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SP0119 Physical exercise in recent rheumatoid arthritis
  1. A Häkkinen
  1. Department of Rehabilitation, Central Hospital, Jyväskylä, Finland

Abstract

The impact of arthritis on the individual is multidimensional and various rehabilitation programs have therefore been developed for these patients. The long-term outcome varies from a minimal loss of function to a shortened life expectancy. Although RA patients represent only 8% of all patients with musculo-skeletal diseases in Finland, they consume 40% of all hospital days used by this patient group making RA a very expensive sickness. Several studies conducted worldwide have shown that more than a half of the patients become work disabled during the first 10 years of disease. Therefore, due to the limited availability of resources, it seems that efforts should be targeted to preventive rehabilitation at the early phases of disease.

The patients with early RA have significantly lower muscle strength levels (as much as 45% in knee extension and 20% in grip strength) compared to healthy persons even at the time of diagnosis of RA.1 Heightened disease activity, nerve function impairment, changes in muscle metabolism, decreased muscle blood flow, degeneration of muscle fibres and disuse of the musculo-skeletal system have been suspected as possible mechanisms for muscular weakness and a loss of physical fitness. An accelerated loss of bone mineral density (BMD) leading to osteoporosis is also regarded as a common clinical problem. Even the early RA patients with high disease activity and glucocorticoids have an increased risk of osteoporosis.2

According the review of Van den Ende et al.,3 dynamic exercise therapy increases aerobic capacity and muscle strength in patients with a longer duration of RA. In our studies prolonged dynamic strength training for several months (with progressively increasing loads from 40–50% to 70–80% of maximum strength) increased the muscle strength values of early RA patients back to the level of healthy subjects.4 The large increase in the knee extension strength was accompanied by a significant enlargement in the cross-sectional area of the quadriceps femoris muscle. The data demonstrate that systematic resistance training can lead, not only to functional, but also to some extent structural adaptations in the neuromuscular system of early RA patients. Furthermore, the strength gains were obtained with no detrimental effects on disease activity or joint erosions. Physical training leads to significant increases in muscle strength and physical function, but it imposes only minor effects on BMD in spine and femoral neck. The “smooth” movements in supine, sitting or standing positions or non weight-bearing exercises, as generally recommended for RA patients, do not generate such ground reaction forces on the skeleton required to increase BMD. However, the physical activity on a certain level must be continuous, because it is known that muscle strength, aerobic capacity or BMD levels obtained by various type of training will be lost during the detraining.5,6,7

The findings concerning the exercise interventions support unanimously the assumption that patients with RA can safely use individually tailored dynamic strength training or aerobic exercises to increase/maintain their muscle strength and overall physical condition without exacerbating the disease. The training to improve muscle strength should follow the same basic principles as for healthy people. These are the principles of overload, sufficient frequency, progressive increase in the amount of training, specificity and individualisation. The safety components need to be emphasised. The patient should be tutored to know how to interpret the symptoms of the disease and how to adapt the exercise programme flexibly to the changes taking place in the disease activity. RA is a chronic disease, which seems to need continuous physical exercise to prevent the loss of muscle strength and functional capacity.

References

  1. Häkkinen, et al. Scand J Rheumatol. 1999;28:1–7

  2. Häkkinen, et al. Arthritis Rheum. 2001, in press

  3. Van den Ende, et al. Br J Rheumatol. 1998;37:677–87

  4. Häkkinen, et al. Scand J Rheumatol. 1994;23:237–42

  5. Van den Ende, et al. Ann Rheum Dis. 1996;55:798–805

  6. Dalsky, et al. Ann Intern Med. 1988;108:824–8

  7. Häkkinen, et al. Br J Rheumatol. 1997;23:237–42

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