Text Reminders Help Patients With RA Sit Less

Janis C. Kelly

September 25, 2019

Simply convincing patients with rheumatoid arthritis (RA) to replace 50 minutes of sitting per day with 50 minutes of standing or walking was as effective as aerobic exercise for improving fatigue, pain, health-related quality of life (HR-QoL), and physical function, according to a study reported September 19 in Arthritis Care & Research. The intervention included three counseling sessions and up to five text messages per week reminding patients to get up and move.

"This health promotion strategy proved effective in reducing daily sitting time, improving self-reported clinical outcomes and cardio-metabolic health in patients with rheumatoid arthritis immediately after a four-month behavioral intervention consisting of motivation counselling and text message reminders," Tanja Thomsen, PhD, and colleagues write.

Thomsen, from the Copenhagen Center for Arthritis Research in Denmark, told Medscape Medical News that in addition to recommending exercise and strenuous activity, clinicians should help patients identify opportunities to move more during the day.

Examples include "going [on] that extra evening walk, raising your desk more often (if office work), walking to the shops/social events, active commuting, et cetera," Thomsen said. "Another important key point in this area is that our everyday lives and priorities can be very different from each other, pointing to the importance in addressing changes in daily activity patterns on an individual basis."

Benefits to RA Patients Continued for 18 Months

"Immediately after the 4-month intervention, the intervention group had reduced their daily sitting time by on average 1.6 hours. As the control group had in fact increased their daily sitting time, the difference between the two groups was 2.1 hours," Thomsen explained.

"We observed similar results/behavioral patterns 18 months after end of the intervention, . . . indicating that the physical activity behavior (increased light-intensity physical activity) was well adopted in the participants' everyday lives. Both at short- (4 months) and long-term (22 months) time points we observed improvements in fatigue, pain, health-related quality of life, physical function, general self-efficacy, and cholesterol levels. Additionally, at the long-term assessment, we also observed significant changes in triglycerides and average blood glucose levels in the intervention group compared to the control group."

The researchers conducted a single-center, two-arm observer-blinded randomized controlled trial. Prospective patients — identified with the DANBIO database — were older than 18 years, had RA for longer than 1 year, had a Health Assessment Questionnaire score below 2.5, had access to a mobile phone, understood and spoke Danish, and reported a baseline sitting time of more than 5 hours per day. Exclusion criteria included pregnancy and more than 8 hours per week of vigorous physical activity. At baseline the participants spent a mean of 9.3 hours per day in a sitting/lying posture, and the intervention group had approximately 1 more hour per day of sitting.

Participants were randomly assigned in a 1:1 ratio to either the intervention group or to the control group (n = 75), which maintained usual activity. The study was powered for an 80% ability to detect a group mean difference of 50 minutes per day of sitting time.

The 4-month intervention included three individual motivational counseling sessions and zero to five text messages per week, with the objective of helping the patient increase light-intensity physical activity and reduce sedentary behavior such as sitting. Participants received written and oral information about the benefits of reducing daily sitting time.

Patients in the intervention group set individual behavioral goals and made action plans in the first session, then reviewed outcomes and modified or set new goals in the two subsequent sessions. After each counseling session a communications specialist drafted text messages reminding participants of their personal behavioral goals, and the participants chose the time and frequency of the text messages.

The authors emphasize that the "intervention was individualized and targeted a low-intensity physical activity behavior that was possible even on days dominated by fatigue, pain and decreased mobility. The focus on reducing sedentary behavior and replacing it with light-intensity physical activity together with the individual and everyday life perspective may explain the sustained effect of the intervention."

Activity Monitor Assessed Sitting Time

Each participant wore an activPAL activity monitor for 7 days at outcome assessments, which were at baseline, after 4 months, after 6 months, and after 18 months. The primary outcome measure was change from baseline to 22 months in daily sitting time. The authors explain that the minimal clinically important difference for daily sitting time has not yet been determined.

Secondary outcomes included self-reported daily sitting time at work and during leisure time, number of breaks in daily sitting time, pain, fatigue, physical function, HR-QoL, Short Form Health Survey, and general self-efficacy.

The researchers also measured resting blood pressure, serum total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, and estimated average glucose.

At 22 months, 57% of the intervention group had reduced their daily sitting time by at least 50 minutes per day, compared with only 9% of the control group.

Most secondary outcomes also improved in the intervention group, including statistically significant improvements in pain, fatigue, HR-QoL, physical function, general self-efficacy, total cholesterol, triglycerides, and estimated average glucose.

Thomsen said, "What we found particularly interesting in our study results was that the effect on fatigue, pain, physical function, and QoL was sustained — even after 22 months."

"Our results are important on more than one level; first, this is the first trial to specifically target if, and to which degree, reduction in daily sedentary behavior and increase in physical activity of light intensity can be achieved in patients with RA. Second, we included a long-term evaluation of this health promotion approach," the authors write.

They conclude, "Our intervention showed highly significant immediate (4 months post-baseline) and long-term (22 months post-baseline) effects on most self-reported clinical outcomes, for example, fatigue, pain, HR-QoL and physical function. These results are comparable to those found as a result of aerobic exercise in patients with RA."

RA Patients "Undoubtedly Healthier" After Intervention

David Bartlett, PhD, Duke University School of Medicine, Durham, North Carolina, and Duke rheumatologist Brian Andonian, MD, who have both studied the effects of walking on RA disease activity, told Medscape Medical News that the data from Thomsen and colleagues are "very good" and suggest that by reducing sitting time and increasing standing time, patients with RA will have better health measures than if they did not change their behaviors.

"One caveat is that the researchers have only reported between-group differences in change scores. Therefore, it is unclear what was driving the significant effects. For example, did the intervention group have significant improvements and the control group have significant decrements? Or was the between-group effect simply because one group was trending to improvements while the other trending towards decrements? Although from a scientific point of view this is important, for the patients on the intervention arm this doesn't matter as much, because they are undoubtedly healthier than had they been on the control arm," they added.

Thomsen said, "Based on the literature and our recent results we would recommend that lifestyle information and guidance in general should be part of the rheumatology treatment package. Based on our results, an important message in this guidance would be that even small changes in physical activity patterns may matter in prevention of RA symptoms and maintaining a good general health status."

RA Experts Recommend Text Messaging

Although Thomsen suggested that preparing and sending the multiple individually tailored text messages on the basis of the participant's behavioral goals might not be feasible in routine clinical practice, Bartlett, who is currently studying home-based exercise training in patients with cancer before they receive stem-cell transplants, has had excellent responses using weekly text messaging and FaceTime communication to encourage patients to keep to the program and make necessary modifications.

Andonian commented, "One of the biggest challenges we have in clinical practice is getting our patients to move more and sit less. A major barrier is that many patients with RA only have contact with the medical community during 15- to 30-minute clinic visits with their provider. . . . The use of text message reminders, as described by Thomsen et al, and other digital health technologies provide one avenue for getting around this problem and should be implemented in routine practice to increase physical activity in patients with RA."

The study authors have disclosed no relevant financial relationships. Bartlett and Andonian have disclosed no relevant financial relationships.

Arthritis Care Res. Published online September 10, 2019. Abstract

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