Rheumatoid arthritis: Exercise as a safe and effective intervention

Rheumatoid arthritis (RA) is a chronic inflammatory disease mainly characterized by bone and cartilage erosion in the peripheral joints, pain, stiffness, and fatigue that can lead to limitations in daily function. Globally over 50% of RA patients are older than 65 and regardless of pharmacological treatment 47-53% of RA patients develop moderate to severe limitations due to persistently high disease activity, joint damage, deformities, and comorbidities. This subgroup of RA patients experience severe limitations and difficulty with activities of daily living (ADL). Additionally, RA is characterized by lower cardiovascular fitness, increased morbidity, and mortality due to cardiovascular disease (CVD).

Major risk factors of CVD include the RA disease itself due to chronic low-grade inflammation, hypertension, metabolic disorders, diabetes, obesity, and physical inactivity. Furthermore, the risk of developing CVD increases with age, with men more likely to develop CVD at an earlier age than women. The European Alliance of Associations for Rheumatology (EULAR) recommend that physical activity and exercise should be promoted by health professionals as a safe and appropriate standard of care in cardiovascular risk management for patients suffering from rheumatic diseases. Regular exercise promotes muscle strength, function, aerobic fitness, and it can also improve non-inflammatory complaints (e.g., pain and fatigue) without further harming the joints, or boosting disease activity in rheumatic conditions.

Several systematic reviews and meta-analyses conclude that exercise therapy improves RA patients’ subjective assessment of physical function despite of diverse therapies and heterogenous target populations. A Scandinavian review by Pedersen and Saltin describe ‘exercise as medicine' in the treatment of 26 chronic conditions, including hypertension, heart failure and rheumatoid arthritis. Furthermore, other studies have found that older age, increased waist circumference, c-reactive protein, and anemia (present in 30-60% of RA) are associated with reduced walking distance (6-minute walk test) and linked to reduced cardiovascular health. Additionally, obesity in the general population is already linked to higher inflammation, pain, and disability, and together with ageing and extended disease duration it could further exacerbates joint damage and chronic disability. In general, RA patients with higher cardiovascular fitness have healthier CVD risk profiles, indicating adherence to physical activity guidelines will improve fitness levels and decrease cardiovascular risk.

Lastly, research has clearly indicated that exercise therapy is a safe management tool and ideal intervention for both physical and cardiovascular decline. Supervised exercise programs improved general fitness, disease activity, and inflammation. As RA and CVD share inflammatory mechanisms it is important to control inflammation through exercise to manage these morbidities. Reflecting on the positive relationship between elevated fitness factors, reduced CVD, and mortality, make exercise an ideal method to improve cardiovascular fitness and overall health in RA. These findings and recommendations also support the WHO’s stance on managing non-communicable chronic conditions, such as RA, through long-term adhesion of physical activity within clinical practice.

Therefore, evidence-based research promotes ongoing physical exercise as a safe intervention that all age groups can benefit from.