The Many Benefits of, and Barriers to, Exercise in Patients With Rheumatologic Diseases

Exercise can be a potent therapy for patients with rheumatologic diseases and can result in improvements in inflammation, disease activity score, pain, stiffness, and fatigue. However, exercise needs to be modified for these patients to address the unique barriers they may have compared with the general population, said panelists during a session at the American College of Rheumatology’s annual meeting.

Rikke Helene Moe, PT, MSc, PhD, chair of health professional in rheumatology in the European League Against Rheumatism and a researcher of the national advisory unit on rehabilitation in rheumatology in the Department of Rheumatology at the Diakonhjemmet Hospital in Oslo, Norway, explained that in the past, there was a fear that exercise would increase symptoms and decrease response, and she admitted to being part of that “shady past.”

“We advised people to rest,” which resulted in them lying in hospital beds day in and day out, she said.

People with rheumatic and musculoskeletal diseases (RMDs) are less activate than the general population, which is already fairly inactive—30% of people globally are insufficiently physically active, and more than 50% of people with RMDs are less active than the recommended 30 minutes per day, Moe said.

Intensity of exercise also matters, and positive effects are greater at higher intensities, but the exercises have to be individually tailored. “It’s easy to put everyone in the same box and have them do the same exercise,” but the likely result is that most people won’t follow through, she said. For instance, clinicians have to be patient when working with someone who has fibromyalgia. It will take these patients more time to reach adequate levels of exercise and activity.

In addition to exercise helping with symptoms of RMDs, it also benefits cardiovascular health. RMDs increase the risk of cardiovascular disease because of the inactivity that comes with pain associated with RMDs, being overweight, and the side effects of drugs. Exercise clearly helps with reducing the risk of cardiovascular disease in these patients.

“Knowing these things is not enough,” Moe admitted. “We are working on implementation, working on barriers….”

Modifying exercise is incredibly important for patients with chronic pain, said Kim Jones, PhD, RN, FNP, FAAN, professor and dean at Linfield College School of Nursing and research professor at the Oregon Health & Science University School of Medicine.

She noted that chronic pain has to be viewed as a disease like rheumatoid arthritis (RA) or diabetes, not just a symptom, so patients will stop chasing something elusive that will get rid of the pain entirely. The goals of exercise for these patients should be to improve body composition, muscular strength, power, endurance, and flexibility.

“What we see in rheumatology, as we increase [exercise] intensity, unless we really know how to do it in a controlled manner, the tradeoff may be that people have more pain, they may even trip into an overtraining syndrome, where they feel depressed and more fatigued,” Jones noted. “So, there seems to be a tradeoff, and we’re figuring out where exactly that line is. And as you might guess, it’s going to be different for different people.”

A Cochrane Review analyzed studies on exercise in patients with pain, and while the studies all varied (with lengths anywhere from 1 to 30 months and with exercises ranging from daily to weekly with varied durations and types of exercises), the review did find small to moderate improvements in physical function all studies. There were also small to moderate effects on pain severity. The impact on psychological function and quality of life varied more. Some of the studies showed a huge difference, while other barely moved the needle, Jones said.

For patients with RA, a lack of knowledge about the benefits of exercise on arthritis may be one barrier to physical activity, said Yvonne M. Golightly, PhD, MS, PT, assistant professor in the Department of Epidemiology and adjunct in the Division of Physical Therapy at the University of North Carolina at Chapel Hill. The truth is, the general population has plenty of barriers to physical activity, including lack of time, not finding exercise enjoyable, concerns about injury, uncertainty of where to start, and a lack of motivation or support.

Patients with RA face all the same barriers that the general population faces, plus the additional barriers of pain, stiffness, fatigue, challenges with mobility/function, and fear of aggravating the disease or damaging their joints. In addition, Golightly noted, these patients may have a lack of advice from healthcare providers regarding physical activity because the providers themselves may feel like they have a lack of knowledge regarding programs that are appropriate.

She has studied high-intensity interval training (HIIT) in patients with arthritis, which is not high impact, so it’s good for the joints. In addition, HIIT may appeal to these patients because bouts of exercise can be as short 60 seconds, and in as little as 2 weeks, patients may start seeing the benefits of the exercise regimen.

It’s important to emphasize the benefits of exercise by increasing knowledge for patients and providing support, Golightly said. Teaching coping strategies to overcome perceived barriers is key, as well. Patients with arthritis who are physically active and those who are physically inactive face the same barriers; the only different is that the physically inactive patients perceive those barriers to be a bigger challenge.

“Teaching coping strategies is critical for overcoming perceived barriers,” Golighty said. “And it’s important to engage in conversations with patients that help them find internal motivation and change their behavior.”