WHAT IS RHEUMATOID ARTHRITIS?
When people hear of arthritis, they generally think of the aches and pains experienced by adults as they grow older. Rheumatoid arthritis (RA), however, is a devastating, progressive autoimmune disease that causes chronic inflammation of the joints that affects more than 1.5 million American adults (1). Although onset is generally around the age of 40, it can develop at any age, and women develop RA two to three times more than men. RA symptoms generally are symmetrical (i.e., affect both sides of the body) and include pain, fatigue, joint limitations, morning stiffness, lumps or nodules under the skin, and impairments in physical function (1). The disability associated with uncontrolled RA can progress quickly, resulting in a significant economic burden to individuals, families, employers, and health care systems (1).
In RA, an increased production of systemic inflammatory agents (at levels up to 100 times those of healthy adults) attacks the synovium (lining) of joints and often other parts of the body (2). High levels of inflammation lead to joint swelling and damage, debilitating fatigue, joint pain, stiffness, and reduced physical function. Although RA initially affects smaller joints in the hands, wrists, and knees, it also can affect the entire body including the internal organs and cardiovascular system. As a result, people with RA experience cardiovascular events nearly a decade earlier than their peers (3).
The inflammation associated with RA can lead to rheumatoid cachexia, a condition characterized by an increase in fat mass, and a loss of muscle with little or no change in weight (3). This is particularly worrisome as the increases in body fat, especially in the trunk area, can result in elevated fasting glucose levels, hypertension, and metabolic syndrome (3,4).
Because a natural reaction to experiencing stiff and sore joints is to reduce activity, people with RA may be more sedentary and deconditioned compared with their peers (2). Although new treatments can adequately control inflammation in almost everyone, they do not reverse the negative changes in body composition that developed even before RA was diagnosed.
EXERCISE AS MEDICINE
In people with RA, exercise can improve cardiorespiratory fitness, cardiovascular health, physical function, muscle mass, and strength and reduce adiposity without aggravating joints (2). Physical activity is one of the best ways to reduce RA-related fatigue, restore joint motion, and improve physical function (2,4). However, creating a safe, fun, and engaging exercise program for RA clients requires some additional considerations as health care providers must work together with clients to evaluate joint health and prescribe exercises that do not aggravate joints thereby increasing stiffness, swelling, and soreness. As RA activity and symptoms also vary naturally from day to day, exercise professionals need to develop flexible programs that can accommodate changing needs. For example, increases in joint soreness or fatigue may signal the need to temporarily focus more on range of motion and stretching activities, rather than attempting to progress to more intense exercises or higher exercise volumes.
Exercise specialists can play a primary role in helping people with RA learn to listen to their bodies to exercise safely, especially for those with little experience exercising before they developed RA. In this article, we will describe some of the common challenges faced by people with RA when adopting an exercise program. We also offer practical strategies for managing symptoms and tailoring exercise to the needs and preferences of individuals to increase motivation and promote long-term adherence to exercise.
CHALLENGE 1: DEALING WITH MUSCULOSKELETAL CONSIDERATIONS
In RA, the immune system affects the lining of the joints resulting in pain, swelling, immobility, and impairments in physical function. Individuals often have problems with daily activities like walking up stairs, standing for long periods of time, grasping small objects, or tying shoe laces. As RA progresses, muscles weaken, balance may be compromised, and damage within joints accrues, limiting normal movements and daily activities. Regular exercise is one of the most important ways to reduce and reverse disability, while also improving inflammation, energy, and RA symptoms such as pain and stiffness (2).
Improving Muscle Mass and Strength
Progressive resistance training has been shown to be safe and effective in building strong muscles and bones and in improving function (2). Because people with RA may already have joint damage and are often worried about exercising, it is especially important that sedentary individuals begin exercising slowly. A strength program that incorporates six to eight exercises for major muscle groups and progresses gradually with small increases in intensity and resistance will yield improvements in muscular strength, function, and exercise confidence (5). Target major muscle groups (e.g., chest, back, gluteals, quadriceps) and focus on teaching proper technique to increase familiarity of certain movements and reduce the chance of injury. It is important to remember that although the workout program should be progressive in nature, people with RA often experience disease flares (exacerbations). For those unfamiliar to training, begin with 2 sets of 12 repetitions using lighter machine weights (about 50% to 60% of the individual’s maximum) (6). Depending on the exercise and the client, this may vary considerably as larger muscles that are used more often (e.g., quadriceps) can lift, pull, or push more weight than smaller, less active muscles (triceps). Once the client becomes comfortable exercising, you can increase the intensity by decreasing repetitions (e.g., six to eight repetitions), increasing resistance and/or increasing sets.
The use of strength training machines (e.g., leg press, leg curl, leg extension, chest press, shoulder press, seated rows, etc.) is often advantageous because they help to control the movement of weight in one plane. Once these movements become more natural, a transition to free weights can be considered for those who wish to exercise at home or increase exercise difficulty (e.g., dumbbell squats, dumbbell bench press, dumbbell rows, etc.). Free weights develop more muscle stabilization as the individual must control the weight’s movement through more than one controlled plane. For example, when a client is completing a chest press, the machine controls the exercise movement in primarily two directions (e.g., forwards and backwards). When completing a repetition of the bench press (similar exercise), the bar has the opportunity to go forwards, backwards, up, down, or any other combination of directions. It is important to recognize that the use of free weights may increase the potential risk of injury if progression is made too quickly and the client doesn’t feel comfortable performing certain movements.
As pain, joint, and muscle stiffness can vary considerably from day to day in people with RA and often signal a disease flare, it is important to ask how clients are feeling and whether they have noticed any changes in joint symptoms before they start exercising. If joint symptoms have increased, be creative and look to accommodate areas of the body that may be more sore or stiff at each session. Completing body weight movements and stretches before adding resistance prepares the body for more intensive activity, offers the opportunity for clients to learn proper technique, and increases awareness of how each exercise should feel when properly executed. Body weight movement exercises (e.g., lunges, squats) performed during the warm-up also allows clients to “survey” how they are feeling, while improving flexibility and range of motion. Above all, it is important to identify the need to modify certain positions that may be painful or uncomfortable because of stiffness, soreness, or inflammation. For individuals with painful knees, a shallower range of motion in exercises such as lunges, or squats, may be beneficial in allowing clients to progress slowly.
For some clients, adaptive devices may be useful for helping alleviate pain during certain exercises or range of motion activities. Padded gloves for holding weights or elevated blocks for squats (added under the client’s heels) may be beneficial and pragmatic for some individuals. In addition, it also may be helpful to create home-based programs that incorporate muscle strengthening exercises to supplement existing programs. For home or travel use, resistance bands have been shown to be safe, versatile, and effective for maintaining and developing muscle (2).
CHALLENGE 2: LIVING WITH A CHRONIC DISEASE
When joints are sore and stiff and energy is low, a natural inclination is to be sedentary. In one sense, people with RA have unique concerns because they live with a chronic condition that varies from day to day and directly impacts the health and function of their musculoskeletal system. On the other hand, they also encounter the same barriers to exercising regularly that most adults face such as lack of motivation, time, or facilities. It is important that exercise specialists work with clients to help them discern when and how exercise should be modified due to changes in disease activity from the times when perhaps clients simply need encouragement to stick with the program.
Living with a chronic disease also can predispose individuals to low mood. Depression (affecting roughly 30% of people with RA) is more prevalent in those with RA than in the general population (7), and similarly, the fatigue associated with RA can reduce interest in exercising. As in the general population, exercise is one of the most effective ways to improve mood and well-being in people with RA (2,5,8), and it may be the optimal way to improve energy (8). Being active also can help reduce pain sensitivity and improve range of motion. Perhaps most importantly, living an active life helps promote a sense of independence and confidence moving about in the world (9). In a study by Loeppenthin et al. (2014), one woman stated, “It means a great deal to me not seeing my body as being ill and physically handicapped, but also experiencing a body being strong and feeling good” (9).
Addressing Potential Barriers to Exercise
Exercise programming for people who have joint or musculoskeletal pain should initially avoid high-impact exercises and activities requiring quick changes in body positioning (e.g., plyometrics, agility exercises, throwing exercises). These activities may increase loads to joints with preexisting issues and may be difficult to execute for clients with some degree of joint soreness, swelling, or damage. Start with low-impact activities such as walking, cycling, swimming, or using the elliptical to improve aerobic fitness while also reducing cardiovascular disease risk, fatigue, and anxiety. Completing these exercises 3 days per week at a moderate-vigorous intensity can yield significant improvements in as little as 12 weeks (10).
Advising clients that they can anticipate some degree of mild muscle soreness, while reaffirming this is evidence the exercises are benefiting them, may help create more positive experiences. Addressing potential concerns regarding stiffness or muscular soreness may be targeted by prescribing flexibility and range of motion activities that are important exercises recommended for all people with RA. These movements have physical (e.g., lubricate joints), psychological (e.g., reduce stress, fatigue), and physiological (e.g., decrease inflammation) benefits (2). Activities such as stretching, yoga, Pilates, and/or Tai Chi for only 10 to 15 minutes twice a week will help improve flexibility, increase range of motion, and enhance joint function (2).
CHALLENGE 3: THE BENEFITS ARE KNOWN, BUT NOT BEING PRESCRIBED
Health care providers and exercise professionals play a key role in helping individuals with RA adopt and maintain active lifestyles (2). Although regular exercise is recommended in public health guidelines and RA treatment guidelines in the United States, Canada, the UK, and elsewhere, up to 40% of adults with arthritis do not receive counseling for physical activity from health care providers (11). Consistent messages of the importance of exercise from health care providers and exercise professionals have been shown to increase motivation and strengthen beliefs that exercise is helpful for managing RA. Stronger beliefs and motivation are associated with higher levels of physical activity (12). Starting slowly, showing clients how to exercise using proper techniques, and offering options for exercise can build confidence in the value and importance of a healthy lifestyle.
Lack of knowledge about physical activity and exercise has significant implications for exercise programming, monitoring, and adherence for both RA clients and health care professionals. To address this issue, taking the time to explain to clients that activities such as walking and stretching are simple, cost-effective ways to be more active anywhere and at any time may yield significant benefits. Once individuals have been trained to use resistance bands, they can be used at home without supervision and may be as effective as using strength training equipment. It may also be helpful to write a letter to treating physicians describing the exercise program and offer periodic updates on improvements observed. Ongoing encouragement from health care professionals about the importance of regular exercise can help reinforce the essential role of exercise in managing RA and promote long-term adherence (2).
One of the most important and challenging components of exercise programming is promoting long-term adherence. Finding a range of activities (e.g., sports or recreation) and environments (e.g., inside, outside, individual, or group) that are accessible and enjoyable is important so that exercising won’t be considered a tedious and inconvenient responsibility. Promoting breaks in sedentary behaviors (setting an alarm to get up and move every 30 to 45 minutes at work) and stretching while seated at work are two examples of simple actions that can keep joints healthy, muscles active, and brains engaged in the task at hand.
Prescribing a balanced mix of resistance and aerobic exercises can lead to benefits in both muscular strength and cardiorespiratory fitness (5). Thus, when appropriate, it is important to consider prescribing aerobic activities such as walking, cycling, running, dancing, or swimming (6). At first, try starting with 5- to 10-minute bouts to accumulate 20 to 30 minutes of activity per day with the goal of reaching 150 minutes of moderate intensity per week (6).
Initially, most sedentary individuals with RA will benefit from working with an experienced exercise professional who can establish a simple routine and make necessary adaptations based on individual needs (2). For example, if a client has stiff or tender joints, and finds exercises that require percussive movements uncomfortable, adjustments can be made such as using a rowing machine, elliptical, or water-based exercises instead of jogging or skipping. When a client has stiff or painful wrists, push-ups or other exercises that stress a bent wrist may be difficult. Using cable machines or different exercises that target the same muscle groups (e.g. chest flies instead of push-ups) are possible options for clients who are experiencing sensitive joints.
TAKE HOME MESSAGES
Exercise participation in people with RA is affected by many factors that impact musculoskeletal health including current disease activity, mobility limitations, joint pain, stiffness, fatigue, muscle mass, muscle strength, and muscle quality. Exercise specialists can play a unique role in helping people with RA become more active. Assessing and identifying individual requirements allows the development of tailored programs that can address what is needed most (e.g., strength, power, flexibility, balance, aerobic, or a combination of these). Moreover, exercise specialists can design a program that incorporates safe and effective progression by adjusting volume and intensity based on changing needs, while introducing new activities to maintain interest and enjoyment. Helping individuals learn to identify for themselves when to persist with exercise and when to temporarily back off is an essential skill that helps increase confidence and self-efficacy. The benefits of resistance training, including increased muscle strength, endurance, and improved body composition, physical function, and well-being, suggest that this should be a core component of all exercise programs.
A program that is progressive (incremental changes in intensity and resistance) and targets large muscle groups can safely and effectively increase muscle strength and function.
From the Arthritis Foundation: arthritis.org/living-with-arthritis/exercise.
BRIDGING THE GAP
Exercise can decrease the pain, stiffness, and systemic inflammation of inflammatory arthritis and improve physical function, cardiovascular health, muscle strength, body composition, mood, and overall well-being without aggravating vulnerable joints. The challenge is to develop personalized exercise programs that are fun and engaging and that accommodate day-to-day variability in fatigue and joint mobility. Creating balanced exercise programs that integrate stretching and range of motion activities with strength and aerobic training can optimize the physical and mental health benefits of exercise in people with inflammatory arthritis.
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