Exercises interventions in people with rheumatoid arthritis

Amal Elramli＊

School of Medicine, University of Glasgow, Glasgow, UK

IntroductIon

Rheumatoid arthritis (RA) is a chronic auto-immune disease of unknown aetiology and is most prevalent among people aged 40–60 years.1,2The pathological process of RA may lead to severe articular destruction, loss of function,accelerated loss of muscle mass, restricted mobility and deformity.1,3RA guidelines emphasise the role of regular physical activity (PA), which is associated with improved health outcomes, both physical and mental, and a 30%reduction in risk of all-cause mortality.4,5People with RA were shown to be less physically active in comparison with healthy people, and had significantly lower energy expenditure, lower aerobic capacity than the normative values and they spent less time undertaking vigorous PA than the healthy controls.6Modern technology may be used to diagnose RA earlier, and new approaches of anti-rheumatic treatment regimens have improved the outcome of the disease, although, those with RA still suffer from progressive, long term disability.1,7Studies revealed that people with RA have a shortened life expectancy of between 3–10 years, with most people dying from cardiovascular disease(CVD), infections, haematological, gastrointestinal or pulmonary complications.1,8-10Specifically, RA is associated with an increased risk of CVD, such as myocardial infarction, ischemic heart disease and heart failure.3,11-13

There is good evidence to show that exercise plays an important role in improving health outcomes and in reducing morbidity and mortality in the general population,14as well as in people with RA.15Regular exercise plays an important role in reducing the risk of hip fracture by up to 68%, depression by 30%, CVD by 35% and all-cause mortality by 30%.16

The following review describes the evidence to support exercise intervention in people with RA.

retrIeval strategy

A literature review provides the background and justification for the research and it allows a comparison of past research studies which investigated exercise for those with RA.The key articles were obtained primarily from PubMed,Medline, Google Scholar, Cochrane Library, and Web of Science. In order to ensure that relevant studies were not missed, the search terms remained broad. These were:rheumatoid arthritis, physical activity and exercise. These terms were then combined with the Boolean operator AND“rheumatoid arthritis AND physical activity”, “rheumatoid arthritis AND exercise”, “rheumatoid arthritis AND strengthening exercise”, “rheumatoid arthritis AND aerobic exercise”, “rheumatoid arthritis AND stretching exercise”.Figure 1shows the flow of literature in this review.

Figure 1: Prisma diagram of the literature search.

DIscussIon

There is a growing body of literature regarding the promotion of exercise in people with RA and this has been discussed in relation to aerobic,18strengthening,19stretching or combined exercises.20-23However, almost all of the exercise interventions are combined. To date, there is no evidence that exercise has any detrimental effect on people with RA and, in fact, it should be encouraged in people with RA.24

Exercise is characterised and described in terms of frequency, intensity and duration. Frequency is defined as the number of times an activity is performed in a given time frame25,26. Duration refers to the total amount of time dedicated to performing the activity, either accumulative or continuously, over a specified time. Intensity is defined as the energy expenditure during a specific activity and is usually measured in metabolic equivalents (METs).27

People with RA, who are physically active, are found to have improved RA symptoms, such as lower levels of pain and fatigue, which conversely, are considered the primary barriers to PA in RA sufferers.28A study by Khoja et al.27on RA reported that very light represented activities between 1.1 and 1.9 METs and light was activities between 2.0 and 2.9 METs and moderate intensity PA represented activities ≥3.0 METs. It was significantly associated with lower functional disability, blood pressure and body mass index (BMI), and improved insulin sensitivity and HDL (P< 0.05). A study undertaken by Stavropoulos-Kalinoglou et al.22reported that CVD was reduced in RA cohorts who participated in programmes consisting of 6 months of high intensity exercise (walking on a treadmill and cycling for 3–4 minutes). Another study showed a reduction in risk of CVD by 20–30% among women and men who engaged in high levels of leisure time PA, while moderate leisure time PA decreased CVD risk by 10–20%.29A review of Randomised Clinical Trials (RCTs) by Metsios et al.30demonstrated a reduced risk of developing CVD and improved functional capacity in RA cohorts who were physically active. The combination of increased PA and effective medication may help to inhibit disease progression, reduce the risk of CVD and improve health outcomes.31It was concluded that PA is important in improving arthritis symptoms and mental health, and in reducing the risk of CVD.15

Many PA guidelines exist across different countries(USA32; Canada33; UK34) and recommend the promotion of moderate intensity PA in the general population. It is recommended that adults (18 to 64 years) and older adults(65 years and more) undertake 150 minutes of moderate intensity PA per week (equivalent to 2½ hours of moderately intense PA of 10 minutes bouts or more, which could be achieved with 30 minutes’ exercise 5 days per week),for general health and to reduce the risk of disease (USA32;Canada33; UK34).

The 2015 update of the 2009 European League Against Rheumatism (EULAR) recommendations for CVD risk management in inflammatory joint disease (IJD) recommended a healthy lifestyle for people with RA, with an emphasis on the benefits of regular exercise.

A study carried out by Hurkmans et al.35investigated the exercise level in people with RA with two questions according to public health recommendations of PA 30 minutes for at least 5 days/week; or vigorous intensity exercise, 20 minutes for at least 3 days/week. The first question asked how many days/week people performed moderate intensity,which was defined as exercise causing a small increase in heart rate or breathing, such as gardening or brisk walking,in the past 3 months. The second question was how many days/week they performed vigorous intensity, which was defined as exercise causing a large increase in heart rate or breathing, such as running, in the past 3 months. The number of participants who met the public health recommendation of moderate-intensity exercise was significantly higher in the intervention group at 24 months compared with the control (P< 0.05). Another randomized controlled trial included 34 RA patients with a mean age of 48 ± 11.3 years.36The intervention consists of aerobic exercise, strengthening exercises and education programme. The results showed a significant improvement of aerobic capacity and health status in the intervention group (12.1%).

The success of exercise intervention was evident in all studies that were reviewed. The majority of studies found an improvement in PA level, regardless of the duration of the intervention or the intensity of the exercise. The level of description of the intervention varied across the studies,especially in terms of descriptions of the type of exercise included. In most of the studies, the intervention/exercise programme consisted of different types of exercises, such as strengthening, stretching and aerobic exercise. Therefore,it is difficult to identify the particular type, frequency and intensity of exercise that helps to improve the PA outcome.It is also difficult to identify the appropriate exercise that should be recommended to people with RA.

conclusIon

Overall, each exercise intervention that was reviewed demonstrated enhanced PA levels and an improvement in health outcome among people with RA. Most of the studies highlighted the evaluation of a combined exercise intervention programme. There were no specific PA guidelines for people with RA; additionally a lack of data regarding the type, frequency and intensity of appropriate exercise in people with RA underlines the fact that further studies are recommended.

Author contributions

The author wrote and revised the manuscript, and approved the final version of the manuscript.

Conflicts of interest

The author declares no competing financial interests..

Plagiarism check

Checked twice by iThenticate.

Peer review

Externally peer reviewed.

Open access statement

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under identical terms.

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