Improving Function Through Exercise in Rheumatoid Arthritis

Recent pharmacologic interventions for rheumatoid arthritis (RA) have significantly improved disease progression and prognosis.¹ However, even with effective drug therapy a substantial number of patients experience joint stiffness, muscle weakness, and deconditioning due to inactivity.² The primary driver for inactivity is pain and fatigue,³ and inactive patients with RA are at increased risk for cardiovascular disease compared with patients with RA who are physically active.⁴

Two recent systematic reviews examined the effects of exercise on RA patients.^5,6 Both reviews support the use of aerobic, resistive, and aquatic exercise to improve patient outcomes or fitness.

A review by Siegel and colleagues⁶ included 54 level 1 studies from 2000 to 2014 examining the effect of aerobic, resistive, dynamic (primarily body movements), home-based, and water-based exercise in addition to Tai Chi and yoga on adults with RA.

Research conducted by Swärdh and Brodin⁵ included 17 randomized controlled trials (RCTs) evaluating the effectiveness of land-based and water-based aerobic and land-based resistive exercise on cardiorespiratory conditioning, strength, activity limitations, and pain in individuals with RA.

Rheumatology Advisor talked with Nina Brodin, PT, PhD, of the Karolinska Institute, about her team’s review.⁵ “The most important takeaway from the study is that exercise should be recommended to all patients with RA and adjusted and supported if needed by physical therapists with knowledge of the disease.” Dr Broden and colleagues found that exercise has the potential to “improve body functions and reduce activity limitations independent of medical treatment.”

Bruno Gualano, PhD, associate professor at the University of São Paulo, Brazil, concurs with the importance of prescribing exercise. “The scientific evidence strongly supports physical activity promotion to mitigate symptoms and improve general health and well-being in rheumatologic diseases,” reports Dr Gualano. “Therefore, promoting physical activity becomes an important part of treatment in rheumatology.”

Aerobic Exercise

The research conducted by Siegel and colleagues⁶ included a meta-analysis of 14 RCTs comparing aerobic exercise (at 50% to 90% of maximal heart rate) with nonaerobic exercise (stretching, no attention, usual care, and relaxation). In an analysis of 5 studies with 586 patients, aerobic exercise had “a small beneficial effect” on quality of life (P <.0001).⁷ In an analysis of 6 studies involving 261 patients, pain measured by the visual analog scale (VAS) significantly improved (P =.02).⁷

The research conducted by Swärdh and Brodin⁵ assessed 4 RCTs that were not included in the review conducted by Siegel et al and found moderate-quality evidence that land-based aerobic exercise (3 times per week for at least 30 minutes’ duration at 40% to 65% VO₂ maximum for 8 to 12 weeks) improved cardiorespiratory fitness. In 3 additional unique RCTs of moderate-quality evidence, water-based aerobic exercise (3 times per week for 60 minutes’ duration at 40% to 80% VO₂ maximum for 8 to 12 weeks) was found to improve cardiorespiratory fitness.

Resistive Exercise

Siegel and colleagues⁶ included 1 meta-analysis and 2 RCTs in their analysis of resistive exercise. The meta-analysis⁸ included 10 RCTs and found improvements in isokinetic strength (weighted mean difference [WMD]: 23.7%; P <.001), erythrocyte sedimentation rate (WMD: -5.17; P =.005), and walking ability (P <.001) in the resistive exercise group compared with controls. In a single small RCT⁹ involving RA patients with varying levels of disease activity including joint damage, a 16-week high-intensity individualized resistance exercise program was compared with usual care. Improvements in strength (mean increase 46.1%; P <.01), function (P =.01), and pain (53%) were found for the resistance exercise group.

Studies involving land-based resistance exercise in the Swärdh and Brodin⁵ review also had patients performing aerobic exercise.  Short-term (12 to 26 weeks) muscle strengthening combined with aerobic exercise had moderate-quality evidence of improved cardiorespiratory fitness but not improved strength. Concerning activity limitations and pain, the researchers added, “There is low-quality evidence on how activity limitations and pain are affected.” The exercise consisted of 30-minute to 80-minute sessions of moderate to high intensity (aerobic: 40% to 80% of VO₂ maximum; resistance: progressive increase up to 70% of 1 repetition maximum) performed 2 to 5 times per week. The aerobic exercise consisted of treadmill, rowing, or bicycle ergometer while the resistance exercises involved gym machines or functional exercises.

Long-term (52 to 104 weeks) muscle strengthening combined with aerobic exercise had moderate-quality evidence of improved cardiorespiratory fitness and muscle strength while reducing activity limitations. Additionally, strength improvements persisted in the long-term group but not in the short-term group. There was only low-quality evidence on how pain was affected. The exercise consisted of 30-minute to 75-minute sessions of moderate to high intensity (aerobic: 40% to 85% of VO₂ maximum; resistance: progressive increase up to 70% of 1 repetition maximum) performed 3 times per week. The aerobic exercises in the long-term group consisted of bicycle ergometer, sports, games, swimming, cycling, running, or jogging, while resistance exercises included rubber expanders, home exercises, and circuit training. 

Contraindications to Exercise

The same contraindications to exercise that apply for the general population should be considered in patients with RA.⁵ Patients with heart failure, pericarditis, pleuritis, vasculitis, pulmonary fibrosis, or kidney enlargement may require individually tailored exercise programs.⁵

According to Swärdh and Brodin,⁵ “individuals with destruction of large joints should be advised that the use of high-intensity exercise should be weighed against the risk of more rapid development of joint destruction. Some caution is recommended for extreme exercise during treatment with cortisone.” The researchers add that in patients on low-dose corticosteroid treatment, the exercise benefits balance the risks.

Keeping Patients Exercising

Although inactivity is common in patients with RA, self-efficacy, social support, and outcome expectations are factors that may help to keep patients exercising.¹⁰ Of these, Dr Brodin considers self-efficacy to be the most important factor. “The patient should also be given the one they enjoy the most, as this will be the one they will continue to do.”

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References

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2. Hallert E, Thyberg I, Hass U, et al. Comparison between women and men with recent onset rheumatoid arthritis of disease activity and functional ability over two years (the TIRA project). Ann Rheum Dis. 2003;62:667-670.
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9. Flint-Wagner HG, Lisse J, Lohman TG, et al. Assessment of a sixteen-week training program on strength, pain, and function in rheumatoid arthritis patients. J Clin Rheumatol. 2009;15(4):165-171.
10. Demmelmaier I, Bergman P, Nordgren B, et al. Current and maintained health-enhancing physical activity in rheumatoid arthritis: a cross-sectional study. Arthritis Care Res (Hoboken). 2013;65(7):1166-1176.