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Introduction

Over the past decades, a number o physical activity andexercise programs or people with arthritis have beendeveloped and evaluated, resulting in a body o evidenceabout their benets (Van den Ende et al 1998, Ettinger etal 1997, Hkkinen et al 2001). Physical activity is denedas any bodily movement that results in energy expenditure,with activities that are not related to work or householdduties being reerred to as leisure-time physical activity(Caspersen et al 1985). Exercise is a subset o physicalactivity that is structured, planned, and repetitive, and isperormed with tness in mind (Caspersen et al 1985).However, in daily practice it appears that there is under-usage o physical activity or exercise programs (Boutaugh2003, Hootman et al 2002) as well as unmet demand orallied health care, including physiotherapy, among peoplewith rheumatoid arthritis (Kjeken et al 2006, Jacobi et al2004). It could thereore be hypothesised that the currentprovision o physical activity programs does not completelymatch the needs and preerences o people with rheumatoidarthritis. This is undesirable, as it has been demonstrated that

programs aimed at promoting physical activity and exerciseare likely to be most eective i they address the needsand interests o the people involved (Green and Kreuter1991). Moreover, there is little inormation on what peoplewith arthritis actually preer with respect to participation

in physical activity and exercise. Thereore, the researchquestions were:

1. What type o physical activity or exercise is undertakenby people with rheumatoid arthritis?

2. What type o physical activity or exercise do theypreer?

3. What is their attitude towards physical activity or

exercise?4. What are the perceived barriers to undertaking physical

activity or exercise?

Method

Design: A random sample o people with rheumatoidarthritis rom the Leiden University Medical Center in theNetherlands was surveyed in April 2004. Participation inleisure-time physical activity and exercise was measuredusing a customised questionnaire. All eligible peoplereceived a postal questionnaire, an inormation letter, anda response envelope. Participants were asked whetherthey currently or in the previous 12 months participatedin 11 predened activities (with examples) or any otherleisure-time physical activities or exercises. Preerenceswere measured by asking people to choose their topthree avourite physical activities rom the 11 predenedactivities. Attitude towards physical activity was measured

Most people with rheumatoid arthritis undertake leisure-

time physical activity and exercise in the Netherlands: an

observational study

Marleen H van den Berg, Ingeborg G de Boer, Saskia le Cessie, Ferdinand C Breedveld andTheodora PM Vliet Vlieland

Leiden University Medical Centre, The Netherlands

Question:What type of physical activity or exercise is undertaken by people with rheumatoid arthritis? What type of physicalactivity or exercise do they prefer? What is their attitude towards physical activity or exercise? What are the perceived barriers toundertaking physical activity or exercise? Design:Survey of a random sample of people with rheumatoid arthritis. Participants:Four hundred people with rheumatoid arthritis in the Netherlands. Results: Of the 252 people who returned the questionnaire(63% response) 201 (80%) people participated in some type of physical activity or exercise. Signicantly more inactive people

were male, less educated, and older than the active people. Of the active people, 45 (22%) participated exclusively in supervisedactivities, 72 (36%) in unsupervised activities, and 84 people (42%) combined supervised and unsupervised activities. Cyclingand walking were the two unsupervised activities people performed most often. Supervised group exercise and unsupervisedindividual physical activity were reported as the favourite activities. Further, more people preferred being physically active underexpert supervision than without supervision and preferred water-based over land-based activities. The most frequently-mentionedbarriers were lack of energy, presence of pain, lack of motivation, lack of information, and fear of joint damage. Conclusion:The majority of people with rheumatoid arthritis participated in some physical activity or exercise, mostly under supervision.Preferences for types of activity varied, underpinning the need for a variety of options for people with rheumatoid arthritis. [vanden Berg MH, De Boer IG, le Cessie S, Breedveld FC, Vliet Vlieland TPM (2007) Most people with rheumatoid arthritisundertake leisure-time physical activity and exercise in the Netherlands: an observational study. Australian Journal ofPhysiotherapy 53: 113118]

Key words: Physical Activity, Exercise, Rheumatoid Arthritis

Australian Journal of Physiotherapy 2007 Vol. 53 Australian Physiotherapy Association 2007 113

van den Berg et al: Activity preferences of people with rheumatoid arthritis


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Descriptive statistics were used to summarise the data.Independent samples t-tests, Pearson Chi-square tests, orFishers Exact tests were used to test whether there weresignicant dierences between responders versus non-responders, active versus inactive people, and males versusemales. A one sample Chi-square test was used to testwhether the proportion o people choosing either o twotypes o physical activity diered signicantly rom 50%.Ap value o less than 0.05 was adopted as the criterion orstatistical signicance.

Results

Flow of participants through the study : O the 400 patientswho received the questionnaire, 204 (51%) returned it within4 weeks. O the 196 patients then contacted by phone, 53

Australian Journal of Physiotherapy 2007 Vol. 53 Australian Physiotherapy Association 2007114

Research

using three statements about the extent to which people witharthritis should get specic help rom proessionals to adoptand maintain a physically-active liestyle. There were also10 statements that dealt with barriers to physical activity.These 13 statements were answered on a 4-point Likert scalewhere 1 = ully disagree/absolutely not applicable to me,and 4 = ully agree/totally applicable to me (see Appendix1 on the eAddenda or the ull questionnaire). Those whodid not respond to the questionnaire within our weeks werecontacted by telephone. The study was judged to be nomedical research under the Medical Research Involving

Human Subjects Act (in Dutch, WMO) by the MedicalEthics Review Committee o the Leiden University MedicalCenter so no individual inormed consent was obtained.Patients were ree to either ll in the questionnaire or not.

Participants: Participants were obtained rom a registryo 1500 patients with a veried diagnosis o rheumatoidarthritis (Arnett et al 1988) who had visited the LeidenUniversity Medical Center rheumatology outpatientclinic in the previous 15 months. The registry was sortedin ascending order by the date o their next visit and therst 400 people were selected. Apart rom the diagnosis orheumatoid arthritis, no other selection criteria were used.Participants were asked their age, sex, educational level

(low, medium, high), living status (living alone yes/no),smoking habits (active smoker dened as smoking one ormore cigarettes per day) and whether they were in paidemployment (yes/no). Height and weight were recordedand the body mass index (BMI = weight in kilograms/heightin metres2) was determined and participants categorised asoverweight (BMI 25.0) or not.

Data analysis: The average proportion o people withrheumatoid arthritis participating in some type o physicalactivity or exercise was assumed to be about 80% (Li et al2004, Gecht et al 1996). It was necessary or this estimate tobe within 5 percentage points (0.05) o the true percentagewith 95% condence, which required a sample size oat least 246 people; the standard error o the estimate isthen less than 2.5%. Assuming a response rate o abouttwo-thirds (Barclay et al 2002), we planned to send 400questionnaires.

Table 1. Characteristics of the 252 respondents.

Characteristic Active

(n = 201)

Inactive

(n = 51)

Total

(n = 252)

Active vs Inactive

p value*

Age (yr) mean (SD) 58.7 (11.3) 67.4 (9.8) 60.5 (11.5) < 0.001

Female, number (%) 151 (75) 31 (61) 182 (72) 0.04

Education level, number (%)

Low

Medium

High

90 (45)

80 (40)

31 (15)

34 (67)

14 (28)

3 (6)

124 (49)

94 (37)

34 (14)

0.02

Overweight (BMI 25.0), number (%) 112 (56) 32 (65) 144 (58) 0.25

Current smoker, number (%) 40 (20) 10 (20) 50 (20) 0.99

Living alone, number (%) 33 (17) 13 (26) 46 (18) 0.14

Employed, number (%) 58 (29) 9 (18) 67 (27) 0.13

*Differences analysed using an independent samples t-test, Chi-square test or Fishers Exact test as appropriate.Educational level: low = up to and including lower technical and vocational training or primary school; medium = up to andincluding secondary technical and vocational training; high = up to and including higher technical and vocational training anduniversity

Table 2. Number (%) of the 201 active respondentsreporting participation in different types of physical activityor exercise.

Type of physical activity or exercise Respondents

Supervised physical activity or exercise(n = 129)

Individual

Group

Water-based

Land-based

91 (71)

71 (55)

29 (23)

60 (47)Unsupervised physical activity orexercise (n = 156)

Individual

Cycling

Walking

Swimming

Other (eg, home exercise,aerobics, gardening)

Group

153 (98)

103 (67)

90 (59)

27 (18)

10 (7)

29 (19)


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could not be reached ater trying at least twice on dierentdays o the week, 79 said they did not want or were not ableto ll in the questionnaire, 4 had moved, and 60 said theywould still return the questionnaire. Finally, 252 patients(63%) returned the questionnaire. The non-responders wereslightly older than the responders (mean age = 62.4, SD14.7, and 60.5, SD 11.5 respectively) and were more otenmale (number = 44 or 30%, and 70 or 28% respectively),but these dierences did not reach statistical signicance

(p = 0.17 and p = 0.68, respectively). Table 1 summarisesthe characteristics o the respondents and shows that 201(80%) respondents were active, ie, they had participated insome type o leisure-time physical activity or exercise inthe previous 12 months. Inactive respondents (n = 51) weremore oten male, had a lower education level, and wereolder than active respondents.

Type of physical activity or exercise undertaken: Table 2shows the types o physical activity or exercise undertaken. Othe 201 physically active respondents, 45 (22%) participatedexclusively in supervised activities or exercise, 84 (42%)combined these activities with unsupervised activities, and72 (36%) exclusively participated in unsupervised activities.

O the 129 respondents who participated in supervisedactivities, 58 (45%) participated exclusively in individualsupervised activities, 38 (30%) participated exclusively ingroup supervised activities, and 33 (26%) participated in acombination o individual and group activities. O the 71respondents participating in any type o supervised groupactivities, 42 (59%) exercised in a gym, 11 (16%) in warmwater, and 18 (25%) in both gyms and in water. Withrespect to the 156 respondents participating in unsupervisedactivities, 127 (81%) participated exclusively in unsupervisedindividual activities, 26 (17%) combined these activitieswith unsupervised group activities, and 3 (2%) participatedexclusively in unsupervised group activities. Furthermore,cycling and walking were the two unsupervised activities

that respondents perormed most oten.

Preferences for type of physical activity or exercise: Table3 shows the numbers o respondents reporting varioustypes o physical activity and exercise as their avourite,

compared with the numbers o respondents who actuallyparticipated in those activities. It appeared that supervisedgroup exercise was the avourite physical activity o mostrespondents and almost hal o these respondents actuallyparticipated in this type o activity. Unsupervised individualphysical activity was the second most avourite activity and83% o these respondents actually participated in this typeo activity.

Table 4 shows that signicantly more respondents preerredto be physically active under expert supervision than withoutthis supervision. In addition, the proportion o respondentsthat preerred to be physically active with other people witharthritis was signicantly greater than the proportion that

preerred to be active with healthy people, and signicantlymore respondents preerred participating in water-basedthan in land-based activities.

Attitude towards physical activity or exercise: O 250responses, 238 (95%) agreed or ully agreed with thestatement that people with arthritis are, just like healthypeople, responsible or being physically active. Further, o249 responses, 175 (70%) did not agree with the statementthat people with arthritis can only be physically activewhen they are being supervised by an expert in the eld orheumatic diseases. However, o 244 responses, 180 (74%)agreed or ully agreed with the statement that people witharthritis should get more assistance rom proessionalsin making decisions about which activities or exercise toparticipate in.

Perceived barriers to undertaking physical activity orexercise: Table 5 shows the numbers o active and inactive

Table 3. Number (%) of respondents reporting varioustypes of physical activity and exercise as their favourite,compared with the numbers of respondents who actuallyparticipated in those activities.

Favourite type ofphysical activity or

exercise

Respondents

(n = 212)

Respondentsactually

participating inactivity

Supervised physicalactivity or exercise

Individual

Group

31 (15)

89 (42)

22 (71)

41 (46)

Unsupervised physicalactivity or exercise

Individual

Group

80 (38)

12 (6)

66 (83)

7 (58)

Table 4. Number (%) of respondents expressing an explicitpreference regarding two opposite attributes of differenttypes of physical activity or exercise.

Attribute of physical activityor exercise

Respondents p value*

Supervision

With vswithout supervision

142 (78) vs41 (22)

< 0.001

Present vsdistant supervision

119 (88) vs16 (12)

< 0.001

Telephone vse-mail supervision

24 (34) vs46 (66)

0.01

Cohort

Individual vsgroup

83 (51) vs81 (49)

0.85

With people with arthritisvs with healthy people

100 (65) vs55 (35)

< 0.001

Setting

Indoor vsoutdoor

75 (44) vs97 (56)

0.09

Home vscommunity

63 (38) vs103 (62)

0.002

Water-based vsland-based

124 (69) vs55 (31)

< 0.001

*Differences analysed using a one sample Chi-square test.


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respondents reporting barriers to undertaking physicalactivity or exercise. For both the active and inactiverespondents, lack o energy, presence o pain, lack omotivation, and ear o damaging joints were barriers thatwere mentioned requently. Comparison o the active andinactive respondents revealed no signicant dierences.

Discussion

Our study showed that, over a period o one year, 80% o thesurveyed people with rheumatoid arthritis currently or in theprevious 12 months participated in some type o physicalactivity or exercise. The majority preerred to be physicallyactive under expert supervision, with other people witharthritis, and they avoured water-based activities overland-based activities. Pain, lack o energy, motivation orinormation, and ear o joint damage were the main barriersto undertaking physical activity.

Regarding the proportion o people participating in sometype o physical activity, our results are similar to those oother studies where proportions varied between 56% and83% (Gecht et al 1996, Semanik et al 2004, Da Costa et al

2003, Li et al 2004, Shih et al 2006). Since we did not evaluaterequency or intensity, we cannot determine whether theseactivities were perormed at a health-enhancing level.

Our observation that signicantly more men than womenwere inactive contrasts with other reports (Abell et al 2005,Fontaine et al 2004, Eurenius and Stenstrom 2005, Hootmanet al 2003), whereas the nding that inactive people weresignicantly older and had a lower level o educationthan active people is consistent with previous reports osociodemographic actors associated with physical activityin people with arthritis (Fontaine et al 2004, Abell et al2005, Fontaine and Haaz 2006, Hootman et al 2003). Theseresults suggest that promoting physical activity or specic

groups, such as the elderly and the less educated, remains amatter o utmost importance.

It was ound that more people participated in supervisedindividual exercise than in supervised group activities,

whereas the preerence or group activities appeared tobe stronger than or individual therapy. This discrepancymay have been caused by limited availability o groupexercise in the region where the study was conducted or byinsucient knowledge o the availability and accessibilityo group programs or people with arthritis. Alternatively, itcould also be hypothesised that health care providers reer

people more or less automatically to individual therapy,perhaps because they are not suciently inormed aboutalternatives, such as group exercises.

In our study, cycling and walking were the two most commonunsupervised individual activities. High participation ratesin walking have been reported in other studies concerningpeople with arthritis as well (Semanik et al 2004, Da Costa etal 2003). The high proportion o people engaged in cyclingcould probably be explained by the act that riding a bicycleis a common means o transportation in The Netherlands.

With respect to perceived barriers to undertaking physicalactivity, our results agree with those o other studies

showing that ear o pain or joint damage, atigue, lacko motivation, lack o perceived benets, or sel-ecacywere reasons or non-participation (Li et al 2004, Resnick2001, Schoster et al 2005, Der Ananian et al 2006, De Jonget al 2004, Greene et al 2006, Wilcox et al 2006). Other,more general, barriers to be taken into account includenancial resources (Ball et al 2006), local acility access,and neighbourhood saety (Booth et al 2000). To achievesustained behavioural change, health proessionals engagedin the promotion o physical activity in rheumatoid arthritismay need additional education, including skills such asproviding eedback (DiClemente et al 2001), setting andmonitoring goals (Strecher et al 1995), and counsellingpeople depending on the stage o their condition (Dearden

and Sheahan 2002, Riebe et al 2005).

Our study was not designed to investigate the comparativeeectiveness or cost between dierent types o physicalactivities or people with rheumatoid arthritis. Futureresearch should urther explore these topics, as appropriatedecision-making is still hampered by lack o knowledgeregarding the optimal timing, duration, intensity and extent,and mode o supervision o exercise and physical activityamong people with rheumatoid arthritis. It is conceivablethat, in the uture, better knowledge o the health benetsobtained rom dierent types o physical activity andexercise might infuence peoples preerences.

A limitation o our study is that it pertained to a selectiono people with rheumatoid arthritis, all living in a specicregion in the Netherlands. The availability and accessibilityo acilities, as well as the general unctionality o theneighbourhood (such as the presence o ootpaths, tracconditions), have a great infuence on peoples physicalactivity (McCormack et al 2004). Thereore, our resultsprobably cannot be generalised to other regions or countriesFuture research should include more regions or may evenbe set up as a nation-wide or international study. Moreover,the people who did not send back their questionnairewere slightly older than the responders group, and it isconceivable that this group was less physically active. In

addition, our outcomes were based exclusively on sel-report measures, which could be subject to memory errorand a tendency towards overestimation (Klesges et al 1990).Finally, this study did not compare the types o activitiespeople with rheumatoid arthritis were engaged in withthose o the general Dutch population. For that purpose, an


Research

Table 5. Number (%) of active vs inactive respondentsreporting barriers to undertaking physical activity andexercise.

Barrier Active

(n = 201)

Inactive

(n = 51)

pvalue*

Lack of energy 111 (56) 34 (71) 0.06

Pain 111 (56) 28 (60) 0.64

Lack of motivation 91 (46) 25 (52) 0.43

Lack of information 81 (41) 22 (47) 0.46

Fear of damagingjoints

72 (36) 24 (51) 0.06

Too expensive 54 (27) 11 (23) 0.58

No appropriatephysical activity orexercise available inneighbourhood

44 (23) 13 (27) 0.52

Lack of time 35 (18) 9 (19) 0.85

*Differences analysed using a Pearson Chi-square test


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additional survey among age- and sex-matched people romthe general population would be needed.

The results o our study imply that with respect to supervisedphysical activity, there is a need to investigate whetherthe supply o water-based, supervised group programs issucient, and whether all stakeholders (people, providers,reerring rheumatologists, and health insurance companies)have sucient knowledge about their potential benetsand accessibility. However, nowadays many people preerto engage in physical activity outside structured settings(King 1998) and the promotion o physical activity that isintegrated in daily lie is advocated increasingly (Dunn etal 1999, Pate et al 1995, Croteau 2004). Consequently, thetraditional concept o a structured exercise program has beenbroadened and encompasses the promotion o moderate dailyphysical activities (Sharpe 2003). Thereore, it is importantor health care providers to promote physical activities thatmatch those activities that people already perorm in dailylie and to ocus on how these activities can be modied insuch a way that they are perormed at a health-enhancing

level. In The Netherlands or example, cycling and (nordic)walking are currently popular activities; individual orgroup programs should preerably t these preerences.In other countries or cultures dierent programs shouldbe developed, since the activities commonly perormed indaily lie may dier.

In conclusion, this study shows that the majority o peoplewith rheumatoid arthritis living in the Leiden region inThe Netherlands participated in some type o physicalactivity or exercise. In addition, their preerences regardingtypes o physical activity or exercise varied, stressing theneed or a choice o activity and exercise interventions.Inormation about the type o activities perormed by

people with rheumatoid arthritis and knowledge o theirpreerences are important or health care proessionalsso that physiotherapists or sel-help organisations canprovide the most appropriate programs. The inormationis also important or other stakeholders, such as reerringrheumatologists, clinical nurse specialists, and healthinsurance companies, since helping people with arthritis toadopt or maintain an enjoyable, physically active liestyleremains a challenge or all health care proessionals dealingwith people with arthritis.

eAddendum:Appendix 1 available at www.physiotherapy.asn.au/AJP.

Acknowledgements: We would like to thank all the peoplewith rheumatoid arthritis who participated in this study. Thisstudy was supported nancially by Stichting Vrienden vanSole Mio (Foundation Friends o Sole Mio), Leiden, TheNetherlands.

Correspondence: MH van den Berg, Leiden UniversityMedical Centre, Department o Rheumatology (C1-R),P.O. box 9600, 2300 RC Leiden, The Netherlands. Email:[email protected]

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Statement regarding registration of clinical trials from the

Editorial Board ofAustralian Journal of PhysiotherapyThis journal is moving towards requiring that clinical trials whose results are submitted or publication inAustralian Journalof Physiotherapy are registered. From January 2008, all clinical trials submitted to the journal must have been registeredprospectively in a publicly-accessible trials register. We will accept any register that satises the International Committee oMedical Journal Editors requirements. Authors must provide the name and address o the register and the trial registrationnumber on submission.

pubmed, ra, physical activity and exercise

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