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4 Articles in this Series
Introduction
Diagnosing and Treating Sjogren's Syndrome More than Meets the Eye
Retaining Mobility May Lead to Pain Reduction
Treatment Uncertainty Remains for Asymptomatic Hyperuricemia
Vitamin D Supplementation May Improve Chronic Widespread Pain

Retaining Mobility May Lead to Pain Reduction

With Stephanie Studenski, MD; Daniel White, PT, ScD, MSc; Devyani Misra, MBBS, and Dorothy Dunlop, PhD

The urgency for pain specialists and primary care practitioners to prescribe physical activity to patients with rheumatic diseases was emphasized as a key recommendation by a panel of experts at the 2017 annual meeting of the American College of Rheumatology in San Diego, California. 

Stephanie A. Studenski, MD, MPH, chief of the longitudinal studies section of the intramural research program at the National Institute on Aging, addressed the functional outcome of mobility  in rheumatology,1 while Daniel White, PT, ScD, MSC, assistant professor of physical therapy at the University of Delaware, focused on using physical activity interventions to improve mobility.2

Embracing the Vital Role of Mobility  

Mobility has been linked to survival and other important health outcomes,1 said Dr. Studenski, so much so that factors influencing the study of rheumatology has lead to research focused on measuring factors influencing mobility and the effects of improved function.

"Beyond rheumatology, medical research has been increasingly focused on the role of gait and mobility as common contributors to disability in older adults, in recent years," she said, with a range of adverse outcomes studied, including higher rates of morbidity and mortality, increased frequency of hospitalizations, and poorer quality of life outcomes.1

The sheer number of published articles about gait speed, for example, introduces a solid indication of the growing interest in this field of study, said Dr. Studenski. In fact,  just 35 years ago, research was sparse, whereas today, there are more than 800 articles on this topic published annually.1

Research has linked gait speed with survival in multiple studies, Dr. Studenski said, citing her own analysis, published in 2011, following more than 34,000 older adults, average age 73, for up to 21 years as a prime example. "Our findings confirmed that gait speed was predictive of survival such that survival increased across the full range with increments per 0.1meters/second," she noted.3

In other research, "gait speed in hospitalized older adults predicted the length of stay; it has also led to a predictive measure for operative mortality following cardiac surgery,"1 she said.

Gait speed often has been discussed as a way to assess which patients may or may not be responsive to therapy and it has been deemed a functional vital sign.4 However,  it is important to note some common exceptions to this general approach, such as the slow walkers who ultimately live longer.

“My father was like this,” she offered as a personal anecdote, “Despite some peripheral musculoskeletal problems, and slow walking speed, he lived to age 95 years.” However, this should be viewed as the exception rather than the rule.

Maintaining or restoring physical mobility may be essential to pain management as we age.Clinicians should prescribe a goal of 10,000 steps a day to lessen chronic pain.

Physicians may be able to measure patients’ walking ability using a 4-meter standing start walk test, by having the patient walk at their usual pace and record it to the closest 0.1 second. The test is quick and simple, given enough space in the office, explained Dr. Studenski. It takes less than two minutes. Based on her research, speeds of 1.0m/second or more may predict healthy aging.1,3

While gait speed lacks information about disease specificity, Dr. Studenski, it may help account for the impact of comorbidities, which many patients diagnosed with the rheumatic disease also have.

Get Your Patients Moving

Encouraging patients to get or stay mobile may be difficult, said Dr. White, who spoke as part of the same mobility track with Dr. Studenski at ACR 2017. Many patients may not realize how much or how intense their activity should be, he said, as they are not familiar with the 2008 Physical Activity guidelines.5

These guidelines—which recommend at least 150 minutes of moderate intensity (eg, walking purposefully) a week, or 75 minutes of vigorous bouts (eg, dancing) lasting at least 10 minutes—should be pointed out to patients,5 according to Dr. Studenski. These guidelines apply to all adults.

Another way to help patients conceptualize physical activity is to have them count the number of steps they take daily. Using an activity tracking device or a step app often proves a good motivator for many people. Often, 10,000 steps are cited as a daily goal for health maintenance, and 12,000 to 15,000 steps for those focused on weight management, said Dr. White.

Patients may track their steps using a variety of monitors—from wrist devices to smartphones. Research shows that people walk about 2,500 steps a day more when they are wearing a pedometer, said Dr. White, adding that “there is a very strong relationship between how much people are doing (activity wise) and how well they move.”

In a pilot study looking at the effects of patients in outpatient physical therapy using wrist device (Fitbit) after total knee replacement, Dr. White and his team found that those in the device group who were given a monitor and weekly step goals increased their moderate to vigorous physical activity by 16.5 minutes a day (sd=20.2). In comparison, those assigned to the therapy-only group increased their activity by 8.6 minutes a day (sd=11.8).

If patients balk at counting steps, Dr. White suggested that “it is reasonable to suggest that they go for a 10-minute walk per day” as a start. If device apps and goal setting do not work, practitioners might be prepared to share with patients a list of potential benefits to be achieved from regular physical activity, including:

  • Reduced risk of premature death
  • Prevention of weight gain
  • Prevention of falls
  • Reduction in depression.

A Clinical Response is Offered

With regard to mobility, Devyani Misra, MBBS, an assistant professor of medicine at Boston University School of Medicine, said the most important message for clinicians to deliver to their patients is how essential it is to keep moving. 

“Mobility is a major indicator of adverse health outcomes,” said Dr. Misra, so we physicians really “need to start paying attention to mobility as a significant factor in preventive health as well as prescriptive care.”

For time-crunched physicians, this message may be delivered to patients in a single sentence, according to Dorothy Dunlop, PhD, professor of medicine and preventive medicine at Northwestern University Feinberg School of Medicine.

“Start with a 10-minute walk every day because it will assure you better health outcomes."

Drs. White and Studenski reported no disclosures.

References

  1. Studenski SA.  Mobility: Why this functional Outcome Matters in Rheumatology. Presented at: The American College of Rheumatology 2017 Annual Meeting, Nov. 3-8, 2017.
  2. White D. Presentation: Mobility: How Can We Use Physical Activity Intervention to Improve Mobility. Presented at: The American College of Rheumatology 2017 Annual Meeting, November 3-8, 2017.
  3. Studenski S et al. Gait Speed and Survival in Older Adults. JAMA. 2011; 305:50-58. 
  4. Middleton A, Fritz SL, Lusardi M. Walking Speed: The Functional Vital Sign. J Aging Phys Act. 2015;23(2):314–322.
  5. US Office of Disease Prevention and Health Promotion. 2008 Physical Activity Guidelines for Americans Summary. Available at https://health.gov/paguidelines/guidelines/summary.aspx. Accessed Nov. 9, 2017.
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