As the population ages, osteoarthritis and rheumatoid arthritis are becoming increasingly common complaints in primary care practices. These disorders affect 27% of adults in the United States and are leading causes of physical disability.1 The annual total cost of arthritis (including both direct and indirect costs) exceeds $80 billion.2 By 2020, it is estimated that over 60 million adults will have arthritis.3
Exercise is a recognized, inexpensive, and effective therapy for arthritis. In this article, we enumerate the benefits of exercise for patients with arthritis, outline the elements of an effective program, and describe a variety of appropriate exercises.
Osteoarthritis is especially common in the elderly; it affects more than 68% of persons over the age of 65 years.4 This degenerative arthritis typically affects the knee, hip, and hands and results in decreased strength, reduced flexibility, diminished proprioception, and joint pain.
Rheumatoid arthritis is less common than osteoarthritis; it occurs in about 1% of adults, two thirds of whom are women.5 This autoimmune, inflammatory process tends to affect joints in the hands, wrists, and elbows.
Both osteoarthritis and rheumatoid arthritis cause muscle atrophy and weakness that often lead to physical inactivity, which then exacerbates muscle wasting. As a result, both types of arthritis lead to reduced lean body mass.
Although there is effective drug therapy for arthritis, regular exercise is also an important part of treatment. Healthy People 2010—the list of US health objectives developed by federal agencies and non-federal partners—advocates participation in an exercise program as an effective self-management strategy for persons with arthritis.6
The benefits of exercise to patients with arthritis are numerous. Direct benefits include reduced pain, improved flexibility, and increased strength (Table). Additional benefits include reduction of cardiovascular risk, improved lipid management, and increased bone mass. In overweight patients with osteoarthritis, a further benefit is weight loss, which lessens the load on joints and ultimately facilitates greater success with an exercise regimen.
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An extensive body of literature demonstrates the effectiveness of exercise for patients with arthritis. Van den Ende and colleagues7 reviewed exercise studies and concluded that exercise was effective at increasing aerobic capacity and muscle strength in patients with rheumatoid arthritis and had no detrimental effects on disease activity, disease progression, or pain levels. Ekblom and associates8 studied patients with rheumatoid arthritis who underwent 6 weeks of daily physical rehabilitation that consisted of muscle strength and joint mobility training. At the end of the study, the participants' cardiovascular fitness, physical performance capacity, and leg muscle strength was significantly improved. In a follow-up study 6 months later, the participants were retested; those who had continued regular physical training maintained their functional improvements, while those who had discontinued their training showed a decrease in the factors studied.8
Long-term studies confirm the effectiveness of exercise. Nordemar9 studied 23 patients with moderate disease activity who underwent physical training for 4 to 8 years. The program consisted of home-based regimens, such as swimming, jogging, or bicycling, as well as hospital-based training. After 5 years of training, progression of radiographic erosion was slower in the patients who participated in physical training than in the control group. Moreover, outcomes in activities of daily living and in overall attitude were better in the training group.
Messier and colleagues10 randomized 316 adults with osteoarthritis of the knee into 4 groups. Therapy for the first group consisted of a healthy lifestyle; for the second, an appropriate diet; for the third, exercise; and for the fourth, diet plus exercise. (Exercise therapy consisted of 60-minute sessions performed 3 days per week.) After 18 months, participants in the diet-plus-exercise group had significant improvement in physical function and reduction in pain compared with participants in the other 3 groups. Exercise was also shown to increase mobility.
Ettinger and colleagues11 randomized 439 elderly adults with radiographic evidence of knee osteoarthritis, pain, and self-reported disability to an aerobic exercise program, a resistance training program, or a health education program. At the end of 18 months, participants in both the aerobic exercise and resistance training programs showed modest improvements in measures of disability, physical performance, and pain compared with participants in the health education program.
Both patients and clinicians sometimes fear that exercise will exacerbate arthritis. Studies do not support this fear. In fact, significant data show that exercise is safe as well as effective for patients with arthritis.12,13
Relative contraindications to exercise include recent joint replacement, significant joint damage, or an actively inflamed joint. Such conditions may necessitate avoidance of certain ranges of motion so as not to increase pain or cause additional damage. However, these conditions are often transient.
Lyngberg and colleagues14 studied patients with rheumatoid arthritis who were taking low-dose corticosteroids. One group of patients underwent progressive interval training (bicycle riding, step climbing) for 3 months. At the end of the study, disease activity in the trained group had not increased, and the patients who underwent training had fewer swollen joints than those in the control group.
Rall and colleagues15 studied high-intensity resistance exercise in patients with rheumatoid arthritis and compared its effect with that on healthy young patients and healthy elderly patients. Eight patients with arthritis, 8 healthy young patients (aged 22 to 30 years), and 8 healthy elderly patients (aged 65 to 80 years) underwent 12 weeks of total-body, high-intensity, progressive-resistance strength training. In addition, 6 healthy elderly patients were randomly assigned to non–strength training regimens, such as swimming. At the end of the study, all participants in the strength training groups demonstrated significant improvement in strength compared with those in the non–strength training group; participants with rheumatoid arthritis demonstrated a greater percentage increase in strength than those in the other 2 strength training groups. There was no change in the number of painful or swollen joints in the patients with arthritis, but there was a significant reduction in self-reported pain and fatigue, as well as improvement in balance and gait.
