold for when to be concerned about pain. 13,40Of note, the 24-hour threshold is supported by a guideline 13   Guidelines included (a) a systematic literature review including a subsequent synthesis of the evidence and a structured consensus process completed by a representative committee (S3), (b) a systematic literature review and synthesis of the evidence only (S2e), (c) a structured consensus process completed by a representative committee only (S2k), or (d) an informal consensus process by a group of experts (S1).Many of the included recommendations suggested using symptoms to guide strength training prescription, but specifics on how to use findings from symptom assessment to inform prescriptions were lacking.For example, it was recommended to assess joint symptoms, pain, and stiffness to determine whether the program needs adaptation on a given day. 37,39,43Using the warm-up was also recommended to assess how the patient is feeling. 39Disease activity and symptom fluctuation is a common experience amongst individuals with RA 61 and a challenge for prescribing strength training, although little evidence is available to guide practice. 30ssessment of other factors beyond disease activity and symptoms may also be important for supporting clients in strength training participation.Recommendations from the European League Against Rheumatism (EULAR) advise comprehensive assessments of physical, social, and psychological factors to adapt programs. 13ikewise, evidence on which factors to assess and how to assess them in the context of strength training has not been described to date.This practice is still in its infancy and further research is needed on what assessments can be used to individualize and adapt strength training prescriptions.In the interim, this process will require ongoing trial and error and collaboration between professionals and their patients.

Patient-Level Factors Remaining to be Addressed
Strength training research and recommendations would benefit from exploring how factors such as sleep, mental health status, fatigue, and medication side effects can be managed to facilitate participation in strength training.3][64][65][66][67] Fatigue has been shown to be associated with mental well-being and sleep disturbance in patients with RA. 68 Also, medications such as methotrexate and prednisone can be associated with side effects including fatigue and sleep disturbance, as well as weight gain, respectively. 64,69Many of the included articles in this scoping review noted strength training's positive effects on mental health and emotional status. 39,50,51However, previous work on general physical activity has acknowledged the potential role of addressing mental health early in the program so that patients with RA can experience these mental health benefits. 18verall, these participation factors have complex relationships amongst themselves and with strength training.Future research should explore how to optimally prescribe strength training in the face of these complex participation factors while considering the unique interconnected relationships at play.

Strengths/Limitations
A few limitations must be acknowledged.First, the inclusion criteria of guidelines, recommendations, and reviews precludes the ability to examine the evidence of relationships between the prescription recommendations and strength training participation.In other words, it is unclear whether applying these recommendations for strength training prescription leads to increases in strength training participation.This may be an area for future research.Second, the broad nature of the research question required including articles of variable quality.This resulted in some conflicting statements in Table 2 which summarizes prescription recommendations made in each article.To address this issue, the summary of recommendations has been contextualized within the quality of their sources in the discussion where appropriate and the use of the AGREE II or other guidelines are encouraged to promote higher methodological quality in future research or guidelines.Third, only articles with full text written in English were included meaning articles in other languages may have been excluded.A strength of this scoping review was the use of an integrated knowledge translation approach, engaging both patient and healthcare professionals throughout the review process, helping improve the relevance to patients with rheumatologic conditions and their healthcare professionals.

Table 1 .
Description of Included Articles.
g., 1 repetition maximum) should be avoided.It may be helpful to have a plan for flare and non-flare days.7.Ask or assess how the client is feeling (e.g., joint symptoms, pain, stiffness) at the 12.To help maintain the program, progress slowly to help overcome fear of being active, incorporate activities that the client enjoys, are convenient, and provide variety.Suggest exercising with a friend or joining a group class, and use behavior change techniques such as goal setting and action planning to help your client stick to their goals.13.If the client's needs for strength training exceed the clinician's scope and experience, the client should be referred to a more appropriate exercise professional.Quality Appraisal Guidelines.The highest average AGREE II domain score was given for clarity of presentation (95%) the lowest average domain score (19%)Figure 1. PRISMA Flow Diagram.

Table 1 .
(continued) a Some articles fulfilled multiple criteria for a given category.RA, rheumatoid arthritis.

Table 2 .
Recommendations for Tailoring Strength Training Prescriptions for People with Rheumatoid Arthritis.
If pain and fatigue are worse over the next few days, recommend doing less for the next session 38 Monitor pain on a scale of 0-10 41 Pain due to muscle soreness is usually harmless, but if it lasts more than 24 hours after exercise consider reducing the intensity13Strength training is discouraged during flare ups, although it is acknowledged that this is based on opinion and not linked to evidence

Table 3 .
Strength training prescription recommendations based on individual characteristics.

Table 4 .
Mean AGREE II Domain Scores for Guidelines a

Table 5 .
AMSTAR-2 Assessment of Systematic Reviews According to Critical Domains.
a Question 11 and Question 15 only applied to systematic reviews with quantitative analysis.