Exercise

Every person with rheumatoid arthritis (RA) should have a regular exercise program specifically tailored to their abilities and needs. The goal of regular exercise is to achieve and maintain optimal health and physical functioning.

Regular exercise, including exercises for strengthening muscles, stretching (range of motion), building endurance, and improving coordination and balance, can be useful in managing many of the symptoms that commonly affect people with RA, including fatigue, stiffness, pain, and weakness. Regular exercise is an important key for maintaining joint and bone health.

How can exercise help?

Exercise also provides general health benefits to people with RA who are at increased risk for cardiovascular disease and osteoporosis (loss of bone with increased risk for fracture). Exercise can help you maintain cardiovascular health, strengthen muscles, and maintain your bones. (This is especially important if you take glucocorticoids to control inflammation.)

In addition, regular exercise can help lift your mood and spirits, improve your outlook on life, improve your sleep (which can be disrupted by RA), and help reduce the effects of depression and other mental health conditions that commonly affect persons living with chronic autoimmune disease.

What do studies tell us about the benefits of exercise?

The benefits of exercise for patients with RA have been demonstrated in a variety of well-controlled studies.^1-4

One study evaluated the benefits of a regular program of strength training combined with aerobic activity for patients with early RA.² The study found that over a two-year period a regular strength training and aerobic exercise program resulted in significant improvements in muscle strength and physical functioning, without any negative effects on disease activity.

Compared to a control group (which was also engaged in an exercise program combining range of motion exercises and regular aerobic activity), the group that combined strength training and aerobic activity had greater improvements in muscle strength, disease activity, and physical functioning, as well as significant improvements in bone mineral density measurements.

Benefits of regular exercise for patients with RA

• Improved muscle strength and function
• Improved joint stability
• Increased endurance
• Improved physical function and performance
• Improved pain control
• Increased quality of life
• Improved bone health

Regular aerobic exercise (such as walking, swimming, supervised aerobic exercise classes, and cycling) has been shown to improve muscle function, the stability of joints, endurance, and physical functioning and performance.

Additionally, aerobic exercise can result in improvements in pain control and overall quality of life for patients with RA.^2-4 Weight training or resistance training may be particularly important because they have been shown to be useful in preventing bone loss (osteoporosis) which can result from the RA disease process as well as from long-term glucocorticoid (steroid) treatment.¹

What are my exercise options?

A wide variety of exercise options are available to you, such as walking, swimming, yoga, weight training, or range of motion activities. But whatever exercise you choose to do, it must be appropriate for your physical abilities and may need to be customized to accommodate your symptoms and limitations.

Members of your care team, including your doctor, nurse, physical therapist (PT), or occupational therapist (OT), can help you in designing an exercise program that suits you. They will have invaluable advice about what sorts of exercises will be most helpful to you and what to avoid. They will also instruct you on proper techniques to prevent joint damage.

Three basic types of exercise you need

Strength: Weight training, yoga, resistance training
Endurance (aerobic): Running, swimming, cycling, walking
Range of motion: Yoga, stretching (passive and active), pilates

You’ll find that certain activities are sources for some or all of the three types of exercise you need. For instance, yoga and Tai Chi can be used to increase or maintain both strength and range of motion. Some water aerobics programs are designed to provide aerobic exercise and increase and maintain strength.

Isotonic versus isometric strength exercises

There are two forms of exercises for building strength, isotonic and isometric exercises. Isotonic exercises are those where your muscles are working against resistance, such as that supplied by gravity, water, weights, rubber bands, or your own body weight.

In isometric exercise, muscles are contracted and relaxed without movement of the joints. An example is when you place your palms together in front of you (in a prayer position) and push them together. Isometric exercises are very useful for RA patients who are limited by disability and pain.

Your PT will help you develop a program of isometric and/or isotonic strength exercises that are appropriate to your needs and abilities.

An abundance of exercise options

The list of activities that you can engage in to get the exercise you need is almost limitless. Whatever activity you choose to engage in, it is important to find the right balance for you. Always keep in mind your goals for exercise. You are trying to improve or maintain strength and endurance without causing damage to your joints. It is important to stretch ligaments and tendons and put your joints through their natural range of motion, but without causing pain.

Exercise options for patients with RA

Aerobic exercises

• Aerobic exercise is any exercise that increases the heart rate and breathing above normal resting levels
• Aerobic exercise options include brisk walking, swimming, running, dancing, bicycling (stationary, trail, or road), elliptical training, stair climbing, and instructor-led movement classes
• Work with your doctor or physical therapist to make sure that you engage in these activities in a way that limits stress on your joints and is adapted to your limitations

Swimming or water exercise

• Water provides buoyancy that makes movements easier and places less strain on joints, muscles, and tendons
• Natural resistance provided by water provides benefits in terms of building strength and stamina
• Individuals with significant disability and limited mobility can perform exercises they are not able to do out of the pool

Yoga

• Provides benefits in terms of range of motion and strength training
• Postures and breathing exercises developed over centuries to alternately stimulate, stretch, and tone the body and provide relaxation
• Can be adapted for individuals with a range of disabilities

Martial arts

• A variety of martial arts are available, including Tai Chi, Kung Fu, karate, and Qi Gong
• Each of these disciplines is useful in building strength and maintain range of motion and flexibility

Pilates

• An exercise system that provides many of the same benefits as yoga
• Involves controlled movements (with emphasis on breathing and precise flow of movement) that promotes both flexibility (range of motion) and strength

Swiss ball

• Your physical therapist can design a program of exercise using a Swiss ball (large inflatable ball) to improve coordination, balance, and strength

Weight training

• Free weights, weight machines, or resistance machines provide a source of strength and endurance exercise
• Workouts can be adapted to individual patient limitations in terms of disability
• Weight and resistance training provides benefits for maintaining bone health

Team and individual sports

• A variety of team and individual sports are available, including golf, volleyball, boating, hiking, tennis, and basketball
• These activities provide both exercise and social interaction and support (team activities)

Dance

• Dance is an activity that can be a great source of exercise
• Can provide aerobic exercise, with added benefit of providing social interaction and enjoyment of music

Consulting with your doctor

Before you start exercising, it is important to talk to your doctor first. Ask your doctor whether it is safe to engage in certain activities when you are experiencing an RA flare.  Ask what alterations you can make to activities to protect your joints from further damage.

Workout length and routine

The answer to this question will depend on your health, abilities, and limitations. Work with your doctor, nurse, PT, or OT to determine exactly how long and how often you should exercise.

Vigorous exercise is important for cardiovascular health. So, if you are able, you should select an endurance (aerobic) exercise that you can engage in for at least 10 minutes consecutively. If you find that your endurance is lacking, start at less than 10 minutes and work up to it slowly over time. A good sign that your endurance exercise is vigorous enough is if you feel an increase in your heart rate and breathing, but that you can still carry on a conversation. Determining your target heart rate is also a way to make sure that you are working hard enough, but not overdoing it.

Always warm up before you engage in endurance or strength training. As a rule of thumb, you should spend at least 10 minutes warming up with gentle stretches. Work slowly and gradually during your warm-up: don’t overdo it. If possible, you should engage in endurance exercises 3 days a week. You can do your endurance workout every other day for at least 10 minutes, with the goal of working up to 30 minutes. Remember to cool down at the end of each endurance session. For example, walk slowly until your heart rate and breathing have returned to the normal range.

Combine endurance with strength training and range of motion exercises, including stretching. Maintaining range of motion is especially important for patients with RA so incorporate stretching into every day. Be sure to stretch a little before your endurance exercise and as you cool down. Try doing your strength training every other day, on the days you don’t do endurance training. Make sure to leave one day a week free for recovery.

Options for limited mobility or access

There are a number of exercise options for individuals with RA who are not mobile, who have certain disabilities, or who just can’t get to the gym.

If you struggle with significant joint disability, water-based exercises are a good option, even better when you have access to a pool and organized classes led by an instructor who understands the needs of people with RA.

Other options include exercises that you can do in a chair, at your desk, in your bed, or while you are standing. We describe a small sample of these exercises below, but your PT or OT, or your doctor or nurse, will be able to show you many more of these kinds of exercises.

If you put aside a certain amount of time each day, even if you lack mobility, you can still engage in activities that will help you maintain muscle tone and range of motion.

Chair exercises

There are a variety of chair exercises that can be done in an office environment or at home in a rigid chair, including chair marching, chair running, chair dancing, and chair fencing.

For each of these exercises sit straight up in your chair with feet pointed straight ahead and planted firmly on the floor. For chair marching, life your entire foot off the floor, if possible, engaging your hip flexors. For chair running, just pick up the pace a bit. With running, you’ll find that you can’t place your whole foot on the floor with each step. Instead, try to touch the floor with your toes or the ball of your foot.

Now add a little music and your favorite dance step and you have chair dancing. Try the polka or, if you like a little Latin rhythm, salsa or merengue.

Finally, try chair fencing. You’ll extend your right leg forward as far as possible, keeping your foot flat on the floor with toes pointed straight forward. Extend your right arm, as if you are thrusting a sword, while keeping your left arm against your side with your fist drawn up next to your left shoulder. Now switch sides, thrusting with your left arm and extending your left leg and foot, while drawing your right arm and leg back.  This activity will work your knees, ankles, shoulders, elbows, possibly wrists, as well as your core muscles.

These are just a few examples of chair-based exercises that can be performed in a seated position. There are others, using stretching bands and free weights. Your PT or OT will be able to suggest more and instruct you in the proper form.

Exercises at the table

A table is the perfect place to get exercise for hands and wrists, the joints of which are often affected by RA.

1. Finger curls. Start with your forearm resting on the surface of the table, palm facing up and fingers extended. Make your fingers curl up into a gentle fist, then gradually uncurl. Repeat this movement slowly and gently 10 times for each hand. (You can do finger curls with both hands at the same time or with each hand separately.)

2. Finger walking. Start with your hands on the surface of the table, palms facing down with fingers stretched out. Keeping your thumbs in place and in contact with the table, walk the fingers of each hand (horizontally) on the surface of the table toward the thumb, then back again where they started. Repeat this 10 times. This activity will help to protect against ulnar shift.

3. Fingertip touches. Start by holding both your hands out in front of you, palms up and fingers outstretched (you can keep your elbows at your sides or lean them comfortably on the surface of the table). Bring the tip of your thumb in contact with each fingertip. Then reach with your thumb to touch the base of each finger. Repeat this pattern 5 times.

4. Wrist circles and lifts. Start by holding both your hands out in front of you, palms down with your fingers formed in a loose fist (you can keep your elbows at your sides or lean them comfortably on the surface of the table). Starting at the wrist, make a slow clockwise circle movement with your hand. Repeat this movement 10 times. Then do the same circle movement, but this time counter-clockwise. Repeat this 10 times. Follow this by gently lifting your wrist toward you, then dropping it back away from you. Repeat this 10 times. You can repeat this exercise, but starting with your palms held upward.

5. Thumb and finger lifts. Start by laying your forearms and hands (fingers extended) on the surface of the table. Press your fingers into the table. Then, lift your thumbs off the surface of the table, hold briefly, and relax. Then lift both index fingers, hold briefly, relax. Continue lifting with each finger while trying to keep the other fingers/thumb pressed into the table. Repeat this exercise 2 times.

6. Tug of war. Start by gripping an envelope or card between your thumb and index finger. With the other hand try to pull the envelope or card free for a count of 3 and resist the pull with your thumb and index finger. Repeat this tug of war using the thumb and each of the other fingers on your hand to resist the pull of your other hand. Then repeat this tug of war, this time reversing the role of your hands.

Elbow exercise

1. Start with the fingertips of each hand touching its corresponding shoulder, elbows facing forward. Gently extend your arms in front of your body at about shoulder height with palms facing upward. Reverse the motion to return your fingertips to each shoulder.

2. Start with the fingertips of each hand touching its corresponding shoulder, elbows to each side. Gently extend your arms to each side of your body at about shoulder height with palms facing upward. Reverse the motion to return your fingertips to each shoulder.

3. As with the exercise above, start with fingertips touching its corresponding shoulder, elbows to each side. Gently extend your arms above your head and reach to the ceiling. Reverse the motion to return your fingertips to each shoulder.

Shoulder stretches

1. Start with your arms hanging loosely by your sides. Slowly raise each shoulder, one at a time or together, toward each corresponding ear. Allow your shoulders to fall gently back to the starting position. Repeat this motion 5 times.

2. Start by placing your hands, palms facing out, at the base of your back near your hips. Gently slide your hands up your back as comfortably as you can go, either both hands together or each hand separately.  Then, slide your hand(s) down your back again.  Repeat this motion 5 times.

3. Start with your hands above your head, arms extended and palms pressed together. Lower both arms gradually until your elbows touch your torso and palms face upward.  Reverse the motion until your palms are once again pressed together about your head.

Exercises for the bed

1. Start by lying flat on your back in the center of the bed with your arms down by your sides, palms facing down. Slowly extend and lift your arms up and over your torso to rest above your head while you breathe in. Slowly reverse the motion as your exhale to your starting position. Repeat this pattern 5 times.

2. Substitute a different exercise for this one which doesn’t put strain on the neck.  Patients with RA in their cervical spine must be extra cautious not to injure themselves. The exercise below should be good.

2. Start by laying flat on your back in the center of the bed. Gently lift your right leg and reach behind your thigh, or around your knee. Gently bring your thigh to your chest and lift your head towards your knee while you exhale. Lower your head back to the bed and straighten your leg to the beginning position. Repeat series with the left leg. Continue this set of motions for 3 rounds.

What to keep in mind about exercise

Living with RA, you may have specific concerns regarding exercise, such as whether to engage in activities when joints are swollen, inflamed, or painful. If the cervical spine is affected, you need to be extra cautious when engaging in activities that put strain on the neck. Remember to always practice good joint preservation techniques.

Starting an exercise program

Start slowly and stay within your ability. With any type of exercise or activity, it is important not to overdo it, especially at the start. If you feel faint, dizzy, nauseous, or have tightness in your chest, stop and call your doctor immediately.

Get some supervision. You should start your exercise program under the supervision of a trained health professional, such as a physical therapist. By working with an experienced professional, you’ll be able to develop the right kind of program and get valuable advice about how to get the most out of exercise without causing damage to your joints. A physical therapist or trainer can help you set goals, such as targets for heart rate and breathing, and monitor you so you don’t overdo it.

Warm-up before exercise. You should warm up for at least 10 minutes before you start your endurance or strength exercise. Be careful during your warm-up not to over-stretch: work carefully and gradually.

Make sure to cool down after exercise. Make sure to cool down gradually. For instance, after running or cycling or brisk walking, you might walk slowly until your heart rate has returned to the normal range .