Can exercise make my rheumatoid arthritis (RA) symptoms worse?

In a cross-sectional, international study (n=5,235) of patients with rheumatoid arthritis (RA), Sokka et al. found that more than 80% of patients in seven countries did not exercise regularly, while 60% to 80% of patients in another 12 countries did not exercise regularly.¹ A literature review of 26 articles assessing the barriers to exercise in patients with RA found that one of the common themes was a worry of causing harm to the joints and a fear of pain.² Even within the healthcare field in the past, professionals debated about the role of exercise for patients with RA and restricted to range of motion exercises with a focus on resting swollen or painful joints.^3,4 

There are data that support the benefits of exercise in patients with RA from both a musculoskeletal and cardiovascular point of view. To address the concerns of physical activity eliciting pain, a number of studies have shown that the risk for flares or an increase in the number of swollen or painful joints is low. Harkcom et al. compared the effects of aerobic exercise (n=11) with no exercise (n=6) on patients with RA in a randomized trial.⁴ The study showed that no patients with RA experienced an acute flare during the 12-week exercise regimen. The mean number of swollen or painful joints significantly decreased from 32.9 to 19.9 (p<0.01) at the end of the 12-week study. In a study of 18 patients with RA, Lyngberg et al. found that strength training of the muscles around swollen joints decreased the number of swollen joints by 35%, while the number of painful joints did not change.⁵ Neuberger et al. examined the effects of a 12-week aerobic exercise program on 32 patients with RA and showed little to no change in the mean number of tender or swollen joints.⁶ In a randomized control trial of 309 patients with RA, de Jong et al. found that a two-year, high-intensity exercise regimen did not increase the radiographic damage of large joints, as determined by the Larsen score, when compared to usual care with physical therapy.⁷ This study also counted the number of swollen or tender joints as part of the Disease Activity Score with 4 variables (DAS4). The DAS4 is a compiled index based on a 44 joint count for swelling (SW44; range 0 – 44), tender joint count (Ritchie Articular Index; range 0 – 78), erythrocyte sedimentation rate, and the patient's global assessment of disease activity measured on a visual analogue scale (range 0 – 100). The DAS4 ranges from 0 (no disease activity) to 10 (severe disease activity). This study found that the number of swollen or tender joints followed the same pattern of the DAS4 score’s gradual decrease from baseline when measured every six months. However, de Jong et al. did not provide the number of swollen or tender joints as separate data points. All studies kept their subjects on their normal medication regimens while exercising and the comparison group was usual care.^4-10

To date, the data available suggests that there is a low risk of increase in RA disease activity with an increase in physical activity. Moreover, several studies have shown that exercise decreases disease activity, as measured by the Disease Activity Score in 28 joints (DAS28).^10,11 DAS28 includes the following variables: tenderness and swelling in 28 joints, the patient’s assessment of general health, and the erythrocyte sedimentation rate.¹² Stavropoulos-Kalinoglou et al. compared the effects of a six-month high-intensity exercise program with advice on exercise and lifestyle changes for 40 patients with RA in a case-control matched study.¹⁰ The scores on the DAS28 for the exercise group decreased after three months (0.6, p<0.05) and six months (0.8, p<0.05). While many of the studies also evaluated the erythrocyte sedimentation rate and C-reactive protein levels, none of them found any association between exercise and the change in level of these inflammatory markers among patients with RA.^5-11

^References

1. Sokka T, Hakkinen A, Kautiainen H, et al. Physical inactivity in patients with rheumatoid arthritis: Data from twenty-one countries in a cross-sectional, international study. Arthritis Rheum. 2008;59(1):42-50.
2. Veldhuijzen van Zanten JJ, Rouse PC, Hale ED, et al. Perceived barriers, facilitators and benefits for regular physical activity and exercise in patients with rheumatoid arthritis: A review of the literature. Sports Med. 2015;45(10):1401-1412.
3. Metsios GS, Stavropoulos-Kalinoglou A, Veldhuijzen van Zanten JJCS, et al. Rheumatoid arthritis, cardiovascular disease and physical exercise: A systematic review. Rheumatology. 2008;47(3):239-248.
4. Harkcom TM, Lampman RM, Banwell BF, Castor CW. Therapeutic value of graded aerobic exercise training in rheumatoid arthritis. Arthritis Rheum. 1985;28(1):32-39.
5. Lyngberg K, Danneskiold-Samsøe B, Halskov O. The effect of physical training on patients with rheumatoid arthritis: Changes in disease activity, muscle strength and aerobic capacity. A clinically controlled minimized cross-over study. Clin Exp Rheumatol. 1988;6(3):253-260.
6. Neuberger GB, Press AN, Lindsley HB, et al. Effects of exercise on fatigue, aerobic fitness, and disease activity measures in persons with rheumatoid arthritis. Res Nurs Health. 1997;20(3):195-204.
7. 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 Rheum. 2003;48(9):2415-2424.
8. Ekdahl C, Andersson SI, Moritz U, Svensson B. Dynamic versus static training in patients with rheumatoid arthritis. Scand J Rheumatol. 1990;19(1):17-26.
9. Minor MA, Hewett JE, Webel RR, Anderson SK, Kay DR. Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis. Arthritis Rheum. 1989;32(11):1396-1405.
10. Stavropoulos-Kalinoglou A, Metsios GS, Veldhuijzen van Zanten JJ, Nightingale P, Kitas GD, Koutedakis Y. Individualised aerobic and resistance exercise training improves cardiorespiratory fitness and reduces cardiovascular risk in patients with rheumatoid arthritis. Ann Rheum Dis. 2013;72(11):1819-1825.
11. Arja H, Tuulikki S, Antero K, Pekka H. A randomized two-year study of the effects of dynamic strength training on muscle strength, disease activity, functional capacity, and bone mineral density in early rheumatoid arthritis. Arthritis Rheum. 2001;44(3):515-522.
12. Prevoo M, Van'T Hof MA, Kuper H, Van Leeuwen M, Van De Putte L, Van Riel P. Modified disease activity scores that include twenty‐eight‐joint counts development and validation in a prospective longitudinal study of patients with rheumatoid arthritis. Arthritis Rheum. 1995;38(1):44-48.