The goal of this observational study is to examine the effects of traditional respiratory rehabilitation and respiratory muscle strengthening training added to this program at the genetic level in in patients with rheumatoid arthritis-associated interstitial lung disease. The main questions it aims to answer are: * Does respiratory muscle strengthening exercise added to respiratory rehabilitation in patients with rheumatoid arthritis-associated interstitial lung disease have additional benefits on rehabilitation outcome measures such as exercise capacity, shortness of breath, and muscle strength? * Does the gain obtained with respiratory muscle strengthening iin patients with rheumatoid arthritis-associated interstitial lung disease increase the quality of life of patients and have a positive effect on their psychological state? * Does respiratory rehabilitation applied to iin patients with rheumatoid arthritis-associated interstitial lung disease have an effect on genetic changes? * Does respiratory muscle strengthening training applied in addition to respiratory rehabilitation in patients with rheumatoid arthritis-associated interstitial lung disease have an effect on genetic changes? * Participants will be included in two different respiratory rehabilitation programs with and without respiratory muscle training, and pre- and post- treatment rehabilitation criteria and genetic changes will be compared.
Rheumatoid arthritis (RA) is a systemic, inflammatory, and autoimmune disease characterized by inflammation of synovial tissue in the joints, which can lead to joint destruction. Although the pathogenesis of the disease is not yet fully understood, it is thought that genetic and environmental factors contribute to the pathological activation of the immune system. The presence of autoantibodies has been demonstrated in the serum of RA patients, including rheumatoid factor (RF), anti-citrullinated protein antibodies (ACPA), anti-carbamylated protein antibodies, and anti-acetylated protein antibodies. The presence of these autoantibodies provides critical insights into the pathophysiology of the disease. RA follows an inflammatory pathway characterized by the overexpression of proinflammatory cytokines. Specifically, TNF-α, IL-6, and IL-1b play significant roles in triggering joint destruction and synovial inflammation, ultimately leading to bone erosion and cartilage damage. In addition to joint involvement, RA can also involve extra-articular organs and tissues, which may lead to significant increases in morbidity and mortality. The lungs are the primary organ affected by extra-articular involvement in RA. Pulmonary involvement in RA negatively impacts prognosis and often necessitates treatment modification. Pulmonary manifestations can present as pleural, parenchymal, or vascular involvement. Among the types of pulmonary involvement associated with RA, interstitial lung disease (ILD) is one of the most common parenchymal manifestations. However, the prevalence of ILD in RA (RA-ILD) patients varies depending on the diagnostic methods used and the populations studied. Studies have shown that ILD significantly worsens the overall prognosis of RA and often requires specific therapeutic approaches, including modifications to immunosuppressive treatments or the addition of antifibrotic therapies. Respiratory dysfunction in RA is not solely limited to parenchymal damage. Inflammatory involvement of respiratory muscles, as well as reduced pulmonary function due to systemic inflammation, are common findings. Pulmonary function tests (PFT) in RA patients often reveal restrictive or obstructive patterns, with significant reductions in forced vital capacity (FVC) and diffusing capacity for carbon monoxide (DLCO). Moreover, seropositive RA patients, particularly those with high titers of RF or ACPA, are more likely to exhibit pulmonary abnormalities compared to seronegative patients. Factors such as age, smoking status, disease duration, and body mass index also contribute to variations in PFT outcomes. The primary treatment goals for RA patients are remission or achieving a state of low disease activity. Disease-modifying antirheumatic drugs (DMARDs) and biological agents are employed to meet these objectives. These therapies aim to suppress systemic inflammation, reduce joint damage, and prevent extra-articular complications. In addition to pharmacological treatments, exercise training is recommended to improve patients' quality of life, enhance functional recovery, and reduce cardiovascular risks. Aerobic and resistance exercises have been shown to be both feasible and effective for RA patients, significantly improving muscle strength, joint mobility, and overall physical function without exacerbating disease activity. Particularly in RA patients with pulmonary involvement, respiratory exercises are gaining attention for their potential to improve respiratory muscle strength and pulmonary function. Studies on respiratory training have demonstrated improvements in inspiratory and expiratory muscle strength, as well as reductions in dyspnea severity. These interventions are especially beneficial in patients with coexisting ILD, where optimizing pulmonary function can contribute to better clinical outcomes and quality of life. LncRNA HOTAIR, a long non-coding RNA known as a repressor of the HOXD gene, has been shown to play a critical role in RA. HOTAIR facilitates inflammatory reactions by releasing inflammatory cellular contents into circulation and contributes to cartilage and bone matrix destruction through the activation of MMP-2 and MMP-9 in osteoclasts. Analyses in RA patients have demonstrated elevated HOTAIR expression levels, which have been associated with disease pathogenesis. The positive correlation between HOTAIR and TNF-α further underscores its impact on inflammation. Additionally, HOTAIR has been shown to enhance the production of MMP-9 and other matrix metalloproteinases, contributing to joint destruction. In recent years, studies investigating the role of epigenetic modifications in the diagnosis, treatment, and progression of RA have gained increasing attention. Long non-coding RNAs (lncRNAs), which are RNA molecules longer than 200 nucleotides that do not code for proteins, are emerging as significant regulators in various biological and pathological processes. LncRNAs influence epigenetic modifications, transcription, post-transcriptional processes, and protein-RNA interactions. Some lncRNAs exhibit oncogenic properties, while others act as tumor suppressors depending on their expression profiles and biological effects in different tissues. In RA, specific lncRNAs, including HOTAIR, have been identified as key players in the inflammatory response and disease progression. Despite the growing body of research on lncRNAs in autoimmune diseases, no studies to date have investigated the impact of exercise training on the regulation of lncRNA HOTAIR in RA-ILD patients. Given the increasing evidence linking lncRNAs to immune regulation and inflammation, understanding how exercise influences these molecules could provide novel insights into RA management. Our study aims to fill this gap by exploring the relationship between exercise training and lncRNA HOTAIR expression in RA patients, with a particular focus on the potential epigenetic mechanisms underlying these interactions. By addressing this unexplored area, we aim to contribute to the development of innovative therapeutic strategies that combine pharmacological treatments with exercise-based interventions.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
39
Patients are asked to perform thoracic, diaphragmatic breathing, and lower basal breathing exercises with 10 repetitions. Then, strengthening exercises are performed on the major muscle groups of the upper and lower extremities. In accordance with the resistance training program in the ATS/ERS guidelines for pulmonary rehabilitation, two to four sets of 6-12 repetitions are performed with intensities ranging from 50% to 85% of one maximum repetition, two to three times a week. During the exercises, the patient is questioned about their fatigue and dyspnea levels using the Borg scale, and breaks are given when necessary. The aerobic exercise program is performed as a 12-week, 3-day-a-week self-walking exercise. The walking program is performed in the form of walking on flat ground at 60% workload, based on the data obtained from the 6-minute walking test result (land-based walking).
In the other arm of the study, respiratory muscle training is performed in addition to the "standard pulmonary rehabilitation program." Respiratory muscle strengthening training is performed with a resistive thereshold inspiratory muscle strengthening device. The exercise is performed at an intensity of 30% of the maximum inspiratory pressure determined by mouth pressure measurement. The exercise is performed in 7 sets, with 2 minutes of work and 1 minute break for a total of 21 minutes.
Peripheral blood samples will be taken once from the participants in the control group and no other intervention will be performed.
University of Health Sciences
Istanbul, Turkey, Turkey (Türkiye)
RECRUITINGlncRNA HOTAIR expression levels
Peripheral blood mononuclear cells (PBMCs) will be isolated from venous blood samples collected at baseline and at Week 12. Total RNA will be extracted from PBMCs and reverse-transcribed into complementary DNA (cDNA). lncRNA HOTAIR expression will be quantified using real-time quantitative polymerase chain reaction (RT-qPCR). Each sample will be analyzed in duplicate. Cycle threshold (Ct) values will be normalized to a reference housekeeping gene to calculate ΔCt values. Changes in HOTAIR expression between baseline and Week 12 will be determined using the ΔΔCt method and expressed as fold change (2-ΔΔCt).
Time frame: Baseline and 12 weeks
Short Form - 36
In the evaluation with the short form-36, it is aimed to learn the patient's views about her own health, how she feels and how much she can perform her daily activities. Each scale is directly transformed into a 0-100 scale on the assumption that each question carries equal weight. The lower the score the more disability. The higher the score the less disability i.e., a score of zero is equivalent to maximum disability and a score of 100 is equivalent to no disability.
Time frame: Baseline and 12 weeks
Respiratory Muscle Strength Measurement
The patient is seated in a straight-backed chair. The patient is asked to grasp the silicone mouthpiece with his/her mouth and inhale and exhale as quickly and deeply as possible. The measurements are repeated until 3 measurement values are obtained with a maximum of 10% deviation between the measured peak value. The maximum value is taken among the measured values.
Time frame: Baseline and 12 weeks
Visual Analog Scale (VAS)
Pain level will be assessed using with Visual Analog Scale. VAS is a scale which consists of a 100-millimetre scale ranging from 0 (no pain at all) to 100 (worst imaginable pain). A higher score indicates greater pain intensity.
Time frame: Baseline and 12 weeks
Exercise capacity (6-minute walk test)
6-minute walk test is performed for exercise capacity. After resting in a chair for a sufficient period (\>30 minutes), patients walk as fast as possible, without running, for 6 minutes on a straight 30-meter corridor. Before and after the test, the patient's fatigue and dyspnea are questioned using the Modified Borg Scale. Oxygen saturation and heart rate are monitored and recorded using a finger pulse oximeter before, during, and after the test.
Time frame: Baseline and 12 weeks
Modified Medical Research Council (mMRC) Dyspnea Scale
mMRC is a 0-4 point category scale where patients select the value that best describes their level of dyspnea. Increases in mMRC levels, especially values of 2 and above, are considered to indicate an increased risk of mortality.
Time frame: Baseline and 12 weeks
HAQ
Health Assessment Questionnaire was used to assess general health. It consists of 20 questions in total, including 8 subsections. Subjects score between 0-3 according to their level of difficulty in activities. The total score is obtained by calculating the arithmetic mean of the sums of the highest scores in the subsections. Higher scores indicate higher functional disability and pain.
Time frame: Baseline and 12 weeks
Forced Expiratory Volume in 1 Second (FEV₁)
Change in forced expiratory volume in one second (FEV₁), measured in liters (L), assessed by spirometry using the Pony Fx spirometry device in accordance with ATS guidelines.
Time frame: Baseline and 12 weeks
Forced Vital Capacity (FVC)
Change in forced vital capacity (FVC), measured in liters (L), assessed by spirometry using the Pony Fx spirometry device in accordance with American Thoracic Society (ATS) guidelines
Time frame: Baseline and 12 weeks
Quality of life level
Saint George Respiratory Questionaire (SGRQ) score: The SGRQ ranges from 0 (no impairment of quality of life) to 100 (highest impairment of quality of life).
Time frame: Baseline and 12 weeks
International Physical Activity Questionnaire-Short form (IPAQ-SF)
It is an internationally valid questionnaire for the assessment of physical activity. The short form of the questionnaire consists of seven questions and provides information about the time spent in sitting, walking, moderate and intense activities. A score is obtained as "MET-minutes/week" by multiplying minutes, days and MET values. The numerical values obtained are classified as inactive, minimally active or very active.
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Time frame: Baseline and 12 weeks
Digital muscle strength measurement
Muscle strength is assessed using an electronic hand dynamometer. The patient is asked to maintain muscle strength against the dynamometer for at least 5 seconds in each attempt, with the force measurement repeated 3 times. The best value from the 3 test results is recorded.
Time frame: Baseline and 12 weeks
FEV₁/FVC Ratio
Change in the FEV₁/FVC ratio, expressed as a percentage (%), assessed by spirometry according to ATS guidelines.
Time frame: Baseline and 12 weeks