Clinical Review: Rheumatoid Arthritis
Guidelines for managing rheumatoid arthritis consistently recommend exercise to support and maintain joint function. In practice, however, when working with people in chronic pain or during an acute flare of the condition, this may not be such an easy task. This is especially true when there may be fears around pain and dysfunction.
Pathophysiology of Rheumatoid Arthritis
Rheumatoid arthritis (RA) is an immune mediated inflammatory disease: immunological activation + inflammatory pathways contribute to an auto-perpetuating process.
RA primarily presents as symmetrical polyarthritis, with patients dealing with painful joints, restricted mobility, and fatigue.
3 phases of disease: initiation phase, amplification phase, chronic inflammatory phase.
TNF, IL-1, and IL-6 are the prominent inflammatory cytokines that mediate the disease response in RA.
Pathobiology of Rheumatoid Arthritis - Smolen et al. (2016)
In RA, the synovial membrane hypertrophies, and becomes infiltrated with inflammatory cells.
This infiltrate is also accompanied by angiogenesis, thus supporting the growth and hypertrophy of the synovial membrane/pannus.
The pannus encroaches into the joint space, eroding the underlying cartilage and bone.
Additionally, the inflammatory disease process diminishes the integrity of the cartilage in clients with RA, impairing the water content and resilience of this tissue.
Inflammatory cytokines encourage the differentiation of osteoclasts, which also drive bony destruction.
Inflammatory effusions collect in the potential joint space, furthering joint degradation.
Inflammatory mediators have autocrine, paracrine, and endocrine effects: this accounts for the many systemic expressions of the disease.
Extra-articular manifestation can involve the heart, lungs, and skin.
Inflammation, steroid treatment, and a propensity to physical inactivity in this population can also lead to osteoporosis.
Decreases in muscle function are noted, and attributed to both inflammation and physical inactivity.
Clients with RA may also be predisposed these to atherosclerosis, loss of muscle mass, and metabolic disorders such as insulin resistance and dyslipidemia, which can be proinflammatory.
Physical Activity for Rheumatoid Arthritis
Exercise training induces an anti-inflammatory response, and specifically suppresses the production of TNF in clients with RA
Physical activity does not worsen radiological progression of the disease.
Clinically-measured disease activity decreases with regular physical exercise.
Functional outcomes improve with physical activity in clients with RA.
Pain and fatigue decrease with regular physical activity.
Cognitive function and mental health outcomes improve with regular physical activity.
Sleep improvements, cardiovascular health, muscle strength, and other expected improvements from physical activity are also observed in clients with RA.
Exercise Guidelines for Rheumatoid Arthritis
Personalise exercise programs for better outcomes; there is no clear evidence on what type of exercise is the most beneficial for clients with RA.
New physical activity should be undertaken incrementally, working within the bounds of strength, fatigue, and pain tolerance.
Pace activities within an exercise session, and ensure exercise is supervised when beginning a new regimen.
Transient increases in pain during/after exercise are okay.
High-intensity resistance exercise programs can lead to increased joint damage if there is already extensive articular damage, especially around the subtalar and glenohumeral joints
However, high-intensity exercise does not need to be avoided altogether: moderate-high intensity exercise are important for cardiovascular health.
(Avoid high-impact, rather than high-intensity.)
Cycling or swimming are indicated over running, due to joint loading.
Progressively adjust joint loads.
Take care with neck exercises if there is upper cervical involvement.
Take care with overhead movements when there is shoulder joint involvement.
Use wrist bandages to support the wrists and hands if they are painful and/or inflamed.
Physical training is not advised in cases of severe pericarditis and pleurisy.
Clinical Pilates in Practice
Support joint stability through full, functional ranges.
Consider pacing through mixing up cardiovascular training on a stationary bike, with loaded resistance training on the equipment.
Take care with nose clocks, Hundreds, and the rolling series, and other exercises where the head is unsupported and requires control around the atlanto-occipital joint.
Closed-kinetic-chain exercises that take the shoulder into greater flexion range will be more supportive than OKC.
→ Shoulder Stretch on the Reformer.
→ Four-Point Rocking.
→ Throwing Pearls/Saw on the Cadillac.
Footwork on all of the apparatus will support control and strength of the feet and ankles.
(Check out the Anatomy Review: The Subtalar Joint post for ideas to support this joint.)
Avoid excessive use of the Jump Board, although judicious use can teach a soft landing for walking/jogging/running.
Consider moving the contact point for hand straps with arm work - elbows/forearms can work well.
Integrate grip strength functionally with upper limb work: use different grips with the hands for midback series, for example.
References
1. Azeez, Maha, Ciara Clancy, Tom O’Dwyer, Conor Lahiff, Fiona Wilson, and Gaye Cunnane. "Benefits of exercise in patients with rheumatoid arthritis: a randomized controlled trial of a patient-specific exercise programme." Clinical Rheumatology 39, no. 6 (2020), 1783-1792. doi:10.1007/s10067-020-04937-4.
2. Hernández-Hernández, María V., and Federico Díaz-González. "Role of physical activity in the management and assessment of rheumatoid arthritis patients." Reumatología Clínica 13, no. 4 (2017), 214-220. doi:10.1016/j.reuma.2016.04.003.
3. Pedersen, B. K., and B. Saltin. "Exercise as medicine - evidence for prescribing exercise as therapy in 26 different chronic diseases." Scandinavian Journal of Medicine & Science in Sports 25 (2015), 1-72. doi:10.1111/sms.12581.
4. Rausch Osthoff, Anne-Kathrin, Carsten B. Juhl, Keegan Knittle, Hanne Dagfinrud, Emalie Hurkmans, Juergen Braun, Jan Schoones, Theodora P. Vliet Vlieland, and Karin Niedermann. "Effects of exercise and physical activity promotion: meta-analysis informing the 2018 EULAR recommendations for physical activity in people with rheumatoid arthritis, spondyloarthritis and hip/knee osteoarthritis." RMD Open 4, no. 2 (2018), e000713. doi:10.1136/rmdopen-2018-000713.
5. Smolen, Josef S., Daniel Aletaha, and Iain B. McInnes. "Rheumatoid arthritis." The Lancet 388, no. 10055 (2016), 2023-2038. doi:10.1016/s0140-6736(16)30173-8.
7. "RA Pathophysiology • Johns Hopkins Arthritis Center." Johns Hopkins Arthritis Center. Last modified March 27, 2019. https://www.hopkinsarthritis.org/arthritis-info/rheumatoid-arthritis/ra-pathophysiology-2/.