Rheumatoid Arthritis and Exercise
Rheumatoid arthritis can affect patients in vastly different ways, and there is no one-size-fits-all approach to exercise for those affected by the disease.
Here’s the thing about rheumatoid arthritis (RA): it’s a bit of a moving target. The onset of the disease can be quick and severe, or it can be milder and develop over time. Symptoms can change quickly, as patients experience bouts of intense disease activity—or flare—and periods of remission. Available treatments can be effective for some and not for others. Some people live life relatively pain-free, while others struggle with pain and disability daily. As a result, treatment plans for patients necessarily evolve over time, and patients learn to adapt to the changing face of the disease on a daily or hourly basis.
Affecting approximately 1.5 million adults in the United States, RA is a chronic, systemic disease that causes inflammation in the lining of the joints, leading to pain and swelling. As it is a systemic disease, it can also affect other internal organs such as the lungs and the heart.1 Women are 2.5 times more likely to be diagnosed with RA as are men, with the majority of diagnoses occurring between the ages of 25 and 50.2
Rebecca Manno, MD, MHS, assistant professor of medicine in the division of rheumatology at Johns Hopkins University, says that among patients newly diagnosed with RA there is often confusion about the disease and how it differs from other types of arthritis, such as osteoarthritis, which affects only the joint at a local level. They may assume, she says, that “arthritis” is the diagnosis, when in fact that is only part of the picture. “Arthritis just means that there is something wrong specifically in the joint, but that doesn’t tell you what’s causing the problem in the joint or what’s driving the process—the erosion of cartilage, the pain, the lack of ability to use the joint as it was intended,” she says. “If the immune system is driving the process, that takes us into the world of inflammatory arthritis, and RA is one type of inflammatory arthritis.”
Because RA is a systemic disease, treatment is also systemic, as opposed to osteoarthritis, which remains at the joint level. Treatment for RA may include a variety of approaches at various points after diagnosis, including anti-inflammatory and pain medications, occupational therapy, physical therapy, and surgery. Dr. Manno describes the goals of treatment as twofold: “first, to control symptoms of joint pain, swelling, and stiffness; second, to prevent joint damage. This is important because once joint damage has occurred, it cannot be repaired with medical therapies. Each treatment plan is unique and tailored to the individual. But every treatment plan for RA should include some type of exercise in addition to standard medication therapy.”
RA and exercise: the data
The highly individualized approach to the treatment of RA also extends to any discussions of exercise. Current data that exist from studies related to the role of exercise in RA has resulted in rheumatologists encouraging patients to be as active as possible—for the cardiovascular, muscle-building, and range-of-motion benefits that exercise provides, as well as for the emotional boost that can improve overall quality of life.
Studies have shown that RA patients are more likely to suffer from cardiovascular disease (CVD) and that exercise may be a key intervention in reducing incidence of CVD.3 In addition, available data show that exercise can help patients build muscle, reduce body fat, and increase joint mobility.4 Though patients may be concerned that exercise will encourage joint deterioration or cause increased pain, the experience of participants in one study reveals that exercise programs designed specifically for RA patients do not increase disease activity.3 Rheumatologist Phillip Molloy, MD, FACP, a practicing rheumatologist in Plymouth, Massachusetts, says the information gathered to date shows that “there is a proven direct benefit from exercise to joint health and an indirect benefit to patients related to cardiovascular, weight, and overall mental and physical health.”
Dr. Manno notes, however, that the relatively rare incidence of RA compared with other chronic conditions means that the data available related to the role of exercise in RA is not extensive: “We are in need of further investigation in the area of exercise and RA so that we can be specific about timing, duration, and methodology for our patients. This will require more studies and more clinical trials with measurement of important outcomes, such as body composition, markers of inflammation, and quality of life.”
An Individualized Approach
The relatively small amount of applicable data related to the role of exercise in the treatment of RA, combined with the unique way patients experience the disease and the broad range of exercise history among patients, means that there is no one-size-fits-all approach for patients and their doctors. “Recommendations are very individualized, depending on which joints are most involved and the person’s baseline level of exercise, conditioning, and motivation,” says Dr. Molloy.
“There are good data to suggest that the combination of cardiovascular and resistance exercise does not exacerbate RA or precipitate flares,” says Dr. Manno. “For that reason, we generally tell patients to try to stay active.” She acknowledges, however, that “staying active” means different things to different people, depending on how the disease is manifesting and their exercise and fitness history.
This is where a commonsense approach enters the picture, Dr. Manno says, as it would with anyone else considering a new exercise program: “If a patient has never exercised before and is diagnosed with RA, this may not be the best time to start a high-intensity training program; but for patients who have been avid exercisers their whole life, there is no reason to stop exercising just because of a diagnosis.” The key, regardless of previous exercise experience, is to “listen to the body and potentially modify the routine if necessary.”
For patients with no previous exercise experience, Dr. Manno says it is important to get expert advice from a physical therapist, trainer, or physician who has experience working with RA patients and can recommend an appropriate program with an emphasis on proper form (and low impact on affected joints) that includes resistance exercise and cardiovascular components. For patients who are comfortable exercising and have experience, she advises increased awareness of specific joints that are causing discomfort and adaptations that help protect the joint. And she is careful to remind patients that “exercise is about supporting the joint with the goals of building muscle, increasing strength, and changing body composition (if desired). Before starting any exercise program, you should work with your physician to outline the goals. This will allow you to focus on specific targets and design a program that is perfect for you, of course, with minimum impact on the joints.”
There is some controversy about whether patients should exercise during periods of active flares, and there is little data available about the role of exercise for patients severely disabled by RA.4 Dr. Manno says that her approach is to encourage rest during major flares. “If a patient has a very inflamed, tender joint, I do not recommend exercising at full capacity; that is the time to avoid exercise and to rest,” she says.
The Patient Perspective
Kelly Young, founder of RA Warrior and the Rheumatoid Patient Foundation, says that this flexible, individual approach that honors patients’ unique experiences and the unpredictability of the disease is critical. “The course of this disease can change from mild to moderate to severe in the same person quite suddenly,” she says. “What’s so important is that advice on exercise is reasonable and relatable and not insulting. We should be careful not to assume that people are simply lazy when they may be privately struggling to perform daily tasks. It can be difficult for others to recognize that many patients experience unrelenting disease activity, making activity progressively more difficult.”
Kelly says that many RA patients struggle with the perception among some people that those living with RA have the disease as a result of inactivity or that they are making their condition worse because they aren’t exercising as much as they should. In a post on RA Warrior, Kelly writes, “We did not get RA because we were less active. We became less active because we have RA.”
As Kelly notes, the role of exercise for many patients living with RA can change quickly with increased disease activity. She recommends that people consider physical aids such as wrist or knee braces to stabilize joints during a new activity and that they consult their general physician regarding systemic symptoms such as fever, fatigue, and shortness of breath. What feels comfortable and beneficial one day might feel totally out of the realm of possibility the next day.
Patient Megan Edwards says that she takes each day as it comes. “I have good days and bad days, and I modify based on how I feel. Ultimately, it’s not about how much I have done; it’s about just being able to do something.”
The unpredictability of the disease can be a barrier for some patients, who worry about exercising too much during a flare or about not being able to exercise, as can uncertainty over proper technique or intensity, and the pain, fatigue, and discomfort that accompany the disease.4 These factors, alongside practical concerns like insurance coverage, cost, and transportation to reach a gym or therapist, can stand in the way of patients’ ability to exercise.4
Dr. Manno hopes that detailed exercise guidelines can be developed for patients that reflect the varied needs of those with RA and encourage a realistic approach to the issue, helping patients find accessible exercise solutions. “My hope is that we can come up with a better prescription for exercise,” she says. “This would allow for flexibility and variability to reflect an individual’s prior experience with exercise and include both resistance exercise and a cardiovascular component.” Most people respond better to directives to exercise if they are given specific parameters and instructions, Dr. Manno adds: “The blanket ‘Go exercise; build muscle; figure it out’ doesn’t work for anyone—whether you have RA or not.”
For many patients, coming to terms with the limitations that RA can place on exercise is a tough adjustment. In Kelly Young’s case, her physical ability changed drastically overnight, as she writes in a blog entry on RA Warrior: “One day I did a hundred push-ups. The next day, I could not carry my own purse.” With these changes, she says, came a period of mourning, as she adjusted to the “new normal” of her life with RA. “I have had to say good-bye to the old me,” Kelly writes. “As if that were not hard enough, someone told me last week that I just needed to be willing to put forth some effort.”
Like anyone looking to benefit from exercise, RA patients need to be aware of their unique concerns and pay attention to their bodies. Every day and every hour may be different, and exercise should remain safe and effective given whatever variables may exist on any given day. Dr. Molloy notes that taking the opportunity to exercise when they are able can provide patients with a welcome opportunity to take a proactive step in the management of the disease: “For many patients, being involved in an exercise program can impart a degree of feeling in control of their RA and its treatment.”
While the RA community awaits more data related to RA and exercise and more-specific guidelines for patients, Dr. Manno says that “patients should keep engaging their doctors about exercise.” If they aren’t getting the information they need or are feeling lost as to how to approach exercise, she recommends reaching out to a different doctor or a physical therapist. “If you don’t get the answer that’s working for you, ask someone else. There is a unique prescription for every individual where exercise is concerned.”
Rheumatoid Arthritis. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/arthritis/basics/rheumatoid.htm#5. Accessed July 5, 2013.
Arthritis in Women. Arthritis Foundation website. Available at: http://www.arthritis.org/conditions-treatments/disease-center/women. Accessed July 5, 2013.
Metsios GS, Stavropoulos-Kalinoglou A, Veldhuijzen van Zanten JJ, et al. Rheumatoid arthritis, cardiovascular disease and physical exercise: a systematic review. Rheumatology. 2008;47(3):239-48.
Cooney JK, Law R, Matschke V, et al. Benefits of exercise in rheumatoid arthritis. Journal of Aging Research. 2011;2011:681640. doi: 10.4061/2011/681640.