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Osteoarthritis (OA), Rheumatoid
Arthritis (RA) and Exercise
Learning outcomes
1.
2.
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7.
Identify OA/RA patients suitable for exercise advice as
part of Making Every Contact Count (MECC)
Learn safe and effective exercise advice for patients with
OA/RA
Have awareness of the benefits of exercise in reducing
heart disease in RA
Have awareness of the benefits of exercise in reducing
pain and potential muscle wasting in OA &RA
Know the contraindications and clinical considerations to
exercise advice in OA/RA patients
Understand the cost effectiveness and evidence for
reducing inactivity, #NCDS disability and death Badley, 2014
Be aware of NICE guidance CG177 on physical activity in
treatment of OA (2014) and CG79 for RA (2009)
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Osteoarthritis (OA)
• Osteoarthritis is a condition that affects the joints
• OA is the most common type of arthritis
– 1 million UK patients see their GP about it every year
– OA was the 6th leading cause of years living with disability at a
global level, accounting for 3% of the total global years of living
with disability (Woolf et al, 2003)
– Exercise therapy is one of the dominant non-pharmacological
interventions recommended by international guidelines NICE 2014 Cochrane
2015
http://www.bmj.com/content/348/bmj.g2472
http://www.who.int/bulletin/volumes/81/9/Woolf.pdf
https://www.nice.org.uk/guidance/cg177/resources/guidance-osteoarthritis-pdf
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Rheumatoid Arthritis (RA)
• RA is an autoimmune disease that causes chronic
inflammation of the joints
• RA causes inflammation of the tissue around the joints, as
well as affecting other organs in the body
– It affects approximately 1% of the population
– Systemic disease with ‘beyond joint’ manifestations
– “A 50-year-old woman with RA is expected to die four
years earlier than a 50-year-old woman without RA”
NICE CG 79
**due for review
– RA doubles the risk of having a heart attack
• Exercise is recommended to reduce cardiovascular risk Peters et al, 2010
Rheumatoid Arthritis: National Clinical Guideline for Management and
Treatment in Adults, 2009
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Benefits of exercise in OA & RA
• Exercise is widely used by health professionals and patients
to reduce pain Messier 2012 , Juhl, 2014
• Improves function Fransen 2015, Uthman 2013, Bartels 007, Juhl, 2014,
• Improves aerobic capacity Bartels 2007
• Tai chi may be effective for pain control Lauche, R. e(2013).
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Benefits of exercise in OA & RA
• Improving general mobility, function, well-being and selfefficacy
• Maintaining a healthy weight
• Improving gait Roddy 2005
• Reducing risk of immobility, disability, #NCDs and death
Badley, 2014
• Potentially reducing other risks of associated conditions such
as cardiovascular disease (Metsios, 2008)
#NCDs = noncommunicable diseases
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Pain levels, exercise & patient care in OA
Pain level decreases both with weight training and with aerobic exercise.
Adapted with permission from Messier et al.
Copyright © 1997 American Medical Association. All rights reserved
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Contraindications and precautions to
exercise in OA & RA
1. New or uncontrolled arrhythmias
2. Resting or uncontrolled tachycardia
3. Uncontrolled hypertension
4. Symptomatic hypotension
5. Unstable angina
6. Unstable or acute heart failure
7. Unstable diabetes
8. Febrile illness
During RA flare-up, exercise should be limited to range of
movement activities
Systemic effects of RA must be considered, particularly
where these could affect exercise capacity e.g. pleural
effusion, intra-pleural nodules or pericarditis
http://www.nchpad.org/112/866/Rheumatoid~Arthritis
FYSS (2014)
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Exercise considerations in OA & RA:
For clinicians
• Prescribe patient centred, individualised programmes, based on
assessment findings
• Moderate loading is recommended Sutton, 2001
• In RA, introduce and progress exercise slowly
• Physical activity programmes should include a range of exercise types:
• Stretching
• Resistance exercise
• Aerobic conditioning
Arthritis Research UK (2014)
Metsios et al (2008), Bennell et al (2014)
Hurkmans et al (2009)
NICE CG179, NICE CG79) , NICE QS87)
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Exercise considerations in OA & RA:
For clinicians
• Well-designed physical activity programmes do not have harmful
effects on disease activity or joint damage
• Correct positioning & technique is critical to prevent muscle tears &
increased pain/joint swelling, particularly in deconditioned patients
• Coaching & counselling for physical activity has a positive impact on
participation & adherence
• Intrinsic & extrinsic factors should be considered
Arthritis Research UK (2014)
Metsios et al (2008), Bennell et al (2014)
Hurkmans et al (2009) NICE CG179, NICE CG79
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Major considerations in designing individualized exercise
training in patients with rheumatoid arthritis
Metsios G S et al. Rheumatology 2008;47:239-248
© The Author 2007. Published by Oxford University Press on behalf of the British Society for Rheumatology.
All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Exercise considerations for patients
KEEP MOVING
• Avoid exercise that causes pain lasting for >1 hour post-exercise
• Use an ice pack (15-20mins) if the joint becomes hot or swollen
• Analgesia may be taken 20 minutes prior to exercise
• Select shoes and insoles for maximum shock absorption
• High impact activities or contact sports are not recommended
• Avoid early morning exercise as joint stiffness/pain can be worse
• Be aware that pain and swelling
may
reduce performance
Arthritis Research
UK (2014)
Bennell et al (2014)
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Adjust & tailor all exercise plans
if patient experiences …
• Severe pain during exercise
• Pain that does not settle to usual levels after
exercise
• Increased night pain post exercise
• Increased joint swelling
Bennell et al (2014)
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Exercise recommendations in OA & RA
Aerobic Training
• 150 minutes/week of heart healthy exercise
– Cycling, Swimming/Aqua-aerobics, Dance, Brisk Walking
– Indoor cycles can be modified to accommodate the needs of most
patients
• Mix of moderate and high intensity exercise
• May be broken into 3 or 4 bouts of 10 minutes/day
Iversen et al (2012), Bennell et al (2014), WHO (2015)
ACSM (2011), NICE CG179, NICE CG79
Metsios et al (2008), Arthritis Research UK (2014), FYSS (2014)
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Exercise recommendations
Strength Training
• Well-constructed, progressive resistance
exercise programmes recommended for
both OA & RA
• Similar benefits for OA patients have been
found with isotonic, isometric & isokinetic
exercise
• Strength training may reverse rheumatoid
cachexia
• All major muscle groups should be
addressed
• Patients with extensive structural damage
may not tolerate significant joint loading
Iversen et al (2012), Bennell et al (2014)
ACSM (2011), NICE CG179, NICE CG79
Metsios et al (2008), Arthritis Research UK (2014), FYSS (2014)
Exercise recommendations:
Strength Training
Training should include
• 2 sessions/week
• 8-10 exercises,
– and 10-15 repetitions
• Balance training in
combination with
resistance exercises
• May be beneficial in
reducing the risk of
falls
Iversen et al (2012), Bennell et al (2014)
ACSM (2011), NICE CG179, NICE CG79
Metsios et al (2008), Arthritis Research UK (2014), FYSS (2014)
Exercise recommendations in OA & RA
Range of Movement (ROM) Training
• Stretching exercises are designed to take the joint
through full range of movement, maintaining the
integrity of peri-articular structures
• Patients should be advised not to over-stretch or
encourage hypermobility
• Stretches should be held for 5-10 seconds
NICE CG79
Arthritis Research UK (2014)
Bennell et al (2014), FYSS (2014)
Most effective exercise intervention for
both pain reduction & function in OA
Exercise for lower limb osteoarthritis: systematic review incorporating
trial sequential analysis and network meta-analysis BMJ 2013;347:f5555
©2013 by British Medical Journal Publishing Group
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Take home messages for OA & RA
• Rest is no longer recommended
• Exercise is important for secondary prevention
and symptom management
• Include a range of exercise
• Flexibility - Strengthening - Aerobic
• Consider strategies to promote
– Participation & Adherence
Aqua fit works: so help patients access it!
Aquatic therapy may be of particular benefit to
patients who are overweight or obese, or who
have severe
joint symptoms
Buoyancy reduces weight bearing
http://www.youtube.com/watch?v=zELVVUsXu5U
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Resources
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ACSM (2011). Quantity and Quality of Exercise for Developing and Maintaining
Cardiorespiratory, Musculoskeletal, and Neuromotor Fitness in Apparently Healthy Adults:
Guidance for Prescribing Exercise. Available at: http://journals.lww.com/acsmmsse/Fulltext/2011/07000/Quantity_and_Quality_of_Exercise_for_Developing.26.aspx
Arthritis Research UK (2014). What sort of exercise is important? Available at:
http://www.arthritisresearchuk.org/arthritis-information/arthritis-and-daily-life/exerciseand-arthritis/what-sort-of-exercise-is-important.aspx
Badley, E. (2014). Inactivity, disability, and death are all interlinked. BMJ 2014;348:g2804
Bartels, EM. et al, (2007). Aquatic exercise for the treatment of knee and hip osteoarthritis
(Cochrane) http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005523.pub2/abstract
Bennell, KL. Dobson, F. Hinman, RS. (2014). Exercise in osteoarthritis: Moving from
prescription to adherence. Clinical Rheumatology;28(1):93-117.
Dunlop, DD. Song, J. Semanik , PA, Sharma L. Bathon , JM. Eaton, CB et al. Relation of physical
activity time to incident disability in community dwelling adults with or at risk of knee
arthritis: prospective cohort study BMJ2014; 348 :g2472
http://www.bmj.com/content/348/bmj.g2472
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Resources
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Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for
osteoarthritis of the knee. Cochrane Database of Systematic Reviews 2015, Issue 1. Art. No.:
CD004376. DOI: 10.1002/14651858.CD004376.pub3
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004376.pub3/abstract
FYSS (2014). Physical Activity in the Prevention and Treatment of Disease. Available at:
http://www.fyss.se/wp-content/uploads/2011/02/fyss_2010_english.pdf
Hurkmans E, van der Giesen FJ, Vliet Vlieland TPM, Schoones J, Van den Ende ECHM. Dynamic
exercise programs (aerobic capacity and/or muscle strength training) in patients with
rheumatoid arthritis. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.:
CD006853. DOI: 10.1002/14651858.CD006853.pub2.
Iversen, M. D., Brawerman, M., & Iversen, C. N. (2012). Recommendations and the state of
the evidence for physical activity interventions for adults with rheumatoid arthritis: 2007 to
present. International Journal of Clinical Rheumatology, 7(5), 489–503.
Juhl, C. Christensen, R. Roos, EM. Zhang, W. Lund, H. (2014). Impact of exercise type and dose
on pain and disability in knee osteoarthritis: a systematic review and meta-regression
analysis of randomized controlled trials. Arthritis Rheumatol. 2014 Mar;66(3):622-36
Lauche, R. et al (2013). A systematic review and meta-analysis of Tai Chi for osteoarthritis of
the knee. Complement Ther Med. 2013 Aug;21(4):396-406.
Messier SP. (2012). Effects of Exercise Interventions in Older Adults with Knee Osteoarthritis.
HSS Journal. 2012;8(1):49-50.
Metsios, GS. et al, (2008) Rheumatoid arthritis, cardiovascular disease and physical exercise:a
systematic review. Rheumatology 2008;47:239–248
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Resources
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NCHPAD (2015) Rheumatoid Arthritis – Precautions and Contraindications. Available at:
http://www.nchpad.org/112/866/Rheumatoid~Arthritis
NICE Guidance CG79 http://www.nice.org.uk/guidance/CG79
NICE Guidance CG177 http://www.nice.org.uk/guidance/cg177
Peters, M. J. L. (2010). EULAR evidence-based recommendations for cardiovascular risk
management in patients with rheumatoid arthritis and other forms of inflammatory arthritis.
Ann Rheum Dis 2010;69:325-331
Roddy, E. Zhang, W. Doherty, M. (2005). Aerobic walking or strengthening exercise for
osteoarthritis of the knee? A systematic review. Ann Rheum Dis. 2005 Apr;64(4):544-8.
Sutton, A., Muir, K., Mockett, S., & Fentem, P. (2001). A case-control study to investigate the
relation between low and moderate levels of physical activity and osteoarthritis of the knee
using data collected as part of the Allied Dunbar National Fitness Survey. Annals of the
Rheumatic Diseases, 60(8), 756–764.
Uthman, OA. van der Windt, DA. Jordan JL. Dziedzic KS. Healey EL. Peat GM. et al. Exercise for
lower limb osteoarthritis: systematic review incorporating trial sequential analysis and
network meta-analysis BMJ 2013; 347 :f5555 http://www.bmj.com/content/347/bmj.f5555
WHO (2014). Global recommendations on physical activity for health. Available at:
http://www.who.int/dietphysicalactivity/factsheet_recommendations/en/
Woolf, AD. Pfleger, B. (2003). Burden of major musculoskeletal conditions. Bulletin of the
World Health Organization 2003, 81 (9)
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