Training and physical exercise in rheumatoid arthritis

Training and exercise in rheumatoid arthritis: Rheumatoid arthritis is a disease that affects the joints and can cause pain, stiffness and disability. In this article we discuss how exercise can be beneficial for patients, improving their joint function, muscle strength and quality of life. In addition, we mention specific recommendations on the type of exercise and its frequency. It is an interesting read to understand how movement can help in the management of this disease.

The cause of rheumatoid arthritis (RA) is unknown, although a genetic predisposition (HLA-DR β1 locus of class II histocompatibility genes), and a possible environmental influence not yet well clarified, have been identified.

It affects approximately 1% of the world population, being six times more frequent in women than in men. The disease usually appears between the third and fourth decade of life, but it can debut at any age.

The main feature of the disease is severe synovial inflammation, with 3- to 100-fold elevations of proinflammatory cytokines, such as tumor necrosis factor-alpha (TNF-α), interleukin 6 (IL-6), interleukin 1β (IL-1β) and C-reactive protein (CRP). As a consequence of the development of the disease patients suffer severe joint pain, reduced muscle strength and impaired physical capacity. The typical course of RA is in exacerbations and remissions, although, during the inactive phases of the disease, systemic cytokine levels remain altered compared to people without the disease.

In affected joints, the synovial membrane develops numerous folds, increasing in thickness due to an increase in the number and size of synovial lining cells, as well as infiltration of lymphocytes and plasma cells. The lining cells produce substances that contribute to cartilage destruction (collagenase, erythromelysin, etc.), interleukin-1, which stimulates lymphocyte production, and prostaglandins. Infiltrating cells that go on to form lymphoid follicles, fibrin deposits, fibrosis and necrosis can be observed. Hyperplastic synovial tissue (pannus) may erode cartilage, subchondral bone, joint capsule and ligaments.

Rheumatoid nodules (located subcutaneously) occur in up to 30% of patients. They are nonspecific necrobiotic granulomas consisting of a central necrotic area surrounded by lymphocytes and plasma cells.

The onset of the disease is usually insidious, with progressive joint involvement, although more rarely it may debut abruptly, with simultaneous inflammation in multiple joints. The most characteristic physical finding is the presence of tenderness in almost all the inflamed joints, with synovial thickening appearing at the end, which is the most characteristic sign, in most of the affected joints, the most frequent being the small joints of the hands, especially the proximal interphalangeal and metacarpophalangeal joints, those of the foot (metatarsophalangeal joints), wrists, elbows and ankles.

Stiffness lasting more than 30 minutes after getting up in the morning or after prolonged activity is very frequent. Early evening fatigue and general malaise also appear.

Up to 75% of patients improve their symptoms with conservative treatment during the first year of the disease. However, more than 10% develop severe disability despite complete treatment.

In addition to the joint aspects of the disease, RA is associated with increased morbidity and mortality from cardiovascular disease. The risk of acute myocardial infarction in women with RA is estimated to be twice as high. This increased risk of cardiovascular disease appears to be independent of traditional risk factors and, given that a chronic increase in systemic inflammation seems to play a key role in the development of atherosclerosis, it seems reasonable to hypothesize that this inflammatory state contributes to the increased incidence of cardiovascular disease in these patients.

On the other hand, the majority (2 out of 3) of RA patients suffer an accelerated loss of muscle mass, known as “rheumatoid cachexia”. This muscle loss affects muscle strength, and contributes to disability, affecting the quality of life of patients. Inadequate nutrition and physical inactivity appear to be factors that facilitate the onset of rheumatoid cachexia.

Nonsteroidal anti-inflammatory drugs (NSAIDs) and salicylates are used in the treatment of RA, the latter being one of the most important resources in pharmacological treatment. If pain and inflammation persist after 4 months of disease despite adequate treatment with aspirin or other NSAIDs, the addition of other drugs (e.g. gold salts, hydroxychloroquine, methotrexate, corticosteroids, etc.) should be considered. Many patients require physiotherapeutic treatment to prevent flexion contractures, and to restore mobility after acute periods of the disease.

The impairment of joint range, muscle strength, and aerobic endurance leads to a significant loss of function, ultimately reducing the quality of life in RA patients. Although pharmacological interventions have markedly improved the evolution and repercussions of the disease, physical therapy in its broadest context is considered essential in the treatment of RA.

Exercise is an effective means in patients with RA, and properly administered does not induce adverse effects. However, while the benefits are fully recognized, the appropriate prescription (duration, modality, frequency, intensity) involves a dynamic process of incorporation of new evidence that attempts to optimize the training process in these patients. In addition, the proposals presented should take into account adherence to the programs, which is essential to link responses and adaptations.

Exercise programs should be initially supervised by healthcare professionals in order to adapt the training plan to the disease activity, joint involvement and symptoms of the patients. This is where digital physiotherapy can play a key role by providing remote and personalized monitoring tools. Through apps and online platforms, physical therapists can monitor patients’ physical activity, adjust exercise programs as needed and offer real-time guidance. This not only improves accessibility to treatment, but also increases adherence to the exercise program by providing ongoing support tailored to each patient’s individual needs.

On the other hand, the evidence for exercise prescription in patients with severe disease is limited, and must be assessed on a patient-by-patient basis. Moreover, it is not clear that exercise, especially strength exercise, should be continued during acute states of inflammation, and more research is needed to assess the effects of exercise in severely damaged joints.

Exercise programs for RA patients address all components of physical fitness, and are considered a fundamental part of disease management, improving functional capacity, cardiovascular health, muscle mass and strength, and reducing body fat, all without exacerbating the disease or causing damage to the affected joints.

The most common interventions and approaches are aerobic training, strength training, and a combination of both.

Pain in patients with RA. In addition, aerobic exercise appears to decrease joint damage and is safe in stable patients.

Several lines of evidence suggest that any type of aerobic exercise is effective, but the most favorable exercise prescription (intensity, duration, frequency and modality) has not been clearly established.

Intensities of 60-80% FCmax or 40-60% VO2max (RPE 11-16/20), performed at least 2-3 days per week, for 30-60 minutes per session are recommended.

There is evidence of positive effects of aerobic training on aerobic capacity in patients with RA, but studies are needed to specifically investigate the effects of aerobic training on cardiovascular disease risk in these patients who are at increased risk for cardiovascular disease.

Joint involvement in RA often leads to deformities and muscle atrophy that is associated in the medium term with disability. The implementation of strength exercise programs in these patients has not been openly contemplated until relatively recently. The results of previous studies that did not clearly show benefits of this exercise modality in RA patients have meant that its application has not been widespread.

Strength exercises decrease disability, improve functional capacity and joint status, and these changes are clinically relevant. A progressive intensity is recommended at 60-80% 1RM, or at % 1RM limited by pain, 10-12 repetitions, 2-3 series and performed 2 or 3 days per week. Circuit work has been shown to be effective and causes greater adherence.

It should be borne in mind that the adaptations achieved with exercise programs disappear rapidly when the training is abandoned, which “forces” these patients to maintain a lifelong maintenance activity.

In summary, strength training is safe and offers significant clinical improvements, with increases in functional capacity and decreases in disability. Along with these anti-inflammatory effects, strength training decreases cardiovascular risk factors. The most effective ratio between aerobic and strength training in these patients remains to be clarified.

Rheumatoid cachexia is characterized by a loss of muscle mass associated with an increase in body fat percentage. These changes not only cause muscle weakness and increased disability, but also contribute to the onset of fatigue and increased risk of diabetes.

The precise mechanism by which rheumatoid cachexia occurs is not well understood, but a reduction in insulin action, muscle IGF-1 levels, testosterone and low physical activity appear to be major contributors. In addition, corticosteroid therapy may promote muscle atrophy.

Loss of strength (≈70%) is a very common finding in these patients, with the decline in muscle mass contributing decisively, although other factors may also contribute: immunologic factors and physical inactivity. The decrease in muscle strength and power leads these patients to a clear functional limitation. Nevertheless, normal values of strength and other muscular properties in quadriceps have been described in patients with stable RA.

It has been shown that high-intensity strength training reverses cachexia in patients with RA, and as a consequence of this restoration of muscle mass, substantially improved functional capacity, reducing disability.

Regarding the magnitude of hypertrophy and strength improvement through specific strength programs in these patients, it is very similar to that obtained in healthy middle-aged or elderly people. This information is important for health professionals and for those who exercise RA patients, as they should expect responses to strength exercise very similar to those in healthy subjects.

Therefore, strength training in general, and high intensity strength training in particular, is fully indicated in these patients, in addition to improvements in balance and coordination, qualities often affected.

Combined aerobic strength-endurance training

The most effective training for RA patients, and the one with the greatest positive effects, is that which combines aerobic and strength training. It is also very useful for maintaining an adequate fat percentage.

Effects of exercise on joints

RA causes inflammation of the tendon sheaths, leading to synovial hypertrophy with infiltration. The potential benefits of training on the tendons of RA patients are unclear and require further research.

Ligaments constitute another essential element of the joint, having as their main function the passive stabilization of the joint, as well as “guiding” the joint through the normal range of motion. In RA patients, regular physical activity helps to strengthen the ligaments and thus the stability of the joint.

For many years, dynamic exercises of a certain intensity, as well as those associated with loads, were considered inappropriate for RA patients because such activities could exacerbate the disease. Currently, exercises associated with cyclic loads (walking, cycling…) are fully indicated, having demonstrated improvements in cartilage integrity and joint lubrication.

On the other hand, it has also been shown that strength training does not exacerbate joint inflammation, and a reduction in the number of clinically active joints has been observed after prolonged periods of training.

In my opinion, any form of exercise will not worsen disease activity, which to some extent shows that exercise is safe for patients with rheumatoid arthritis. The combination of aerobic exercise and strength training is recommended, thereby improving joint range of motion, muscle strength, aerobic capacity and physical capacity without increasing fatigue and joint symptoms.

To obtain the maximum benefit from exercise in patients with rheumatoid arthritis, different exercise modalities should be selected according to the progression of the disease in each patient. For RA patients, any exercise is better than no exercise, but exercise modality, intensity, frequency and duration must be individually determined for best results while maintaining patient safety.

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