Exercise in the Older Adult with Rheumatoid Arthritis

**Introduction**1,2

Rheumatoid arthritis (RA) is a chronic autoimmune disorder characterized by inflammation, swelling, pain, and stiffness in the joints, particularly the hands, feet, wrists, elbows, knees, and ankles. In an attempt to protect the body from foreign bacteria and viruses, the body’s immune system mistakenly attacks the synovial lining of its own joints. They synovial lining becomes thickened and swollen, causing pain, stiffness, and if uncontrolled, can lead to joint erosion, irreversible loss of motion, and joint deformity. About 1.5 million people in the U.S. have RA, and the prevalence of RA is highest among woman and individuals over the age of 70 years of age. Due to the varying clinical severities of this disease as well as the fear of worsening an individual’s existing joint condition, exercise prescription may be challenging and even inadequate for these patients.

**Objectives:**

1.      Discuss perceptions about exercise in individuals with RA

2.      Discuss the benefits of exercise in individuals with RA

3.      Discuss exercise prescription: aerobic, resistance, mobility

4.      Discuss general exercise guidelines

**Perceptions about Exercise in Individuals with RA**

* Fear that exercise may increase painful joints and be harmful to joint health3
* Acknowledgment of benefits of exercise but lack of clarity on which type of exercise to perform, especially how to modify exercise based on symptom severity3,4
* Lack of clarity on how to perform exercises prescribed5
* Lack of sufficient exercise knowledge from health professionals6

**Benefits of Exercise in Individuals with RA**

* Improved cardiovascular fitness and cardiovascular health. Individuals with RA are generally less active and therefore, demonstrate significant risk factors for cardiovascular disease, including higher blood pressure, elevated total cholesterol, elevate low-density lipoprotein levels.7 An estimated 20-30% decrease in aerobic capacity has been reported in the literature.8
* Increased muscle mass. Up to 70% of individuals with RA demonstrate a loss of strength, with an estimated 25-50% reduction in strength compared to age matched controls.8,9 A condition called reumatoid cachexia may a contributing factor to this loss in strength. Rheumatoid cachexia is experienced by about 67% of individuals with RA and is characterized by a decrease in muscle mass and increase in adipose tissue.10
* Increased bone mineral density. Individuals with RA are at risk for significant losses of bone mineral density due to the tendency to exhibit inactive lifestyles as well as the tissue loss related to corticosteroid treatment of the condition.11
* Enhanced cartilage integrity and joint lubrication through cyclic loading of the joint
* Increased range of motion12
* Decreased pain, morning stiffness, and fatige13
* Improved psychological wellbeing13
* Improved function without exacerbating symptoms

**Aerobic Exercise Prescription**9

* For the best results, exercise at 60-80% max heart rate, 30-60 minutes, 3-5 days/week. It is recommended by ACSM to focus on increasing duration of this exercise first, then focus on increasing intensity once optimal duration of 30-60 minute is achieved.
* Cycling, walking, jogging, dance, elliptical training, stair climbing, swimming and other aquatic aerobic exercise

**Resistance Exercise Prescription**

* Progressive resistance training (PRT) has been shown to be safe and beneficial in improving functional strength of older adults, including those with RA. PRT does not exacerbate joint inflammation.9,14,15,16
* High-intensity resistance training has shown to be safe and does not increase radiologic damage of the large joints.17,18,19
* For the best results, exercise at 50-80% 1RM, 8-12 repetitions per muscle group, 2-3 sets, 2-3 days/week. It is recommended to increase intensity over time. 9
* It is recommended to focus on 8-10 large muscle groups with the goal of producing muscle hypertrophy and strength gains. 18
* Hand strengthening exercises have shown to be effective as well (see additional resources for example exercises)20
* Options include using free weights, therabands, aquatic resistance, and weight machines

**Mobility Exercise Prescription**9

* For the best results, exercise to improve range of motion and flexibility is recommended for 10-15 minutes at least 2 days/week
* Modes of exercise include static stretching, Tai Chi exercises, yoga and pilates

**General Exercise Guidelines**

* Supervise initial exercise programs in individuals with RA
* High-intensity and high-frequency to maintain aerobic and strengthening gains. High-intensity exercise has been shown to be superior to low-intensity exercise for improving aerobic capacity, muscle strength, and joint mobility without exacerbating disease activity in individuals with stable and active RA.18,21
* Minimum exercise dosage is unknown but in general, even one exercise session a week has shown to be beneficial.22
* Initiate exercise programs at low-intensity and then progress to high-intensity
* Further research necessary to determine if aerobic and resistance training should be continued during periods of inflammatory flare-ups

**Additional Resources****:**

https://www.consultant360.com/articles/rheumatoid-arthritis-older-patient

https://www.ncbi.nlm.nih.gov/pubmed/11410765

https://www.rheumatoidarthritis.org/ra/

https://rheumatoidarthritis.net/exercise/

https://rheumatoidarthritis.net/exercise/stretching/

https://www.webmd.com/rheumatoid-arthritis/features/hand-exercises-rheumatoid-arthritis#1

**References**

1. Rasch EK, Hirsch R, Paulose-Ram R, Hochberg MC. Prevalence of rheumatoid arthritis in persons 60 years of age and older in the United States: effect of different methods of case classification. Arthritis Rheum. 2003;48(4):917-926

2. Let's Dig Into Everything about RA. RheumatoidArthritis. https://www.rheumatoidarthritis.org/ra/. Accessed July 7, 2018.

3. Law R-J, Breslin A, Oliver EJ, et al. Perceptions of the effects of exercise on joint health in rheumatoid arthritis patients. Rheumatology. 2010;49(12):2444–2451.

4. Iversen MD, Fossel AH, Daltroy LH. Rheumatologist-patient communication about exercise and physical therapy in the management of rheumatoid arthritis. Arthritis Care and Research. 1999;12(3):180–192.

5. Lambert BL, Butin DN, Moran D, et al. Arthritis care: comparison of physicians’ and patients’ views. Seminars in Arthritis and Rheumatism. 2000;30(2):100–110.

6. Hutton I, Gamble G, McLean G, Butcher H, Gow P, Dalbeth N. What is associated with being active in arthritis? Analysis from the obstacles to action study. Internal Medicine Journal. 2010;40(7):512–520.

7. Metsios GS, Stavropoulos-Kalinoglou A, Panoulas VF, et al. Association of physical inactivity with increased cardiovascular risk in patients with rheumatoid arthritis. European Journal of Cardiovascular Prevention and Rehabilitation. 2009;16(2):188–194.

8. Stenström CH, Minor MA. Evidence for the benefit of aerobic and strengthening exercise in rheumatoid arthritis. *Arthritis Care & Research*. 2003;49(3):428-434.

9. Cooney JK, Law R-J, Matschke V, et al. Benefits of Exercise in Rheumatoid Arthritis. *Journal of Aging Research*. 2011;2011:681640.

10. Roubenoff R, Roubenoff RA, Ward LM, Holland SM, Hellmann DB. Rheumatoid cachexia: depletion of lean body mass in rheumatoid arthritis. Possible association with tumor necrosis factor. Journal of Rheumatology. 1992;19(10):1505–1510.

11. Franck H, Gottwalt J. Peripheral bone density in patients with rheumatoid arthritis. Clinical Rheumatology. 2009;28(10):1141–1145.

12. Van Den Ende CHM, Breedveld FC, Le Cessie S, Dijkmans BAC, De Mug AW, Hazes JMW. Effect of intensive exercise on patients with active rheumatoid arthritis: a randomised clinical trial. *Annals of the Rheumatic Diseases*. 2000;59(8):615–621.

13. Neill J, Belan I, Ried K. Effectiveness of non-pharmacological interventions for fatigue in adults with multiple sclerosis, rheumatoid arthritis, or systemic lupus erythematosus: a systematic review. Journal of Advanced Nursing. 2006;56(6):617–635.

14. Lyngberg KK, Ramsing BU, Nawrocki A, Harreby M, Danneskiold-Samsøe B. Safe and effective isokinetic knee extension training in rheumatoid arthritis. Arthritis and Rheumatism. 1994;37(5):623–628.

15. Liu C, Latham NK. Progressive resistance strength training for improving physical function in older adults. *The Cochrane database of systematic reviews*. 2009;(3):CD002759.

16. Marcora SM, Lemmey AB, Maddison PJ. Can progressive resistance training reverse cachexia in patients with rheumatoid arthritis? Results of a pilot study. Journal of Rheumatology. 2005;32(6):1031–1039.

17. De Jong Z, Munneke M, Zwinderman AH*,* Kroon HM, Ronday KH, Lems WF, Dijkmans BAC, Breedveld FC, Vlieland TPM, Hazes JMW, Huizinga TWJ. Long term high intensity exercise and damage of small joints in rheumatoid arthritis. *Annals of the Rheumatic Diseases.*2004;63:1399-1405.

18. Lemmey AB, Marcora SM, Chester K, Wilson S, Casanova F, Maddison PJ. Effects of high-intensity resistance training in patients with rheumatoid arthritis: a randomized controlled trial. Arthritis Care and Research. 2009;61(12):1726–1734.

19. De Jong Z, Munneke M, Zwinderman AH, et al. Is a long-term high-intensity exercise program effective and safe in patients with rheumatoid arthritis? Results of a randomized controlled trial. Arthritis and Rheumatism. 2003;48(9):2415–2424.

20. Brorsson S, Hilliges M, Sollerman C, Nilsdotter A. A six-week hand exercise programme improves strength and hand function in patients with rheumatoid arthritis. Journal of Rehabilitation Medicine. 2009;41(5):338–342.

21. Van Den Ende CHM, Hazes JMW, Le Cessie S, et al. Comparison of high and low intensity training in well controlled rheumatoid arthritis. Results of a randomised clinical trial. Annals of the Rheumatic Diseases. 1996;55(11):798–805.

22. Linde L, Sorensen J, Ostergaard M, et al. What factors influence the health status of patients with rheumatoid arthritis measured by the SF-12v2 health survey and the health assessment questionnaire? Journal of Rheumatology. 2009;36(10):2183–2189.