While Rheumatoid Arthritis (RA) is a systemic disease that can affect the heart, lungs, blood vessels, skin, and eyes, it’s effect on joints is what makes it so well known and quite difficult at times. It is a chronic inflammatory autoimmune disease. The human immune system creates antibodies to protect us from infections. It becomes autoimmune when those antibodies turn against the body and begin attacking it as if it were a foreign invader. The damage to the human body from these antibodies can be mild and a mere discomfort, or they can be catastrophic. In Rheumatoid Arthritis, The antibodies begin attacking the synovial lining of joints. There are four stages of Rheumatoid Arthritis, depending on the severity, and our job is to maintain range of motion and make sure this person has the strength and energy to get through their day. The joint pain and stiffness can be a significant challenge for a fitness professional. It can be intimidating, and it can create the illusion that options are severely limited. I’ll be sharing several workout alternatives that may make it a bit easier.
As fitness professionals, the symptoms of RA that affect program design the most are fatigue (often overwhelming at times) and joint pain, tenderness, swelling, redness, warmth, stiffness, and loss of range of motion. This joint pain is usually the worst first thing in the morning, or after prolonged periods of inactivity. (This fact should be used to increase adherence, because movement, even if it hurts at first, will reduce the pain.). There can be flare-ups followed by remission, and it tends to cause damage to the small joints of the hands, wrist, feet, and ankles first. If progression occurs, the knees, hips, spine, and shoulders can become involved. It is often quite symmetric, as the picture shows. I won’t go into the diagnosis too much, but on an x-ray, the synovial lining slowly detaches from the joint, and the joint space becomes cloudy, with an almost raggedy aspect to the pieces of synovial lining extending into the joint space. The tendons and ligaments of the joint weaken and stretch overtime, which results in the joint losing its shape and alignment. It is much more common in middle-aged women, and it is believed to be a combination of genetic predisposition combined with an environmental stimulus.
Movement and exercise are a key to decreasing progression of the disease. A common saying in medicine and physical therapy is “motion is lotion”. Before I get into the types of exercise we can do, I’d like to go over some broad guidelines to follow. Before starting a fitness program with someone with RA (or any known disease process), please make sure that they have discussed it with their doctor. For many people with RA, exercise may temporarily increase their discomfort. A general guideline to follow is, if their pain is not back to their baseline level of pain within 2 hours after the workout, the workout was too hard. Heat or ice, depending on which feels better, can be used after a workout to ease discomfort. We always want to be working on making sure that range of motion does not decrease. If you notice this, please refer this person to their doctor. Holding onto dumbbells may cause significant discomfort in the hands, if that is the case, using medicine balls, tubing, wrist wraps, foam handles on the dumbbells, or even exercise in a pool may all be beneficial. Although machines take away any core activation, in more severe cases, they may be beneficial for training deceleration. If movement is too painful in a particular joint, isometrics can be used with tubing, against a solid object, or with partner assistance. Isometrics eliminate any movement of the joint.
Before starting to work on a particular joint and the muscles around it, muscle imbalances around that joint must be corrected. By middle age, almost everyone has a muscular imbalance that reflects the positions they have been in the most for the previous two or three decades. With this disease, we already have joint, ligaments, and tendons that are breaking down, we cannot allow misalignment of a joint on top of that.
The eccentric phase (coming back to the position you started the rep) is where the most strength and power are created. For this population, eccentric training is essential. It must be slow and controlled. To accentuate this phase, you can assist someone with moving the weight during the concentric phase, and then ask them to hold it and go as slow as they can on the way back. (Keep in mind, the eccentric phase is also the phase that creates Delayed Onset Muscle Soreness). Start slow, allow adequate recovery time in between workouts, and describe the difference between joint pain and muscle pain. The eccentric phase is also what gives us the ability to brake/decelerate movement. A strong core program must be started at the beginning of the program as well. The core attaches the upper and lower body together, and is also essential for maintaining correct posture, as well as decelerating movement. Strength gains will come faster if the core is firing the way it should be. All of these will help someone with RA if they get out of bed in the morning, feel a crushing pain in their feet and ankles and start to fall. Patience is key. It doesn’t do any good to work someone out for two hours a week followed by 166 hours in bed because of soreness. Go easy. The initial strength training program should start with higher reps with endurance in mind, and then progress to strength and power.
Cardio is a great way to increase energy levels and oxygen delivery and usage within the body. It’s great if you can always be switching it up, but if there is a particular kind of cardio that increases discomfort, let them do the type that is the most comfortable. This is where a pool comes in very handy. If the elliptical machine is an option, I would recommend going backwards. Most cardio is forward and very hip flexor dominant. Going backwards on the elliptical activates the hamstrings and glutei in a way other methods of cardio cannot achieve. The most important thing about cardio is that they do it. We want to help achieve normal weight to stop the possibility of a joint developing Osteoarthritis on top of the Rheumatoid Arthritis, but we really want to increase energy levels and oxygen delivery abilities.
Strength training is essential. Besides correcting any pre-existing muscular imbalances, you also want to make sure that perfect form is maintained. Don’t sacrifice form for weight. The weight will come. Standing exercises (on one leg if possible to challenge balance) which combine upper and lower body, especially when done one arm at a time are tremendously helpful. This tricks the brain into recruiting more muscle fibers for faster strength gains, it brings the core into the exercise, and possibly most important of all, it creates force coupling. Force coupling is when all of the muscles that stabilize a joint contract at the right time with the right amount of force to keep the joint in its correct position. What could possibly be better than that? Adequate force coupling often increases the joint space, because the muscles are all doing their job to hold the joint in place. This has the potential to slow the progression of bone against bone damage once the synovium has been compromised. The central nervous system responds quickly and neurological adaptation can be seen as soon as the second set. (A great example of the brain trying to create this is when someone does a shoulder press with dumbbells for the first time. They are shaking, and their arms are all over the place. This is the brain figuring out which muscles fibers to fire and when.)
I’m going to leave the diagnosis and medications out of this one. That’s something to be determined by their doctor. This has been a lot of information, but I hope I’ve been able to describe the critical role of the fitness professional with this disease. Please feel free to send questions or comments if you’d like more information.