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Get moving! Dynamic exercise therapy for rheumatoid arthritis
Available online at www.sciencedirect.com
Joint Bone Spine 75 (2008) 3e4 http://france.elsevier.com/direct/BONSOI/
Editorial
Get moving! Dynamic exercise therapy for rheumatoid arthritis
Keywords: Rheumatoid arthritis; Rehabilitation therapy; Physical exercise; Dynamic; Reconditioning
1. Introduction Rest is a time-honored treatment for various musculoskeletal disorders, yet its benefits are being increasingly challenged [1]. Rest may seem reasonable, since a number of physical activities exacerbate the pain, which in turn hinders daily activities. The temporal and, apparently, causal relationship between physical activity and symptoms has led to the belief that patients with rheumatoid arthritis (RA) should choose an inactive lifestyle. The presumed adverse effects of exercise on joint inflammation and joint destruction are ascribed to the loads produced by joint movements [2e4]. Stretching and isometric exercises, which do not involve joint motion, are usually allowed. However, joint movements are needed to accomplish most of the activities of daily living and to engage in recreational activities. Therefore, current recommendations place severe restrictions on the patient. In addition, a chronically low level of physical activity may result in deconditioning [5], which adds to the disability. Warning patients against physical activity may lead to social isolation and to increased anxiety and depression, which in turn may generate further inhibition. The benefits of bed rest in patients with RA were long overestimated. Bed rest is beneficial only during severe inflammatory flares [6]. Over the last 20 years [7], numerous studies have evaluated the benefits and safety of moderate to intense dynamic exercise in patients with RA. The results have been the focus of several reviews [8e13]. Overall, dynamic exercise, most notably as part of aerobic activities, improved the health of patients with RA, without inducing adverse effects. As a result, the latest American College of Rheumatology recommendations for the management of patients with RA include regular participation in dynamic exercise programs [14]. 2. Getting our patients to move Patients with RA are generally concerned that dynamic exercise may worsen their joint disease. This concern is
unfounded. Dynamic and aerobic exercises do not exacerbate the joint inflammation in patients with RA. Moderate or even intense physical exercise programs, including dynamic exercises and aerobic weight-bearing activities, are safe provided the disease is well controlled. In a randomized controlled study of patients with early RA, a self-administered program of dynamic exercises designed to strengthen the limb and trunk muscles, combined with a recommendation to engage in recreational physical activities 2e3 times a week, was associated with decreases in the disease activity score (DAS) after 2 and 5 years [15]. These decreases were similar in magnitude to those seen with a self-administered program of conventional exercise emphasizing stretching. Similarly, an intensive training program called the Rheumatoid Arthritis Patients in Training Program (RAPIT), which involved two weekly 75-minute group sessions of dynamic muscle-strengthening exercises and weight-bearing moderate-impact aerobic activities for 2 years was effective and as safe as conventional management in terms of DAS values in patients with stable RA [16]. As a precaution, dynamic exercises are not advisable during flares. However, a randomized controlled study of an intense and supervised physical exercise program was conducted in patients with active RA who were managed during flares [17]. Isokinetic and isometric muscle-strengthening exercises, including train on an exercise bicycle and stretching, were performed at home. After 6 months, the DAS showed similar decreases in the intervention group and in the control group managed with a program of limited maintenance exercises. Dynamic muscle-strengthening exercises, including moderate-impact weight-bearing exercises, do not seem to accelerate the joint destruction. Nevertheless, caution is in order in patients with severe joint damage. Few data are available on this issue. In one of the above-mentioned randomized controlled studies [15], no significant difference in joint destruction was found between the two groups. The joint lesions had worsened slightly in both groups at the end of the 5year follow-up period. The RAPIT did not accelerate the rate of radiographic destruction at the hands or feet. Nevertheless,
1297-319X/$ - see front matter Ó 2007 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.jbspin.2007.04.012
4
Editorial / Joint Bone Spine 75 (2008) 3e4
the authors cautioned against high-impact weight-bearing activities responsible for loading of joints with pre-existing destructive lesions. Patients with RA derived greater benefits from dynamic exercises than from static or isometric exercises. Dynamic exercises improved muscle performance and aerobic capacity, thereby preventing loss of function. In addition, regular participation in moderate-intensity aerobic activities may improve psychological well-being, decrease fatigue, and improve quality of life. However, aerobic exercise is beneficial only when performed at moderate- to high-intensity (greater than 50% of the maximal heart rate) for at least 30 min/day, 5 days a week. The same characteristics are recommended for cardiovascular disease prevention in the general population [18], which is of interest given the increased cardiovascular risk patients with RA. 3. Educating healthcare professionals Unfortunately, a large proportion of rheumatologists and physical therapists still advise patients with RA to limit their physical activities [19]. Physiotherapy is often the only physical treatment prescribed to patients with RA. Efforts are needed to educate healthcare professionals about the benefits of appropriately designed exercise programs in patients with RA. 4. Educating rheumatoid arthritis patients The time has come to recommend weight-bearing or nonweight-bearing (e.g., in water) physical activities to patients with RA at any stage. Because physical activity can be adjusted, it is appropriate even in patients who are unable to train. Patients should receive reassurance that remaining active is their best option. They should be taught to reinterpret the pain that they experience during physical exertion and to adjust their physical activity according to the course of their joint disease. An individually tailored program of physical exercise should be incorporated into the overall treatment strategy. RA runs a variable course, and patients should therefore be told to expect ups and downs. Patients must learn to adjust their exercise program according to their current state of health and to the effects of their exercises. Finally, patients who have no major lesions to the lower limb joints and who understand when to increase and when to limit their physical activity can participate in programs intended for the general population, provided they receive regular medical follow-up. Surprisingly, the numerous studies that have provided evidence over the last two decades of the benefits and safety of dynamic exercises in patients with RA have had little impact. The results of these studies need to be disseminated widely, in multiple languages [20]. References [1] Allen C, Glasziou P, Del Mar C. Bed rest: a potential harmful treatment needing more careful evaluation. Lancet 1999;354:1229e33. [2] Jivoff L. Rehabilitation and rheumatoid arthritis. Bull Rheum Dis 1975e1976;26: 838e11.
[3] Mills J, Pinals R, Ropes M, Short CL, Sutcliffe J. Value of bed rest in patients with rheumatoid arthritis. N Engl J Med 1971;284:453e8. [4] Swezey R. Essentials of physical management and rehabilitation in arthritis. Semin Arthritis Rheum 1974;3:349e68. [5] Stewart AL, Hays RD, Wells KB, Rogers WH, Spritzer KL, Greenfield S. Long-term functioning and well-being outcomes associated with physical activity and exercise in patients with chronic conditions in the medical outcomes study. J Clin Epidemiol 1994;47:719e30. [6] Alexander GJ, Hortas C, Bacon PA. Bed rest, activity and the inflammation of the rheumatoid arthritis. Br J Rheumatol 1983;22:134e40. [7] Harkcom TM, Lampman RM, Banwell BF, Castor CW. Therapeutic value of graded aerobic exercise training in rheumatoid arthritis. Arthritis Rheum 1985;28:32e9. [8] Van den Ende CH, Vliet Vlieland TP, Munneke M, Hazes JM. Dynamic exercise therapy in rheumatoid arthritis: a systematic review. Br J Rheumatol 1998;37:677e87. [9] Munneke M, De Jong Z. The role of exercise programs in the rehabilitation of patients with rheumatoid arthritis. Int Sport Med J 2000;1:12. [10] Westby MD. A health professional’s guide to exercise prescription for people with arthritis: a review of aerobic fitness activities. Arthritis Care Res 2001;45:501e11. [11] Stenstro¨m CH, Minor MA. Evidence for the benefit of aerobic and strengthening exercise in rheumatoid arthritis. Arthritis Rheum 2003; 49:428e34. [12] Ha¨kkinen A. Effectiveness and safety of strength training in rheumatoid arthritis. Curr Opin Rheumatol 2004;16:132e7. [13] de Jong Z, Vlieland TP. Safety of exercise in patients with rheumatoid arthritis. Curr Opin Rheumatol 2005;17:177e82. [14] Guidelines for the management of rheumatoid arthritis: 2002 update. Arthritis Rheum 2002;46:328e46. [15] Ha¨kkinen A, Sokka T, Kautiainen H, Kotaniemi A, Hannonen P. Sustained maintenance of exercise induced muscle strength gains and normal bone mineral density in patients with early rheumatoid arthritis: a 5 year follow up. Ann Rheum Dis 2004;63:910e6. [16] de Jong Z, Munneke M, Zwinderman AH, Kroon HM, Jansen A, Ronday KH, et al. Is a long-term high-intensity exercise program effective and safe in patients with rheumatoid arthritis? Results of a randomized controlled trial. Arthritis Rheum 2003;48:2415e24. [17] van den Ende CH, Breedveld FC, le Cessie S, Dijkmans BA, de Mug AW, Hazes JM. Effect of intensive exercise on patients with active rheumatoid arthritis: a randomized clinical trial. Ann Rheum Dis 2000;59:615e21. [18] Manson JE, Greenland P, LaCroix AZ, Stefanick ML, Mouton CP, Oberman A, et al. Walking compared with vigorous exercise for the prevention of cardiovascular events in women. N Engl J Med 2002;347:716e25. [19] Munneke M, de Jong Z, Zwinderman AH, Ronday HK, van den Ende CH, Vliet Vlieland TP, et al. High intensity exercise or conventional exercise for patients with rheumatoid arthritis? Outcome expectations of patients, rheumatologists, and physiotherapists. Ann Rheum Dis 2004;63:804e8. [20] Gaudin P, Leguen-Guegan S, Allenet B, Baillet A, Grange L, Juvin R. Is dynamic exercise beneficial in patients with rheumatoid arthritis? Joint Bone Spine 2008;75:11e7.
Anne Mayoux-Benhamou Musculoskeletal and Spinal Functional Rehabilitation, Fonctionnelle de l’Appareil Locomoteur et des Pathologies du Rachis, 75014 Paris, France E-mail address: [email protected] 8 February 2007 Available online 15 August 2007
Joint Bone Spine 75 (2008) 3e4 http://france.elsevier.com/direct/BONSOI/
Editorial
Get moving! Dynamic exercise therapy for rheumatoid arthritis
Keywords: Rheumatoid arthritis; Rehabilitation therapy; Physical exercise; Dynamic; Reconditioning
1. Introduction Rest is a time-honored treatment for various musculoskeletal disorders, yet its benefits are being increasingly challenged [1]. Rest may seem reasonable, since a number of physical activities exacerbate the pain, which in turn hinders daily activities. The temporal and, apparently, causal relationship between physical activity and symptoms has led to the belief that patients with rheumatoid arthritis (RA) should choose an inactive lifestyle. The presumed adverse effects of exercise on joint inflammation and joint destruction are ascribed to the loads produced by joint movements [2e4]. Stretching and isometric exercises, which do not involve joint motion, are usually allowed. However, joint movements are needed to accomplish most of the activities of daily living and to engage in recreational activities. Therefore, current recommendations place severe restrictions on the patient. In addition, a chronically low level of physical activity may result in deconditioning [5], which adds to the disability. Warning patients against physical activity may lead to social isolation and to increased anxiety and depression, which in turn may generate further inhibition. The benefits of bed rest in patients with RA were long overestimated. Bed rest is beneficial only during severe inflammatory flares [6]. Over the last 20 years [7], numerous studies have evaluated the benefits and safety of moderate to intense dynamic exercise in patients with RA. The results have been the focus of several reviews [8e13]. Overall, dynamic exercise, most notably as part of aerobic activities, improved the health of patients with RA, without inducing adverse effects. As a result, the latest American College of Rheumatology recommendations for the management of patients with RA include regular participation in dynamic exercise programs [14]. 2. Getting our patients to move Patients with RA are generally concerned that dynamic exercise may worsen their joint disease. This concern is
unfounded. Dynamic and aerobic exercises do not exacerbate the joint inflammation in patients with RA. Moderate or even intense physical exercise programs, including dynamic exercises and aerobic weight-bearing activities, are safe provided the disease is well controlled. In a randomized controlled study of patients with early RA, a self-administered program of dynamic exercises designed to strengthen the limb and trunk muscles, combined with a recommendation to engage in recreational physical activities 2e3 times a week, was associated with decreases in the disease activity score (DAS) after 2 and 5 years [15]. These decreases were similar in magnitude to those seen with a self-administered program of conventional exercise emphasizing stretching. Similarly, an intensive training program called the Rheumatoid Arthritis Patients in Training Program (RAPIT), which involved two weekly 75-minute group sessions of dynamic muscle-strengthening exercises and weight-bearing moderate-impact aerobic activities for 2 years was effective and as safe as conventional management in terms of DAS values in patients with stable RA [16]. As a precaution, dynamic exercises are not advisable during flares. However, a randomized controlled study of an intense and supervised physical exercise program was conducted in patients with active RA who were managed during flares [17]. Isokinetic and isometric muscle-strengthening exercises, including train on an exercise bicycle and stretching, were performed at home. After 6 months, the DAS showed similar decreases in the intervention group and in the control group managed with a program of limited maintenance exercises. Dynamic muscle-strengthening exercises, including moderate-impact weight-bearing exercises, do not seem to accelerate the joint destruction. Nevertheless, caution is in order in patients with severe joint damage. Few data are available on this issue. In one of the above-mentioned randomized controlled studies [15], no significant difference in joint destruction was found between the two groups. The joint lesions had worsened slightly in both groups at the end of the 5year follow-up period. The RAPIT did not accelerate the rate of radiographic destruction at the hands or feet. Nevertheless,
1297-319X/$ - see front matter Ó 2007 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.jbspin.2007.04.012
4
Editorial / Joint Bone Spine 75 (2008) 3e4
the authors cautioned against high-impact weight-bearing activities responsible for loading of joints with pre-existing destructive lesions. Patients with RA derived greater benefits from dynamic exercises than from static or isometric exercises. Dynamic exercises improved muscle performance and aerobic capacity, thereby preventing loss of function. In addition, regular participation in moderate-intensity aerobic activities may improve psychological well-being, decrease fatigue, and improve quality of life. However, aerobic exercise is beneficial only when performed at moderate- to high-intensity (greater than 50% of the maximal heart rate) for at least 30 min/day, 5 days a week. The same characteristics are recommended for cardiovascular disease prevention in the general population [18], which is of interest given the increased cardiovascular risk patients with RA. 3. Educating healthcare professionals Unfortunately, a large proportion of rheumatologists and physical therapists still advise patients with RA to limit their physical activities [19]. Physiotherapy is often the only physical treatment prescribed to patients with RA. Efforts are needed to educate healthcare professionals about the benefits of appropriately designed exercise programs in patients with RA. 4. Educating rheumatoid arthritis patients The time has come to recommend weight-bearing or nonweight-bearing (e.g., in water) physical activities to patients with RA at any stage. Because physical activity can be adjusted, it is appropriate even in patients who are unable to train. Patients should receive reassurance that remaining active is their best option. They should be taught to reinterpret the pain that they experience during physical exertion and to adjust their physical activity according to the course of their joint disease. An individually tailored program of physical exercise should be incorporated into the overall treatment strategy. RA runs a variable course, and patients should therefore be told to expect ups and downs. Patients must learn to adjust their exercise program according to their current state of health and to the effects of their exercises. Finally, patients who have no major lesions to the lower limb joints and who understand when to increase and when to limit their physical activity can participate in programs intended for the general population, provided they receive regular medical follow-up. Surprisingly, the numerous studies that have provided evidence over the last two decades of the benefits and safety of dynamic exercises in patients with RA have had little impact. The results of these studies need to be disseminated widely, in multiple languages [20]. References [1] Allen C, Glasziou P, Del Mar C. Bed rest: a potential harmful treatment needing more careful evaluation. Lancet 1999;354:1229e33. [2] Jivoff L. Rehabilitation and rheumatoid arthritis. Bull Rheum Dis 1975e1976;26: 838e11.
[3] Mills J, Pinals R, Ropes M, Short CL, Sutcliffe J. Value of bed rest in patients with rheumatoid arthritis. N Engl J Med 1971;284:453e8. [4] Swezey R. Essentials of physical management and rehabilitation in arthritis. Semin Arthritis Rheum 1974;3:349e68. [5] Stewart AL, Hays RD, Wells KB, Rogers WH, Spritzer KL, Greenfield S. Long-term functioning and well-being outcomes associated with physical activity and exercise in patients with chronic conditions in the medical outcomes study. J Clin Epidemiol 1994;47:719e30. [6] Alexander GJ, Hortas C, Bacon PA. Bed rest, activity and the inflammation of the rheumatoid arthritis. Br J Rheumatol 1983;22:134e40. [7] Harkcom TM, Lampman RM, Banwell BF, Castor CW. Therapeutic value of graded aerobic exercise training in rheumatoid arthritis. Arthritis Rheum 1985;28:32e9. [8] Van den Ende CH, Vliet Vlieland TP, Munneke M, Hazes JM. Dynamic exercise therapy in rheumatoid arthritis: a systematic review. Br J Rheumatol 1998;37:677e87. [9] Munneke M, De Jong Z. The role of exercise programs in the rehabilitation of patients with rheumatoid arthritis. Int Sport Med J 2000;1:12. [10] Westby MD. A health professional’s guide to exercise prescription for people with arthritis: a review of aerobic fitness activities. Arthritis Care Res 2001;45:501e11. [11] Stenstro¨m CH, Minor MA. Evidence for the benefit of aerobic and strengthening exercise in rheumatoid arthritis. Arthritis Rheum 2003; 49:428e34. [12] Ha¨kkinen A. Effectiveness and safety of strength training in rheumatoid arthritis. Curr Opin Rheumatol 2004;16:132e7. [13] de Jong Z, Vlieland TP. Safety of exercise in patients with rheumatoid arthritis. Curr Opin Rheumatol 2005;17:177e82. [14] Guidelines for the management of rheumatoid arthritis: 2002 update. Arthritis Rheum 2002;46:328e46. [15] Ha¨kkinen A, Sokka T, Kautiainen H, Kotaniemi A, Hannonen P. Sustained maintenance of exercise induced muscle strength gains and normal bone mineral density in patients with early rheumatoid arthritis: a 5 year follow up. Ann Rheum Dis 2004;63:910e6. [16] de Jong Z, Munneke M, Zwinderman AH, Kroon HM, Jansen A, Ronday KH, et al. Is a long-term high-intensity exercise program effective and safe in patients with rheumatoid arthritis? Results of a randomized controlled trial. Arthritis Rheum 2003;48:2415e24. [17] van den Ende CH, Breedveld FC, le Cessie S, Dijkmans BA, de Mug AW, Hazes JM. Effect of intensive exercise on patients with active rheumatoid arthritis: a randomized clinical trial. Ann Rheum Dis 2000;59:615e21. [18] Manson JE, Greenland P, LaCroix AZ, Stefanick ML, Mouton CP, Oberman A, et al. Walking compared with vigorous exercise for the prevention of cardiovascular events in women. N Engl J Med 2002;347:716e25. [19] Munneke M, de Jong Z, Zwinderman AH, Ronday HK, van den Ende CH, Vliet Vlieland TP, et al. High intensity exercise or conventional exercise for patients with rheumatoid arthritis? Outcome expectations of patients, rheumatologists, and physiotherapists. Ann Rheum Dis 2004;63:804e8. [20] Gaudin P, Leguen-Guegan S, Allenet B, Baillet A, Grange L, Juvin R. Is dynamic exercise beneficial in patients with rheumatoid arthritis? Joint Bone Spine 2008;75:11e7.
Anne Mayoux-Benhamou Musculoskeletal and Spinal Functional Rehabilitation, Fonctionnelle de l’Appareil Locomoteur et des Pathologies du Rachis, 75014 Paris, France E-mail address: [email protected] 8 February 2007 Available online 15 August 2007