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 Table of Contents  
Year : 2017  |  Volume : 2  |  Issue : 4  |  Page : 160-163

Exercises interventions in people with rheumatoid arthritis

School of Medicine, University of Glasgow, Glasgow, UK

Date of Web Publication5-Dec-2017

Correspondence Address:
Amal Elramli
School of Medicine, University of Glasgow, Glasgow
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2542-4157.219378

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This review will examine publications which have investigated exercise intervention to promote physical activity in people with rheumatoid arthritis. Literature was searched using PubMed, Medline, Google Scholar, Cochrane Library and Web of Science. Overall, the studies demonstrated the promotion of physical activity in people with rheumatoid arthritis. Although there were aerobic, strengthening, stretching or combined exercise interventions, the majority of studies evaluated used combined exercise. There were no specific physical activity guidelines for people with rheumatoid arthritis and, additionally, a lack of data regarding the type, frequency and intensity of appropriate exercise in people with rheumatoid arthritis, therefore further studies are recommended.

Keywords: physical activity; exercise; rheumatoid arthritis

How to cite this article:
Elramli A. Exercises interventions in people with rheumatoid arthritis. Clin Trials Orthop Disord 2017;2:160-3

How to cite this URL:
Elramli A. Exercises interventions in people with rheumatoid arthritis. Clin Trials Orthop Disord [serial online] 2017 [cited 2020 Nov 29];2:160-3. Available from: https://www.clinicalto.com/text.asp?2017/2/4/160/219378

  Introduction Top

Rheumatoid arthritis (RA) is a chronic auto-immune disease of unknown aetiology and is most prevalent among people aged 40–60 years.[1],[2] The pathological process of RA may lead to severe articular destruction, loss of function, accelerated loss of muscle mass, restricted mobility and deformity.[1],[3] RA guidelines emphasise the role of regular physical activity (PA), which is associated with improved health outcomes, both physical and mental, and a 30% reduction in risk of all-cause mortality.[4],[5] People with RA were shown to be less physically active in comparison with healthy people, and had significantly lower energy expenditure, lower aerobic capacity than the normative values and they spent less time undertaking vigorous PA than the healthy controls.[6] Modern technology may be used to diagnose RA earlier, and new approaches of anti-rheumatic treatment regimens have improved the outcome of the disease, although, those with RA still suffer from progressive, long term disability.[1],[7] Studies revealed that people with RA have a shortened life expectancy of between 3–10 years, with most people dying from cardiovascular disease (CVD), infections, haematological, gastrointestinal or pulmonary complications.[1],[8],[9],[10] Specifically, RA is associated with an increased risk of CVD, such as myocardial infarction, ischemic heart disease and heart failure.[3],[11],[12],[13]

There is good evidence to show that exercise plays an important role in improving health outcomes and in reducing morbidity and mortality in the general population,[14] as well as in people with RA.[15] Regular exercise plays an important role in reducing the risk of hip fracture by up to 68%, depression by 30%, CVD by 35% and all-cause mortality by 30%.[16]

The following review describes the evidence to support exercise intervention in people with RA.

  Retrieval Strategy Top

A literature review provides the background and justification for the research and it allows a comparison of past research studies which investigated exercise for those with RA. The key articles were obtained primarily from PubMed, Medline, Google Scholar, Cochrane Library, and Web of Science. In order to ensure that relevant studies were not missed, the search terms remained broad. These were: rheumatoid arthritis, physical activity and exercise. These terms were then combined with the Boolean operator AND “rheumatoid arthritis AND physical activity”, “rheumatoid arthritis AND exercise”, “rheumatoid arthritis AND strengthening exercise”, “rheumatoid arthritis AND aerobic exercise”, “rheumatoid arthritis AND stretching exercise”. [Figure 1] shows the flow of literature in this review.
Figure 1: Prisma diagram of the literature search.
Note: Adopted from Moher et al.[17]

Click here to view

  Discussion Top

There is a growing body of literature regarding the promotion of exercise in people with RA and this has been discussed in relation to aerobic,[18] strengthening,[19] stretching or combined exercises.[20],[21],[22],[23] However, almost all of the exercise interventions are combined. To date, there is no evidence that exercise has any detrimental effect on people with RA and, in fact, it should be encouraged in people with RA.[24]

Exercise is characterised and described in terms of frequency, intensity and duration. Frequency is defined as the number of times an activity is performed in a given time frame [25],[26]. Duration refers to the total amount of time dedicated to performing the activity, either accumulative or continuously, over a specified time. Intensity is defined as the energy expenditure during a specific activity and is usually measured in metabolic equivalents (METs).[27]

People with RA, who are physically active, are found to have improved RA symptoms, such as lower levels of pain and fatigue, which conversely, are considered the primary barriers to PA in RA sufferers.[28] A study by Khoja et al. [27] on RA reported that very light represented activities between 1.1 and 1.9 METs and light was activities between 2.0 and 2.9 METs and moderate intensity PA represented activities ≥3.0 METs. It was significantly associated with lower functional disability, blood pressure and body mass index (BMI), and improved insulin sensitivity and HDL (P < 0.05). A study undertaken by Stavropoulos-Kalinoglou et al. [22] reported that CVD was reduced in RA cohorts who participated in programmes consisting of 6 months of high intensity exercise (walking on a treadmill and cycling for 3–4 minutes). Another study showed a reduction in risk of CVD by 20–30% among women and men who engaged in high levels of leisure time PA, while moderate leisure time PA decreased CVD risk by 10–20%.29 A review of Randomised Clinical Trials (RCTs) by Metsios et al. [30] demonstrated a reduced risk of developing CVD and improved functional capacity in RA cohorts who were physically active. The combination of increased PA and effective medication may help to inhibit disease progression, reduce the risk of CVD and improve health outcomes.[31] It was concluded that PA is important in improving arthritis symptoms and mental health, and in reducing the risk of CVD.[15]

Many PA guidelines exist across different countries (USA32; Canada33; UK34) and recommend the promotion of moderate intensity PA in the general population. It is recommended that adults (18 to 64 years) and older adults (65 years and more) undertake 150 minutes of moderate intensity PA per week (equivalent to 2½ hours of moderately intense PA of 10 minutes bouts or more, which could be achieved with 30 minutes' exercise 5 days per week), for general health and to reduce the risk of disease (USA32; Canada33; UK34).

The 2015 update of the 2009 European League Against Rheumatism (EULAR) recommendations for CVD risk management in inflammatory joint disease (IJD) recommended a healthy lifestyle for people with RA, with an emphasis on the benefits of regular exercise.

A study carried out by Hurkmans et al. [35] investigated the exercise level in people with RA with two questions according to public health recommendations of PA 30 minutes for at least 5 days/week; or vigorous intensity exercise,[20] minutes for at least 3 days/week. The first question asked how many days/week people performed moderate intensity, which was defined as exercise causing a small increase in heart rate or breathing, such as gardening or brisk walking, in the past 3 months. The second question was how many days/week they performed vigorous intensity, which was defined as exercise causing a large increase in heart rate or breathing, such as running, in the past 3 months. The number of participants who met the public health recommendation of moderate-intensity exercise was significantly higher in the intervention group at 24 months compared with the control (P < 0.05). Another randomized controlled trial included 34 RA patients with a mean age of 48 ± 11.3 years.[36] The intervention consists of aerobic exercise, strengthening exercises and education programme. The results showed a significant improvement of aerobic capacity and health status in the intervention group (12.1%).

The success of exercise intervention was evident in all studies that were reviewed. The majority of studies found an improvement in PA level, regardless of the duration of the intervention or the intensity of the exercise. The level of description of the intervention varied across the studies, especially in terms of descriptions of the type of exercise included. In most of the studies, the intervention/exercise programme consisted of different types of exercises, such as strengthening, stretching and aerobic exercise. Therefore, it is difficult to identify the particular type, frequency and intensity of exercise that helps to improve the PA outcome. It is also difficult to identify the appropriate exercise that should be recommended to people with RA.

  Conclusion Top

Overall, each exercise intervention that was reviewed demonstrated enhanced PA levels and an improvement in health outcome among people with RA. Most of the studies highlighted the evaluation of a combined exercise intervention programme. There were no specific PA guidelines for people with RA; additionally a lack of data regarding the type, frequency and intensity of appropriate exercise in people with RA underlines the fact that further studies are recommended.

  References Top

Cooney JK, Law RJ, Matschke V, et al. Benefits of exercise in rheumatoid arthritis. J Aging Res. 2011;2011:681640.  Back to cited text no. 1
Ottawa Panel. Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercises in the management of rheumatoid arthritis in adults. Phys Ther. 2004;84:934-972.  Back to cited text no. 2
Metsios GS, Stavropoulos-Kalinoglou A, Veldhuijzen van Zanten JJ, et al. Rheumatoid arthritis, cardiovascular disease and physical exercise: a systematic review. Rheumatology (Oxford). 2008;47:239-248.  Back to cited text no. 3
Knittle K, De Gucht V, Hurkmans E, et al. Targeting motivation and self-regulation to increase physical activity among patients with rheumatoid arthritis: a randomised controlled trial. Clin Rheumatol. 2015;34:231-238.  Back to cited text no. 4
Sokka T, Hakkinen A, Kautiainen H, et al. Physical inactivity in patients with rheumatoid arthritis: data from twenty-one countries in a cross-sectional, international study. Arthritis Rheum. 2008;59:42-50.  Back to cited text no. 5
Munsterman T, Takken T, Wittink H. Are persons with rheumatoid arthritis deconditioned? A review of physical activity and aerobic capacity. BMC Musculoskelet Disord. 2012;13:202.  Back to cited text no. 6
Avina-Zubieta JA, Choi HK, Sadatsafavi M, et al. Risk of cardiovascular mortality in patients with rheumatoid arthritis: a meta-analysis of observational studies. Arthritis Rheum. 2008;59:1690-1697.  Back to cited text no. 7
Dougados M, Soubrier M, Antunez A, et al. Prevalence of comorbidities in rheumatoid arthritis and evaluation of their monitoring: results of an international, cross-sectional study (COMORA). Ann Rheum Dis. 2014;73:62-68.  Back to cited text no. 8
John H, Carroll D, Kitas GD. Cardiovascular education for people with rheumatoid arthritis: what can existing patient education programmes teach us? Rheumatology (Oxford). 2011;50:1751-1759.  Back to cited text no. 9
Sattar N, McCarey DW, Capell H, McInnes IB. Explaining how “high-grade” systemic inflammation accelerates vascular risk in rheumatoid arthritis. Circulation. 2003;108:2957-2963.  Back to cited text no. 10
Houri Levi E, Watad A, Whitby A, et al. Coexistence of ischemic heart disease and rheumatoid arthritis patients-A case control study. Autoimmun Rev. 016;15:393-396.  Back to cited text no. 11
Kerola AM, Kerola T, Kauppi MJ, et al. Cardiovascular comorbidities antedating the diagnosis of rheumatoid arthritis. Ann Rheum Dis. 2013;72:1826-1829.  Back to cited text no. 12
Pieringer H, Pichler M. Cardiovascular morbidity and mortality in patients with rheumatoid arthritis: vascular alterations and possible clinical implications. QJM. 2011;104:13-26.  Back to cited text no. 13
Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. CMAJ. 2006;174:801-809.  Back to cited text no. 14
van Zanten JJV, Rouse PC, Hale ED, et al. Perceived barriers, facilitators and benefits for regular physical activity and exercise in patients with rheumatoid arthritis: a review of the literature. Sports Med. 2015;45:1401-1412.  Back to cited text no. 15
Public Health England. Health matters: getting every adult active every day - Publications - GOV.UK. 2016; https://www.gov.uk/government/publications/health-matters-getting-every-adult-active-every-day. Accessed 12-05-, 2017.  Back to cited text no. 16
Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6:e1000097.  Back to cited text no. 17
Baillet A, Zeboulon N, Gossec L, et al. Efficacy of cardiorespiratory aerobic exercise in rheumatoid arthritis: meta-analysis of randomized controlled trials. Arthritis Care Res (Hoboken). 2010;62:984-992.  Back to cited text no. 18
Wessel J. The effectiveness of hand exercises for persons with rheumatoid arthritis: a systematic review. J Hand Ther. 2004;17:174-180.  Back to cited text no. 19
Hurkmans E, van der Giesen FJ, Vliet Vlieland TP, Schoones J, Van den Ende EC. Dynamic exercise programs (aerobic capacity and/or muscle strength training) in patients with rheumatoid arthritis. The Cochrane Library. 2009;CD006853.  Back to cited text no. 20
Lemmey AB, Marcora SM, Chester K, Wilson S, Casanova F, Maddison PJ. Effects of high-intensity resistance training in patients with rheumatoid arthritis: a randomized controlled trial. Arthritis Care Res (Hoboken). 2009;61:1726-1734.  Back to cited text no. 21
Stavropoulos-Kalinoglou A, Metsios GS, van Zanten JJV, Nightingale P, Kitas GD, Koutedakis Y. Individualised aerobic and resistance exercise training improves cardiorespiratory fitness and reduces cardiovascular risk in patients with rheumatoid arthritis. Ann Rheum Dis. 2013;72:1819-1825.  Back to cited text no. 22
Stenström CH, Minor MA. Evidence for the benefit of aerobic and strengthening exercise in rheumatoid arthritis. Arthritis Care Res (Hoboken). 2003;49:428-434.  Back to cited text no. 23
Agca R, Heslinga SC, Rollefstad S, et al. EULAR recommendations for cardiovascular disease risk management in patients with rheumatoid arthritis and other forms of inflammatory joint disorders: 2015/2016 update. Ann Rheum Dis. 2017;76:17-28.  Back to cited text no. 24
Hamilton MT, Healy GN, Dunstan DW, Zderic TW, Owen N. Too little exercise and too much sitting: inactivity physiology and the need for new recommendations on sedentary behavior. Curr Cardiovasc Risk Rep. 2008;2:292-298.  Back to cited text no. 25
Macera CA, Hootman JM, Sniezek JE. Major public health benefits of physical activity. Arthritis Rheum. 2003;49:122-128.  Back to cited text no. 26
Khoja SS, Almeida GJ, Chester Wasko M, Terhorst L, Piva SR. Association of light-intensity physical activity with lower cardiovascular disease risk burden in rheumatoid arthritis. Arthritis Care Res (Hoboken). 2016;68:424-431.  Back to cited text no. 27
Veldhuijzen van Zanten JJ, Rouse PC, Hale ED, et al. Perceived barriers, facilitators and benefits for regular physical activity and exercise in patients with rheumatoid arthritis: a review of the literature. Sports Med. 2015;45:1401-1412.  Back to cited text no. 28
Li J, Siegrist J. Physical activity and risk of cardiovascular disease--a meta-analysis of prospective cohort studies. Int J Environ Res Public Health. 2012;9:391-407.  Back to cited text no. 29
Metsios GS, Stavropoulos-Kalinoglou A, Panoulas VF, et al. Association of physical inactivity with increased cardiovascular risk in patients with rheumatoid arthritis. Eur J Cardiovasc Prev Rehabil. 2009;16:188-194.  Back to cited text no. 30
Metsios GS, Stavropoulos-Kalinoglou A, Treharne GJ, et al. Disease activity and low physical activity associate with number of hospital admissions and length of hospitalisation in patients with rheumatoid arthritis. Arthritis Res Ther. 2011;13:R108.  Back to cited text no. 31
Health.gov. Physical Activity Guidelines. 2017. Accessed 28-08-2017, 2017.  Back to cited text no. 32
Canadian physical activity guidline. Candian physical activity guidline. 2012. Accessed 28-08, 2017.  Back to cited text no. 33
UK physical activity guidelines. Obesity and healthy eating. 2011.  Back to cited text no. 34
Hurkmans EJ, van den Berg MH, Ronday KH, Peeters AJ, le Cessie S, Vlieland TP. Maintenance of physical activity after Internet-based physical activity interventions in patients with rheumatoid arthritis. Rheumatology (Oxford). 2010;49:167-172.  Back to cited text no. 35
Breedland I, van Scheppingen C, Leijsma M, Verheij-Jansen NP, van Weert E. Effects of a group-based exercise and educational program on physical performance and disease self-management in rheumatoid arthritis: a randomized controlled study. Phys Ther. 2011;91:879-893.  Back to cited text no. 36

Author contributions
The author wrote and revised the manuscript, and approved the final version of the manuscript.
Conflicts of interest
The author declares no competing financial interests..
Plagiarism check
Checked twice by iThenticate.
Peer review
Externally peer reviewed.


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