The evidence for the effectiveness and

safety of intensive land-based exercise

in patients with rheumatoid arthritis

19/09/06: Zuzana de Jong, rheumatologist Leiden University Medical Centre

The evidence for the effectiveness and safety of intensive land-based exercise in patients with rheumatoid arthritis

Zuzana de Jong, Rheumatologist, Leiden University Medical Centre

For different reasons patients with rheumatoid arthritis (RA) are being discouraged by their physician and physical therapist from participation in fitness programs. However, there is recent scientific evidence that RA patients can benefit safely from intensive weight-bearing exercises, and enjoy participation for a prolonged period of time. This article gives evidence for this statement by presenting the results of a long-term intensive exercise trial performed in Leiden, the Netherlands.

Introduction

Patients with RA are, as a consequence of their disease and its treatment, less fit and more at risk of cardiovascular diseases and osteoporosis than their healthy peers . Long-term exercises of moderate to high intensity have proven effective in improving physical fitness and in decreasing the risk of cardiovascular events and of osteoporosis. People who exercise on a regular basis live longer.

Intensive exercises for RA patients. Why not?

Patients and physicians were, for a long time, worried about the safety of intensive exercises. Many of them also believed that patients with RA are unable to participate in intensive exercises for a prolonged period of time due to the uncertain and undulating course of their disease. In addition, the intuitive approach to give rest to inflamed joints, the fear of damage to the joints and of exacerbation of joint inflammation, often results in advising RA patients against participation in such exercises.

These fears are unjustified.

Recent research

In the past 2 years, a group of Dutch rheumatologists and movement scientists from the Leiden University Medical Center presented results of a large trial on the effectiveness and safety of intensive supervised exercise program in patients with RA (RAPIT-trial). One hundred and fifty patients between 20 and 70 years and with a moderate disease activity participated in this 2-year trial. Patients with prostheses of a hip, knee or ankle were excluded since the effect of vigorous activities on the durability of these prostheses is not yet well explored.

Build-up of the exercise program The program was performed in classes of 10-15 patients and took place twice a week. Each session lasted 75 minutes and consisted of 3 parts: bicycle training (20 minutes), exercise circuit (20 minutes), and sport and game s (20 minutes). Examples of sport activities and games used are: badminton, volleyball (if necessary with a soft ball), indoor soccer, basketball, relay games, pat-catch games. Each session was preceded by a warm up and ended with a cool down.

Importantly, the classes were supervised by physical therapists experienced with RA

and the program was adjusted to meet the individual’s needs. Patients with a disease exacerbation were encouraged to continue their participation.

Evidence for the effectiveness of intensive exercises

After 2 years, the participants in the exercise group improved their muscle strength, endurance (physical fitness), and reported a significantly better emotional health. They reported also significantly better performance in activities of daily living, vocational and social activities. In addition, less exercising patients developed osteoporosis.

Feasibility of the program

After 2 years, most (81%) participants still followed the classes. Despite the fact that many participants (65%) reported to experience pain “sometimes”, 78% claimed they would (strongly) recommend the training to other RA patients. Moreover, 73% of the patients who started the classes said they wish to continue classes after 2 years of trial.

Evidence for safety of intensive exercises 

Surprisingly, the participants in the intensive exercise programme developed less damage of the joints of the hands and feet than expected, and the joints of the feet seemed to profit the most. A small group of patients, identified as those with extensive large joint damage already present before the start of exercise classes, developed somewhat more damage to these joints.

The fear of increase in disease activity by exercising appeared baseless. The number of swollen joints and painful joints decreased and there was no need to intensify the anti-rheumatic drug treatment or the use of painkillers.

What to advise a patient who wishes to participate in intensive exercises?

According to the Dutch investigators, there is no reason to discourage the patients from participation in intensive exercises. Most of them can benefit safely. Patients at risk of undesirable side effects are those with prostheses of weight-bearing joints and those with extensive damage of the shoulders, elbows, hips, knees or ankles. These patients should be identified (by means of radiographs) and preferably not be advised to exercise vigorously. Alternatively, their exercise program should be adjusted to a level that is safe yet still effective. For the best advice, joint consultation between the patient, her/his treating rheumatologist and skilled physical therapist is essential and indispensable.