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Extremity and Joint Conditions/Section Articles

Exercise for Athletes With Inflammatory Arthritis

Powell, Amy P. MD, FACP; English, Joy MD, RMSK

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Current Sports Medicine Reports: September 2018 - Volume 17 - Issue 9 - p 302-307
doi: 10.1249/JSR.0000000000000518
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Abstract

Introduction

A variety of inflammatory and degenerative arthritic conditions result in pain and disability. Inflammatory arthritis in particular impacts children and younger adults when functional limits are unusual and unexpected; these athletes are in the primes of their lives. This article will review the current evidence supporting exercise as a component of overall health, exercise as a form of disease management, forms of exercise recommended for specific inflammatory conditions, and where necessary, exercise that should be avoided in specific circumstances.

Key take-home points:

  • - Exercise is an important component of life-long health and well-being, especially for those with chronic disease.
  • - Inflammatory conditions are associated with an increased risk for cardiovascular disease, making exercise an especially important disease-modifying management approach.
  • - Exercise has been shown to exert anti-inflammatory effects in many chronic conditions, including inflammatory arthritis.
  • - Exercise has not been shown to accelerate joint destruction in patients with inflammatory arthritis.
  • - Exercise offers key health benefits to patients with inflammatory arthritis in terms of preservation of function and overall mobility.
  • - Specific inflammatory conditions result in potentially serious consequences of which sports medicine physicians should be aware. Screening for risk of spinal cord injury in contact/collision sport athletes may be required.
  • - Patients with inflammatory arthritis may be on medications that:
    • ○ Increase risk of infection
    • ○ Should be avoided due to end-organ issues.

Each inflammatory arthritis disease state with evidence-based recommendations for exercise or sport participation will be discussed below.

Rheumatoid Arthritis

Disease Basics

Rheumatoid arthritis (RA) is an autoimmune disorder characterized by inflammation in the synovium and ultimately irreversible destruction of the synovium in any given joint. It is the most common inflammatory rheumatologic condition and is characterized by an insidious onset of joint pain, swelling, and morning stiffness in multiple joints. Classic RA most commonly manifests in the small joints of the hands and feet, specifically the MCP and PIP joints in the hand, the IP joint in the thumb, and the MTP joints in the feet (1). Large joint involvement also occurs and is common in the shoulders, elbow, knees, and ankles. Involvement of the axial or central skeleton is less common and only occurs in 20% to 50% of patients. Joint involvement is often symmetric and can be migratory, intermittent, or monoarticular. Early in the disease, extra-articular symptoms can include fatigue, low grade fevers, myalgias, depression, carpal tunnel syndrome, exercise intolerance, and weight loss. Throughout the course of the disease, patients may experience skin ulcers, scleritis, pericarditis, myocarditis, neuropathy, vasculitis, and renal disease (2). Typical laboratory findings present in RA include rheumatoid factor and antibodies to cyclic citrullinated peptide (anti-CCP).

Disease Complications Impacting Exercise

The risk of cardiovascular disease in patients with RA is twice that in the general population and is equivalent to the cardiovascular risk associated with diabetes mellitus (3). The risk of myocardial infarction in patients with RA is similar to those who are 10 years older without RA (4). The predisposition to cardiovascular risk in patients with RA is attributed to dyslipidemia, increased coronary atherosclerosis, impairments in the cardiac autonomic system, endothelial dysfunction and diminished arterial compliance (3). Adequate disease control is necessary to lower cardiovascular risk (3). Before the implementation of a vigorous exercise program in the general population, the current AHA guidelines for the general population suggest that asymptomatic men >45 years and women >55 years who have DM or two major coronary risk factors, undergo a medical evaluation, risk assessment, and exercise testing (5). Based on the risk profile present in patients with RA, it is reasonable to suggest that these individuals undergo cardiac screening 10 years earlier than general population.

Joint destruction in the cervical spine can cause instability and malalignment posing serious risks to affected individuals. Instability in the cervical spine occurs at the atlantoaxial joint and can cause multidirectional subluxation with cord compromise (6). It is most often related to erosions in the odontoid process or breakdown of the transverse ligament between C1 and C2 (7). Cervical spine involvement occurs later in the disease and corresponds to the severity of RA in other peripheral joints, such as the hip and knees (8). Increased CRP levels, early progression of peripheral RA, joint subluxation, and older age at onset are risk factors for the development of cervical involvement (9). Once instability is detected on plain radiographs, the 5-year mortality rate reaches 17% (10). Scarce evidence exists regarding the prevention of cervical spine involvement in RA but few studies have shown decreased incidence with initiation of combination DMARD therapy versus single DMARD therapy (11). Initiation of biologic therapy is also thought to reduce risk (12). Although no formal recommendations exist regarding atlantoaxial instability and participation in sports, the risk should be taken into consideration when determining the type of exercise to recommend to any given individual. Complete avoidance of contact sports or high-impact sports should be advised if there is any evidence of instability and surgical intervention may be considered.

With classic RA, patients may experience extraarticular symptoms including a low-grade fever. The American College of Sports Medicine (ACSM) generally recommends against training with a fever of 100.4 or greater. Resumption of activity can resume once the patient becomes afebrile.

Anemia of chronic disease may occur in up to 60% of those affected by RA. Current ACSM guidelines recommend that exercise begin with shorter sessions only lasting 10 to 15 min. This can be gradually increased in 5-min intervals every couple of weeks up to 30 to 60 min 3 to 4 d·wk−1 for those affected by RA. If any chest pain, shortness of breath, or extreme fatigue occurs the activity should be stopped immediately.

Commonly Used Medications and Side Effects Pertinent to Sports Medicine

Several different drug classes are used in the treatment of RA, including nonbiologic disease-modifying antirheumatic drugs (DMARDs), biologic DMARDs, glucocorticoids, nonsteroidal anti-inflammatories (NSAIDs) and analgesics. Biologic DMARDs appear to increase risk of infection. The nonbiologic DMARDs may cause myelosuppression which can in turn cause anemia and shortness of breath. Monitoring is performed with a complete blood count every 2 to 4 wk for the first 3 months. Glucocorticoids and cyclosporine can cause elevation of blood pressure and this should be monitored serially with initiation of therapy. If the resting blood pressure is greater than 180/110, exercise should be avoided. Clear evidence exists regarding long term use of NSAID and renal disease. NSAID use should generally be avoided during rigorous exercise where dehydration and the potentiation of renal impairments may occur.

Exercise Recommendations

It has been well established that regular participation in an exercise program increases self-esteem, decreases depression, and increases one’s ability to cope with life stressors. Current guidelines from ACSM recommend 30 min of moderate exercise on at least 5 d·wk−1 (13). Despite data showing benefits of exercise, patients with RA are less active than healthy controls (14). The lack of physical activity in patients with RA may be attributed to a lack of knowledge from health care providers and therefore failure to promote physical activity (15). It also may be attributed to poor patient motivation and lack of education. Contrary to prior recommendations to remain sedentary, there have been several recent articles promoting dynamic exercise as part of an aerobic exercise program to promote health without incurring unpleasant side effects (16). Verhoeven et al. (17) showed that physical activity in RA can decrease the disease activity score (DAS), decrease fatigue and pain, enhance self-esteem, decrease depression, decrease femoral bone loss, improve sleep and quality of life, and slow untoward cardiovascular processes.

Physical activity can be broken down into joint range of motion, cardiovascular exercise, and strength training. It is recommended that active joint range of motion be performed one to two times per day with 6 to 10 repetitions during each session for each joint. The joint should only be pushed to the limit that is comfortable for the patient. Regarding cardiovascular exercise, current recommendations for those with RA are the same as in the general population; 30 min of moderate exercise on five or more days per week. Smooth and repetitive motions, such as swimming or cycling, are recommended and high-impact activities should be avoided (18). A combination of land-based and water-based activities should be used based on the patient’s disease activity. Regarding strength training, dynamic exercises are recommended using a low to moderate load with high repetition. In those with active painful joint disease, isometric contraction can be used to maintain strength (19). Hakkinen et al. (20) showed a decrease in the DAS at 2 and 5 years with a self-administered home exercise program plus recreational activities two to three times per week. De Jong et al. (21) also showed similar benefits with a 75-min dynamic muscle-strengthening exercise session with moderate-impact aerobic activities twice per week. Not only did patients have lower disease activity scores with the implementation of these exercise programs but the study also showed a decrease in joint destruction at the 5-year follow-up.

Juvenile Idiopathic Arthritis

Disease Basics

Juvenile idiopathic arthritis (JIA) is a term that describes a heterogeneous group of inflammatory arthritic conditions affecting children younger than 16 years and persisting six or more weeks. JIA is one of the most common childhood chronic diseases (22). There are multiple JIA subtypes, but symptoms of arthralgia, joint swelling, and stiffness are common to each subtype. Despite advances in medical management, children with JIA may suffer from disabling symptoms into adulthood.

Children with JIA are known to have lower muscle strength, aerobic and anaerobic fitness, bone mineral density, and overall well-being than healthy peers (23), despite improved pharmacologic management options. They participate in fewer recreational activities, and report lower functional abilities than their healthy peers. Lower levels of physical activity (PA) contribute to social isolation common to those with chronic disease. Low PA is not associated with disease activity, nor does disease treatment correspond with increasing PA (1). Juvenile idiopathic arthritis patients appear to be at increased risk for developing cardiovascular conditions later in life. The disability and deconditioning resulting from low physical activity in the JIA population may increase adult cardiovascular mortality.

Exercise Recommendations

Exercise has been used in populations of children with JIA with the goals of improving strength, joint range of motion, cardiovascular fitness, bone mineral composition, overall function, and general sense of well-being. Several studies have investigated land- and/or pool-based home exercise programs for children and adolescents with JIA. Sandstedt et al. (23) showed improvements in strength with JIA after participating in a 12-wk land-based program including high-impact jumping exercises, without increasing pain symptoms. Tarakci et al. (24) investigated a daily individualized land-based exercise program completed at home under parental supervision. At the end of the 12-wk program, there were statistically significant improvements in functional ability and quality of life compared to the control group, with no increase in pain. Mendonca (25) compared a conventional exercise program to a Pilates-specific exercise program and found statistically significant improvements in physical (strength, ROM) and psychosocial measures in the Pilates group when compared with JIA conventional exercise controls. These authors recommend a regular multimodal exercise program for all children and adolescents with JIA to preserve joint ROM, manage pain, promote lifelong exercise habits, and improve cardiovascular disease risk profiles.

No exercise modalities are specifically restricted in patients with JIA, although high-impact exercise on actively inflamed joints is avoided. Because the knee is the most commonly affected joint in JIA, special focus on hip and knee strengthening should be considered.

The American Academy of Pediatrics Council on Sports Medicine has provided guidance for the preparticipation physical evaluation of athletes with JIA (26). Depending on the disease and disease activity, specific cardiac clearance may be recommended. If there is significant involvement of the cervical spine, a risk-benefit discussion including the athlete and athlete’s parents should be undertaken to determine potential risk for spinal cord injury. If an athlete has uveitis, he or she may need to be treated as a functionally one-eyed athlete.

Idiopathic Inflammatory Myositis

Disease Basics

Idiopathic inflammatory myositis (IIM) is a group of conditions including polymyositis, dermatomyositis, inclusion body myositis, and juvenile dermatomyositis. Symptoms vary by condition, but generally include fatigue, muscle pain, and muscle weakness. Proximal musculature is more commonly affected. Aerobic capacity is lower in IIM patients compared with healthy individuals (27). While these conditions are rare, there are evidence-based exercise recommendations for those affected by these diseases.

Exercise Recommendations

In the past, patients with IIM were counseled to avoid exercise secondary to fear of increasing disease activity and muscle inflammation. A large body of literature now supports encouraging resistance and aerobic training in patients with IIM to improve overall function, reduce inflammation, and reduce disease activity (28). Resistance training has been shown to improve strength and perception of well-being without increasing measures of serum, muscle tissue (biopsy), or radiographic (MRI) inflammatory markers (29). Intensive aerobic training has been shown to improve aerobic capacity and strength in short term (6 wk) and longer term (6 months) studies (27). Both resistance training and aerobic training programs improve quality of life and are well tolerated by IIM patients.

Creatine supplementation has been shown to positively enhance the effect of exercise for those with known polymyositis and dermatomyositis. When combined with resistance training 5·d·wk−1 over 6 months, creatine was shown to improve global physical function and measures of muscle endurance compared in IIM patients when compared to strength training plus a placebo supplement (30). Creatine is now commonly recommended as an adjunct to exercise for IIM patients.

Systemic Lupus Erythematosus

Disease Basics

Systemic lupus erythematosus (SLE) is a chronic, multisystem autoimmune disease characterized by arthralgia and fatigue that leaves virtually no physiologic system untouched. SLE patients are known to have reduced muscle strength, lower functional performance and quality of life, and greater fatigue than healthy age-matched controls (31). Physical exercise has been shown to positively impact physical fitness, fatigue, sleep quality, and overall quality of life in patients with SLE.

Table 1
Table 1:
SLE extraarticular manifestations.

Barriers to exercise in SLE include joint pain, fatigue, and stiffness. Only about one third of patients with SLE meet guideline recommendations of >150 min of moderate-intensity exercise per week for health promotion (32). This is an important fact given that SLE patients are at higher risk for developing cardiovascular disease even after controlling for higher rates of traditional CVD risk factors, suggesting that the disease itself contributes to the increased CVD risk. Endothelial dysfunction contributes to increased CVD risk in SLE (33). A 16-wk supervised exercise program has been shown to positively impact endothelial function in patients with systemic lupus (34).

Table 2
Table 2:
Evidence-based exercise outcomes in inflammatory diseases.

Disease Complications Impacting Exercise

As SLE pharmacologic treatments have improved, SLE patients are living longer, healthier lives, shifting the focus back to healthy lifestyle behaviors in those affected by lupus. Still, however, extraarticular manifestations of SLE are common, and medications used to treat SLE can be toxic (Table 1). Hydroxychloroquine has a special place in treatment of SLE. Annual ophthalmologic monitoring is recommended secondary to the risk of developing retinopathy.

Extraarticular SLE manifestations are important for sports medicine physicians to recognize and include complications with renal, pulmonary, cardiovascular, and hematologic issues. Because hypertension and lupus nephritis are relatively common in SLE, patients should be advised to use NSAIDs cautiously and judiciously.

Exercise Recommendations

While exercise in general is known to improve functional measures and health related quality of life, it is unknown which types of exercise physicians should recommend to SLE patients. Abrahao et al. (35) randomized SLE patients to one of three groups: cardiovascular exercise, resistance training, or control group. After 12 wk, both the cardiovascular and resistance training groups improved in measures of physical function, but the cardiovascular exercise group had improved health related quality of life compared to the resistance training group. No change in disease activity was noted. These authors conclude that physicians should be recommending exercise for SLE patients as an important component of management, and in this study, walking and cycling were effective and tolerated by patients (Table 2).

Ankylosing Spondylitis/Axial Spondyloarthritis

Disease Basics

Ankylosing spondylitis (AS) is a systemic inflammatory disease primarily affecting the axial skeleton. AS falls under the umbrella of “spondyloarthropathies.” Men are more commonly affected than women, and age of symptom onset is typically between 20 and 30. AS is a chronic disease leading to significant pain and disability, and negatively impacts quality of life. It is characterized by the presence of inflammatory back pain, defined as back pain that improves with exercise and does not improve with rest. AS patients are known to be less physically active than the general population, have a lower V˙O2max, and less than half meet PA recommendations (36).

Management of AS is directed toward reducing symptoms, preserving function, and preventing structural joint destruction. Exercise is considered an important component of AS disease management for several proposed reasons, including a direct anti-inflammatory effect of exercise. Exercise induces muscular release of IL-6, which in turn inhibits tumor necrosis factor (TNF)-α, an important regulator of inflammation in AS.

Exercise Recommendations

A prior Cochrane review of exercise in AS found that exercise improves spinal mobility and physical function. Jennings et al. (37) found that physical exercise improved functional capacity, disease activity, and overall mobility in patients with AS, and that addition of a cardiovascular exercise component (walking) had the added benefit of improving cardiopulmonary fitness and the 6-min walk test. Forty percent of this study population was on biologic anti-TNF therapy, and this group still showed improvement with exercise. The intervention (walking plus stretching) and control (stretching only) groups were directly supervised for 12 wk but advised to continue the program for a full 24 wk. Compliance with exercise in the intervention group was 82.5% and 81.4% in the control group. These authors hypothesized that “breaking the cycle of inactivity” by starting with a supervised exercise program allowed AS patients to develop healthy exercise habits that lead to sustained functional improvements.

Similar studies have used other exercise modalities, including swimming, dance, yoga, tai chi, and Pilates. Similar functional improvements are noted, with no worsening of disease activity in any exercise study. In one small study (38), TNF-α levels decreased at the end of a 12-wk exercise intervention, similar to prior literature on non-AS patients.

Safety of exercise/sport participation needs to be assessed for all athletes with AS; the presence of spinal ankylosis should be assessed on a case-by-case basis. Contact or collision sports, martial arts, and other activities, such as four-wheel driving, especially in advanced disease with concomitant osteoporosis, may be contraindicated due to fracture risk.

Patients with AS have a higher risk of developing cardiovascular disease than the general population. The underlying mechanism of increased CVD risk is unclear, but modification of traditional CVD risk factors is imperative. One recent study compared physical activity (PA) and disease activity in AS patients with controls and found that AS patients with high disease activity were less active than those with lower disease activity and controls (39). This study group also found that AS patients tended to spend more time on low-intensity back exercises (MET, 3.5) than controls, who performed higher-intensity exercise, such as cycling or hiking (MET 8.0). Patients with AS, particularly those with high disease activity, should be encouraged to consider vigorous exercise to optimize health benefits of physical activity.

Pharmacologic management has dramatically improved clinical outcomes in AS. A recent meta-analysis (40) comparing TNF inhibitors alone to TNF inhibitors plus exercise in patients with AS showed that the concurrent exercise interventions improved spinal mobility, ability to perform daily activities, and quality of life. Even in the era of biologic agents, nonpharmacologic management including exercise is important for treatment of AS. There appears to be a synergistic effect of exercise and anti-TNF-α treatment for patients with AS.

Conclusions

Studies have consistently shown an inverse association between the amount and intensity of exercise performed and systemic inflammation as measured by inflammatory markers (41). This has many implications for the general population as chronic exposure to low grade inflammation is linked to the development of atherosclerosis, insulin resistance, metabolic syndrome, dementia, and several other disease states (42). Whereas exercise was previously thought to exacerbate symptoms related to inflammatory arthritis, it is now being used as an intervention. In RA, exercise has been shown to decrease disease activity scores and increase physical fitness without worsening joint inflammation (43). In polymyositis and dermatomyositis where exercise was previously contraindicated, it has been shown to improve strength and help with performance of daily activities when used alongside conventional treatments (44). Although further research is needed regarding specific protocols for the individual inflammatory disorders, current evidence suggests that there is a large role for exercise as both a local and systemic anti-inflammatory (44). Even though treatment of inflammatory arthritis has significantly evolved over the past decade, and specific pharmacologic therapies have had a profoundly positive impact on disease progression, exercise remains a mainstay of treatment to preserve strength, mobility, and function. Early data suggest that exercise improves inflammatory markers in certain inflammatory conditions, meaning overall reduction in disease activity could be seen with sustained, regular exercise.

In review of the literature, there is good evidence that exercise improves certain functional outcomes and overall quality of life in patients diagnosed with inflammatory arthritis. It also is clear that exercise does not result in negative impact on disease activity in inflammatory arthritis.

No single exercise program has been shown superior to another. In general, the more effective programs were group or supervised one-to-one sessions rather than home-based or conventional exercise programs. Successful programs included a strong educational component and consistent support and oversight to the patient. A practical approach would be to initiate an exercise program in a sedentary patient with inflammatory arthritis slowly, using exercise specialists including exercise physiologists and physical therapists, followed by transition over time to a home- or gym-based program the patient finds enjoyable to enhance compliance.

Sports medicine physicians should recognize the impact exercise can have on patients and athletes diagnosed with inflammatory arthritis and educate our athletes and other health care providers about the power of exercise regarding disease management. Further studies will elucidate the anti-inflammatory nature of exercise on inflammatory conditions to better define dosing, timing, and intensity of exercise for disease-modifying properties. Until then, current data provide assurance that encouraging exercise in inflammatory conditions is helpful, not harmful.

The authors declare no conflict of interest and do not have any financial disclosures.

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