RA-Specific Physical Activity Resources Provide Guidance but Need Improvement

While some high-quality rheumatoid arthritis (RA)–specific physical activity resources provide actionable advice, overall effectiveness remains an area for improvement, according to a study published in BMJ Open.¹

The researchers emphasized that effective disease self-management among patients with RA between regularly scheduled follow-up appointments is crucial to quality care. Physical activity is strongly recommended as part of effective RA self-management. Regular physical activity can significantly reduce fatigue, pain, inflammation, and the risk of all-cause mortality or cardiovascular disease.

However, patients with RA lack disease-specific physical activity resources, rarely receive physical activity advice from their care team, and express doubts about the safety and effectiveness of it.² The researchers noted that publicly available, RA-specific physical activity resources may help address these problems, but the quality of online health information varies widely.¹

An extensive library of physical activity resources will better support the different needs, capabilities, and considerations of patients with rheumatoid arthritis (RA), according to the researchers. | Image Credit: Halfpoint - stock.adobe.com

Therefore, they completed an environmental scan of publicly available physical activity resources for patients with RA to outline their characteristics and evaluate their quality. It was conducted through Google searches, using various combinations of related terms from January to April 2024. Because most online search traffic is on the first 2 results pages, the researchers reviewed all links on these pages plus those on pages 3 through 5 to ensure no relevant resources were missed.

Eligible resources were freely available, written in English, developed specifically for patients with RA, and contained at least one physical activity recommendation. Included resources underwent a comprehensive critical appraisal for medical appropriateness, readability, understandability, actionability, quality of exercise recommendations, and the use of behavior change techniques.

Two independent experts completed a medical review to ensure each resource was safe and appropriate for patients with RA. Only resources that had no concerns across safety and appropriateness were approved as medically suitable for patients with RA. Also, Readability was assessed using the Flesch-Kincaid Reading Grade score. The score ranges from 1 to 18, corresponding to the US school grade reading level required to understand the resource.

Next, understandability and actionability were assessed using the Patient Education Materials Assessment Tool. The understandability domain evaluated 6 subdomains for content, use of numbers, organization, use of visual aids, word choice and style, and layout and design. On the other hand, actionability measures the degree to which a resource provides actionable steps for patients using the provided information.

Each item was rated as 1 (agree), 0 (disagree), or not applicable by 3 assessors. The researchers calculated mean scores using equal weighting for the consensus score, with a higher percentage indicating better understandability or actionability.

Additionally, the quality of exercise recommendations was evaluated by a single expert reviewer. The presence of exercise recommendations, cautions, actionable tips, and tailored advice for patients with RA in each resource was analyzed closely. Similarly, a single reviewer evaluated the presence of physical activity behavior change techniques recorded across 16 groups from the behavior change technique taxonomy; the groups were considered present if one or more techniques from that group were identified.

The initial search yielded 33 potential resources, but only 23 met the inclusion criteria. The medical review determined that only 17 of the 23 resources were appropriate and safe for patients with RA. All 17 resources originated from English-speaking countries: Canada (n = 8), the UK (n = 5), the US (n = 3), and Australia (n = 1).

Of the resources, 10 were print materials and 7 were audiovisual resources. The involvement of health care professionals was documented in 14 of the 17 resources, but only 6 of the 17 included an interactive component.

The researchers found that the mean (SD) reading grade level of the 10 print resources was grade 9.0 (1.5), while the recommended level is grade 6 or lower. Among the resources, only one met this guideline, while another was slightly above, falling within the 7th-grade range. The remaining materials required a grade 9 or higher reading level.

Also, the mean (SD) understandability ratings were 80.0 (9.8) for print materials and 86.0 (9.2) for audiovisual materials. The researchers noted that the mean (SD) accountability ratings were lower for print materials (60.0 [27.7]) than for audiovisual resources (86.9 [22.9]). While all resources scored above 60% for understandability, 50.0% (n = 5) of the print resources and 14.3% (n = 7) of the audiovisual resources had actionability ratings below 60%.

Additionally, 82.4% (n = 14) of the resources included specific exercise recommendations. Among them, 13 (92.9%) provided guidance on cardiovascular and/or strength exercises, 6 (42.9%) included flexibility exercise recommendations, and 5 (35.7%) gave balance exercise recommendations.

Lastly, in the review of physical activity behavior change techniques, the researchers determined that the mean (SD) number of behavior change groups used was 9.0 (4.4) for PDF resources, 6.3 (4.5) for audiovisual materials, and 5.7 (2.1) for websites. All 16 behavior change groups were included in at least 1 resource, with “identity,” “scheduled consequences,” and “convert learning” being the least common. Conversely, the most frequently used were “shaping knowledge” and “natural consequences.”

The researchers acknowledged their study’s limitations, one being that the exercise and behavioral appraisal were completed by one person. Although this individual had significant expertise in the topic areas, potential coding biases may have emerged. Despite their limitations, the researchers used their findings to suggest next steps.

“More work is needed to create resources that provide complete FITT [frequency, intensity, time, type] recommendations for exercise and go beyond providing knowledge to truly empowering behavior change,” the authors concluded. “…A bigger library of excellent physical activity resources will better support the different needs, capabilities, and considerations of individuals with RA.”

References

1. Ester M, Zafar S, Dhiman K, et al. Online physical activity resources for individuals with rheumatoid arthritis: an environmental scan and quality appraisal. BMJ Open. 2025;15(2):e094220. doi:10.1136/bmjopen-2024-094220
2. Veldhuijzen van Zanten JJ, Rouse PC, Hale ED, et al. Perceived barriers, facilitators and benefits for regular physical activity and exercise in patients with rheumatoid arthritis: a review of the literature. Sports Med. 2015;45(10):1401-1412. doi:10.1007/s40279-015-0363-2