Physical exercise was once believed to exacerbate inflammation and disease activity in patients with rheumatoid arthritis (RA), but current research now shows physical activity is safe – and possibly helpful – for supporting overall physical and metabolic health in this patient population.1 Physical activity levels in patients with RA and other types of arthritis are largely suboptimal, and many patients report they do not receive exercise guidance from their care providers.2 Low physical activity in patients with RA is also affected by functional disabilities, high body mass index, and beliefs regarding the influence of physical activity on disease outcomes.3

We spoke with Patricia Katz, PhD, of the Department of Medicine at University of California San Francisco, who has been involved in research focused on the benefits and promotion of physical activity in patients with RA.4

Why are physical activity levels suboptimal in patients with RA?


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Dr Katz: First off, the entire US population is fairly inactive, so it starts at a broader level. But I also think that people who have chronic rheumatic autoimmune diseases experience some symptoms that might be barriers to physical activity. Fatigue is a really common symptom, and it’s counterintuitive to tell these patients that if they move around more then they wouldn’t be so tired. Some people also have pain in their joints, which might be something that would lead them to be more inactive. When people are really sick, they’re also obviously not going to feel like moving around. There are also other environmental barriers, including not having a safe place to walk or not having access to a gym, but those are not necessarily unique to people with rheumatic diseases.

If patients with RA improve their physical activity levels, what kinds of health benefits can they expect to experience?

Dr Katz: There’s a lot of research to suggest that people who are more active have better cardiovascular (CV) health, which is an important finding considering many patients with rheumatic diseases tend to have a higher risk for CV disease.5 Regular physical activity also seems to be associated with improved function, better pain tolerance, and better sleep. There’s also some evidence that physical activity may improve disease activity, and that’s something that I think people don’t really appreciate. Additional evidence suggests that other symptoms like pain or fatigue may also improve with more physical activity. I’m using the word “activity” and not “exercise” specifically, because often people think “exercise” means they have to go to the gym and they have to do something that’s really intense. But honestly, it’s all about decreasing the time spent sitting and increasing the time spent moving around, and that can be something as simple as making sure you get in a 15- to 20-minute walk into your day. That can really make a difference.

Do some patients with RA hold limiting beliefs that physical activity is at all harmful or not helpful?

Dr Katz: A number of years ago, the rule of thumb used to be to tell people that if they were tired or their joints were bothering them, they needed to rest more. We’re finding now that that’s bad advice, based on current research. I think people are also worried that if they are active, it’s going to hurt their joints and it’s going to make their disease worse. I think there are ultimately 2 issues: historically bad advice and ill-conceived perceptions among patients about physical activity in relation to disease. The other thing is – and this is in some sense not different from the rest of the population – if you tell people they need to exercise more, that advice is too general, and people don’t know what to do. Specific guidance is necessary.

And are there guidelines available for clinicians regarding the recommendations of physical activity for people with RA or rheumatoid diseases?

Dr Katz: There are guidelines for physical activity in RA and arthritis in general, both from professional organizations as well as the Centers for Disease Control.6 The American College of Sports Medicine and the American Medical Association combined their efforts and developed a guidance program called “Exercise is Medicine” that has some general information about exercise that clinicians can use but also specific recommendations for people with different chronic diseases, including RA.7 But if you ask 100 rheumatologists if they knew evidence-based resources were available, the answer would probably be a 100%, “No, I didn’t know anything about it.” And I think that if you asked most rheumatologists, they would recognize that that people need to be more active, but I also don’t think that exercise prescription is routinely taught in medical school.

What are the most promising interventions that can positively change beliefs and behaviors regarding physical activity among patients with RA and the clinicians who manage them?

Dr Katz: People are really complicated, and I think that behavior change interventions are tough. There have not been many [behavioral interventions] done in RA specifically that’s focused on changing beliefs; it’s more about changing behaviors. I think the main thing is there a lot of things that can be done, but I think helping patients have some kind of support is important. I’ve done an intervention in RA and we were guiding people to increase the amount of time or steps they took while they were walking. During this intervention, we had very regular contact with them to give them their new goals. I think that having that kind of either support or accountability is helpful.

In some sense, however, people with RA are not any different than the rest of us. We all need some motivation, and where that comes from can vary. Some people can provide their own motivation, some people like to exercise with friends, and some people need to be accountable to somebody else. Overall, it’s just the same issues that are true with any type of behavior change. The literature would suggest that the biggest motivator for a patient can be a message from their physician that physical activity is important, but that has to be backed up with some specific information about what types of exercise to do as well as reassurance that the patient is not going to hurt themselves. Given that most of a rheumatology visit is focused on getting the disease under control, the challenge lies in how to best integrate those additional health messages about physical activity into the clinic visit.

References

  1. Sul B, Lee KB, Joo YB, et al. Twelve weeks of strengthening exercise for patients with rheumatoid arthritis: A prospective intervention study. J Clin Med. 2020;9(9):2792. doi:10.3390/jcm9092792
  2. Freid LM, Ogdie A, Baker JF. Physical activity patterns in people with inflammatory arthritis indicate they have not received recommendation-based guidance from health care providers. ACR Open Rheumatol. 2020;2(10):582-587. doi:10.1002/acr2.11183
  3. Haider S, Sedlak M, Kapan A, et al. Factors associated with objectively measured physical activity in patients with seropositive rheumatoid arthritis. Int J Environ Res Public Health. 2020;17(23):9008. Published 2020 Dec 3. doi:10.3390/ijerph17239008
  4. Katz P, Andonian BJ, Huffman KM. Benefits and promotion of physical activity in rheumatoid arthritis. Curr Opin Rheumatol. 2020;32(3):307-314. doi:10.1097/BOR.0000000000000696
  5. Buleu F, Sirbu E, Caraba A, Dragan S. Heart involvement in inflammatory rheumatic diseases: A systematic literature review. Medicina (Kaunas). 2019;55(6):249. doi:10.3390/medicina55060249
  6. Centers for Disease Control and Prevention (CDC). Physical Activity for Arthritis. https://www.cdc.gov/arthritis/basics/physical-activity-overview.html. Updated November 8, 2018. Accessed August 16, 2021.
  7. American College of Sports Medicine. Exercise is Medicine website. https://www.exerciseismedicine.org. Accessed August 16, 2021.