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

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 and
Theodora 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 physical
activity or exercise do they prefer? What is their attitude towards physical activity or exercise? What are the perceived barriers to
undertaking 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. Significantly more inactive people
were male, less educated, and older than the active people. Of the active people, 45 (22%) participated exclusively in supervised
activities, 72 (36%) in unsupervised activities, and 84 people (42%) combined supervised and unsupervised activities. Cycling
and walking were the two unsupervised activities people performed most often. Supervised group exercise and unsupervised
individual physical activity were reported as the favourite activities. Further, more people preferred being physically active under
expert supervision than without supervision and preferred water-based over land-based activities. The most frequently-mentioned
barriers 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. [van
den Berg MH, De Boer IG, le Cessie S, Breedveld FC, Vliet Vlieland TPM (2007) Most people with rheumatoid arthritis
undertake leisure-time physical activity and exercise in the Netherlands: an observational study. Australian Journal of
Physiotherapy 53: 113–118]
Key words: Physical Activity, Exercise, Rheumatoid Arthritis

Introduction in physical activity and exercise. Therefore, the research
questions were:
Over the past decades, a number of physical activity and
exercise programs for people with arthritis have been 1. What type of physical activity or exercise is undertaken
developed and evaluated, resulting in a body of evidence by people with rheumatoid arthritis?
about their benefits (Van den Ende et al 1998, Ettinger et 2. What type of physical activity or exercise do they
al 1997, Häkkinen et al 2001). Physical activity is defined prefer?
as any bodily movement that results in energy expenditure, 3. What is their attitude towards physical activity or
with activities that are not related to work or household exercise?
duties being referred to as leisure-time physical activity
(Caspersen et al 1985). Exercise is a subset of physical 4. What are the perceived barriers to undertaking physical
activity that is structured, planned, and repetitive, and is activity or exercise?
performed with fitness in mind (Caspersen et al 1985). Method
However, in daily practice it appears that there is under-
usage of physical activity or exercise programs (Boutaugh
Design: A random sample of people with rheumatoid
2003, Hootman et al 2002) as well as unmet demand for
arthritis from the Leiden University Medical Center in the
allied health care, including physiotherapy, among people
Netherlands was surveyed in April 2004. Participation in
with rheumatoid arthritis (Kjeken et al 2006, Jacobi et al
leisure-time physical activity and exercise was measured
2004). It could therefore be hypothesised that the current
using a customised questionnaire. All eligible people
provision of physical activity programs does not completely
received a postal questionnaire, an information letter, and
match the needs and preferences of people with rheumatoid
a response envelope. Participants were asked whether
arthritis. This is undesirable, as it has been demonstrated that
they currently or in the previous 12 months participated
programs aimed at promoting physical activity and exercise
in 11 predefined activities (with examples) or any other
are likely to be most effective if they address the needs
leisure-time physical activities or exercises. Preferences
and interests of the people involved (Green and Kreuter
were measured by asking people to choose their ‘top
1991). Moreover, there is little information on what people
three’ favourite physical activities from the 11 predefined
with arthritis actually prefer with respect to participation
activities. Attitude towards physical activity was measured

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

Table 1. Characteristics of the 252 respondents.

Characteristic Active Inactive Total Active vs Inactive
(n = 201) (n = 51) (n = 252) 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 90 (45) 34 (67) 124 (49) 0.02
Medium 80 (40) 14 (28) 94 (37)
High 31 (15) 3 (6) 34 (14)
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 Fisher’s Exact test as appropriate.

Educational level: low = up to and including lower technical and vocational training or primary school; medium = up to and
including secondary technical and vocational training; high = up to and including higher technical and vocational training and

using three statements about the extent to which people with Table 2. Number (%) of the 201 active respondents
arthritis should get specific help from professionals to adopt reporting participation in different types of physical activity
and maintain a physically-active lifestyle. There were also or exercise.
10 statements that dealt with barriers to physical activity.
These 13 statements were answered on a 4-point Likert scale Type of physical activity or exercise Respondents
where 1 = fully disagree/absolutely not applicable to me,
Supervised physical activity or exercise
and 4 = fully agree/totally applicable to me (see Appendix (n = 129)
1 on the eAddenda for the full questionnaire). Those who
did not respond to the questionnaire within four weeks were Individual 91 (71)
contacted by telephone. The study was judged to be ‘no Group 71 (55)
medical research’ under the Medical Research Involving Water-based 29 (23)
Human Subjects Act (in Dutch, WMO) by the Medical Land-based 60 (47)
Ethics Review Committee of the Leiden University Medical Unsupervised physical activity or
Center so no individual informed consent was obtained. exercise (n = 156)
Patients were free to either fill in the questionnaire or not. Individual 153 (98)
Participants: Participants were obtained from a registry Cycling 103 (67)
of 1500 patients with a verified diagnosis of rheumatoid Walking 90 (59)
arthritis (Arnett et al 1988) who had visited the Leiden Swimming 27 (18)
University Medical Center rheumatology outpatient Other (eg, home exercise, 10 (7)
clinic in the previous 15 months. The registry was sorted aerobics, gardening)
in ascending order by the date of their next visit and the Group 29 (19)
first 400 people were selected. Apart from the diagnosis of
rheumatoid 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 defined as smoking one or
more cigarettes per day) and whether they were in paid
employment (yes/no). Height and weight were recorded Descriptive statistics were used to summarise the data.
and the body mass index (BMI = weight in kilograms/height Independent samples t-tests, Pearson Chi-square tests, or
in metres2) was determined and participants categorised as Fisher’s Exact tests were used to test whether there were
overweight (BMI ≥ 25.0) or not. significant differences between responders versus non-
responders, active versus inactive people, and males versus
Data analysis: The average proportion of people with females. A one sample Chi-square test was used to test
rheumatoid arthritis participating in some type of physical whether the proportion of people choosing either of two
activity or exercise was assumed to be about 80% (Li et al types of physical activity differed significantly from 50%.
2004, Gecht et al 1996). It was necessary for this estimate to A p value of less than 0.05 was adopted as the criterion for
be within 5 percentage points (0.05) of the true percentage statistical significance.
with 95% confidence, which required a sample size of
at least 246 people; the standard error of the estimate is Results
then less than 2.5%. Assuming a response rate of about
two-thirds (Barclay et al 2002), we planned to send 400 Flow of participants through the study: Of the 400 patients
questionnaires. who received the questionnaire, 204 (51%) returned it within
4 weeks. Of the 196 patients then contacted by phone, 53

114 Australian Journal of Physiotherapy 2007 Vol. 53 – © Australian Physiotherapy Association 2007
van den Berg et al: Activity preferences of people with rheumatoid arthritis

Table 3. Number (%) of respondents reporting various Table 4. Number (%) of respondents expressing an explicit
types of physical activity and exercise as their favourite, preference regarding two opposite attributes of different
compared with the numbers of respondents who actually types of physical activity or exercise.
participated in those activities.

Attribute of physical activity Respondents p value*
Favourite type of Respondents Respondents or exercise
physical activity or (n = 212) actually
exercise participating in
activity With vs 142 (78) vs < 0.001
Supervised physical without supervision 41 (22)
activity or exercise Present vs 119 (88) vs < 0.001
distant supervision 16 (12)
Individual 31 (15) 22 (71)
Telephone vs 24 (34) vs 0.01
Group 89 (42) 41 (46) e-mail supervision 46 (66)
Unsupervised physical Cohort
activity or exercise
Individual vs 83 (51) vs 0.85
Individual 80 (38) 66 (83) group 81 (49)
Group 12 (6) 7 (58) With people with arthritis 100 (65) vs < 0.001
vs with healthy people 55 (35)
Indoor vs 75 (44) vs 0.09
outdoor 97 (56)
Home vs 63 (38) vs 0.002
community 103 (62)
Water-based vs 124 (69) vs < 0.001
could not be reached after trying at least twice on different land-based 55 (31)
days of the week, 79 said they did not want or were not able
to fill in the questionnaire, 4 had moved, and 60 said they *Differences analysed using a one sample Chi-square test.
would still return the questionnaire. Finally, 252 patients
(63%) returned the questionnaire. The non-responders were
slightly older than the responders (mean age = 62.4, SD
14.7, and 60.5, SD 11.5 respectively) and were more often
male (number = 44 or 30%, and 70 or 28% respectively),
but these differences did not reach statistical significance
(p = 0.17 and p = 0.68, respectively). Table 1 summarises compared with the numbers of respondents who actually
the characteristics of the respondents and shows that 201 participated in those activities. It appeared that supervised
(80%) respondents were active, ie, they had participated in group exercise was the favourite physical activity of most
some type of leisure-time physical activity or exercise in respondents and almost half of these respondents actually
the previous 12 months. Inactive respondents (n = 51) were participated in this type of activity. Unsupervised individual
more often male, had a lower education level, and were physical activity was the second most favourite activity and
older than active respondents. 83% of these respondents actually participated in this type
of activity.
Type of physical activity or exercise undertaken: Table 2
shows the types of physical activity or exercise undertaken. Of Table 4 shows that significantly more respondents preferred
the 201 physically active respondents, 45 (22%) participated to be physically active under expert supervision than without
exclusively in supervised activities or exercise, 84 (42%) this supervision. In addition, the proportion of respondents
combined these activities with unsupervised activities, and that preferred to be physically active with other people with
72 (36%) exclusively participated in unsupervised activities. arthritis was significantly greater than the proportion that
Of the 129 respondents who participated in supervised preferred to be active with healthy people, and significantly
activities, 58 (45%) participated exclusively in individual more respondents preferred participating in water-based
supervised activities, 38 (30%) participated exclusively in than in land-based activities.
group supervised activities, and 33 (26%) participated in a
combination of individual and group activities. Of the 71 Attitude towards physical activity or exercise: Of 250
respondents participating in any type of supervised group responses, 238 (95%) agreed or fully agreed with the
activities, 42 (59%) exercised in a gym, 11 (16%) in warm statement that people with arthritis are, just like healthy
water, and 18 (25%) in both gyms and in water. With people, responsible for being physically active. Further, of
respect to the 156 respondents participating in unsupervised 249 responses, 175 (70%) did not agree with the statement
activities, 127 (81%) participated exclusively in unsupervised that people with arthritis can only be physically active
individual activities, 26 (17%) combined these activities when they are being supervised by an expert in the field of
with unsupervised group activities, and 3 (2%) participated rheumatic diseases. However, of 244 responses, 180 (74%)
exclusively in unsupervised group activities. Furthermore, agreed or fully agreed with the statement that people with
cycling and walking were the two unsupervised activities arthritis should get more assistance from professionals
that respondents performed most often. in making decisions about which activities or exercise to
participate in.
Preferences for type of physical activity or exercise: Table
3 shows the numbers of respondents reporting various Perceived barriers to undertaking physical activity or
types of physical activity and exercise as their favourite, exercise: Table 5 shows the numbers of active and inactive

Australian Journal of Physiotherapy 2007 Vol. 53 – © Australian Physiotherapy Association 2007 115

Table 5. Number (%) of active vs inactive respondents whereas the preference for group activities appeared to
reporting barriers to undertaking physical activity and be stronger than for individual therapy. This discrepancy
exercise. may have been caused by limited availability of group
exercise in the region where the study was conducted or by
Barrier Active Inactive p
insufficient knowledge of the availability and accessibility
value* of group programs for people with arthritis. Alternatively, it
(n = 201) (n = 51) could also be hypothesised that health care providers refer
Lack of energy 111 (56) 34 (71) 0.06 people more or less automatically to individual therapy,
Pain 111 (56) 28 (60) 0.64 perhaps because they are not sufficiently informed about
Lack of motivation 91 (46) 25 (52) 0.43 alternatives, such as group exercises.
Lack of information 81 (41) 22 (47) 0.46
Fear of damaging 72 (36) 24 (51) 0.06 In our study, cycling and walking were the two most common
joints unsupervised individual activities. High participation rates
Too expensive 54 (27) 11 (23) 0.58 in walking have been reported in other studies concerning
people with arthritis as well (Semanik et al 2004, Da Costa et
No appropriate 44 (23) 13 (27) 0.52
physical activity or al 2003). The high proportion of people engaged in cycling
exercise available in could probably be explained by the fact that riding a bicycle
neighbourhood is a common means of transportation in The Netherlands.
Lack of time 35 (18) 9 (19) 0.85
With respect to perceived barriers to undertaking physical
*Differences analysed using a Pearson Chi-square test activity, our results agree with those of other studies
showing that fear of pain or joint damage, fatigue, lack
of motivation, lack of perceived benefits, or self-efficacy
were reasons for non-participation (Li et al 2004, Resnick
2001, Schoster et al 2005, Der Ananian et al 2006, De Jong
et al 2004, Greene et al 2006, Wilcox et al 2006). Other,
respondents reporting barriers to undertaking physical more general, barriers to be taken into account include
activity or exercise. For both the active and inactive financial resources (Ball et al 2006), local facility access,
respondents, lack of energy, presence of pain, lack of and neighbourhood safety (Booth et al 2000). To achieve
motivation, and fear of damaging joints were barriers that sustained behavioural change, health professionals engaged
were mentioned frequently. Comparison of the active and in the promotion of physical activity in rheumatoid arthritis
inactive respondents revealed no significant differences. may need additional education, including skills such as
Discussion providing feedback (DiClemente et al 2001), setting and
monitoring goals (Strecher et al 1995), and counselling
Our study showed that, over a period of one year, 80% of the people depending on the stage of their condition (Dearden
surveyed people with rheumatoid arthritis currently or in the and Sheahan 2002, Riebe et al 2005).
previous 12 months participated in some type of physical Our study was not designed to investigate the comparative
activity or exercise. The majority preferred to be physically effectiveness or cost between different types of physical
active under expert supervision, with other people with activities for people with rheumatoid arthritis. Future
arthritis, and they favoured water-based activities over research should further explore these topics, as appropriate
land-based activities. Pain, lack of energy, motivation or decision-making is still hampered by lack of knowledge
information, and fear of joint damage were the main barriers regarding the optimal timing, duration, intensity and extent,
to undertaking physical activity. and mode of supervision of exercise and physical activity
Regarding the proportion of people participating in some among people with rheumatoid arthritis. It is conceivable
type of physical activity, our results are similar to those of that, in the future, better knowledge of the health benefits
other studies where proportions varied between 56% and obtained from different types of physical activity and
83% (Gecht et al 1996, Semanik et al 2004, Da Costa et al exercise might influence peoples’ preferences.
2003, Li et al 2004, Shih et al 2006). Since we did not evaluate A limitation of our study is that it pertained to a selection
frequency or intensity, we cannot determine whether these of people with rheumatoid arthritis, all living in a specific
activities were performed at a health-enhancing level. region in the Netherlands. The availability and accessibility
Our observation that significantly more men than women of facilities, as well as the general functionality of the
were inactive contrasts with other reports (Abell et al 2005, neighbourhood (such as the presence of footpaths, traffic
Fontaine et al 2004, Eurenius and Stenstrom 2005, Hootman conditions), have a great influence on people’s physical
et al 2003), whereas the finding that inactive people were activity (McCormack et al 2004). Therefore, our results
significantly older and had a lower level of education probably cannot be generalised to other regions or countries
than active people is consistent with previous reports of Future research should include more regions or may even
sociodemographic factors associated with physical activity be set up as a nation-wide or international study. Moreover,
in people with arthritis (Fontaine et al 2004, Abell et al the people who did not send back their questionnaire
2005, Fontaine and Haaz 2006, Hootman et al 2003). These were slightly older than the responders group, and it is
results suggest that promoting physical activity for specific conceivable that this group was less physically active. In
groups, such as the elderly and the less educated, remains a addition, our outcomes were based exclusively on self-
matter of utmost importance. report measures, which could be subject to memory error
and a tendency towards overestimation (Klesges et al 1990).
It was found that more people participated in supervised Finally, this study did not compare the types of activities
individual exercise than in supervised group activities, people with rheumatoid arthritis were engaged in with
those of the general Dutch population. For that purpose, an

116 Australian Journal of Physiotherapy 2007 Vol. 53 – © Australian Physiotherapy Association 2007
van den Berg et al: Activity preferences of people with rheumatoid arthritis

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This journal is moving towards requiring that clinical trials whose results are submitted for publication in Australian Journal
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118 Australian Journal of Physiotherapy 2007 Vol. 53 – © Australian Physiotherapy Association 2007