Features April 2004 Issue

RA And Exercise: A Delicate Balance

The right amount of physical activity—not too little, not too much—can help maintain joint strength and function.

Just about everyone—including hundreds of thousands of American adults with rheumatoid arthritis (RA)—can benefit significantly from a well-conceived and properly executed program of physical exercise. All such programs must, of course, be carefully tailored according to an individual’s age, overall health, physical limitations, and other factors that will determine the advisable frequency, intensity, duration, and types of activities comprising the optimal workout agenda.

These factors are especially critical for RA patients. “In the early stages of the disease,” says Gary Calabrese, PT, director of sports health and orthopaedic rehabilitation at The Cleveland Clinic, “there’s a certain amount of leeway in the activities that a person can safely perform. In advanced RA, however, excessive exercise will aggravate the inflammation in an already deformed joint.”

For those patients, Calabrese stresses, inappropriate physical activity is very likely to do far more harm than good.

Known benefits
The benefits of a well-designed fitness program are clear. Routine workouts that include aerobic activity improve cardiac health. Joint function and the body’s flexibility can be enhanced by stretching and lifting routines that build and strengthen the bones, muscles, ligaments, and tendons. And physical activity in general helps to control body weight, thus reducing the burden on load-bearing joints.

These and a wide range of other physical benefits are available to many RA patients who, under the guidance of medical and physical therapy specialists, adhere to a custom-designed, moderately demanding exercise program. In one recent study, for example, patients with early-stage RA engaged in a program involving biweekly sessions, each of which included 20 minutes of strength training with weights, 20 minutes of stationary bike riding, and 20 minutes of such sports as badminton, volleyball, and soccer. After tracking the patients over a two-year period, researchers found that those who began the program free of notable large joint damage experienced significantly improved aerobic fitness and muscle strength while suffering no significantly harmful damage to their weight-bearing joints.

Psychological barriers
Despite abundant evidence that regular physical activity—modulated according to the condition of a patient’s joints—is likely to yield substantial health benefits, a disturbingly low number of people with RA commit themselves to an exercise program. For many patients, says Dr. Salim Hayek, a staff physician in The Cleveland Clinic’s Department of Pain Management, the barrier is psychological. “Anytime there is a functional disability,” Dr. Hayek points out, “the impairment can affect one’s mood and motivation for taking care of oneself.” For RA patients, he says, severe joint pain and inflammation may well prompt feelings that range from a sense of hopelessness and helplessness to severe depression.

But exercise, he notes, is likely to foster significant improvement in mood, since physical activity stimulates the release of certain “endogenous neurotransmitters”—especially the hormone endorphin—that are known to have a positive impact on one’s sense of confidence and well-being. Endorphins and other brain chemicals, he adds, are also known to play a role in easing real pain as well as the feelings of distress that pain tends to cause.

“If patients can overcome the psychological barriers and somehow start to exercise,” says Dr. Hayek, “they will really do much better than they would do by sitting at home feeling sorry for themselves. They have to break the negative cycle in which pain becomes self-propagating.”

Starting out
Gary Calabrese agrees, adding, “The typical family doctor may lack a full understanding of RA and the very special therapy that the condition requires. In fact, since the risks are high, the family doctor may avoid prescribing any kind of therapy for fear of making an affected joint flare up.”

To play it safe, he advises, the patient should be initially assessed by a specialist qualified to establish the range, duration, and intensity of appropriate therapeutic exercises. Once those parameters have been set, a corresponding regimen of specific exercises should be developed by a professional physical therapist who is well acquainted with RA. After several sessions have been completed under the therapist’s guidance, during which the safety and efficacy of specific exercises have been confirmed, the typical patient will usually be able to continue the program unsupervised in a gym or at home.

“But the patient has to understand the limits of every exercise,” says Calabrese, “and the amount of rest that is needed before moving from one activity to the next.”

Easing the load
Calabrese tends to be conservative in developing exercise strategies for RA patients, inclined always to have patients take it easy on their inflamed joints rather than overworking them. He is especially wary of exercises that “load”—or put additional pressure—on a joint. “Impact loading that occurs in simple walking,” he says, “is good for bone strength in most people. But in those with the RA factor [a blood abnormality found in the majority of RA patients], loading has a disruptive influence. So we limit the amount of walking that we recommend. Instead, we focus largely on unloading the joints—moving them without stressing them with additional weight.”

The idea, he says, is to take the burden off the joint itself while striving to strengthen the supporting muscles, ligaments, and tendons. In every instance, moderation is of paramount importance in achieving the goal of maintaining and, possibly, improving joint rotation and overall functionality. “Don’t work a joint at the end range of its capability,” he warns. “Try to stay in the mid-range. And rest between exercises.”