Presentation
A 54-year-old woman who has had rheumatoid arthritis (RA) for almost 2 years presents at a regular medical check-up with her rheumatologist. She is married and employed as a nurse at a local hospital, but has not been able to work, other than for short periods, since the time of her diagnosis. Her height is 1.65 m, her body weight is 74 kg, and her blood pressure is 160/110 mm Hg. Medication with methotrexate, 20 mg/week, and oral corticosteroids, 5 mg/day controls inflammation well; a few finger joints are still swollen and her Disease Activity Score (DAS28) score is 3.2. Her Visual Analog Scale (VAS) rating of pain and global disease impact are 23 and 25, respectively, her Health Assessment Questionnaire (HAQ) score is 0.50. She reports severe fatigue as the reason for a mainly sedentary lifestyle and her inability to work. This worries her because the family economy has declined as a consequence of her work disability. Other concerns relate to her sedentary lifestyle and overeating, which has made her put on weight, and to her strong heredity for cardiovascular disease because she knows that her RA increases the risk of cardiovascular comorbidity.
Discussion
Further investigation into whether this patient is at risk for developing cardiovascular disease and diabetes type II is warranted because of her strong family history, high blood pressure, medication with corticosteroids and an unhealthy lifestyle.
Assessment by a physical therapist is also indicated in order to test body functions, to survey cognitive-behavioral factors related to lifestyle, and to prescribe an individualized physical activity program that may help reduce not only her fatigue but also the risk of future cardiovascular disease. Body function testing reveals that the patient has reduced grip strength, reduced lower limb function, and poor cardiovascular fitness compared with norm data. Joint motion, particularly that of hands and shoulders, is painful and their range of motion reduced. Metatarsophalangeal joints are tender. Previously the patient used to be physically active with hiking and biking, and she is ready to change her current sedentary lifestyle. Specific goals for changed physical activity behavior are thus discussed and set. The ultimate goal will be daily brisk walks, strength training twice a week, and range-of-motion (ROM) exercises for painful and stiff joints, when indicated. However, this goal will be approached in small steps that are written down and defined as to mode, time, place, frequency, duration, and intensity. Plans for progression as well as for relapse prevention are made. The importance of appropriate footwear, including insoles, is discussed. The patient will keep a physical activity log and regular visits, more frequent during the initial phase, are scheduled with the physical therapist in order to avoid relapse, check progress, and instruct in new exercises. The expected outcome of these interventions, based on evidence from randomized and longitudinal studies, is reduced fatigue and improved body functions, but also reduced risk for cardiovascular disease and diabetes.
Presentation
A 48-year-old woman with fluctuating pain for 3 years, without any signs of inflammation in joints or muscles, consults a rheumatologist for overall deterioration of functioning. Her pain, along with stiffness, has worsened during the past 5 months, with tangible consequences for employment, household, and leisure time. She describes difficulty in walking longer than 15 minutes, climbing stairs, standing for a prolonged time, and carrying and lifting objects. She has discontinued all physical exercise and heavier household tasks, because physical activity aggravates her pain. She is a social worker, married, and has two children. During recent months, she has worked only 50% of her regular full-time schedule because of her disabilities. Her height is 1.74 m, her body weight 82 kg, and her blood pressure is 115/70 mm Hg. She rates her pain as 65 on a 100 VAS, whereas pain in the right hip, leg, and lower back from time to time increases to 80 on a VAS. She rates her fatigue as 60 and global disease impact as 65 on a VAS. Her current medication with nonsteroidal anti-inflammatory drugs (NSAIDs) does not alleviate pain. Clinical examination does not show any swollen joints, signs of bursitis, or neurologic origins for her pain, but does reveal a lowered pain threshold at palpation (allodynia) all over the body. Pain localization covers the definition of generalized pain according to the American College of Rheumatology (ACR) criteria for fibromyalgia (FM). A total of 16 positive tender points are found by specific examination of such points. Blood tests do not show any signs of inflammation.
Discussion
A diagnosis of FM is made. Pharmacologic therapy is initiated to alleviate generalized pain and fatigue. She is referred to a physical therapist for further investigation of impairments in the right hip, leg, and lower back and for a comprehensive assessment of body functions, as well as interventions to improve overall body function and to prevent further inactivity. A referral to a patient education program is also considered.
Assessment of the lower extremities and lower back by a physical therapist reveals muscular imbalance involving shortened muscles, reduced muscle strength, increased muscle tension, and pain at various muscles. The pain is aggravated by physical loading, especially in the right leg. The patient expresses being motivated to start exercising, but fears further deterioration of her functioning, because pain affects her working capacity. Short-term and long-term goals for exercise are discussed and set. At this initial phase, starting regular exercise is determined as the first priority, whereas the duration and intensity of exercise are secondary priorities. The patient receives instructions for a home exercise program to increase mobility, blood circulation, and muscle endurance of the lower extremities and the low back, limited to 40% to 50% of the maximal performance capacity, so as not to further increase the pain. The patient is also referred to a supervised exercise program in a temperate pool for a period of time in order to improve muscle function by stretching and strengthening exercises, combined with body awareness and relaxation. In parallel, daily walks, starting with a short duration and at low intensity, are planned and initiated. Information on the risks and benefits of exercise is given. Plans for management of activity-induced pain, modification of the exercises, and a long-term plan to escalate the exercise level in terms of mode, duration, intensity and frequency are discussed and set. The long-term goal is exercise at 60% to 70% of maximum capacity three times a week. Information on generalized pain and FM is given, and written information is forwarded. The patient will keep a physical activity log and regular visits, more frequent during the initial phase, are scheduled with the physical therapist in order to avoid relapse, and to modify and progress the exercise level. The expected outcome of the planned interventions, based on evidence from randomized and longitudinal studies, is improved walking capacity and overall health status including reduced pain. The increased amount of physical exercise is expected to reduce or postpone the risks for disorders associated with inactivity.
The interventions discussed in the present chapter are physical activity and exercise; the latter being a subset of the former ( Fig. 30-1 ). Physical activity includes all bodily movement that requires muscle work and results in increased energy expenditure compared to that in a resting position. Thus, physical activity includes all the activities of daily life that are performed without any specific intention to improve functioning or health. Health-enhancing physical activity denotes a level of activities that prevents the development of lifestyle related disease. Exercise is performed in a planned and structured way, with the aim to improve or maintain body functions. In the rheumatic diseases exercise targets are mainly joint ROM, muscle function, and cardiovascular capacity, whereas adequate levels of physical activity target immediate general physical and psychological well-being and a long-term reduction of risks for lifestyle-related diseases. Although planned and structured exercise interventions aiming at improved body functions have gradually become a self-evident intervention in the rheumatic diseases during the past decades, the importance of health-enhancing physical activity in daily life has received much less attention.
Health-Enhancing Physical Activity
A sedentary lifestyle is one of the most important independent predictors of poor general health and premature death, and it is well known that appropriate physical activity protects against cardiovascular disease as well as against poor health due to other physical and psychological conditions. Despite this, it is estimated that approximately half the world’s population is mainly sedentary or accumulates too little physical activity to preserve good health. People with rheumatic disease accumulate less physical activity than healthy individuals, but their physical activity behavior does not seem to be determined by disease activity or degree of disability. There are good reasons to believe that physical activity in rheumatic disease would help reduce not only the risk of additional health problems such as stress, anxiety, and depression, but also the risk of future comorbidity and premature death that is related to several of the inflammatory rheumatic diseases.
Public health recommendations include levels of physical activity to prevent poor health not only among the general public, but also in different subpopulations. Recommendations for healthy people aged older than 65 years and for those between 50 and 64 years with a chronic condition such as arthritis are shown in Figure 30-2 . Thus, it is recommended that a basis for health-enhancing physical activity consists of either 30 minutes of moderately intense daily physical activity or 20 minutes of high-intensity exercise at least three times a week. This basis should be supplemented with strength training 2 to 3 times a week, and with ROM exercises and balance exercises whenever indicated. An exercise plan is also recommended.
Physical activity intensity is classified as low (< 40% of V o 2 max), moderate (40% to 60% of V o 2 max) or high (> 60% of V o 2 max). In the absence of heart rate monitoring examples of typical activities, age-predicted maximum heart rate (220 − age), or rating of perceived exertion may be used to estimate physical activity intensity. Thus, a brisk walk that increases breathing and induces sweating, but still allows for conversation, corresponds to moderate intensity. A heart rate of 55% to 70% of age-predicted maximum, in a person with normal body weight, and ratings of perceived exertion about 12 to 13 on the Borg RPE scale also indicate moderate intensity. Some caution as to the interpretation of perceived exercise load may be adequate because patients’ understanding of this phenomenon may vary greatly.
No scientific evidence has yet been found to support the idea that physical activity prevents comorbidity and premature death specifically among people with rheumatic disease. However, because public health recommendations include people with chronic disease, our present hypothesis should be that they, irrespective of age and disability status, should be recommended health-enhancing physical activity, adapted to their condition, in order to maintain good general health. One important piece of information for individuals who have difficulties to perform 30 minutes of physical activity at one time is that physical activity accumulated in 10-minute bouts during the day and adding up to at least 30 minutes may be equally beneficial for their health.
Joint Range of Motion Exercise
Many rheumatic joint diseases result in reduced ROM in peripheral as well as in spinal joints. In the early course of the disease, stiffness and restricted movement are often related to joint pain, muscle spasm, and swelling. In patients with long-standing disease ROM is more likely to be restricted by soft tissue contractures or by destructions of cartilage and bone. Patients should be recommended to check ROM in affected joints regularly in order to detect signs of reduction and, during periods when ROM is threatened, be advised to perform regular exercise in order to preserve optimal joint function.
ROM exercise may be performed actively, with or without assistance, or passively. Active exercise should be preferred, but if the patient is in too much pain or is too weak or fatigued, it may be necessary to reduce body weight during exercise. Such reduction can be obtained by use of equipment, in water, or manually by a physical therapist. Sometimes passive mobilization of joint structures may be indicated in order to avoid manifest contractures. Such techniques are frequently used in exercises for patients with ankylosing spondylitis (AS) and similar conditions when body weight is used to passively stretch out structures that tend to contract. Specific manual passive mobilization of joints by a physical therapist may also be indicated occasionally.
Muscle Training
Reduced muscle function is common in all kinds of rheumatic diseases. In some conditions, endurance is reduced to a greater extent than strength and may be caused by selective type II fiber atrophy. Other causes of reduced muscle function are pain, reflex inhibition, changes in muscle metabolism, reduced numbers of working fibers, poor biomechanical conditions due to damaged bone and cartilage, peripheral nerve injury, and physical inactivity. Patients with rheumatic disease should be recommended to perform muscle training and to continue physical activity in order to preserve or restore muscle function.
Muscle training consists of different components directed toward improved strength, endurance, or balance and coordination. Exercise for strength and endurance may be static or dynamic. Static exercise implies muscle contraction without concomitant joint motion, whereas dynamic exercise is performed by muscle contraction during simultaneous joint motion. Strength training is performed with a relatively higher load and fewer repetitions compared with endurance training. Dynamic training may be performed with a constant load through the whole range of motion or through certain parts of it where increased strength is required. The load may also be isokinetic, which means that it is adjusted to fit the actual strength in different parts of the motion range. Furthermore, the dynamic training may be eccentric or concentric, which means that the muscles involved work during phases of lengthening or shortening respectively. For example, muscles that extend the knees work eccentrically while descending stairs but concentrically while ascending stairs. Balance and coordination exercises are either performed very specifically to increase voluntary muscle control or in situations that simulate daily activities to increase safety and avoid falls.
In sedentary individuals with weak muscles, the output of muscle training is often general, resulting in increased strength as well as improved endurance and coordination, although the training program does not include elements specifically targeting all of them. This might be due to neuromuscular adaption and recruitment of new motor units rather than increased muscle mass. However, the basic rule is that improvement of muscle function is specific, that is, it occurs in the area targeted by the training program, for example, strength or coordination. Thus, it is important that muscle training is preceded by thorough analysis in order to be as effective as possible. In rheumatic disease, additional factors related to risk of injury should be included in the analysis. There are no absolute contraindications toward muscle training in rheumatic diseases. However, a number of relative contraindications exists and should be considered in the prescription of exercise programs. They are related to degree of local inflammation and joint destruction, decreased solidity of bone and soft tissues following previous inflammation, long-term steroid intake and prolonged periods of physical inactivity.
Muscle training may be performed in a number of ways, and individual preferences should be considered when designing the program. It may include training with more or less advanced technical equipment in a clinic or in a public gym; be performed at home with simple devices such as rubber bands, weight cuffs, or resisted by body weight; or take place in a pool using water resistance. The recommended doses of muscle training given in Table 30-1 are based on those used in scientifically evaluated programs resulting in benefits for patients with rheumatoid arthritis (RA). Thus, the present evidence suggests that principles for dosage of muscle training to patients with RA do not differ much from general dosage principles. However, it is important to bear in mind that 1 repetition maximum (RM), that is, the weight that can be lifted only once, may be lower in an individual with rheumatic disease than in a healthy person and thus the actual training load may be considerably lower for the former. For optimal training results, 1 RM should be tested regularly during a training program and the load adjusted to a recent test value.
| Target | Frequency (times/week) | Duration (minutes) | Intensity (% of max) | Load (% of 1 RM) |
|---|---|---|---|---|
| Increased strength | 2–3 | – | – | 50–80 |
| Increased endurance | 2–3 | – | – | 30–40 |
| Increased cardiovascular fitness | 3 | 30–60 | 60–85 | – |
Cardiovascular Fitness Training
Cardiovascular fitness, that is, maximal oxygen uptake, may be reduced for several reasons in patients with rheumatic disease. Many try to reduce pain and fatigue by resting it away. This leads to a physically inactive lifestyle that eventually results in reduced fitness. Restricted thoracic movement and subsequently reduced lung volumes in patients with AS may cause poor cardiovascular fitness. The general systemic involvement in several rheumatic diseases may also confer poor function of oxygen-transporting organs. Moreover, exercises targeting cardiovascular fitness may also be helpful in reducing pain and improving function, and are therefore recommended as an intervention for people with rheumatic disease.
The maximum oxygen uptake needs to be determined or estimated before appropriate cardiovascular fitness training can be prescribed. The most valid method for this is a maximum work capacity test. However, submaximal tests on ergometer bicycles or on treadmills are often preferred in clinical practice because they are more convenient. Standardization of the tests is of utmost importance, and sources of error should be eliminated to the greatest extent possible. Thus, patients should be advised not to exercise, eat, or smoke within 1 hour before the test, it should not be performed in a busy environment, and no conversation should be allowed during testing. The exercise load needs to be heavy enough (heart rate >100–120 beats/minute) because psychological effects such as anxiety are then less likely to bias the outcome. On the other hand, loads that are too high demand high motivation and confer a risk of overload on affected joints and muscles. Thorough inquiry and, in case of suspected cardiovascular disease, consultation with the patient’s medical doctor, should precede the testing in order to exclude contraindications for this measurement.
Cardiovascular fitness training can be performed in many ways and may include elements of simultaneous ROM exercise and muscle training. Scientific evidence exists for fitness training in the form of biking, brisk walking, aquaerobics, and different types of circuit training. Thus, exercise modes may vary depending on the patients’ preferences, but with the goal in mind to improve cardiovascular fitness, accurate dosage is far more important than mode. The dosage guidelines presented in Table 30-1 are based on scientifically evaluated training programs resulting in positive effects on cardiovascular fitness in patients with RA but do not differ substantially from those targeting the general public.
Rheumatic diseases per se do not represent any absolute contraindications to cardiovascular fitness training. However, it is important to remember that conditions representing relative contraindications, or requiring special attention in relation to fitness training may be more frequent in this population. Furthermore, a number of issues of certain importance to fitness training in rheumatic disease needs to be highlighted:
- •
The training program should be designed to spare potentially painful joints, bone, and soft tissue that may be less solid, and contracted or unstable joints;
- •
To avoid increased symptoms and subsequently reduced self-efficacy for exercise, the training should be increased gradually, that is, loads should initially be less, sometimes much less than those recommended to give beneficial fitness effects, and then gradually increased;
- •
It cannot be expected that training intensity will be consistently increased as in a healthy individual but must always be adjusted to variations in the disease course.
Physical Activity and Exercise in the Patient with Inflammatory Rheumatic Disease
Specific Indications for Exercise
Poor physical fitness has been found to predict mortality and physical inactivity to predict poor general health perception in patients with RA. Thus, health-enhancing physical activity, as well as planned and structured exercise, is important to maintain or improve body functions, and to reduce the increased risk of comorbidity and the emotional distress caused by an unpredictable short- and long-term disease course. Although the introduction of new drugs has dramatically improved the health of people with rheumatic diseases during the past decade, a large proportion of patients may still have impaired body functions despite well-controlled inflammation. However, the rheumatic diseases may also represent barriers, mental as well as physical, to physical activity and exercise among patients and health professionals. Thus, rehabilitation measures may often be limited to those aimed at immediate symptom relief rather than considering them as a help to overcome barriers to a healthy lifestyle. A fear of aggravating symptoms by exercise possibly also still exists. Thus, although there is a strong argument for people with rheumatic disease to be physically active, they have repeatedly been reported to have similar or lower activity levels compared with the general population.
Evidence for Physical Activity and Exercise
It was concluded in a meta-analysis that dynamic exercise therapy of moderate intensity is effective at increasing cardiovascular fitness and muscle strength in patients with RA. However, effects on activity limitation and radiologic progression were unclear. No signs of detrimental effects on disease activity and pain were observed in the included studies. It also seems that high-intensity training is safe and beneficial for most patients with RA. Thus, a training program applied twice a week for 75 minutes including cycling at 70% to 90% of maximum heart rate, circuit training, and sports resulted in beneficial effects on cardiovascular fitness, muscle strength, reduced activity limitation, and improved emotional status over the 2-year study period. No detrimental effect on disease activity was found, but a slightly increased radiologic progression among those with considerable baseline damage.
Increasingly higher educational levels and greater access to information among the public, together with improved inflammation control among patients with inflammatory diseases, call for new forms of administering physical activity interventions. Thus, many patients can and should probably be able to accumulate health-enhancing physical activity in their daily life with support from a physical therapist. Two studies on such coaching interventions, including elements of cognitive-behavioral techniques, for patients with RA show promising results. In both studies, a few clinical physical therapy sessions were supplemented with individualized coaching over the Internet and telephone, respectively. Beneficial outcomes related to physical activity behavior, general health perception, and body functions were reported. It seems that the attitude of the physical therapist toward exercise-induced pain in RA plays a role in the outcome, and that a focus on exercise goals rather than on exercise-induced pain is more beneficial.
A meta-analysis of exercise studies including patients with AS drew several conclusions. Thus, individual home-based or supervised exercise programs are better than no intervention, that supervised group physiotherapy is better than home exercises, and that combined inpatient spa-exercise therapy, followed by group physiotherapy is better than group physiotherapy alone. It also seems that patients with SLE and Sjögren’s syndrome can take advantage of exercise. However, the evidence for this is limited, because few studies have so far been carried out, and more research is needed. Increased muscle strength and endurance as well as reduced activity limitation among patients with poly- and dermatomyositis have been reported.
Possible Risks
A fear that physical activity and exercise may aggravate the short-term and long-term disease course of the rheumatic diseases still exists. However, so far, in studies with carefully selected patients and exercise programs designed in accordance with the above-mentioned guidelines, no signs of increased local or systemic inflammatory activity have been reported. This also seems to be valid for patients with active inflammation and severe disability. Only a few exercise studies have included radiologic assessment. One study on high-intensity exercise in patients with RA reported increased joint destruction after 2 years for a subgroup of patients. The subgroup consisted of those patients, who already initially had severe joint destruction of large joints. However, negative side effects of high-intensity as well as other exercise could probably be avoided if the guidelines given above for the prescription of muscle training and cardiovascular fitness training are followed.
There is a more obvious risk of exercise complications in various organ systems among patients with systemic rheumatic diseases. So far there are only a few studies, many to be considered as pilot studies that report exercise outcomes in patients with, for example, systemic lupus erythematosus (SLE) and polymyositis or dermatomyositis. Strength training in patients with myositis does not seem to confer negative side effects in either the acute nor in chronic phases. Exercise also seems to be safe for patients with SLE. However, it is important to bear in mind that study participants with systemic diseases have been carefully selected in order to avoid negative side effects and, thus, study results can only be generalized to certain subgroups of patients with similar characteristics.
Secondary fibromyalgia in patients with inflammatory rheumatic diseases require specific attention, as described later.
Exercise and Inflammation
In a comprehensive review of randomized controlled trials of exercise in RA, it was noted that six out of the 14 included studies reported signs of reduced inflammation, assessed by swollen joint count, erythrocyte sedimentation rate (ESR), or C-reactive protein (CRP). Similar observations have been reported in exercise studies including patients with polymyositis and dermatomyositis. Although the primary target of physical activity and exercise is not to reduce inflammation, some interesting hypotheses for such effects may be formulated based on results from basic and clinical studies involving healthy subjects as well as patients with chronic disease, including those with rheumatic conditions. Accumulating evidence in these studies suggests that exercise might have beneficial effects on certain molecular processes in skeletal muscle and cartilage, as well as in reducing both local muscle inflammation and systemic inflammation ( Fig. 30-3 ).
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