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

Rheumatoid Arthritis (RA) is a chronic, autoimmune, inflammatory disease of unknown aetiology. Characterised by erosive synovitis and severe inflammation, RA primarily effects the joints triggering progressive pain/tenderness, swelling and eventual destruction. These features result in functional decline and disability which negatively impact on activities of daily living. 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.

#### Prevalence

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

## Associated Morbidity and Mortality in Rheumatoid Arthritis

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

#### Cardiovascular Disease (CVD)

* Risk of CVD mortality is increased by approximately 50% in RA patients.
Consequence of high-grade inflammation which accelerates atherosclerotic processes including;
* Insulin resistance, dyslipidemia, oxidative stress and endothelial dysfunction.

#### Rheumatoid Cachexia

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

## Benefits of Exercise

Exercise has previously been avoided by persons suffering RA for fear of exacerbating joint damage and worsening disease characteristics. 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. Now considered as one of the most important non-pharmacological interventions in the management of RA, exercise is observed to bestow the following benefits;
* Improvement in body composition (increased hypertrophy and decreased fat mass).
* Reduction in pain and tender joint count.
* Improvement in balance, flexibility and range of motion.
* Improvement in psychological wellbeing.
* improvement in strength and functional ability: isometric/isokinetic tests of knee flexors/ extensor can be reduced by 25% compared to healthy individuals.
* improvement in Cardiorespiratory fitness: Aerobic capacity can be reduced by 20% as compared to healthy individuals.
These benefits are combined with well established anti-atherogenic and anti-inflammatory effects of exercise which hence also reduce CVD risk.

#### Exercise recommendations for persons with RA

| Target | Type of exercise | Example | Intensity/Frequency |
| Cardiovascular health | Aerobic | Aquatics Walking Jogging Aerobic classes | 60-85% of maximum heart rate 30-60min 30 times per week |
| Strength/Muscle mass | Resistance | Static/dynamic exercises against body weight or using resistance equipment Pulley apparatus Dumbbells Elastic bands | 50-85% of maximum velocity of contraction 8-10 exercises 8-12 reps 2-3 sets 2-3 times per week |
| ROM and flexibility | Tai Chi | Sun style Tai Chi exercises Basic or advanced movements Perform sitting exercises if standing is uncomfortable | 10-15 min 2 days per week |
To receive maximal benefit patients should have well controlled (stable) RA before commencing exercise and continue to maintain anti-inflammatory medications.

## Limitations and Considerations

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

#### Barriers to Exercise

Many adults with arthritis fail to achieve physical activity levels recommended for good health. When examining factors associated with inactivity, arthritis, pain and fatigue are cited as the top 3 barriers to exercise.
Other barriers to exercise include;
* Psychological; confidence and motivation.
* Environmental; lack of equipment and access to facilities.
* Social; inconvenience and lack of support.
Considerations of the above should be made to ensure the efficacy of exercise interventions.

## Further reading

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 2 3 4 5 6 7 8 Walsmith, J & Roubenoff, R. 'Cachexia in Rheumatoid arthritis'. International Journal of Cardiology 2002; 85; 89-99.
* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Strenstorm, CH & Minor, MA. 'Evidence for the benefit of aerobic and strengthening exercise in Rheumatoid Arthritis'. Arthritis and Rheumatism 2003; 49(3); 428-434.
* 1 2 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.
* ↑ 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.
* ↑ 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.
* 1 2 3 4 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.
* 1 2 3 4 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.
* 1 2 3 4 5 6 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.
* 1 2 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.
* 1 2 3 4 5 6 7 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.
* 1 2 3 4 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.