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Physical activity, exercise and rheumatoid arthritis: Effectiveness, mechanisms and implementation

https://doi.org/10.1016/j.berh.2019.03.013Get rights and content

Abstract

Rheumatoid arthritis (RA) is characterised by functional disability, pain, fatigue and body composition alterations that can further impact on the physical dysfunction seen in RA. RA is also associated with systemic manifestations, most notably an increased risk for cardiovascular disease. There is strong evidence to suggest that increasing physical activity and/or exercise can simultaneously improve symptoms and reduce the impact of systemic manifestations in RA. However, implementation of interventions to facilitate increased physical activity and/or exercise within routine clinical practice is slow because of not only patient-specific and healthcare professional-related barriers but also lack of relevant infrastructure and provision. We review the evidence supporting the physiological adaptations and beneficial effects occurring as a result of increased physical activity and/or exercise in RA and propose an implementation model for facilitating the long-term engagement of patients with RA. We propose that implementation should be led, in a pragmatic manner, by rheumatology healthcare practitioners and supported by social innovation.

Introduction

Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disease, typically presenting as symmetrical polyarthritis of proximal small and other synovial joints. It affects approximately 1% of the adult general population, and it is accompanied by symptoms – such as pain, stiffness, swelling and fatigue – that may have debilitating effects on the functional ability and quality of life of affected patients. In addition, RA is accompanied by systemic manifestations, most notably an increased risk for cardiovascular disease (CVD), as well as detrimental changes in body composition, hence favouring increased fat mass deposition and reduced muscle mass [a condition termed ‘rheumatoid cachexia’ [1]]. These, in turn, further deteriorate function and the ability to perform daily tasks [1]. Therefore, it is not surprising that almost a third of patients with RA become unemployed as a result of their condition [2] and have 10 times the work disability rate compared to the general population [3]. The introduction of early, intensive anti-inflammatory/immune-modulating treatments and strategies involving conventional synthetic and biologic disease-modifying anti-rheumatic drugs (DMARDs) and, more recently, newer small molecules has significantly improved the health outcomes of these patients but, thus far, without substantial changes to their employment ability and with a significant increase (approximately 300%) in the direct healthcare costs [3]. As such, identifying beneficial, sustainable and cost-effective interventions that may alleviate the burden of RA for the individual, healthcare services and society as a whole should be adopted and implemented as part of routine clinical practice.

Increase in physical activity is an intervention that can improve both disease-related and systemic manifestations in RA, while at the same time reduce the overall cost associated with the disease. Physical activity is any bodily movement that increases energy expenditure above resting levels, such as walking and gardening. Exercise, on the other hand, is a mode of physical activity that is planned, structured and repetitive, such as swimming three times per week.

Over the last two decades, good-quality evidence has accumulated, clearly demonstrating that increasing physical activity is a behaviour that can significantly improve many different disease-related (e.g. fatigue, functional disability and inflammation) and systemic outcomes (e.g. CVD risk and body composition), as well as impact beneficially on RA costs. Specifically, in terms of cost, increased physical activity in RA is associated with a reduced number of hospital admissions and days of hospitalisation [4]; this is also confirmed in patients with CVD, where increasing physical activity through cardiac rehabilitation, is both an effective and cost-effective intervention for reducing national healthcare costs [5]. For health outcomes in RA, we and others have shown in systematic reviews (two published by the Cochrane Collaboration) that increased physical activity results in significant improvements in functional ability, cardiorespiratory fitness and strength [6], [7], [8], cardiovascular health [9] and fatigue [10]. Moreover, randomised and controlled clinical trials consistently demonstrate significant reductions in radiological damage in small and large joints, as a result of increased levels of physical activity participation [11], [12], [13], [14], as well as reduced CVD risk and beneficial body composition changes that can reverse rheumatoid cachexia [14], [15], [16], [17]. It is important to note that, increasing physical activity or engaging in different types of exercise, even in high-intensity exercise, is safe in RA, with no studies reporting any adverse effects [18]; in contrast, a sedentary lifestyle in RA can further promote the increased risk for future development of CVD [19], [20], [21].

Despite this well-described cumulative evidence about its beneficial effects, methods to improve physical activity levels in patients with RA are not incorporated in routine clinical care. Consequently, patients RA remain physically inactive, with activity levels well below those recommended [22], while their cardiorespiratory fitness – a factor that demonstrates very strong associations with all-cause and cardiovascular mortality [23] – is still alarmingly low [24].

Section snippets

Physiological effects of physical activity on RA symptoms and systemic manifestations

Physical activity is a stimulus that results in significant functional and structural adaptations in different physiological systems, which, in turn, may beneficially impact on the overall RA symptomatology. The benefit of increasing physical activity and exercise is that it can simultaneously improve different physiological mechanisms, which with regard to RA, can benefit two main categories of outcomes for RA patients: disease-related symptoms and systemic manifestations.

Barriers for physical activity implementation in clinical practice

Despite the well-documented benefits of physical activity and exercise on various different physiological mechanisms that can significantly ameliorate disease symptoms and improve the overall function and quality of life in RA [59], the physical activity and fitness levels of patients with RA remain significantly lower than those of the general population. The QUEST-RA study that investigated physical activity levels in patients with RA from 58 sites in 21 countries revealed that only 13.8% of

How can we implement physical activity advice in clinical practice

As described above, there is convincing data at present to suggest that increasing physical activity can improve disease outcomes in RA, thus leading to better disease management. It is expected, therefore, that attempts would be made in the last decade to help implement programmes aiming to improve physical activity as integral parts of the overall management of RA, or at least that physical activity is promoted more actively within clinical practice. However, this is not the case.

Several

Summary

Increasing physical activity and/or exercise can beneficially and simultaneously impact on different disease-related symptoms and systemic manifestations of RA. However, implementing physical activity in routine practice has always been a challenge for healthcare practitioners because of unfounded patient-specific barriers, lack of understanding or misconceptions of health practitioners and lack of relevant infrastructure and provision. Implementation of physical activity in clinical practice

Conflicts of interest

The authors disclose that they do not have any conflicts of interest.

Funding statement

The authors did not receive funding for this narrative review.

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