身體活動與類風濕性關節炎患者自述健康之相關

Physical Activity and Patient-Reported Outcomes among Patients with Rheumatoid Arthritis

楊君瑩(Chun-Ying Yang)

指導教授 ： 季瑋珠

國立臺灣大學/公共衛生學院/流行病學與預防醫學研究所/碩士(2018年)

https://doi.org/10.6342/NTU201802460

摘要

研究背景：
類風濕性關節炎 (Rheumatoid arthritis, RA) 是一種慢性、發炎性的自體免疫疾病，主要造成患者關節的腫脹以及疼痛。由於RA致病機轉複雜、不明確，目前其治療策略除控制疾病進程外，也希望能夠提升患者之生活品質 (Quality of life, QOL) 。過去曾有研究指出，接受運動計畫介入之RA患者可提升介入後生活品質但其疾病活動度並未受到顯著的影響。然過去甚少研究探討日常身體活動(Physical activity, PA) 對患者健康結果之影響，卻常見將PA是否提升作為運動計畫介入後之結果。而本研究旨在了解現今患者身體活動程度與健康結果之相關及PA如何影響RA患者的自評健康 (Patient-reported outcomes, PROs) 。

研究方法：
在此世代追蹤研究中，自2017年12月至2018年6月，共接觸了來自台大醫院風濕免疫科的151位RA患者。健康結果包含了QOL、健康評值、疾病活動度、紅血球沉降速率 (Erythrocyte sedimentation rate, ESR) 四者，分別以 短版36健康量表 (Short Form-36) 、健康評值-殘疾指標 (Health assessment questionnaire- disability index, HAQ-DI) 及二十八處關節疾病活動度量表 (Disease activity score with 28 joints count, DAS 28) 評估及參考病歷得之。將PA分為低、中、高三組，以單因素方差分析 (One-way analysis of variance, 1-ANOVA) 及卡方檢定 (chi-square test) 檢定三組間人口學變項與健康結果差異是否顯著。PA與健康結果間相關性則分別以皮爾森 (Pearson) 、斯皮爾曼 (Spearman) 相關係數檢視其線性與非線性之相關。以線性回歸建立PA與健康結果之相關模型並校正共變數。當 P < 0.05 視為達統計顯著意義。

研究結果：
當患者的PA程度越高，QOL總分越高、HAQ-DI總分越低並達到統計上顯著意義，而發炎指數ESR在中度PA組別中最低。將PA 作為連續變項時，其與QOL (r = 0.24)及HAQ-DI (r = -0.19)之間存在顯著之線性相關。考量非線性相關時，除QOL (r = 0.28)、HAQ-DI (r = -0.27) 外，PA與DAS28 (r = -0.20) 間亦存在顯著之相關。經4-24週追蹤後，僅QOL在中 (ΔPCS = 3.7)、高度 (ΔMCS = 3.7) PA提升達顯著，ESR於中度PA患者中亦達顯著之增加 (ΔESR = 2.9)。經追蹤後，PA與健康結果之改變均未出現顯著相關。三組間人口學變項分布皆未達顯著。

結論：
本研究可作為一臨床證據，證實較高的PA程度與較佳的QOL、較低的失能相關，且疾病活動度在三組間無顯著之差異。然經追蹤後健康結果大多未有顯著之提升，甚至在較高PA組別中ESR有上升的傾向。因此作者認為RA患者保持身體活動的同時應尋求專家建議並同時監控發炎指數。由於多數健康結果改變經追蹤後並未達顯著，未來需由更多長期追蹤研究確立PA與健康結果間相關之時序性。

關鍵字

類風濕性關節炎 ； 身體活動 ； 自評健康 ； 生活品質 ； 健康評值 ； 疾病活動度

並列摘要

Background:
Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease which mainly causes swelling and pain in joints. Because of the complicated mechanism of RA, the treatment goal is not only to control the disease progression but to improve patients' quality of life (QOL). Former studies had found that exercise can improve post-intervention QOL, but disease activity was similar in both intervention and control groups. However, few studies evaluated how PA affected health outcomes, but took if PA improved as study outcomes. This study aimed to explore the distribution of health outcomes among different level of PA and how daily physical activity (PA) affects patient-reported outcomes (PROs) among patients with RA.

Method:
In this prospective cohort study, a total of 151 patients from division of allergy, immunology and rheumatology in National Taiwan University Hospital were recruited from Dec. 2017 to Jun. 2018. The primary outcome contained QOL, health assessment, disease activity, and erythrocyte sedimentation rate (ESR) evaluated by SF-36, HAQ-DI, DAS28, and medical records respectively. PA was classified, following the scoring guideline of International Physical Activity Questionnaire (IPAQ), into three levels, low, moderate, and high according to the amounts and intensities of PA of each patient in a week, one-way analysis of variance (1-ANOVA) and chi-square test were used to test the difference of demographic factors and PROs among three levels (low, moderate, and high) of PA. Pearson and Spearman correlation coefficients were used to investigate the linear and non-linear correlation between PA and health outcomes. Linear regression was used to model the relationship between PA and health outcomes and adjust for covariates. A p value < 0.05 was defined as statistically significant.

Result:
As the PA level got higher, patients had better QOL, lower HAQ-DI score, and the lowest inflammatory index, ESR, in the moderate PA level. Considering PA as continuous score, it existed linear correlations between PA and QOL (r = 0.24), HAQ-DI (r = -0.19) score. As for the non-linear correlation, PA had a significant association between DAS28 (r = -0.20) besides QOL (r = 0.28) and HAQ-DI (r = -0.27) score. After a follow-up period of 4-24 weeks, QOL improved in moderate (ΔPCS = 3.7) and high (ΔMCS = 3.7) levels of PA, ESR increased significantly in moderate level of PA (ΔESR = 2.9). Correlations between PA and changes of health outcomes did not reach statistical significance after the follow-up period. No significant difference of demographic factors were detected.

Conclusion:
This study provided an evidence that higher PA is associated with better QOL and less disability, while no difference in disease activity. However, after a follow-up period, most of health outcomes did not improve significantly, ESR even increased in high PA level. Therefore, we suggested that patients with RA should be advised to keep physically active following experts' advices and keep their disease activity and inflammatory index under monitor. For the non-significant results after follow-up, further researches with longer follow-up period are needed to confirm the temporality of the relationship.

並列關鍵字

Rheumatoid arthritis (RA) ； Physical activity (PA) ； Patient-reported outcomes (PROs) ； Quality of life (QOL) ； Health assessment (HAQ-DI) ； Disease activity (DAS28)

參考文獻

1. Myasoedova E, Crowson CS, Kremers HM, et al. Is the incidence of rheumatoid arthritis rising? Results from Olmsted County, Minnesota, 1955-2007. Arthritis and rheumatism 2010;62(6):1576-82.

2. GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet 2015;385(9963):117-71.

3. Smolen JS, Aletaha D, McInnes IB. Rheumatoid arthritis. The Lancet 2016;388(10055):2023-38.

4. Albano SA, Santana-Sahagun E, Weisman MH. Cigarette smoking and rheumatoid arthritis. Seminars in arthritis and rheumatism 2001;31(3):146-59.

5. Sugiyama D, Nishimura K, Tamaki K, et al. Impact of smoking as a risk factor for developing rheumatoid arthritis: a meta-analysis of observational studies. Annals of the rheumatic diseases 2010;69(1):70-81.