Exercise in Rheumatic Disease

For many years people with inflammatory arthritis were told to rest painful joints, and many still fear that activity will cause harm. The evidence is now clear that the opposite is true. Regular exercise reduces pain, fatigue and morning stiffness, improves joint mobility, muscle strength and aerobic capacity, and maintains the ability to carry out everyday tasks, without increasing average disease activity or the rate of joint damage, though symptoms and loading may need adjusting during active inflammation. It also addresses two problems that shorten and worsen lives in rheumatic disease. The first is cardiovascular risk: chronic inflammation raises the risk of heart disease, and exercise improves cardiovascular risk factors and should accompany good control of inflammation and standard cardiovascular prevention. The second is bone loss, which is common because of inflammation, reduced activity and steroid treatment, and which weight-bearing and resistance activity help to counter. European recommendations on physical activity in rheumatoid arthritis, spondyloarthritis and hip and knee osteoarthritis confirm that general physical activity guidance applies to people with these conditions and that exercise should be a routine part of care. Framed positively, activity is not a risk to be managed but a treatment to be prescribed.

A rounded programme for inflammatory rheumatic disease includes the same components recommended for the general population, applied thoughtfully. Aerobic exercise such as walking, cycling or swimming builds cardiovascular fitness and helps manage weight and mood. Resistance training maintains and rebuilds the muscle strength that protects and supports affected joints. Flexibility and range-of-movement work preserves the mobility that stiffness threatens. Aquatic exercise is particularly useful, because the buoyancy of water reduces load on painful joints while still providing resistance, and it is often a good starting point for people with significant pain. Axial spondyloarthritis deserves special mention, because here regular exercise is a cornerstone of treatment rather than an add-on. Daily mobility, stretching and posture exercises help maintain spinal movement and reduce stiffness, and referral to a specialist physiotherapist for an individualised, structured programme is recommended, typically including stretching, strengthening, posture, spinal mobility, breathing and aerobic exercise, with group or hydrotherapy options to supplement it. Across the conditions, the general aim mirrors national guidance of at least 150 minutes of moderate or 75 minutes of vigorous aerobic activity a week, together with muscle-strengthening on at least two days, adapted to disease activity, symptoms and fitness, and started gradually.

Exercise is individualised to the person's condition, disease activity and joints involved, and built up gradually from their current level. Between flares, when disease is well controlled, people can and should exercise much as anyone else, progressing aerobic, strength and flexibility work as fitness improves, and person-centred, moderate to higher intensity programmes are safe and effective. During a flare, when joints are hot, swollen and painful, activity is modified rather than abandoned: gentle range-of-movement exercises and light or isometric activity help maintain mobility and function, heavy loading and high-impact stress on acutely inflamed joints are avoided, and normal activity is resumed as the flare settles. Keeping moving gently during a flare is better than complete rest, which stiffens joints and weakens muscles, but a significant or persistent flare warrants clinical or rheumatology review to optimise disease control, and adapting exercise does not replace that assessment or disease-modifying treatment. Fatigue is a prominent and disabling feature of inflammatory disease, and it is managed by pacing activity and building up gradually rather than by avoiding it. A physiotherapist, ideally one with rheumatology experience, helps set a safe, effective and motivating programme, particularly for people with significant joint involvement or complex disease.

Exercise is safe in inflammatory rheumatic disease, but a few condition-specific points deserve attention. Because cardiovascular risk is raised, activity is encouraged for its protective effect, while any new cardiac symptoms are assessed rather than assumed to be musculoskeletal. In long-standing rheumatoid arthritis, instability of the upper neck, known as atlantoaxial subluxation, can develop, though it is far from universal. New neck or occipital pain, neurological symptoms, known cervical involvement, contact-sport exposure or planned airway manipulation for anaesthesia should prompt specialist assessment, and caution is sensible with heavy neck loading and contact activity. Joint protection principles, using larger and stronger joints where possible and avoiding sustained high loads on damaged joints, help people stay active without aggravating symptoms, and attention to footwear, foot care and orthoses supports those with foot and ankle involvement. Exercise complements but does not replace medical treatment, including disease-modifying antirheumatic drugs (DMARDs) and, where used, non-steroidal anti-inflammatory drugs (NSAIDs) and biologic therapies, which control the underlying inflammation. Referral to a physiotherapist with rheumatology experience is valuable for people with significant joint involvement, axial SpA or complex needs. The overarching message is encouraging and evidence-based: exercise is a safe, effective and disease-appropriate treatment that people with rheumatic disease should be actively supported to take up and maintain.

• •Exercise is safe in inflammatory rheumatic disease and does not worsen disease activity or accelerate joint damage.
• •It reduces pain, fatigue and stiffness, improves strength and fitness, protects bone, and lowers the raised cardiovascular risk of chronic inflammation.
• •Recommend aerobic, resistance and flexibility work, with aquatic exercise useful for painful joints; general guidance is at least 150 minutes of moderate or 75 minutes of vigorous activity a week plus strengthening on at least two days.
• •In axial spondyloarthritis, daily mobility, stretching and posture exercise is a cornerstone, and referral to a specialist physiotherapist for an individualised structured programme is recommended.
• •During a flare, keep moving gently with range-of-movement and light activity, avoid heavy loading of hot, swollen joints, and arrange review if the flare is significant or persistent.
• •Exercise improves cardiovascular risk factors alongside inflammation control; in long-standing rheumatoid arthritis consider atlantoaxial instability where there are new neck symptoms, known cervical involvement, contact sport or planned airway manipulation; exercise complements disease-modifying antirheumatic drugs rather than replacing them.