Journal of Physical Activity and Health, 2014, 11, 1248-1261

http://dx.doi.org/10.1123/jpah.2012-0194
2014 Human Kinetics, Inc.

Official Journal of ISPAH

www.JPAH-Journal.com
REVIEW

Correlates of Physical Activity in Adults

With Rheumatoid Arthritis: A Systematic Review
Louise Larkin and Norelee Kennedy
Background: Physical activity (PA) is an important component in the management of Rheumatoid Arthritis (RA). To date the
correlates of PA have not been thoroughly investigated in the RA population. The aim of this systematic review was to determine
the correlates of PA in the adult RA population. Methods: A search of Medline, EMBASE, AMED, CINAHL plus, Pubmed,
Web of Science, and the Cochrane Library was conducted. A manual search of reference lists was conducted to compliment
the electronic search. Ten studies fulfilled the inclusion criteria and were assessed for methodological quality. Results: Results
determined correlates in 4 categories: sociodemographic, physical, psychological and social variables. The variables varied greatly
and were inconsistently studied. Changes were noted from a previous review in 2005 in relation to the association between certain variables and PA, including age, gender, disease duration, pain, exercise beliefs and social support. Conclusions: Positive
associations with PA were found for motivation, self-efficacy, health perception, and previous PA levels. Negative associations
were found for fatigue, a coerced regulation style and certain physiological variables. In addition differences between correlates
of PA in the adult RA population and other chronic disease and healthy adult populations have been demonstrated.
Keywords: exercise, factors, participation, exercise beliefs
Rheumatoid arthritis (RA) is a chronic, inammatory disease,
characterized by joint swelling, joint tenderness and destruction of
synovial joints.1,2 The incidence of RA is variable, ranging from
0.10.5/1000 and is dependent on geographical location,3 with
females being affected 5 times more than males.4
Physical activity (PA), defined as any bodily movement produced by skeletal muscles that results in energy expenditure,5 is
reported to have beneficial effects on cardiovascular disease in the
RA population.6 The terms PA and exercise are often used interchangeably.7 A distinction between the two should be noted; exercise
is PA that is planned, structured, repetitive, and purposive in the
sense that improvement or maintenance of 1 or more components of
physical fitness is an objective, and thus exercise is a subset of PA.5
Increasing participation in PA is important for everyone,
including people with RA.4,6 The reported benefits of PA for
the RA population include improved aerobic fitness and muscle
strength, resulting in enhanced ability in activities of daily living
and health-related quality of life,2 and an improvement in diseaserelated characteristics, such as pain and stiffness.6 PA has also been
shown to improve factors associated with cardiovascular disease,
including decreased expression of proinflammatory cytokines and
decreased C-reactive protein,6 which is an important benefit for the
RA population. A study of people with RA in 21 countries found
that that the majority of people with RA were physically inactive,
with 80% not participating in regular weekly exercise in 7 countries,
and 60% to 80% not participating in regular weekly exercise in
another 12 countries.8 This study reported that 13.8% of all patients
exercised 3 times per week.8 Although this study explored exercise
levels rather than PA levels it highlights the low levels of activity
in the RA population. More recently a study measuring total daily
PA (household, leisure, occupational and planned exercise) found
that 75% of females with RA reported an average of 55 minutes per
Larkin (Louise.Larkin@ul.ie) and Kennedy are with the Dept of Clinical
Therapies, University of Limerick, Limerick, Ireland.
1248

day in self-reported moderate-level activity.9 For PA interventions

to be effective, the underlying variables that influence PA must be
addressed. Thus, determining the correlates of PA is imperative
before designing such interventions.
A previous review of correlates of PA in arthritis yielded a
range of correlates of PA including sociodemographic (age, gender,
race, educational level, income level, marital status, and employment status), psychological (self-efficacy, perceived benefits of
and barriers to PA, mental health factors, behavioral factors),
health-related (pain, disease severity), body mass index (BMI),
social (social support), and environmental (access to facilities)
correlates.10 Self-efficacy, perceived benefits and barriers, mental
well-being, prior PA, and pain were identified as the most consistent
correlates of PA in the RA population.10 Sociodemographic, social,
and environmental variables were the least studied.10 A limitation
of the review was the inclusion of various forms of arthritis, with
limited differentiation between the various categories of arthritis.
Thus the aim of this review is to systematically review the correlates
of PA in people with RA.

Methods
Search Strategy
An electronic database search was conducted in December 2011 of
Medline and EMBASE, as recommended by the Cochrane Handbook of systematic reviews.11 In addition the electronic databases of
AMED, CINAHL plus, Pubmed, Web of Science and the Cochrane
Library were searched in December 2011. The search dates were
from January 1, 2004 to December 12th, 2011, to prevent an overlap with a previous publication on the topic of correlates of PA in
arthritis.10 Searches were limited to human trials published in the
English language. Key word searches in EMBASE and Medline, in
combination with rheumatoid arthritis and physical activity or
exercise, were correlate, factor, participation, and exercise

Correlates of Physical Activity in Rheumatoid Arthritis 1249

belief. Key word searches in all other databases were conducted

using rheumatoid arthritis and physical activit* or exercise in
combination with correl*, factor*, participat*, and exercise
belief*, where * indicates the wildcard which denotes the use of
all possible suffixes. All abstracts returned in the database searches
were reviewed by the primary author (LL). Full text articles were
obtained of all studies that met the aim of this review. A manual
search of reference lists of all relevant articles was completed for
additional studies by the primary author (LL).

of bias in the study is included. Thus each article received a quality

indicator score out of 7, with 0 being the lowest quality and 7 being
the highest quality. Three reviewers (LL, NK, JR) independently
assessed and scored the quality of the selected studies. A consensus
method was used to solve disputes regarding the quality of individual
articles. All disputes were resolved without further consultation from
a fourth individual, through discussion between all 3 reviewers.

Inclusion/Exclusion Criteria

Potentially further analysis of data, for example meta regression

analysis, could have provided further information on the association
between certain variables and PA. However following consultation
with the Statistical Consultation Unit (SCU) at the University of
Limerick it was recommended that further data synthesis was not
possible due to the nature of the studies included in the review and
also the poor reporting of statistical results in the studies.

The inclusion criteria for this review included that the study was
conducted between January 2004 and December 2011 (as a review
of correlates of PA had been published in 2005), and that the full
text article of the study was available. Study participants had to be
aged 18 years or older and study participants had to have a diagnosis
of RA according to ACR/EULAR criteria.1 Any experimental study
type was suitable for inclusion and studies which examined 1 or
more types of arthritis but where RA group results were differentiated were also included. Studies also had to incorporate a measure
of PA, namely a self-report and/or an objective measurement. These
measures included questionnaires, accelerometers, pedometers,
heart rate monitors, calorimetry, or doubly labeled water.12 Exclusion criteria were that the study included participants aged less than
18 years, was published before 2004 and studies that examined only
physiological or functional outcomes of PA in RA.
Three reviewers (LL, NK, JR) independently applied the inclusion/exclusion criteria to papers identified from the literature search,
before combining results. A consensus method was used to solve
disputes regarding the study articles to include or exclude. Following
discussion between the reviewers all disputes were resolved without
further consultation from a fourth individual.

Data Extraction
Data extraction was conducted by the primary author (LL). For each
article that met the inclusion criteria, the following information
was extracted and recorded: (1) study citation, (2) study population
(ie, number of participants, age range, number of male and female
participants), (3) study design, (4) PA measure(s) used, (5) correlate
variables and other measure(s) that were examined in the study, (6)
the statistical tests used, and (7) statistical results.

Methodological Quality
Articles successfully fulfilling the inclusion criteria were subsequently examined for methodological quality. The majority of
studies for inclusion were of cross-sectional study design. There
is no one recommended way of assessing the quality of crosssectional studies.13 What is recommended is that quality evaluation
tools should include a small number of key domains, be as specific
as possible (with due consideration of the particular study design
and topic area), be a simple checklist rather than a scale and show
evidence of careful development, and evidence of their validity and
reliability.13 As per these recommendations the quality of each study
was assessed using a tool appropriate to the study design, based on
the Crombie criteria for assessment of cross-sectional studies14
adapted by Petticrew and colleagues15 (see Table 1).
The assessment tool consisted of 7 criteria in total, with 6
of these individual criterion requiring a yes or no response. The
remaining criterion required a numeric response (ie, response rate or
number of participants). An additional criterion regarding evidence

Data Synthesis

Results
Study Selection
The electronic search yielded 1100 potentially relevant citations.
Three hundred twenty-eight duplicates were removed. Seven hundred fifty-six articles were removed after screening of the article
title and abstract; thus, 16 articles remained. Excluded articles were
deemed not to be pertinent to the aim of this systematic review. Following a manual search of the reference lists of the 16 remaining
articles, 2 additional articles were retrieved. The primary author
(LL) became aware of 2 further texts, following discussion with the
coauthor (NK), which were deemed relevant to the aim of the review.
Thus 20 full-text articles were retrieved for review. Following a
full-text review 10 articles were excluded. Reasons for exclusion of
10 articles were that studies did not include correlates of PA as an
outcome, that PA was not measured at all or not measured accurately
(ie, through the use of a subjective or objective measure), and that
1 study included a mixed RA/osteoarthritis sample (see Figure 1).

Description of Included Studies

A detailed description of the studies included in this review is
available in Table 2. The majority (n = 8/10) of included studies
were cross-sectional in design; the remaining studies (n = 2) were
observational (n = 1) and randomized (n = 1) studies. The number of
study participants ranged from 52 to 6336. The study participant age
range was 19 to 90 years. All studies had a majority of female study
participants, with some studies (n = 2) incorporating female participants only. The correlate variables and other measures examined in
the studies are detailed in Table 2. The most commonly used statistical tests were correlation coefficient and regression analysis tests.

Measurement/Reporting of Physical Activity

Nine studies used a subjective, self-report method of measuring PA. Four studies used established self-report questionnaires,
namely the Yale PA Survey,16 International PA Questionnaire,17
Short Questionnaire to Assess Health-Enhancing PA,18 and the PA
and Disability Survey,19 with the remaining studies (n = 5) using
customized, self-report measures of PA. One study used an accelerometer, the GT1M Actigraph, as an objective measure of PA.20
Finally 1 study recorded attendance at an intervention, in addition
to the participants self-report of PA outside of the intervention
study, to measure PA levels.21

1250

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Ehrlich-Jones et al 2011

Elkan et al 2011

Hurkmans et al 2010

Eurenius et al 2005

Greene et al 2006

Mock et al 2010

Neuberger et al 2007

Eurenius et al 2007

van den Berg et al 2007

Abbreviations: N/A, not applicable.

Yes

Semanik et al 2004

Author and year

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Appropriate Appropriate
research
recruitment
design
strategy

63%

34%

71%

N/A

78%

62%

42%

100%

100%

84%

Response
rate/%
participants

Yes

Yes

Noage 40-70yrs

Yes

No

Yes

Yes

No

Yes

Unclear

Nodisease duration 6.5yrs

Noage over 30 yrs

Yes

Yes

Unclear

Yes

Objective
and reliable
measures?

Nolimited to patients with

established RA (mean disease
duration = 10yrs)

Nofemale only, age 57-64

Yes

Nowell-educated, white
women, 60+ years only

Is sample representative?
(all clinic populations)

Table 1 Methodological Quality of Studies Included in the Systematic Review

No

No

Yes

No

No

Yes

No

No

Yes

No

Power
calculation/
justification
of numbers?

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Selection bias

Convenience sample

Measurement bias

Convenience sample

Convenience sample

Measurement bias

Possibility of recall bias

Convenience sample

No

Possible bias in
response rates

Appropriate
statistical
analysis? Evidence of bias?

4/7

6/7

6/7

4/6

5/7

5/7

5/7

5/7

6/7

5/7

Quality
indicators
met

Correlates of Physical Activity in Rheumatoid Arthritis 1251

Figure 1 Flowchart of study selection procedure. * ACR, American College of Rheumatology; EULAR, European League Against Rheumatism;
RA, rheumatoid arthritis; OA, osteoarthritis; PA, physical activity.

Description of Results: Correlates of Physical

Activity
A detailed description of the 10 studies included in this systematic
review can be found in Table 2. Some of the studies included did not
conduct correlational statistical analysis (ie, analysis to describe the
strength and direction of the linear relationship between 2 variables).
In this case the relationship between PA and specific variables will
be referred to as an association rather than correlation.

Sociodemographic
Age. Age was assessed in 8 of the studies in this review,9,2024,26,28

with inconsistent correlations between age and PA in the RA population being reported. Younger age positively correlated with PA in
2 studies (r = .493, P = .01),22 (r and p not reported),23 while older
age negatively correlated with PA in 2 studies (r = 0.195, P < .01),9
(r not reported, P < .001),28 with 4 studies reporting no correlation
between age and PA.20,21,24,26
Gender. Six studies examined gender in relation to PA.2024 Incon-

sistent results for correlation between gender and PA were found.

Positive correlation for PA was found females (r = .13, P = .04)22

and males (r and p not reported).23 Negative correlation was also
found for male gender (r not reported, P = .04).28 Three studies found
no significant statistical association between gender and PA.20,24,26
Race/Ethnicity. Four studies found no statistically significant
correlation between racial characteristics or ethnicity and PA levels
in the RA population.9,20,24,26
Education. Five studies explored the association between educational level and PA.9,22,24,26,28 A high educational level positively
associated with PA in 1 study (r not reported, P = .02),22 with
another negatively associating a lower educational level with PA
(r not reported, P = .02).28 Three studies reported no correlation
between educational level and PA.9,24,26
Employment and Income. Five studies reported on employment

status in relation to PA with conflicting results.9,22,24,26,28 Being

retired negatively associated with PA (r not reported, P = .001).9
The remaining 4 studies found no association between employment
status and PA.22,24,26,28 Two studies found no statistically significant
correlation between income and PA levels.9,26

1252

N = 61
60.8yrs (57.364.4)

Elkan et al
2011

61F

N = 185
55yrs () 14
155F
25M

185F

Study population
N = 185
70yrs (60-88 range)

EhrlichJones et al
2011

Citation
Semanik et
al 2004

Cross-sectional

Cross-sectional

Study design
Cross-sectional

International Physical
Activity Questionnaire
(IPAQ)

GT1M Actigraph

PA measure
Yale PA survey

Correlates/other measures
Age
Race
Educational Level
Employment Status
Marital Status
Annual Income
Number of Years Since RA Diagnosis (disease
duration)
Age
Gender
Race/Ethnicity
Body Mass Index (BMI)
Disease Severity (Clinical Disease Activity Index)
Beliefs related to PA (Customized questionnaire)
Increased Motivation for PA (Customized questionnaire based on Perceived Competence Scale)
Life worries (Customized questionnaire based on
Social Functioning Scale)
Age
Ever Smoker
RA Duration
Disease Activity Score 23 (DAS23)
Stanford Health Assessment Questionnaire (HAQ)
Waist Circumference
Body Mass Index (BMI)
Fat Mass %
Fat Mass Index (FMI)
Body Composition
Food Frequency Questionnaire (FFQ)
Higher Plasma Glucose/Insulin
Total Cholesterol
Low-density Lipoprotein (LDL)
Lower High-density Lipoprotein (HDL)
Lower Apolipoproteion A1 (apoA1)
Apolipoproteion B (apoB)
Oxidized LDL (oxLDL)
Lower Antibodies against Phosphorylcholine
(anti-PC)

Table 2 Description of Studies Included in the Systematic Review

P = .05

P = .05
P = .005

P = .016

Spearman rank correlation

Spearman rank correlation

Spearman rank correlation

(continued)

P = .027 (adjusted)
P = .007 (adjusted)

F = 7.81; df = 2; P = .001

Stats
r = 0.195; P < .01

Spearman rank correlation

Multiple linear regression

Multiple linear regression

Analysis of variance

Stat tests
Pearson Correlation Coefficients

1253

Mock et al
2010

11.53 (2.4) age

analyses range
60.12% F 39.88M

N = 6,286

66F
10M

60.9yrs (13.9;
25-90yrs range)

Retrospective
Cross-Sectional

Cross-sectional

N = 72 (RA & OA)

RA = 52/72

Greene et
al 2006

Study design
Cross-sectional

Cross-sectional

Study population
N = 221
62 14yrs
178F
93M

Eurenius et N = 248
al 2005
220 F
55yrs (19-90 range)
73M
63yrs (22-84yrs
range)

Citation
Hurkmans
et al 2010

Table 2 (continued)

Escola Paulista de Medicina-Range of Motion

(general ROM)
Functional Balance
Self-reported Pain (Visual Analog ScaleVAS)
Health Assessment Questionnaire (HAQ)
Disease Activity Score 23 (DAS23)
C-reactive protein (CRP; disease activity)
Physical activity and dis- Age
ability survey (PADS)
Gender
Race/Ethnicity
Educational Level
Employment Status
Comorbidities
Body Mass Index (BMI)
Arthritis Self-Efficacy Scale (ASES)
Outcome Expectations for Exercise (OEE) Scale
Health Assessment Questionnaire (HAQ)
Pain (VAS of HAQ)
Medical Outcomes Study (MOS) Social Support
Survey
Higher Mental Health Rating (Customized quesCustomized self-report
tionnaire)
measure of physical
activity
Higher Physical Health Rating (Customized
questionnaire)
Sense of Belonging (Customized questionnaire)

PA measure
Correlates/other measures
Short questionnaire to Age
assess health-enhancing Gender
physical activity
Living Status
Educational Level
Employment Status
Disease Duration
Health Assessment Questionnaire (HAQ)
Treatment Self-Regulation Questionnaire (TSRQ)
Health Care Climate Questionnaire (HCCQ)
Rheumatoid Arthritis Disease Activity Index
(RADAI)
Age
Customized self-report
measure of physical
Gender
activity
Aerobic Fitness (VO2max)
Timed-Stands Test (lower-limb muscle function)
Grippit (grip strength)
P = .015

Pearson Correlation Coefficients

P < .001
P < .001

Linear regression analysis

Linear regression analysis

(continued)

P < .001

P < .001

Multiple hierarchical regression

Linear regression analysis

P = .002

Pearson Correlation Coefficients

R2 = .12; P = 0.01

P = .016

Pearson Correlation Coefficients

Multivariate regression analysis

Stats
P < .001
P = .036

Stat tests
Pearson Correlation Coefficients
Pearson Correlation Coefficients

1254

Observational

N = 202
60.5yrs (11.5)
182F
70M

van den
Berg 2007

Study design
Randomized
Study

Cross-Sectional

82.7% F
17.3% M

Study population
N = 220
55.5yrs (range
40-70yrs)

Eurenius et N = 102
al 2007
57yrs (range
19-84yrs)
76F
21M

Citation
Neuberger
et al 2007

Table 2 (continued)

Customized self-report
measure of physical
activity

Customized self-report
measure of physical
activity

PA measure
1. Self-report mean minutes of aerobic exercise per
week + mean minutes per
week of aerobic portion of
intervention 2. Self-report
mean minutes of aerobic
exercise per week

Medical Outcomes Study (MOS) Social Support

Survey
Self-Efficacy (mean of 2 confidence measures)
Medications
Previous Physical Activity Levels
Multidimensional Health Locus of Control
Scales, form C
Timed-Stands Test (lower-limb muscle function)
Grippit (grip strength)
Escola Paulista de Medicina-Range of Motion
(general ROM)
Functional Balance
Pain (VAS)
General Health Perception (VAS)
HAQ Disability Index
Disease Activity Score 23 (DAS23)
Age
Gender
Educational Level
Body Mass Index (BMI)
Current Smoker
Living Status
Employment Status

Correlates/other measures
Age
Gender
Race/Ethnicity
Educational Level
Annual Income
Marital Status
Employment Status
RA Duration
Comorbidities
Higher Global Fatigue Index of Multidimensional Assessment of Fatigue Score
Short Form of McGill Pain Questionnaire
Centre for Epidemiologic Studies Depression Scale
25-item Profile of Moods States Short Form
Total Joint Count (disease activity)
Erythrocyte Sedimentation Rate (ESR)
C-reactive protein (CRP; disease activity)
Grip Strength
Walk Time (no of seconds to walk 50 feet)
Aerobic Fitness (VO2max)
Life Orientation Test
Exercise Benefits/Barriers Scale Score

P = .001

Simple logistic regression

analysis

P < .001
P = .04
P = .02

Score < 117 exercise

average 62min/week,
117 exercise average
95min/week

Classification and regression tree

(CART) analysis

Independent samples t test, Chisquare test or Fishers Exact test

Fatigue score: 26
exercise average 62min/
week, < 26 exercise
average 85min/week

Stats

Classification and regression tree

(CART) analysis

Stat tests

Correlates of Physical Activity in Rheumatoid Arthritis 1255

Marital and Living Status. Two studies reported on the correlation

between marital status9,26 or living status22,28 and PA respectively.

No statistically significant correlation between either martial or
living status was found by any of the 4 studies.

Psychological

Physical

Exercise Beliefs and Expectations. Three studies explored

beliefs relating to PA.20,24,26 A positive correlation between increased
beliefs about the benefits of PA and PA levels was reported (r not
reported, P = .001) by Ehrlich-Jones et al.20 Neuberger et al26
found a negative association between lower exercise beliefs and PA
levels.26 Greene et al24 examined the relationship between PA levels
and outcome expectations for exercise, finding that no statistically
significant association exists between the two.

RA Duration. The association between RA duration and PA was

Motivation. One study investigated the association between moti-

Smoking. Two studies explored the correlation between smoking,

(ever smoked)21 and (current smoker).28 No correlation was found

between PA and smoking.

examined in 4 studies.9,21,22,26 Shorter RA disease duration positively correlated with PA in 1 study (r = .19, P = .002),22 with the
remaining 3 studies reporting no statistically significant correlation
between disease duration and PA.
Body Mass Index (BMI). Four studies reported participants

BMI.20,21,24,28 No statistically significant association was found

between BMI and PA in the RA population.

Comorbidities. No correlation was found between reported

comorbidities and PA level.24,26
Disease Activity. Disease activity was investigated by 6 studies.2023,26,27 One study22 reported a positive correlation between
lower RA disease activity and PA (r = .16, P = .015).22 This result
is inconsistent with the findings of the other studies, which found
no statistically significant correlation between disease activity and
PA.20,21,23,26,27
Disease Severity. One study20 reported no correlation between

disease severity and PA.

Aerobic Fitness. Aerobic fitness was explored by 2 studies,23,26

both of which reported no association between aerobic fitness and

PA.
Strength and Muscle Function. Grip strength was examined by

studies.23,26,27

3
The findings of all 3 studies concluded that grip
strength had no association with PA in the RA population. Two
studies examined lower-limb muscle function and reported no correlation between it and PA.23,27
Range of Motion (RoM). General RoM was determined to have

no association with PA by 2 studies.23,27

Balance. Functional balance was recorded by 2 studies,23,27 which

found no association between functional balance and PA.

vation for PA and PA.20 This study found that increased motivation
for PA is positively associated with PA (r nor reported, P = .003).

Self-Efficacy. Two studies explored the association between PA

and self-efficacy.24,26 Contrasting results are reported, with Greene

et al24 finding a positive correlation between greater self-efficacy and
PA (r2 = .12, P = .01), and Neuberger et al26 reporting no association
between self-efficacy and PA.
Depression. Neuberger et al explored the association between
PA and depression, using 2 different outcome measures.26 The
study found no association between depression and PA in the RA
population.
Life Worries. One study examined the association between life

worries and PA.20 No correlation between life worries and PA levels

was found by this study.
Regulation Style. Hurkmans et al22 investigated the association

between PA and the extent to which RA patients believe that PA

is a goal set by themselves (autonomous regulation) or by others
(coerced regulation). A more autonomous regulation style was
positively associated with PA (r not reported, P < .001), whereas
a more coerced regulation style is negatively associated with PA.22
Health Perception. Two studies investigated the correlation
between general health perception and PA,25,27 with contrasting
results. Mock et al25 explored general health perception through a
self-report physical health and mental health rating. This study found
that both a higher physical health rating and a higher mental health
rating positively correlate with PA, both P < .001 (mental health
perception r = .08, physical health perception r = .12).25 Eurenius
et al27 used a self-report measure of general health perception, and
reported no relationship between general health perception and PA.
Other. Other psychological correlates of PA that have been inves-

Pain. Four studies examined the association between PA and

pain,23,24,26,27 finding no correlation between pain and PA.

tigated include sense of belonging,25 life beliefs26 and health locus

of control.27 Mock et al25 found a positive association between sense
of belonging and PA (r not reported, P < .001). Neuberger et al26
reported no association between beliefs regarding positive outcomes
in life and PA, while Eurenius et al27 found no association between
health locus of control and PA.

Fatigue. One study examined fatigue as a correlate of PA and

found a negative association between PA and fatigue.26

Social

Function. Functional status was investigated by 5

studies.2124,27

All 5 studies findings report that no statistically significant correlation between functional status and PA levels exists.

Other. One study conducted a comprehensive assessment of body

composition (see Table 3), through the use of whole-body dualenergy x-ray absorptiometry, and biochemical measures, including
blood lipids and antibodies against phosphorylcholine (anti-PC).21
Higher plasma glucose (P = .05), lower high-density lipoprotein
(P = .05), lower apolipoprotein 1 (P = .005) and lower antibodies
against anti-PC (P = .02) were negatively associated with PA.21

Social Support. Three studies examined the association between

social support and PA.22,24,26 Sources of social support that were

explored were autonomy supportiveness of a rheumatologist22 and
general social support.24,26 General social support was measured
using a standardized outcome measure, the Medical Outcomes Study
(MOS) Social Support Survey.29 All 3 studies reported no statistically significant association between social support and PA.22,24,26

Table 3 Summary of Study Results: Positive, Negative, or No Correlation With Physical Activity in People With
Rheumatoid Arthritis
Sociodemographics
Age
Gender
Race/ethnicity
Educational level
Employment status
Annual income
Marital status
Living status
Smoking
Physical
RA Duration
Body Mass Index (BMI)
Comorbidities
Disease activity
Disease severity
Aerobic fitness
Strength and muscle function
Range of motion
Balance
Function
Pain
Fatigue
Other
Waist circumference
Fat Mass Index
Body composition
Plasma glucose/insulin
Total cholesterol
Low-density lipoprotein (LDL)
High-density lipoprotein (HDL)
Apolipoproteion A1 (apoA1)
Apolipoproteion B (apoB)
Oxidized LDL (oxLDL)
Antibodies against phosphorylcholine (anti-PC)
Psychological
Exercise beliefs and expectations
Motivation
Self-efficacy
Depression
Life worries
Regulation style
Healthp
Other
Sense of belonging
Life beliefs
Health locus of control
Social
Social support
Environmental
Other
Previous levels of PA
Medications

1256

Positive correlation
22, 23
22, 23

Negative correlation
9, 28
28

22

28
9

22

22

No correlation
20, 21, 24, 26
20, 24, 26
9, 20, 24, 26
9, 24, 26
22, 24, 26, 28
9, 26
9, 26
22, 28
21, 28

Not measured
25, 27
9, 21, 25, 27
21, 22, 23, 25, 27, 28
20, 21, 23, 25, 27
20, 21, 23, 25, 27
2025, 27, 28
2025, 27, 28
9, 20, 21, 2327
9, 20, 2227

9, 21, 26
20, 21, 24, 28
24, 26
20, 21, 23, 26, 27
20
23, 26
23, 26, 27
23, 27
23, 27
2124, 27
2324, 2627

20, 2325, 27, 28

9, 22, 23, 2527
923, 25, 27, 28
9, 24, 25, 28
9, 2128
922, 24, 25, 27, 28
922, 24, 25, 28
922, 2426, 28
922, 2426, 28
921, 25, 26, 28
922, 25, 28
925, 27, 28

21
21
21

9, 20, 2228
9, 20, 2228
9, 20, 2228
9, 20, 2228
9, 20, 2228
9, 20, 2228
9, 20, 2228
9, 20, 2228
9, 20, 2228
9, 20, 2228
9, 20, 2228

26

21
21
21
21
21
21
21
21
20
20
24

24

22
25

22

26

27

9, 2123, 25, 27, 28

9, 2128
2023, 25, 27, 28
925, 27, 28
9, 2128
921, 2328
926, 28

26
27

924, 2628
925, 27, 28
926, 28

22, 24, 26

921, 23, 25, 27, 28

26

926, 28
925, 27, 28

26
26
20

25

27

Correlates of Physical Activity in Rheumatoid Arthritis 1257

Environmental

Main Findings

None of the studies included in this systematic review examined

the association between environmental factors and PA.

Positive statistical associations with PA were found for motivation,

self-efficacy, health perception, sense of belonging, previous PA
levels and an autonomous regulation style in the studies reviewed.
Negative statistical associations with PA were demonstrated
for fatigue, a coerced regulation style and certain physiological
variables (plasma glucose/insulin, total cholesterol, high density
lipoprotein, and apolipoprotein A1). Mixed statistical associations
were reported for age, gender, education, employment status and
expectations and beliefs related to exercise. All of the other variables
explored by studies in this review reported no correlation with PA
in patients with RA. Changes were noted from a previous review10
in relation to the association between numerous variables and
PA, namely age, gender, education, employment, income, marital
status, disease duration and severity, pain, fatigue, exercise beliefs
and expectations, depression, health perception, and social support
(see Table 4).
Variables that demonstrated a positive correlation with PA in
patients with RA were not consistently reviewed in the 10 articles.
Self-efficacy24,26 and health perception25,27 were included in 2
studies, with the remaining variables being examined in 1 study
onlymotivation,20 sense of belonging,25 previous PA levels,27
and autonomous regulation style.22 Greater self-efficacy is usually associated with greater PA, in the general arthritis,10 multiple
sclerosis30 and healthy adult populations.31 Our review, although
demonstrating a weak positive association (r2 = .12) in 1 study,
does not confirm with absolute certainty that the same is true for
the RA population. This concurs with the results of Wilcox et al10
who reported weak or mixed evidence of a positive association
between PA and self-efficacy in the RA population. The studies
in our review used the Arthritis Self-efficacy Scale (ASES) and a
customized measure of SE to assess SE (see Table 2). The use of a
customized measure is problematic in terms of the validity of the

Other
Previous PA Levels. One study examined the association between
previous PA levels (measured 1 year before the study) and current
PA levels,27 and found a positive association (r not reported, P =
.001) between current PA levels and previous high levels of PA.
Medications. One study recorded the number of medications of

each participant.26 No association between number of medications

and PA levels was reported.

Methodological Study Quality

A detailed analysis of the quality of the studies included in this
review is provided in Table 1. The majority of studies scored well
on quality, with 8 studies scoring either 5 or 6 out of a possible 7,
where 7/7 is of the highest quality. The primary issues with quality
were lack of justification of sample size and also the representativeness of sample population to the general RA population. The issue
of poor representation of the general RA population consistently
occurred in studies which involved convenience samples.

Discussion
This article reviews in detail 10 studies that examined the sociodemographic, physical, psychological, and social correlates of PA in
the RA population. Environmental variables were not examined in
any of the studies included in this review, thus environmental correlates of PA will not be discussed.

Table 4 Comparison of Results Between Wilcox et al14 and Current Review

Wilcox et al14

Updated review
(Larkin et al)

References

Change?

Age

924, 26, 28

Gender

20, 2224, 26, 28

920, 24, 26

Education

9, 22, 24, 26, 28

Employment

00

9, 22, 24, 26, 28

Income

00

9, 26

Marital status

Variable
Sociodemographic

Race/ethnicity

00

9, 26

Living status

00

22, 28

Smoking

00

21, 28

Physical
Disease duration

9, 2122, 26

Body mass index (BMI)

00

00

2021, 24, 28

Comorbidities

00

24, 26

Disease activity

2021, 23, 2627

Disease severity

20

Aerobic fitness

00

23, 26

00

23, 2627

Muscle strength

(continued)

Table 4 (continued)
Updated review
(Larkin et al)

References

Muscle function

00

23, 27

Range of motion

00

23, 27

Balance

00

23, 27

00

2124, 27

00

2324, 2627

26

Waist circumference

21

Fat mass index

21

Body composition

21

Plasma glucose/insulin

21

Total cholesterol

21

Low-density lipoprotein (LDL)

21

High-density lipoprotein (HDL)

21

Apolopoprotein A1 (apoA1)

21

Apolopoprotein B (apoB)

21

Oxidized LDL (oxLDL)

21

Antibodies against phosphorylcholine (anti-PC)

21

20, 24,26

20

Self-efficacy

24, 26

Perceived barriers

Depression

26

20

+ (autonomous regulation)

22

Variable

Wilcox et al14

Change?

Physical (continued)

Function
Disability

Pain

Stiffness

00

Fatigue

Psychological
Exercise beliefs and expectations
Motivation

Life worries
Anxiety

Regulation style

(coerced regulation)
Health perception

Well-being/quality of life

25, 27

Sense of belonging

25

Life beliefs

26

Health locus of control

27

00

22, 24, 26

27

26

Social
Social support

Environmental
Rural residence

Other
Previous PA levels
Medications

* Variable not examined in pervious reviews; ++ repeatedly documented positive association with physical activity; + weak or mixed evidence of positive association
with physical activity; 00 repeatedly documented lack of association with physical activity; 0 weak or mixed evidence of no association with physical activity;repeatedly
documented negative association with physical activity;weak or mixed evidence of negative association with physical activity; * mixed evidence of positive, negative
or lack of association with physical activity.
Note. Blank spaces indicate no data available.

1258

Correlates of Physical Activity in Rheumatoid Arthritis 1259

results; however the ASES is a commonly used outcome measure

for general SE and has demonstrated good psychometric properties.
Interestingly our findings indicate a positive, although weak ( =
0.12), association between health perception and PA, which conflicts
with the findings of a previous review.10 That review included only
1 study which examined health perception and self-report PA. In
that study self-report PA was measured using a 7-day activity recall,
which is comparable to the self-report methods used in the Mock et
al25 and Eurenius et al27 studies. Variations in sample populations
may account for the conflicting findings between this systematic
review and the Wilcox et al10 review. The study included in the
Wilcox et al review10 included a mixed sample of OA and RA,
while the studies in this review examined RA participants exclusively. The positive correlation between autonomous regulation
style and PA was demonstrated in 1 study only in this review, as
this theory was not commonly selected for studying correlates of
PA in the adult RA population. The strength of this correlation was
not reported however, which is problematic in terms of determining
how important regulation style is in increasing PA levels. Previous
levels of PA are positively associated with PA levels,27 as reported
by 1 study included in this review, which is in agreement with a
previous review.10
This review found a negative correlation between PA and
fatigue, coerced regulation style and certain physiological variables
(see Table 3). The association between disease symptoms and PA
levels has been shown in other chronic diseases, such as multiple
sclerosis.32 Fatigue was found to have a negative correlation with PA
in the RA population.26 Pain was the only other symptom explored
in this review, and was found to have no association with PA in the
RA population.
Our findings with regard to age concur with a previous review
of the correlates of PA in the arthritis population, who reported
mixed evidence of statistical association between age and PA.10 This
review demonstrated that 25% of studies (n = 2) reported a negative
association, 25% (n = 2) reported a positive association and 50% (n
= 4) reported no association between PA levels and age in the RA
population. In a healthy adult population age is inversely associated
with PA participation,31 indicating a difference between people with
RA and the healthy adult population. This contrast may be explained
by narrow age ranges in the sample populations, as seen in the Neuberger et al26 who reported a median age of 55 years and an age range
of 40 to 70 years. In this review employment status was reported to
have no association with PA levels by the majority of studies (80%,
n = 4) who examined this variable, concurring with the findings
of Wilcox et al.10 The remaining study (20%, n = 1) reported that
being retired is negatively associated with PA. Occupational status is
reported to be a consistent determinant of PA in healthy adults; however this does not appear to be the case in people with RA. Exercise
beliefs and expectations were explored by 3 studies,20,24,26 with each
exploring varying aspects of this variable, namely beliefs related to
PA20 (positive association), outcome expectations of exercise (ie, the
perceived consequences of exercise24 [negative association]), and the
perceived benefits of and barriers to exercise26 (no association). As
reported previously10 perceived benefits of and barriers to exercise
have no association with PA levels and this was confirmed by 33%
of studies (n = 1).26 However our finding is based on 1 study alone,
which was conducted in a sample of participants within a limited
age range of 40 to 70 years, and thus cannot be generalized to the
entire RA population on this basis alone.
Finally we found no association between certain variables in
all four categories (sociodemographic, physical, psychological and
social) and PA in people with RA. Interestingly in our review race

and/or ethnicity, annual income, smoking, marital status and living

status were reported to have no correlation with levels of PA in the
RA population. Wilcox et al10 reported only on employment and
marital status in relation to the RA population. Studies reported
mixed associations between marital status and PA levels,10 contrasting with our finding of no correlation between marital status and
PA. The association between marital status and PA levels in healthy
adults agrees partially with the findings of both our review and the
Wilcox et al10 review, with both positive and no association between
the 2 being reported.31 While smoking showed no correlation with
PA levels in the studies we reviewed21,28 smoking has been found
to have a negative association with PA levels in other adult populations.31 Shorter disease duration and lower disease activity were
found to be positively correlated with PA by 1 study only,22 with
the remaining studies consistently reporting no correlation between
PA and these variables.9,21,23,26,27 These contrasting findings are in
agreement with a previous review of correlates of PA in the general
arthritis population.10 Notably no correlation was reported between
BMI and PA in the RA population.20,21,24,28 This contrasts with the
impact of being overweight or obese (ie, having an increased BMI) on
PA levels in other adult populations, where it is consistently associated with decreased PA levels.31 Functional ability was consistently
measured in the studies that we reviewed with the Health Assessment
Questionnaire (HAQ),33 which was positive in terms of comparing
results. This review found no correlation between functional ability
and PA levels in people with RA, as reported previously.10 However
the reporting of the HAQ as functional ability, rather than as disability, may be problematic as some may view the HAQ as a measure
of disability rather than as a measure of functional ability. The only
social variable investigated in the studies we reviewed was social
support.22,24,26 No correlation was found between social support and
PA levels indicating that the role of social support in promoting PA
may not be important in the promotion of PA within the RA population. This contrasts with findings in both the MS population30 and
the general adult population,31 where social support is known to
be a correlate of PA. Wilcox et al10 reported a positive association
between social support and PA in the general arthritis population.
The conflict between our review and their findings may be attributed
to the different types of social support examined, namely family
support and the support of healthcare professionals.

Clinical Implications
Currently there are no definite correlates of PA for the RA population. This poses a challenge to clinical practitioners in developing
and implementing programs to promote PA levels in people with RA.

Research Implications
The findings of this review indicate the further research is required
to determine the correlates of PA, specific to the RA population. By
determining the correlates of PA for the RA population programs
can be developed and delivered to promote PA in the RA population. The majority of studies that examined correlates of PA were
cross-sectional in design. Cross-sectional study designs do not
however allow determination of causal effects, thus longitudinal
and intervention studies are needed.

Limitations
A limitation of this systematic review is the small number of studies
included in the review. A range of variables were included in the
studies and were measured using a variety of tools, negating the

1260Larkin and Kennedy

pooling of results to make definitive conclusions on the strength of

association between variables and PA. Studies which examined the
correlates of both PA and exercise were included, and while it may
be argued that exercise levels are not an accurate reflection of daily
PA levels, as previously stated exercise is a subset of PA7 and thus
was deemed to be pertinent for inclusion in this review.

Conclusions
This review found positive associations between PA and motivation,
self-efficacy, health perception and previous PA levels, and negative
associations with fatigue, a coerced regulation style, and certain
physiological variables including plasma glucose, high density lipoprotein, apolopoprotein, and antibodies against phosphorylcholine.
These findings will be of benefit in the design of interventions to
promote PA in RA; however, more research is needed to further
explore the correlates of PA in this population.
Acknowledgments
The authors would like to acknowledge Julianne Ryan for acting as a third
reviewer for the articles included in this review. The authors would also
like to acknowledge the Statistical Consultation Unit at the University of
Limerick for their assistance in relation to data analysis. This research is
funded by the primary author as part of her postgraduate studies.

References
1. Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham
CO 3rd, et al. 2010 Rheumatoid Arthritis Classification Criteria: an
American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010;62:25692581.
PubMed doi:10.1002/art.27584
2. Plasqui G. The role of physical activity in rheumatoid arthritis. Physiol Behav. 2008;94:270275. PubMed doi:10.1016/j.
physbeh.2007.12.012
3. Alamanos Y, Voulgari PV, Drosos AA. Incidence and prevalence
of rheumatoid arthritis, based on the 1987 American College of
Rheumatology Criteria: a systematic review. Semin Arthritis Rheum.
2006;36:182188. PubMed doi:10.1016/j.semarthrit.2006.08.006
4. Tierney M, Fraser A, Kennedy N. Physical activity in rheumatoid
arthritis: a systematic review. J Phys Act Health. 2012;9:10361048.
PubMed
5. Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise,
and physical fitness: definitions and distinctions for health-related
research. Public Health Rep. 1985;100(2):126131. PubMed
6. Metsios GS, Stavropoulos-Kalinoglou A, Sandoo A, et al. Vascular
function and inflammation in rheumatoid arthritis: the role of physical
activity. The Open Cardiol Med J. 2010;4:8996. PubMed
7. Taylor HL. Physical activity: is it still a risk factor? Prev Med.
1983;12:2024. PubMed doi:10.1016/0091-7435(83)90164-0
8. Sokka T, Hakkinen A, Kautiainen H, Maillefert JF, Toloza S, Hanesn
TO, et al. Physical inactivity in patients with rheumatoid arthritis: data
from twenty-one countries in a cross-sectional, international study.
Arthritis Care Res. 2008;59(1):4250. doi:10.1002/art.23255
9. Semanik P, Wilbur J, Sinacore J, Chang RW. Physical activity behavior
in older women with rheumatoid arthritis. Arthritis & Rheum. Arthritis
Care Res. 2004;51(2):246252. doi:10.1002/art.20245
10. Wilcox S, Der Ananian C, Sharpe PA, Robbins J, Brady T. Correlates
of physical activity in persons with arthritis: review and recommendations. J Phys Act Health. 2005;2:230252.

11. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic

Reviews of Interventions Version 5.1.0 [updated March 2011]. The
Cochrane Collaboration, 2011. Available from www.cochranehandbook.org
12. Warren JM, Ekelund U, Besson H, et al. Assessment of physical
activitya review of methodologies with reference to epidemiological
research: a report of the exercise physiology section of the European
Association of Cardiovascular Prevention and Rehabilitation. Eur J
Cardiovasc Prev Rehabil. 2010;17(2):127139. PubMed doi:10.1097/
HJR.0b013e32832ed875
13. Anderson S, Tatt ID, Higgins JPT. Tools for assessing quality and
susceptibility to bias in observational studies in epidemiology: a
systematic review and annotated bibliography. Int J Epidemiol.
2007;36:666676. PubMed doi:10.1093/ije/dym018
14. Crombie I. The pocket guide to critical appraisal. London: BMJ
Publishing Group; 1996.
15. Petticrew M, Roberts H. Systematic reviews in the social sciences: a
practical guide. Oxford: Blackwell; 2006.
16. DiPietro L, Caspersen CJ, Ostfeld AM, Nadel ER. A survey for
assessing physical activity among older adults. Med Sci Sports Exerc.
1993;25:628642. PubMed doi:10.1249/00005768-199305000-00016
17. Orsini N, Bellocco R, Bottai M, et al. Validity of self-reported total
physical activity questionnaire among older women. Eur J Epidemiol.
2008;23(10):661667. PubMed doi:10.1007/s10654-008-9273-z
18. Wendel-Vos GC, Schuit AJ, Saris WH, Kromhout D. Reproducibility and relative validity of the short questionnaire to assess healthenhancing physical activity. J Clin Epidemiol. 2003;56:11631169.
PubMed doi:10.1016/S0895-4356(03)00220-8
19. Rimmer JH, Riley BB, Rubin SS. A new measure for assessing the
physical activity behaviors of persons with disabilities and chronic
health conditions: the Physical Activity and Disability Survey. Am J
Health Promot. 2001;16:3442. PubMed doi:10.4278/0890-117116.1.34
20. Ehrlich-Jones L, Lee J, Semanik P, Cox C, Dunlop D, Chnag RW.
Relationship between beliefs, motivation, and worries about physical
activity and physical activity participation in persons with rheumatoid arthritis. Arthritis Care Res. 2011;63(12):17001705. PubMed
doi:10.1002/acr.20616
21. Elkan A-C, Hkansson N, Frostegrd J, Hafstrm I. Low level of
physical activity in women with rheumatoid arthritis is associated
with cardiovascular risk factors but not with body fat massa cross
sectional study. BMC Musculoskelet Disord. 2011;12:1318. PubMed
doi:10.1186/1471-2474-12-13
22. Hurkmans EJ, Maes S, De Gucht V, et al. Motivation as a determinant
of physical activity in patients with rheumatoid arthritis. Arthritis Care
Res. 2010;62(3):371377. PubMed doi:10.1002/acr.20106
23. Eurenius E, Stenstrom CH, The Para Study Group. Physical activity,
physical fitness, and general health perception among individuals
with rheumatoid arthritis. Arthritis & Rheum. Arthritis Care Res.
2005;53(1):4855. doi:10.1002/art.20924
24. Greene BL, Haldeman GF, Kaminski A, Neal K, Lim SS, Conn DL.
Factors affecting physical activity behavior in urban adults with
arthritis who are predominantly African-American and female. Phys
Ther. 2006;86(4):510519. PubMed
25. Mock SE, Fraser C, Knutson S, Prier A. physical leisure participation
and the well-being of adults with rheumatoid arthritis: the role of
sense of belonging. Act Adaptation Aging. 2010;34(4):292302. doi
:10.1080/01924788.2010.523870
26. Neuberger GB, Aaronson LS, Gajewski B, et al. Predictors of exercise
and effects of exercise on symptoms, function, aerobic fitness, and
disease outcomes of rheumatoid arthritis. Arthritis & Rheum. Arthritis
Care Res. 2007;57(6):943952. doi:10.1002/art.22903

Correlates of Physical Activity in Rheumatoid Arthritis 1261

27. Eurenius E, Brodin N, Lindblad S, Opava CH, The Para Study Group.
Predicting physical activity and general health perception among patients
with rheumatoid arthritis. J Rheumatol. 2007;34(1):1015. PubMed
28. van den Berg MH, de Boer IG, le Cessie S, Breedveld FC, Vliet
Vlieland TPM. Most people with rheumatoid arthritis undertake
leisuretime physical activity and exercise in the Netherlands: an
observational study. Aust J Physiother. 2007;53:113118. PubMed
doi:10.1016/S0004-9514(07)70044-2
29. Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci
Med. 1991;32:705714. PubMed doi:10.1016/0277-9536(91)90150-B
30. Motl RW, Snook EM, McAuley E, Scott JA, Douglass ML. Correlates of physical activity among individuals with multiple

sclerosis. Ann Behav Med. 2006;32(2):154161. PubMed doi:10.1207/

s15324796abm3202_13
31. Trost SG, Owen N, Bauman AE, Sallis JF, Brown W. Correlates of adults participation in physical activity: review and
update. Med Sci Sports Exerc. 2002;34(12):19962001. PubMed
doi:10.1097/00005768-200212000-00020
32. Motl RW, Snook E, McAuley E, Gliottoni RC. Symptoms, selfefficacy, and physical activity among individuals with multiple
sclerosis. Res Nurs Health. 2006;29:597606. PubMed doi:10.1002/
nur.20161
33. Fries JF, Spitz P, Kraines RG, Holman HR. Measurement of patient
outcome in arthritis. Arthritis Rheum. 1980;5:119129. PubMed

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