Exercise Recommendations for Rheumatoid Arthritis
Adults with rheumatoid arthritis should engage in regular exercise combining both aerobic and resistance training, following the same public health recommendations as healthy adults, with modifications based on individual disease activity and joint involvement. 1
Core Exercise Prescription
Aerobic Exercise
The 2018 EULAR guidelines establish that patients with RA can safely follow standard public health recommendations for aerobic activity: 1
- Frequency: ≥5 days/week of moderate intensity OR ≥3 days/week of vigorous intensity 1
- Duration: 30-60 minutes/day (150 minutes/week) of moderate exercise OR 20-60 minutes/day (75 minutes/week) of vigorous exercise 1, 2
- Intensity: Moderate to vigorous for most adults; light to moderate for deconditioned patients 1
- Type: Walking, cycling, swimming, low-impact aerobics, or Tai Chi—activities involving major muscle groups in continuous, rhythmic patterns 1, 2
- Pattern: Can be performed in one continuous session or multiple bouts of ≥10 minutes 1
The 2022 ACR guidelines provide a strong recommendation for consistent engagement in exercise overall (moderate certainty evidence), but only a conditional recommendation specifically for aerobic exercise due to very low to low certainty evidence showing improved physical function but no difference in pain. 1
Resistance Training
Resistance exercise should be incorporated 2-3 days per week: 1
- Frequency: Each major muscle group trained 2-3 days/week 1
- Intensity: Start with 40-60% of one repetition maximum (1RM) for patients with active RA, progressing to 60-70% of 1RM for novice to intermediate exercisers 1, 2
- Repetitions: Begin with as few as 2-3 repetitions based on pain threshold, gradually working up to 8-12 repetitions (or 10-15 for older adults) 1, 2
- Type: Isokinetic weight machines, resistance bands, or isometric exercises 2
The ACR conditionally recommends resistance exercise based on very low to low certainty evidence showing improvements in both physical function and pain, emphasizing the importance of appropriate prescription and supervision by physical therapists to prevent harm. 1
Aquatic Exercise
Water-based exercise is particularly valuable for patients with significant joint pain or difficulty with weight-bearing: 1, 2
- Combines aerobic fitness and joint range of motion in a low-impact environment 2
- Conditionally recommended by ACR based on low certainty evidence showing improved physical function but no difference in pain 1
Mind-Body Exercise
Yoga, Tai Chi, and Qigong are conditionally recommended: 1, 2
- Based on very low to low certainty evidence showing improved physical function but no difference in pain 1
- Provides benefits for patients who prefer these modalities 2
Implementation Strategy
Starting an Exercise Program
Begin with repeated short bouts of low-intensity exercise daily, progressively increasing duration. 2
- For cardiovascular exercise, start with brief 10-minute sessions, adding 5 minutes per session until reaching 30 minutes 2
- Use a gradual progression of exercise volume by adjusting duration, frequency, and/or intensity to enhance adherence and reduce risk of musculoskeletal injury 1
- Exercise affected joints using a pain-free range of motion for flexibility training 2
Supervision and Support
Exercise programs are more effective when supervised by physical therapists, sometimes in a class setting, rather than performed alone at home. 2
- Comprehensive physical therapy is conditionally recommended 1, 2
- Comprehensive occupational therapy is conditionally recommended, particularly for patients with hand involvement 1, 2
- Programs are more effective when combined with self-efficacy training and self-management interventions 2
Critical Safety Considerations
When to Exercise
- Exercise affected joints through pain-free range of motion 2
- There is no uniformly accepted pain threshold; use shared decision-making between clinician and patient 2
- Morning exercise may need to be avoided if RA-related morning stiffness is present 2
When to Stop or Modify
Discontinue exercise if the patient experiences: 2
- Unusual or persistent fatigue
- Increased weakness
- Decreased range of motion
- Joint swelling or pain lasting more than one hour after exercise
Activities to Avoid
- Avoid vigorous, repetitive exercises that use unstable joints and overstretching 2
- Avoid exercising joints during disease flare-ups 2
- Do not perform exercises that significantly exacerbate joint pain or inflammation 2
Evidence Quality and Strength
The recommendation for exercise in RA is supported by moderate certainty evidence showing improved physical function and pain when considering all exercise types together. 1 However, when examining specific exercise modalities individually, the evidence quality drops to very low to low certainty for most types. 1 Despite this, the 2018 EULAR guidelines demonstrate that patients with inflammatory arthritis can safely meet public health recommendations for physical activity without exacerbating disease activity. 1
A critical pitfall: Healthcare providers and patients may be reluctant to engage in physical activity due to fears of flare-ups or joint damage, but evidence shows that properly prescribed exercise is safe and does not accelerate disease progression. 1, 3, 4 In fact, exercise training has been shown to reverse rheumatoid cachexia, substantially improve function, and likely reduce cardiovascular risk without exacerbating disease activity. 3
Practical Barriers
Exercise recommendations should address patient preferences and access, which are important barriers to participation. 2 The specific elements of an exercise intervention should be tailored to each patient considering their capabilities, access, other health conditions, disease activity level, presence of joint damage or deformities, and comorbidities. 1