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Exercise as it relates to Disease/Exercise in the management of Rheumatoid Arthritis

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Rheumatoid Arthritis (RA) is a chronic, autoimmune, inflammatory disease of unknown aetiology.[1] Characterised by erosive synovitis and severe inflammation, RA primarily effects the joints triggering progressive pain/tenderness, swelling and eventual destruction.[2] These features result in functional decline and disability which negatively impact on activities of daily living.[3] Current treatment for RA is focused on reducing symptoms and improving quality of life via disease modifying antirhuematic drugs (DMARDS) and rehabilitation or surgical avenues.[4]

Prevalence

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RA is estimated to affect 0.5-1% of the global population.[1] Of those affected, there is a Two to Four fold higher prevalence in women[1] with the average age of onset between 45-65yrs.[3] Smoking, alcohol consumption, stress and diet represent environmental risk factors that may contribute to the prevalence of RA.[1]

Associated Morbidity and Mortality in Rheumatoid Arthritis

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The mean life expectancy of persons with RA is decreased by 5-10years[1](dependent on disease severity) chiefly as a consequence of the following comorbidities.

Cardiovascular Disease (CVD)

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  • Risk of CVD mortality is increased by approximately 50% in RA patients.[5]

Consequence of high-grade inflammation which accelerates atherosclerotic processes including;

  • Insulin resistance, dyslipidemia, oxidative stress and endothelial dysfunction.[6]

Rheumatoid Cachexia

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  • Characterised by loss of body cell mass-predominately skeletal muscle.[2]
  • Occurs in 75% of patients with RA and is mediated by a tumor necrosis factor.[2]
  • Causes muscle weakness, reduced function and impairment in the ability to fight secondary infections.[2]

Benefits of Exercise

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Exercise has previously been avoided by persons suffering RA for fear of exacerbating joint damage and worsening disease characteristics.[7] However, assessment of the safety of long-term intensive exercise shows- there is generally no increase in radiographic damage of large joints (shoulders, hips, knees, elbows and ankles) nor worsening of disease activity.[4] Now considered as one of the most important non-pharmacological interventions in the management of RA,[7] exercise is observed to bestow the following benefits;

  • Improvement in body composition (increased hypertrophy and decreased fat mass).[7]
  • Reduction in pain[8] and tender joint count.[9]
  • Improvement in balance, flexibility and range of motion.[9]
  • Improvement in psychological wellbeing.[9]
  • improvement in strength and functional ability:[8] isometric/isokinetic tests of knee flexors/ extensor can be reduced by 25% compared to healthy individuals.[10]
  • improvement in Cardiorespiratory fitness:[8] Aerobic capacity can be reduced by 20% as compared to healthy individuals.[10]

These benefits are combined with well established anti-atherogenic and anti-inflammatory effects of exercise which hence also reduce CVD risk.[7]

Exercise recommendations for persons with RA

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Target Type of exercise Example Intensity/Frequency
Cardiovascular health Aerobic
  • 60-85% of maximum heart rate[3]
  • 30-60min[3]
  • 30 times per week[3]
Strength/Muscle mass Resistance
  • Static/dynamic exercises against body weight or using resistance equipment[3]
  • Pulley apparatus[3]
  • Dumbbells[3]
  • Elastic bands[3]
  • 50-85% of maximum velocity of contraction[3]
  • 8-10 exercises[11]
  • 8-12 reps[11]
  • 2-3 sets[11]
  • 2-3 times per week[3]
ROM and flexibility

Tai Chi

Sun style Tai Chi exercises[9]

  • Basic or advanced movements[9]
  • Perform sitting exercises if standing is uncomfortable[9]

To receive maximal benefit patients should have well controlled (stable) RA before commencing exercise and continue to maintain anti-inflammatory medications.[8]

Limitations and Considerations

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  • Intensity and duration of exercise should be increased over time with adjustments made where necessary.[2][11]
  • Exercise programmes must account for pre-exercise disease status and degree of joint defects.[2][11]
  • Contraindications to exercise as a result of comorbidities need to be monitored by a physician.[2]
  • Correct technique and appropriate safety measures of exercise interventions need to be demonstrated by a qualified trainer.[2]

Barriers to Exercise

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Many adults with arthritis fail to achieve physical activity levels recommended for good health. When examining factors associated with inactivity, arthritis, pain and fatigue[12] are cited as the top 3 barriers to exercise.
Other barriers to exercise include;

  • Psychological; confidence and motivation.[12]
  • Environmental; lack of equipment and access to facilities.[12]
  • Social; inconvenience and lack of support.[12]

Considerations of the above should be made to ensure the efficacy of exercise interventions.

Further reading

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Centers for Disease Control and Prevention; Rheumatoid Arthritis http://www.cdc.gov/arthritis/basics/rheumatoid.htm
Exercise and Arthritis; http://www.rheumatology.org/Practice/Clinical/Patients/Diseases_And_Conditions/Exercise_and_Arthritis/
Arthritis Foundation; http://www.arthritis.org/

References

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  1. ↑ a b c d e Kvien, TK.'Epidemiology and burden of illness of Rheumatoid Arthritis'.Pharmacoeconomics 2004; 22(1);1-12.
  2. ↑ a b c d e f g h Walsmith, J & Roubenoff, R. 'Cachexia in Rheumatoid arthritis'. International Journal of Cardiology 2002; 85; 89-99.
  3. ↑ a b c d e f g h i j k l m n o Strenstorm, CH & Minor, MA. 'Evidence for the benefit of aerobic and strengthening exercise in Rheumatoid Arthritis'. Arthritis and Rheumatism 2003; 49(3); 428-434.
  4. ↑ a b de Jong, Z, Munneke, M, Zwinderman, AH, Kroon, HM, Jansen, A, Ronday, KH, Schaardenburg, DV, Dijkmans, BAC, van den Ende, CHM, Breedveld, FC, Vliet Vlieland, TPM & Hazes, JMW. 'Is a long-term-high-intensity exercise program effective and safe in patients with Rheumatoid Arthritis?'. Arthritis and Rheumatism 2003; 48(9); 2415-2424.
  5. ↑ Antonio Avina-Zubieta, J, Choi, HK, Sadatsafovi, M, Etminan, M, Esdalle, JM & Lacaille, D. 'Risk of cardiovascular mortality in patients with Rheumatoid Arthritis; a meta-analysis of observational studies'. Arthritis and Rheumatism 2008; 59(12); 1690-1697.
  6. ↑ Saltar, N, McCarey, DW, Capell, H & McInnes, IB. 'Explaining how 'high-grade' systemic inflammation accelerates vascular risk in Rheumatoid Arthritis'.Journal of the American Heart Association 2003; 108; 2957-2963.
  7. ↑ a b c d Metsios, GS, Stavropoulos-Kalingoglou, Sandoo, A, Veldhuijzen Van Zanten, JJCS, Toms, TE, John, H & Kitas, GD. 'Vascular function and inflammation in Rheumatoid Arthritis; the role of physical activity'. The Open Cardiovascular Medicine Journal 2010; 4;89-96.
  8. ↑ a b c d Strasser, B, Leeb, G, Strehblow, C, Schobersberger, W, Haber, P & Cauza, E .'The effects of strength and endurance training in patients with Rheumatoid Arthritis'. Clinical Rheumatology 2010; 30; 623-632.
  9. ↑ a b c d e f Lee, H-Y, Hale, CA, Hemingway, B & Woolridge, MW . 'Tai Chi exercise and auricular acupressure for people with rheumatoid Arthritis; an evaluation study'. Journal of Clinical Nursing 2011; 21; 2812-2822.
  10. ↑ a b Ekdahl, C & Broman, G. 'Muscle strength, endurance, and aerobic capacity in Rheumatoid Arthritis: a comparative study with healthy subjects'. Annals of the Rheumatic Diseases 1992; 51; 35-40.
  11. ↑ a b c d e f g Cooney, JK, Law, R-J, Matschke, V, Lemmey, AB, Morre, JP, Ahmad, Y, Jones, JG, Maddison, P & Thom, JM.'Benefits of exercise in Rheuamtoid Arthritis'. Journal of Aging Research 2011; 2; 1-12.
  12. ↑ a b c d Hutton, I, Gamble, G, McLean, G, Butcher, H, Gow, P & Dalbeth, N. 'What is associated with being active in arthritis? Analysis of the obstacles to action study'. International Journal of Medicine 2010; 40; 512-520.
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