Trainingstherapie bei Rheumatoider Arthritis: Eine systematische Übersicht

Zusammenfassung

Einleitung: Schmerzen und Einschränkungen der Gelenkbeweglichkeit führen bei der Rheumatoiden Arthritis (RA) zu einer Minderung der Muskelkraft und Ausdauer. Als Spätfolgen besteht bei der RA ein erhöhtes Risiko für das Auftreten einer Osteoporose und kardiovaskulärer Erkrankungen. Körperliches Training ist eine etablierte Form der Therapie und Prävention dieser krankheitsassoziierten gesundheitlichen Probleme. Der klinische Stellenwert, die Inhalte des Trainings sowie die für das Training geeigneten Patienten sind bei der RA bisher unzureichend definiert.

Methodik: Es wurde eine systematische Literaturrecherche in den Datenbanken MEDLINE und PubMed sowie eine Durchsicht verfügbarer Publikationen zu den Schlüsselworten „Rheumatoid Arthritis, dynamic exercise, aerobic exercise” durchgeführt.

Ergebnisse: In immunologischen Untersuchungen konnten keine durch das Training induzierten nachhaltigen und klinikrelevanten Veränderungen nachgewiesen werden. 12 randomisiert kontrollierte Studien wurden gefunden, in denen die Wirkung eines dynamischen Trainings mit ausreichender Intensität und Dauer (>6 Wochen) geprüft wurde. Alle Übersichtsarbeiten und alle Studien mit einer Beobachtungsdauer bis 5 Jahre belegen, dass ein dynamisches Training bei kindlichen ebenso wie erwachsenen RA Patienten mit leichter bis mäßiger Beeinträchtigung und stabilem Verlauf als sicher betrachtet werden kann. Mit guter Evidenz ist eine Verbesserung von aerober Ausdauer, Muskelkraft und Beweglichkeit sowie eine verzögerte Abnahme der Knochendichte bei erwachsenen, nicht aber kindlichen Patienten nachgewiesen. Ähnliche Effekte sind mit Selbstübungsprogrammen zu erzielen, vorausgesetzt, dass eine kompetente Einweisung und eine regelmäßige weitere Kontrolle statt findet. Widersprüchlich sind die Befunde zur Verbesserung der Alltagsaktivitäten und gesundheitsbezogenen Lebensqualität trainierter RA Patienten, keine Daten liegen zur Prävention kardiovaskulärer Erkrankungen vor.

Schlussfolgerung: Die positiven Effekte rechtfertigen einen breiten Einsatz des körperlichen Trainings sowohl aus therapeutischen wie präventiven Gründen bei erwachsenen RA Patienten mit geringer Beeinträchtigung und stabilem Krankheitsverlauf. Nachteilige langfristige Effekte auf große, Gewicht tragende Gelenke können derzeit nicht sicher ausgeschlossen werden, hohe Übungsbelastungen sind bei vorgeschädigten Gelenken zu vermeiden. Die Bedeutung des Trainings bei kindlicher RA und Patienten mit schwerer Beeinträchtigung ist unklar. Insbesondere in akuten Krankheitsschüben sowie bei betagten, schwer dekonditionierten Patienten wird die konventionelle Physiotherapie ein wesentliches Element zumindest der initialen Behandlung bleiben.

Abstract

Introduction: In rheumatoid arthritis (RA) pain and reduced joint mobility lead to impairments of muscle strength and endurance. In the long term RA is associated with increased risks of osteoporosis and cardiovascular disease. Physical exercise is considered to be an important cornerstone both in therapy for and prevention of these disease-related problems. However, its clinical relevance, the composition of efficient programmes, and their target population remain obscure.

Methods: Medline and PubMed databases as well as available publications were searched in this systematic review by using the key words “rheumatoid arthritis, dynamic exercise, aerobic exercise”.

Results: No immunological reactions in response to exercise are described with relevance to the clinical course of the disease. 12 randomised controlled studies were identified with sufficient intensity and duration (>6 weeks) of dynamic exercises. All reviews and all studies with observation periods up to 5 years agree that dynamic exercises are safe in adult as well as juvenile RA patients with mild to moderate impairment and stable disease. There is good evidence for an improvement of aerobic capacity, muscle strength, mobility and a reduced decrease of bone mineral density by intensive supervised training programmes in adult, but not juvenile patients. Some evidence exists that home-based programmes of similar intensity may work as well, provided that patients are correctly instructed at the onset and controlled at regular intervals. Conflicting evidence exists considering the clinical consequences of training programmes to functional capacity and health-related quality of life, no data are available on the prevention of cardiovascular complications.

Conclusion: The positive effects support a wider use of physical exercise programmes in adult RA patients with mild impairment and stable disease, both as therapy and prevention. However, the occurrence of adverse long-term effects on large, weight-bearing joints cannot be completely excluded with the available data. High exercise loads should be avoided in patients with joint damage. The role of physical exercise in juvenile RA patients and patients with severe impairments remains unsettled. In particular, in acute flares and in elderly, severely deconditioned patients conventional physiotherapy will remain an essential part at least of initial treatment.

Schlüsselwörter

Rheumatoide Arthritis - dynamische Trainingstherapie - aerobe Trainingstherapie - Trainingstherapie

Key words

rheumatoid arthritis - dynamic exercise - aerobic exercise - exercise therapy

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