Arthritis Patients Show Long-term Benefits From 3 Weeks Intensive Exercise Training Directly Following Hospital Discharge

Y. Bulthuis; K. W. Drossaers-Bakker; E. Taal; J. Rasker; J. Oostveen; P. van't Pad Bosch; F. Oosterveld; M. van de Laar


Rheumatology. 2007;46(11):1712-1717. 

In This Article

Abstract and Introduction


Objective. To examine the efficacy of short-term intensive exercise training (IET) directly following hospital discharge.
Methods. In the Disabled Arthritis Patients Post-hospitalization Intensive Exercise Rehabilitation (DAPPER) study, patients with rheumatoid arthritis or osteoarthritis were eligible when they needed hospitalization for either a flare-up in disease, elective hip or knee arthroplasty. The intervention group received IET for 3 weeks immediately after discharge; the control group was treated with the usual care (UC). The intensive exercise was provided in a resort. Outcomes were assessed at baseline, after 3, 13, 26 and 52 weeks. Range of motion was measured using the Escola Paulista de Medicina–Range of Motion scale (EPM-ROM), disability was measured using the HAQ and the McMaster Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR), and for health-related quality of life (HRQoL), the Research and Development 36-Item Health Survey (RAND-36) was used.
Results. The IET showed a better and faster improvement than UC on all outcome measures except for HRQoL. Up to 52 weeks after baseline, the EPM-ROM and the MACTAR remained favourable in IET compared with UC. At 3 weeks, the MACTAR improved significantly more in the IET compared with the UC: mean difference –5.5 (95% CI –8.4 to –2.2). At 26 weeks, the mean difference remained significant (–5.2; 95% CI –10.0 to –0.34). At 52 weeks, the effect was not significant; however, the mean difference in improvement between the groups can be considered clinically relevant. At 3 weeks, the IET had improved significantly more on the HAQ walking and rising subscales.
Conclusion. Intensive short-term exercise training of arthritis patients, immediately after hospital discharge results in improved regain of function. The DAPPER programme has a direct effect, which lasts up to 52 weeks.


Despite different pathophysiological processes, patients suffering from either rheumatoid arthritis (RA) or osteoarthritis (OA) experience pain and a gradual decline in muscle strength, eventually resulting in loss of function and quality of life. Hospitalization is required for arthritis patients who have a flare-up in disease activity or those requiring elective joint replacement. Especially during hospitalization, a rapid decline of function is observed.[1] Increasing evidence shows that physical exercise improves function and prevents loss of function in both RA and OA.[2–6]

In hospitalized patients suffering from arthritis (OA as well as RA), the ability to regain function is retarded.[7,8] Although, inpatient exercise is shown to be beneficial, the effects of intensive training directly following discharge has never been studied in these patients. Since risk factors for arthritis such as senescence and obesity in the population will increase, more arthritis patients will require hospitalization for joint replacement. Therefore, research into an optimal strategy to regain function and quality of life is warranted.

In RA patients, several exercise programmes have been investigated. Long-term high-impact exercise has been proven to be beneficial regarding function and muscle strength in patients with low disease activity in an outpatient setting. In contrast to the earlier belief, exercise did not increase disease activity.[6,9,10] In RA patients with active disease, an inpatient programme with frequent exercise therapy was found to be superior to usual care (UC) regarding disease activity as well as muscle strength.[9] However, inpatient interventions are costly. Physical exercise in a resort might be more acceptable to patients, and might be as effective as an inpatient hospital programme at lower costs.

Exercise was also found to have beneficial effects in OA patients. Positive effects were found in function, pain and muscle strength.[11–18] In patients with moderate functional limitations, early mobilization after arthroplasty resulted in improved functional ability.[19,20] Even elderly, frail patients admitted for joint replacement were able to tolerate early intensive inpatient exercise therapy resulting in faster attainment of functional ability.[21] However, studies reporting the long-term effects of exercise following joint replacement are lacking.[22]

We hypothesize that the recovery of function in arthritis patients improves with a short-term intensive exercise programme in a resort following hospital discharge. To test this hypothesis, the Disabled Arthritis Patients Post-hospitalization Intensive Exercise Rehabilitation (DAPPER) study was designed to investigate the short- and long-term effects of an intensive short-term exercise programme on function and health-related quality of life (HRQoL) in arthritis patients directly following hospital discharge.


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