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Rheumatoid Arthritis

Exercise Programming for the Strength and Conditioning Professional

Cheatham, Scott W. DPT, ATC, CSCS, NSCA-CPT; Cain, Matt MS, CSCS, USAW

Author Information
Strength and Conditioning Journal: February 2015 - Volume 37 - Issue 1 - p 30-39
doi: 10.1519/SSC.0000000000000117
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Abstract

Rheumatoid arthritis (RA) has been described as a chronic, systemic, polyarticular inflammatory disease that affects the inner lining of the joint capsule (15). This inflammatory response is known to spread to tissues that surround the joint, which results in erosion and destruction of the bone and cartilage (59). This can cause joint deformity and functional deficits. In severe cases, RA can spread systemically and eventually cause inflammation in the vital organs such as the heart and lungs (50,59).

According to the National Arthritis Data Workgroup, RA has affected about 1.3 million Americans and is growing (31). The onset often begins in the second and third decade of life but is more prevalent in the fourth decade with women being affected 2.5 times more than men (39). The average age of individuals with RA is 66.8 years (31). With these individuals, the strength and conditioning (S&C) professional needs to be proficient at safely prescribing exercise programs. This article will discuss the etiology, client presentation, medical management, exercise programming, types of exercise, and nutritional considerations for the adult client with RA.

ETIOLOGY

RA is a chronic disease that causes pain, stiffness, swelling, and limited motion in the joints of the body (50). The etiology or cause of RA is still unknown. RA has been classified as an autoimmune disease with an idiopathic (e.g., unknown) onset and systemic effects on the body (20,50). The disease process is triggered by an autoimmune response from a faulty immune system, which results in the body attacking its own healthy tissues (60). Current theory points to some type of triggering event such as an infection in a genetically susceptible person, which unleashes an immune response that attacks the joints of the body (50,59). This response may directly or indirectly destroy the synovial capsules, local bone, and connective tissues (Figure 1).

Figure 1
Figure 1:
Stages of rheumatoid arthritis.

CLIENT PRESENTATION

The S&C professional must be aware that the client with RA may have multiple joints affected. Often the wrists and hands are affected first (Figure 2) (59). These clients are typically under the care of a rheumatologist and should have clearance before beginning or returning to physical activity.

Figure 2
Figure 2:
Hands affected by rheumatoid arthritis.

Clients with RA often suffer from a chronic disease process marked by exacerbations and remissions of symmetrical (bilateral) joint pain and swelling. The client may complain of the following symptoms: (a) pain, redness, warmth, swelling, and/or stiffness of multiple joints, (b) increased joint pain with movement, (c) joint stiffness in the morning and after inactivity, (d) general feeling of fatigue and unwell (malaise, flu-like symptoms), (e) sleep disturbances, (f) loss of appetite, (g) firm, painless growths under the skin near the joints called nodules, and (h) fear of activity and depression (26,37,59,60). Because of all these symptoms, individuals with RA may have varying functional levels. The American College of Rheumatology (ACR) has provided a functional classification system for RA (Table 1), which may help the S&C professional understand the client's functional level (32). The most important aspect for these individuals is to refrain from strenuous activity when they are experiencing an exacerbation of symptoms. The client may describe this as a painful episode or “flair-up.” When the joints are painful and sore, they may be at risk for further damage because of the inflammatory process (59).

Table 1
Table 1:
Classification of global functional status in rheumatoid arthritis

MEDICAL MANAGEMENT

In the presence of a painful episode, conservative treatment includes avoiding strenuous activity, use of assistive devices (e.g., reacher, jar opener), and modalities. The use of warm hydrotherapy, electrical, and thermal modalities has shown favorable results in the literature (1,54). The physician may also prescribe specific medication such as nonsteroidal anti-inflammatory medication (e.g., ibuprofen) or disease-modifying antirheumatic drugs (Table 2) (33,38). Other medications that may be prescribed include corticosteroids, biological agents, and antimalarial medication (18,33). Physical therapy may also be prescribed to maintain mobility, strength, and function (55,59). Exercise programming has been shown to be an effective intervention for the individual with RA, which will be discussed in the following section on “exercise programming.” If conservative treatment fails, surgical intervention may be needed to correct joint deformities or related impairments (59).

Table 2
Table 2:
Disease modifying antirheumatic drugs

EXERCISE PROGRAMMING

The exercise program for the client with RA will differ from the exercise program for healthy individuals. RA is a degenerative joint condition that must be handled with caution. The affected joints may be eroding and can be further damaged if they are overstressed and become inflamed through physical activity. For example, the client may find it difficult to use their hands to grasp objects such as a dumbbell or bar. These need to be considered when designing an exercise program in which modifications are available for such physical impairments. Exercise programming for these individuals should include a multimodal approach that emphasizes client screening, education, teaching strategies, and monitoring the patient during activity.

CLIENT SCREENING

Prior to designing an exercise program, the S&C professional needs to determine the overall impact that RA has on the client. Clients with RA may be at a lower functional level and may require more specialized testing. The initial interview will provide insight into the client's goals, physical abilities, current and past exercise experience, comorbidities, and medications. The effects of fatigue and the client's perceived exercise benefits and barriers have been reported to influence exercise participation. These should be considered during the screening process (49). Table 3 provides some suggested questions that may be most appropriate for clients who are higher functioning (ACR classes I and II) but may still be appropriate for lower functioning clients (ACR classes III and IV).

Table 3
Table 3:
Suggested screening questions

For fitness testing, individuals with RA may be able to participate as long as the testing matches their physical abilities (e.g., adequate grip strength). For anaerobic assessment, clients with RA may be able to undergo a 10, 3, or 1 repetition maximum (1RM) test for all major muscle groups. Studies have used 1RM testing to determine baseline strength and the reported no adverse events (3,57). For submaximal aerobic assessment, there are 2 field tests that have been reported in the literature. Verberkt et al. (64) created the Fox-walk test, which is a self-monitored walking test. The individual walks for a specified distance on a track and records their results on a Web site, which then provides them with guidelines (64). This test has demonstrated good reliability (ICC = 0.98) over multiple testing sessions and moderate to good correlation (r = 0.52–0.82) with the Astrand cycle test (53,64). Cooney et al. (2014) also created a submaximal step test designed for clients with RA based on the Siconolfi protocol (13). The test consists of stepping up and down on a 10-in (25.4 cm) step for 3 minutes per stage, for a maximum of 3 stages. The stepping rate can range from 17 to 34 steps per minute using a metronome, and results are calculated with established equations (13). This test has shown good reliability (Intraclass correlation coefficient [ICC] = 0.97) over multiple sessions and good correlation (r = 0.79) with the Astrand cycle test (13). Other traditional methods that have been shown effective include the submaximal bicycle and treadmill test (27,46). General flexibility and movement (e.g., Functional Movement Screen) assessment may provide some further insight but should be performed with caution (9). The overall goal of the screening process is to determine whether exercise is safe or whether further clearance by a medical professional is warranted.

CLIENT EDUCATION

Individuals with RA tend to be more deconditioned with lower aerobic capacity when compared with normative values of healthy individuals (47). They also spend less time doing vigorous activity possibly because of the symptoms that occur with RA (47). The metabolic cost of physical activity can increase because of pain, joint stiffness, and functional deficits (e.g., gait abnormalities) (45,51). Education for physical activity should include avoidance of painful exercise, activities that protect the joints, proper body mechanics, and safe modes of exercise. The mode or type of exercise should be determined by the site and severity of the affected joints. The client should be pain free after activity and may benefit from modalities (e.g., hydrotherapy) after exercise to prevent any latent discomfort.

The S&C professional needs to be aware of the psychological effects that RA can have on a client. Clients with RA may have certain levels of depression, poor quality of sleep, and fear avoidance to physical activity, which can be barriers to successful exercise programs (37,41). Recent investigations have suggested that exercise can improve symptoms of depression and sleep quality in subjects with RA (37,42). Understanding the client's perception toward physical activity and how they learn will help the S&C professional design an appropriate exercise program.

STAGES OF LEARNING

Using the stages of learning (cognitive, associative, and autonomous) model may be an effective way to introduce exercise to the client with RA. Fitts and Posner (1967) were the first to introduce this 3-stage model that described how a human acquires information (43). Clients with RA may fall into one of the 3 stages depending on their current functional level, current workout regimen, workout history, and perception toward exercise. We will apply the 3-stage model to training the client with RA with related suggestions.

During the cognitive stage, the client will be developing the basic movement pattern for the chosen exercises. There is a high degree of cognitive activity. Movements are asynchronous, jerky, deliberate, slow, and lack control (43). The client is learning what to do and will make errors trying to master the skill. This phase may frustrate the client, which requires more guidance and patience by the S&C professional. Clients with RA, who begin in this stage, may lack the past exercise experience or have refrained from exercise because of their symptoms. This stage is most important to establish a successful foundation and help the client overcome their fears of exercise. The S&C professional needs to systematically progress the client and allow time to monitor for postexercise symptoms and allow proper adaptation. Pain-free activity and slow progressions are the focus of this stage.

During the associative stage, the client will be refining the basic movement pattern for the chosen exercises. There is a lower degree of cognitive activity because they are familiar with the motor skill and can successfully perform it. Movements are smoother, less shaky, faster, and more controlled (43). The client will make less errors and be able to perform movements with fewer cues. This phase may require the S&C professional to develop a standard routine for the client and build a consistent workout schedule. Clients with RA, who begin in this stage, may already have a workout history and are familiar with specific modes of exercise. Clients progressing from the cognitive to associative stage have gained workout experience, are less fearful, and may want to progress their exercises. This is where a slow systematic progression is needed to keep the client interested, avoid overtraining and postexercise symptoms, and ensure the motor skills are mastered.

During the autonomous stage, the client will have mastered the basic movement pattern for the chosen exercises. There is minimal cognitive activity because the motor skills are successfully performed. Movements are smooth, effortless, and take less concentration (43). The client will make virtually no errors and be able to self-correct the movements with minimal cuing. This phase may require the S&C professional to be creative with program modification and progressions while avoiding overtraining and postexercise symptoms. Clients with RA, who begin in this stage, will already have a strong workout history and are familiar with many modes of exercise. Clients progressing from the associative to autonomous stage have mastered the workout, are maintaining a regular routine, and are interested in trying new types of exercise. It is recommended to slowly introduce new types of exercise because the client may begin at the cognitive stage for each new exercise or motor skill. This will help keep the client stay interested while ensuring a safe progression.

MEASURING EXERCISE INTENSITY

The client with RA may benefit from using a numerical scale to measure their exertion level during exercise. The Borg rating of perceived exertion (RPE) scale measures a person's perception of physical exertion by using numbers and corresponding expressions. The RPE scale has been shown to have a strong correlation with the heart rate (6,8). The original 15-point scale ranges from 6 to 20, where 6 means “no exertion at all” and 20 represents “maximal exertion” (7). The scale has been updated to the Borg CR-10 that has a point range from 0 to 10, where 0 means “nothing at all” and 10 means “very very hard” (52). The Borg CR-10 has become a standard measurement tool for exercise testing, physical training, and rehabilitation (68). The Borg scale may be an effective way of communicating the client's response to exercise, which may help guide future exercise sessions.

Using an 11-point numerical pain rating scale (NPRS) with 0 (no pain) to 10 (worst pain imaginable) can also be another tool where clients can monitor the effects of exercise (67). The NPRS is commonly used to measure pain and fatigue in individuals with RA, which may be beneficial in guiding their exercise program (21,44).

TYPES OF EXERCISE

AEROBIC EXERCISE

Research has suggested that individuals with RA may have lower aerobic capacity and decreased energy expenditure because of avoidance of physical activity (47). This supports the importance of a regular exercise program for these individuals. Aerobic activity has been shown to be an effective intervention for individuals with RA. Baillet et al. (4) conducted a systematic review of the literature assessing the effects of aerobic activity for individuals with RA. They found that a supervised 60-minute program (50–80% of the maximal heart rate) performed 2 times per week or less was better when compared with an unsupervised home-based program performed 3 times per week (4). Hurkmans et al. (34) also conducted a systematic review and found that for aerobic exercise to be effective, it must be performed at least 2 times per week for 20 minutes or more (greater than 55% of the maximum heart rate) over a 6- to 12-week period (35). It is recommended that aerobic exercise consists of low-loading activity such as cycling, walking, and aquatic exercise. Table 4 provides a summary of these findings.

Table 4
Table 4:
Exercise guidelines for individuals with rheumatoid arthritis

AQUATIC EXERCISE: WARM WATER

Aquatic exercise in warm water or hydrotherapy may be a good alternative because of the warmth and buoyancy the water creates. This helps to unload the joint in a warm environment, which may be favorable to these individuals. With some clients, repetitive land-based activity (e.g., walking) is cautioned because of the risk of further joint trauma, which makes aquatic exercise a viable option. Al-Qubaeissy et al. (2012) conducted a systematic review and found that hydrotherapy programs improved individual's pain, strength, and function (1). The aquatic programs ranged for 30–60 minutes (moderate aerobic activity), 2 to 3 time per week, for 4–12 weeks in a water temperature of 30–35°C. Kamioka et al. (36) also conducted a systematic review and found that aquatic exercise programs from 3 to 12 months have a positive effect on pain, function, and quality of life in individuals with RA. The main issue all authors noted is the lack of quality and heterogeneity of methodology among hydrotherapy studies (1,36). Other modes of aquatic exercise, such as underwater treadmill walking, have shown to improve aerobic capacity in subjects with RA (28). The outcomes of these investigations are promising; however, further research is needed to assess the efficacy of warm water aquatic exercise as a long-term intervention. Table 4 provides a summary of these findings.

RESISTANCE TRAINING

Research has suggested that light to moderate resistance training may be beneficial for individuals with RA (55,34). Although strengthening can be an effective intervention, it should be performed with caution. Joint instability and range of motion deficits can pose a problem with resistance training because of the injury potential. Poorly controlled or high-impact movements may create a risk for injury. This is why a modified strengthening program may be safer than more intense modes of training. Resistance training may include a combination of isometric exercises, elastic bands, machines, and free weights (19). Hurkmans et al. (2010) found resistance training at 30–50% of the 1RM to be effective in building strength in individuals with RA (34). Baillet et al. (3) conducted a systematic review and found that resistance training programs improved isokinetic, isometric, and grip strength in individuals with RA. The resistance training programs ranged from 15 to 60 minutes, 2–7 days per week for 3–104 weeks. The exercises were performed at a load ranging from 30 to 100% or 1RM for 1 to 4 sets of 5–30 repetitions. The S&C professional must be aware of the patient's symptoms during and after exercise. The program goal should be to increase basic muscular strength and joint stability. However, exercise intensity, mode, and frequency will be determined by the pain and severity of the affected joints.

Light to moderate resistance activity has always been the common exercise intensity prescribed to individuals with RA (12). High-intensity exercise has traditionally been prescribed with caution because of the possible damage it can have on the joints and soft tissue (3). Research has shown promise for high-intensity exercise. Flint-Wager et al. (24) has shown that a 16-week (3 times per week) high-intensity resistance training program improved strength, pain, and function in subjects with RA (N = 16) when compared with a matched control group (N = 8). The authors did note that the effects of high-intensity training on joint integrity are not completely known and should be considered when prescribing this type of exercise (24). de Jong et al. (17) examined the long-term effects of high-intensity weight-bearing exercises on joint damage in the hands and feet in subjects (N = 145) with RA. They assessed joint damage by radiographic analysis before and after the intervention period of 24 months. They found that no progression of joint damage occurred in the subjects and that high-intensity exercise may have a protective effect in the joints of the feet (17). de Jong et al. (16) conducted a long-term follow-up of 18 months after the initial study. Seventy-one subjects were available and 84% (N = 60) were still exercising with similar intensity and 16% (N = 11) reported lower level or no activity. Radiographic follow-up analysis showed no detrimental effects of disease damage to the joints for all subjects (16). Despite these outcomes, further research is needed to assess the efficacy of high-intensity exercise with these individuals. Table 4 provides a summary of these findings.

STRETCHING AND MYOFASCIAL RELEASE

Maintaining proper muscle length and symmetry around the joint may be a challenge for the RA client. Range of motion in affected joints may be restricted by pain, stiffness, swelling, and bony changes. The pathological changes create weakened unstable joints (50,59). The S&C professional must use caution not to overstretch an unstable joint or have the client overstretch. The research on stretching for individuals with RA is sparse with the available literature focusing on stretching as rehabilitation intervention for the hands (66). Because of lack of literature, the authors recommend the American College of Sports Medicine (ACSM) guidelines for physical activity for the older adult (11,48). ACSM recommends at least 2 days per week at a moderate intensity (5–6 on a scale of 10) for the major muscle groups. Slow static stretching held for 30 seconds in a pain-free range is preferred over ballistic stretching (11).

Myofascial release (MFR) may be an effective treatment for fascial or soft-tissue dysfunction in individuals with RA. MFR is often used to increase joint range of motion (ROM), while decreasing fascial and muscular pain and tension. MFR is often performed by a health professional or by the client using tools such as foam rolls, bars, and balls. The research on this technique for individuals with RA is still emerging. A case report by Cubick et al. (15) found that sustained MFR (performed for at least 3–5 minutes) lead to improvements in a patient with RA and collagenous colitis. The 6-session intervention resulted in a 5-week improvement in the patient's joint pain, ROM, gastrointestinal function, and fatigue (15). Despite these positive outcomes, MFR is still understudied. MFR needs to be performed with caution to protect the joints and avoid any adverse soreness. Proper programming of stretching and MFR may effectively restore muscle length and symmetry, increase joint mobility, and decrease pain and stiffness in individuals with RA. Table 4 provides a summary of these findings.

ALTERNATIVE EXERCISE

If the client with RA cannot participate in a conventional anaerobic or aerobic program, then the S&C professional may want to suggest some alternative forms of exercise. A growing body of literature has supported the use of yoga and Tai Chi for individuals with RA. Several investigations suggest that yoga may improve pain, depression, and quality of life in individuals with RA (2,14,22,23,62). Tai Chi may also have positive benefits such as improved pain, ROM, balance, and strength in individuals with RA (29,40,63,65). These forms of exercise may be a good alternative or adjunct to aerobic and resistance exercise.

NUTRITIONAL CONSIDERATIONS

Nutritional guidance should be part of a comprehensive exercise program for clients with RA. However, nutritional guidance needs to be provided by a qualified licensed health professional. Before giving nutritional information to the client, the S&C professional needs to consider their state laws regarding “scope of practice” to avoid any legal issues. In this section, particular nutritional issues are discussed that can have an impact on a client's fitness level and overall health.

GENERAL NUTRITION

Generally, a diet rich in whole grains, fruits, vegetables, high-quality protein, and healthy low-fat dairy products is recommended to all individuals, including those with RA or those individuals who are at risk of developing RA (58). Individuals with RA may benefit from consuming foods that have high nutrient density. Research suggests that many individuals with RA experience rheumatoid cachexia or loss in muscle mass and strength because of the chronic inflammation (12). The literature takes into account that inadequate nutritional consumption has been shown in this population and that improper nutrition may have a significant impact on the outcome of developing rheumatoid cachexia in individuals with RA (12,58). Thus, symptoms of RA may be impacted through proper nutrition (58).

CARDIOVASCULAR DISEASE AND OBESITY

Individuals with RA may participate in less activity because of their physical impairments, which may put them at increased risk for cardiovascular disease (CVD) (47). Individuals with RA have been shown to have a higher risk for CVD because of insufficient nutritional consumption, which may be one of the factors impacting this chronic development (25,58). Another concern is the growing obesity epidemic in the United States, which is linked to inactivity and may be a secondary risk for individuals with RA (58). Individuals with obesity may be in a state of chronic low-grade inflammation, which is directly linked to CVD (56). Therefore, the client with RA may benefit from exercise and nutritional recommendations for preventing CVD and obesity.

ANEMIA AND BONE DENSITY

Inadequate nutrient intake may lead to iron deficiency or anemia and may be prevalent in up to one-third of the individuals with RA (58). Therefore, foods containing an adequate amount of iron, such as spinach, may be beneficial for these individuals. The literature also has shown that dietary consumption in individuals with RA may lack the recommended intake for calcium and vitamin D (30,58). Adequate calcium and vitamin D intake should be taken into consideration because they have an essential role in maintaining adequate bone density and prevention of osteoporosis (30).

INFLAMMATION

Research suggests that n-3 polyunsaturated fatty acids consumption may be beneficial in reducing RA symptoms because of anti-inflammatory effects (58). The literature also suggests that diets containing antioxidant-rich foods, such as vegetables and fruit, may beneficially impact the risk of developing RA (5,58). Specifically, the antioxidant selenium may have beneficial effects; however, the literature has shown mixed results as far as its true effects on RA (10,58).

A complete nutritional analysis for these individuals can be a complex one and should be performed by a qualified licensed health professional. Proper nutrition may play a pivotal role in preventing and reducing the symptoms associated with RA. This section provides a brief discussion of the specific nutritional issues that can occur in individuals with RA. The reader is referred to the work by Rennie et al. (58) that provides a more comprehensive discussion of these topics.

IN SUMMARY

Exercise programming for individuals with RA can be a challenge because of the physical impairments that accompany the disease. Because of the prevalence of this condition, it is important for the S&C professional to have an understanding of the disease process and guidelines for exercise prescription. Clients with RA tend to be more deconditioned with lower aerobic capacity and spend less time doing vigorous activity (47). Exercise programming for these individuals should include a multimodal approach that emphasizes client screening, education, teaching strategies, proper monitoring during activity, and nutritional considerations. Perhaps, the best mode of exercise would be resistance exercise to help with joint stability and strength and aerobic exercise to improve endurance (34,55,61). Future research is still needed to assess the long-term efficacy of these modes of exercise.

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Keywords:

rheumatoid arthritis; arthritis; exercise

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