Wirkmechanismen und Stellenwert von Sport und Training beim Management rheumatischer Erkrankungen

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1 Wirkmechanismen und Stellenwert von Sport und Training beim Management rheumatischer Erkrankungen Prof. Dr. G. Huber Institut für Sportwissenschaft der Universität Heidelberg

2 Gliederung 1. Stellenwert von körperlicher Aktivität und Sport 2. Wirksamkeit (Evidenz) bei Erkrankungen des rheumatischen Formenkreises Rheumatoid arthritis Osteoarthritis andere Formen 3. Wie wirkt körperliche Aktivität und Sport? Wirkmechanismen Konzeption der Bewegungstherapie 4. Zusammenfassung und Perspektiven

3 Shape of the Dose- Response Curve: Relative Risks of All- Cause Mortality by Physical Activity Level (Studies With at Least 5 Levels of Physical Activity)

4 2006 by Canadian Medical Association Warburton D E et al. CMAJ 2006;174:

5 Daily physical activity duration and all-cause mortality reduction Wen et al. 2011

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7 UPDATE: Rheumatische Erkrankungen Was wissen wir bereits? Unschädlichkeit der angemessenen Bewegungstherapie Machbarkeit der Bewegungstherapie Akzeptanz der Bewegungstherapie Wirksamkeit? Wirkmechanismen? Dosierung??? Patientenorientierung????

8 The exercise prescription in rheumatoid arthritis: Primum non nocere Finck et al Clinically, these studies suggest caution in prescribing exercise to patients who already have significant joint damage, especially of weightbearing joints. High-impact exercise might be relatively contraindicated, and, if exercise is prescribed, it should involve modalities that don't load the joint, such as water walking, swimming, biking, rapid walking, or strengthening. In cardiovascular risk prevention, recommendations have changed from high-intensity aerobic exercise to regular physical activity (a total of 30 minutes a day, 3 times a week), since both seem to confer similar cardiovascular benefits

9 Is a long term high intensity exercise program effective and safe in patients with rheumatoid arthritis?: Results of a randomized controlled trial de Jong et al (N = 309) Arthritis & Rheumatism Volume 48, Issue 9, pages , 11 SEP 2003 DOI: /art

10 Is a longterm high intensity exercise program effective and safe in patients with rheumatoid arthritis?: Results of a randomized controlled trial de Jong et al (N = 309) Arthritis & Rheumatism Volume 48, Issue 9, pages , 11 SEP 2003 DOI: /art

11 Is a long term high intensity exercise program effective and safe in patients with rheumatoid arthritis?: Results of a randomized controlled trial de Jong et al (N = 309) Change in McMaster Toronto Arthritis (MACTAR) Patient Preference Disability Questionnaire score after first and second years of treatment. Arthritis & Rheumatism Volume 48, Issue 9, pages , 11 SEP 2003 DOI: /art

12 BENEFITS of Exercise in Rheumatoid Arthritis Cooney et al Thus, all RA patients should be encouraged to include aerobic and resistance exercise training as part of routine care. Understanding the perceptions of RA patients and health professionals to exercise is key to patients initiating and adhering to effective exercise training. RA patients demonstrated awareness of the advantages of exercise for their joints, both experientially and through education. However, they perceived that health professionals lacked certainty and clarity regarding specific exercise recommendations and the occurrence of joint damage. Thus, to enhance patient-centred exercise prescription in the RA population, uncertainties surrounding joint health, pain symptoms and exercise specificity need to be addressed, alongside continual emphasis of exercise benefits Law et al. 2010

13 Arthritis Care & Research Volume 59, Issue 1, pages 42-50, 28 DEC 2007 DOI: /art Physical inactivity in patients with rheumatoid arthritis: Data from twentyone countries in a crosssectional, international study Soka et al. 2008

14 Bewegungsbezogener Gesamtenergieverbrauch/Monat vor und nach der Erkrankung (N = 583,-p =,000)in Kcal vor Erkrankung nach Erkrankung "Norm" Huber & Eckert 2011

15 Bewegungsbezogener Energieverbrauch vor und nach der Erkrankung (N = 568) Alle Orthopädie Onkologie Kardiolog. Psychosom. Pneumologie sonst. vor Erkrankung nach Erkrankung Huber & Eckert 2011

16 Gliederung 1. Stellenwert von körperlicher Aktivität und Sport 2. Wirksamkeit (Evidenz) bei Erkrankungen des rheumatischen Formenkreises Rheumatoid arthritis Osteoarthritis andere Formen 3. Wie wirkt körperliche Aktivität und Sport? Wirkmechanismen Konzeption der Bewegungstherapie 4. Zusammenfassung und Perspektiven

17 Effect of Therapeutic Exercise for Hip Osteoarthritis Pain: Results of a Meta-Analysis HERNA NDEZ-MOLINA et al Forest plot of hip osteoarthritis (OA) data. B, Forest plot of hip as the index joint with OA

18 The MOVE Consensus Roddy E, Zhang W, Doherty M, et al. Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee the MOVE consensus. Rheumatology 2005; 44: Both strengthening and aerobic exercise can reduce pain and improve function and health status in patients with knee or hip OA. 2. There are few contraindications to strengthening or aerobic exercise in hip or knee OA. 3. Both aerobic and strengthening exercises are an essential aspect of management for every patient with knee or hip OA. 4. Exercise therapy for hip or knee OA should be individualized. 5. Exercise programs should include advice and education to promote increased physical activity. 6. Group exercise and home exercise are equally effective, so patient preference should be considered. 7. Adherence is the main predictor of long-term outcome from exercise in hip or knee OA. 8. Strategies to improve adherence should be adopted, such as long-term monitoring. 9. The effectiveness of exercise is independent of the severity of radiographic damage. 10. Improvements in muscle strength and proprioception from exercise may reduce OA progression.

19 Exercise for osteoarthritis of the hip This summary of a Cochrane review presents what we know from research about the effect of exercise for people with osteoarthritis (OA) of the hip. The review shows that in people with hip OA, exercise -May reduce pain slightly -May not improve physical function. Fransen M, McConnell S, Hernandez-Molina G, Reichenbach S. Exercise for osteoarthritis of the hip. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD DOI: / CD007912

20 Weiter Erkrankungen Gicht: ungenügende Studienlage Fibromyalgie: Aerobic-only training has beneficial effects on physical function and some FM symptoms. Strength-only training may improve FM symptoms, but requires further study. Large, high-quality studies of exercise-only interventions that provide detailed information on exercise prescription and adherence are needed. Busch et al Osteoporose Hohe Evidenz für Wirksamkeit BMD, Schmerz, LQ, Sturzhäufigkeit

21 Gliederung 1. Stellenwert von körperlicher Aktivität und Sport 2. Wirksamkeit (Evidenz) bei Erkrankungen des rheumatischen Formenkreises Rheumatoid arthritis Osteoarthritis andere Formen 3. Wie wirkt körperliche Aktivität und Sport? Wirkmechanismen Konzeption der Bewegungstherapie 4. Zusammenfassung und Perspektiven

22 Wirkmechanismen Cooney et al. 2011

23 . The anti-inflammatory effect of exercise Petersen A M W, Pedersen B K J Appl Physiol 2005;98: by American Physiological Society

24 Antiinflammatorische Wirkung der Bewegung Association between Different Domains of Physical Activity and Markers of Inflammation CHRISTINE AUTENRIETH1,2, ANDREA SCHNEIDER1, ANGELA DO RING1, CHRISTA MEISINGER1, CHRISTIAN HERDER3, WOLFGANG KOENIG4, GERHARD HUBER2, and BARBARA THORAND /09/ /0 MEDICINE & SCIENCE IN SPORTS & EXERCISE Copyright 2009 by the American College of Sports Medicine

25 Antiinflammatorische Wirkung der Bewegung Review (Kasapis et al. 2005) Exercise produces a short-term, inflammatory response, whereas both cross-sectional comparisons and longitudinal exercise training studies demonstrate a long-term antiinflammatory effect. This anti-inflammatory response may contribute to the beneficial effects of habitual physical activity. (J Am Coll Cardiol 2005;45:1563 9)

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27 Biopsychosoziale Perspektive 1. Biologisch funktionelle Effekte 2. Psychosoziale und einstellungsverändernde Effekte 3. Kognitive Effekte

28 Funktionelle Dimension - Trainieren - Pädagogische Dimension - Lernen - Psychosoziale Dimension - Erleben -

29 Modellierung der Wirkmechanismen Vermittelt spezifisches Wissen Sorgt für soziale Unterstützung Optimiert physiologische Prozesse (antiinflammatorisch) Körperliche Aktivität und rheumatische Erkrankungen Erhöht Muskelmasse, Verhindert Sarkopenie Erhöht internale Kontrollüberzeugung und Selbstwirksamkeit

30 Die Bewegungspyramide für den Patienten mit einer rheumatischen Erkrankungen Selten: sitzen Mindestens 2 mal pro Woche. Mind. 10 Minuten Aufbau & Erhalt der Muskelmasse (5 10 METS) Mindestens 3 mal pro Woche: Mindestens 20 Minuten Walking, Radfahren, Schwimmen etc. (3-5 METS) Jeden Tag: Mindestens 30 Minuten: Spazierengehen, Hund ausführen, wenn möglich Treppensteigen, Bewegung im Haus, Garten und Beruf (2-3 METS) Ein MET = 1 kcal (or kj). kg-1. hr-1

31 Die Wirkung angemessener Bewegung ist unstrittig Kombination von Kraft und Ausdauer sinnvoll Nachhaltige Bewegung im Alltag anstelle von limitierten Sportprogrammen Entscheidend ist die langfristige Bindung an körperliche Aktivitäten Bewegungstherapie als wichtige biopsychosoziale Intervention Wirkmechanismen und Dosierungen sind noch weiter zu untersuchen Intensivere Patientenorientierung notwendig Verbindung von Effektwissen und Handlungswissen

32 Thus, all RA patients should be encouraged to include aerobic and resistance exercise training as part of routine care. Understanding the perceptions of RA patients and health professionals to exercise is key to patients initiating and adhering to effective exercise training. Cooney et al. Journal of Aging Research, 2011, 2011, 1 Furthermore, to enable clinicians and relevant health professionals to prescribe appropriate PRT programs, the principles of PRT program. Lemmey, International Journal of Clinical Rheumatology April 2011, Vol. 6, No. 2, Pages Rheumatologists, nurses, and physical therapists considered regular physical activity to be an important health goal for RA patients. The majority of them commonly gave advice on physical activity but felt not sufficiently competent and indicated a need for additional education. Emalie J. Hurkmans et al. Promoting physical activity in patients with rheumatoid arthritis: rheumatologist and health professionals practice and educational needs, Clinical Rheumatology, 2011, 30, 12, 1603