There are multiple benefits of exercising for patients with rheumatoid arthritis (RA) such as improvement in physical function, RA disease activity, level of fatigue, mood, and body composition. Several studies examined how exercise improves physical function and RA disease activity parameters (such as the number of swollen and tender joints) among patients with RA.1-3 In a 10-year prospective cohort study (n=4289, mean age 49.2) examining inflammatory markers and physical activity, participants who adhered to physical activity guidelines had lower loge C-reactive protein (B coefficient -0.07, confidence interval [CI] [-0.12 – -0.02]) and loge interleukin-6 (B coefficient -0.07, CI [-0.10 – -0.03]) compared to participants who were inactive.4 The coefficients calculated by the linear regression model used in this study correspond to a difference of 0.18 mg/l in C-reactive protein and 0.20 pg/ml in interleukin-6 between the physical activity group and the inactive group. Other studies used the Health Assessment Questionnaire (HAQ) to measure functional status and consists of eight sections that include patient-reported assessments in areas such as dressing, walking, and grip. Each section is scored from 0 to 3, corresponding to the qualifiers “without any difficulty” to “unable to do” – a lower score corresponds to a higher functional status.5 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.1 The study found that the exercise group showed a significant decrease in the mean HAQ score after six months (0.9 ± 0.6) when compared to the group’s baseline value of (1.4 ± 0.8). The total mean change of 0.5 (p<0.001) is more than the established minimal clinically important difference (MCID)5 of 0.22. Minor et al. showed a significant increase in grip strength at 12 weeks for both the aerobic (pool and walking) exercise (n=19) and nonaerobic (range-of-motion) control (n=9) groups of patients with RA in a randomized trial, with a mean increase of 30.4 ± 32.5 mm Hg (p£0.01) and 18.8 ± 14.0 mm Hg (p£0.01), respectively.6 Neuberger et al. examined the effects of a 12-week aerobic exercise program on 32 patients with RA and showed a significant improvement in the 50-foot walk time7 after 12 weeks (10.41 sec to 9.44 sec, p<0.05). The 50-foot walk time is the amount of time, in seconds, that it takes for the subject to walk 50 feet on flat, straight ground.7
Several studies suggest that exercise improves fatigue, mood, and self-reported measures of pain.2,3,6,8 Harkcom et al. compared the effects of aerobic exercise (n=11) with no exercise (n=6) for patients with RA in a randomized trial.3 They reported subjective assessments from patients and showed improvements in fatigue, joint pain, and overall mood. De Jong et al. conducted a randomized trial of patients with RA comparing a long-term, high-intensity exercise regimen (n=150) with physical therapy (n=150) for two years.8 The Hospital Anxiety and Depression scale was used to measure the level of psychological distress experienced during the program, and at 24 months, there was a significant decrease of anxiety and depression in the exercise group from baseline (-1.2 ± 4.1, p=0.007) when compared to the change from baseline of the physical therapy group (0.1 ± 4.0). Using the Arthritis Impact Measurement Scale with scores from 0 to 10, Minor et al. found that pain significantly decreased from baseline in the nonaerobic exercise group (-0.94 ± 1.0, p£0.05), versus the aerobic exercise group (0.68 ± 1.7). There was also a significant decrease in anxiety in the aerobic exercise group (-1.2 ± 1.6, p£0.01 versus 0.37 ± 1.4 in the nonaerobic group) and depression (-0.98 ± 1.2, p£0.01 versus 0.62 ± 0.97 in the nonaerobic group), with significant between-group (aerobic exercise versus nonaerobic exercise) differences (p£0.05).6 In a randomized controlled trial (n=346), Callahan et al. investigated the effects of an 8-week, community-based exercise program on fatigue and self-efficacy.9 When compared to the control group (n=171), the intervention group (n=175) showed improvements in fatigue, as reported by the 100-mm fatigue Visual Analogue Scale, with a decrease in the range of 7.4 to 9.2 points (p<0.01), which is more than the MCID of 6.7 points.10 The intervention group also showed improvements in self-efficacy and arthritis self-management, as reported by the Rheumatoid Arthritis Self-Efficacy scale, with an increase in the range of 5.1 to 6.8 points, which is more than the MCID of 5 points.11 Katz et al. had also showed that as little as 1500 additional steps per day could improve fatigue scores (Patient‐Reported Outcome Measurement Information System Fatigue Short Form 7a), function (HAQ), and self-reported disease activity (Rheumatoid Arthritis Disease Activity Index (RADAI)).12
Evidence suggests that exercise can reverse sarcopenia, which is a loss of muscle mass and an increase of fat mass found in two-thirds of patients with RA.13,14 Marcora et al. compared 10 patients with RA who underwent progressive resistance training for 12 weeks and were compared to a control group of 10 age- and sex-matched patients with RA.13 The exercise group had significant increase in lean body mass (1253 g, p=0.004) and a significant reduction in percent body fat (1.1%, p=0.047). Measurement of fat-free mass served as a proxy to suggest muscle growth, and increase in arm lean mass correlated with an increase in handgrip strength (r=0.444, p=0.050) and elbow flexor strength (r=0.511, p=0.021) while an increase in leg lean mass correlated with a decrease in the advanced activities of daily living (ADL) score (r=-0.496, p=0.026).
While there is a limited number of studies on how exercise can improve RA symptoms, the results are in favor of exercising as a way of improving RA pain and other symptoms associated with this disease. Although there is a recommended amount of physical activity per week, the 2018 Physical Activity Guidelines state that “some activity is better than none,” and benefits can be seen even at lower levels of activity.15 Three of the studies had participants exercising for one hour, three times a week, while Harkcom et al. found that benefits were still seen when exercising for 15 minutes, three times a week.1,3,6,7 A recent study of 194 patients with RA found that improved function, as measured by the Multidimensional Health Assessment Questionnaire (MDHAQ), was associated with exercising at least once per week when compared with no regular exercise.16 All of these studies included a small number of participants, but the results still showed significant differences. However, studies involving lifestyle changes such as exercise is challenging, thus the relatively short observation period for these interventions. Lastly, the majority of the study designs were randomized, which is the preferred study design to reduce spurious causality and bias in the comparison between groups.
References
- 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.
- Häkkinen A, Sokka T, Kotaniemi A, Hannonen P. 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.
- 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.
- Hamer M, Sabia S, Batty GD, et al. Physical activity and inflammatory markers over 10 years: Follow-up in men and women from the whitehall ii cohort study. Circulation. 2012;126(8):928-933.
- Gossec L. Chapter 5 - monitoring of disease and treatment of patients with rheumatic disease. In: Atzeni F, Masala IF, Aletaha D, Lee M, Baraliakos X, eds. Handbook of systemic autoimmune diseases. Vol 15. Elsevier; 2018:97-125.
- 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.
- 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.
- 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.
- Callahan LF, Mielenz T, Freburger J, et al. A randomized controlled trial of the people with arthritis can exercise program: Symptoms, function, physical activity, and psychosocial outcomes. Arthritis Rheum. 2008;59(1):92-101.
- Wells G, Li T, Maxwell L, MacLean R, Tugwell P. Determining the minimal clinically important differences in activity, fatigue, and sleep quality in patients with rheumatoid arthritis. J Rheumatol. 2007;34(2):280-289.
- Hewlett S, Cockshott Z, Kirwan J, Barrett J, Stamp J, Haslock I. Development and validation of a self-efficacy scale for use in british patients with rheumatoid arthritis (rase). Rheumatology (Oxford). 2001;40(11):1221-1230.
- Katz P, Margaretten M, Gregorich S, Trupin L. Physical activity to reduce fatigue in rheumatoid arthritis: A randomized controlled trial. Arthritis Care Res (Hoboken). 2018;70(1):1-10.
- Marcora SM, Lemmey AB, Maddison PJ. Can progressive resistance training reverse cachexia in patients with rheumatoid arthritis? Results of a pilot study. J Rheumatol. 2005;32(6):1031-1039.
- 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.
- 2018 physical activity guidelines advisory committee scientific report. Washington, D.C.: U.S. Department of Health and Human Services;2018.
- Gibson K, Hassett G, Descallar J. Assessment of barriers to exercise participation in patients with ra [abstract]. Arthritis Rheumatol. 2018;70 (suppl 10).