Contrary to the perception that an intensive, weight-bearing exercise regimen increases the rate of radiological joint damage of the hands and feet in patients with rheumatoid arthritis (RA), a Dutch study suggests that a long-term, high-intensity program that results in improvement in aerobic fitness and involves "impact-generating" activities may have a protective effect on the joints of the feet.
A team from Leiden University Medical Centre, Leiden, The Netherlands, reported that 136 participants in a high-intensity exercise regimen developed significantly less radiologic damage than the 145 participants in a usual care (UC) physical therapy group. The mean increase in damage was 3.5% in the exercise group, compared with 5.7% in the UC group.
A subanalysis of the data showed that the joints of the feet were more protected than the joints of the hands in the high-intensity exercise group. The researchers, writing in Annals of Rheumatologic Diseases,1 also found that the rate of damage was independently associated with less disease activity, less frequent use of glucocorticoids, and an improvement in aerobic fitness.
"This is the first study to suggest that high-intensity weight-bearing exercise might retard radiographic progression in rheumatoid arthritis," said Richard Brasington, MD, Associate Professor of Medicine and Co-Director of Rheumatology at Washington University School of Medicine, St. Louis, Missouri. "Although there are conflicting data from previous studies, this work challenges rheumatologists to consider the recommendation of such exercise to our patients. These data will reassure patients currently engaged in such exercise programs that they are not putting their joints at risk."
Z de Jong, MD, and colleagues at the Department of Rheumatology at Leiden University Medical Centre, collected data on 281 subjects in RAPIT (the Rheumatoid Arthritis Patients in Training study) who completed a 24-month randomized controlled trial comparing the effects of UC with high-intensity weight-bearing exercises.
The researchers examined disease activity, use of medications, and changes in physical capacity and bone mineral density (BMD), and assessed the following joints: the 10 proximal interphalangeal joints, the 10 metacarpophalangeal joints, the wrists, the fifth to the second metatarsophalangeal joints, and the first interphalangeal joints.
They found that those individuals who had an improvement in aerobic fitness through diverse exercises such as bicycling, stepping, stair walking, and sports activities experienced a protective effect on the joints of the feet.
It has already been shown that a long-term high-intensity weight-bearing exercise program may increase physical capacity, functional ability, and emotional status of RA patients compared with UC physical therapy. However, the Leiden team said that little has been known about the effects of this type of exercise program on radiological joint damage of the hands and feet.
To date, 4 studies have reported the effects of long-term intensive exercises on the radiological damage of the joints of the hands and feet in RA patients.2-5 Three of the studies did not show any significant differences in the rate of damage of the joints between those in an exercise program and a control group.3-5 One study showed a decreased rate of radiological damage of the joints of the hands and the feet.2
The researchers report that these study findings support the theory that loading of the skeleton by weight-bearing and impact-delivering exercises may activate bone remodeling. They said this may increase BMD and production of bone, which may be more resistant to stress. This hypothesis may explain why the greatest benefits were seen in the joints of the feet instead of the hands.
The authors concluded, "This is the first time that improvement in aerobic fitness has been shown to predict, independently of other factors, a decrease in the rate of local bone damage."
Reference:
- De Jong Z, Munneke M, Zwinderman AH, et al. Long term high intensity exercise and damage of small joints in rheumatoid arthritis. Ann Rheum Dis. 2004;63:1399-1405.
- Nordemar R, Ekblom B, Zachrisson L, Lundqvist K. Physical training in rheumatoid arthritis: a controlled long-term study Scand J Rheumatol. 1981;10:17-23.
- Hansen TM, Hansen G, Langgaard AM, Rasmussen JO. Longterm physical training in rheumatoid arthritis. A randomized trial with different training programs and blinded observers. Scand J Rheumatol. 1993;22:107-112.
- Stenström CH, Lindell B, Swanberg E, Swanberg P, Harms-Ringdahl K, Nordemar R. Intensive dynamic training in water for rheumatoid arthritis functional class II â€" a long-term study of effects. Scand J Rheumatol. 1991;20:358-365.
- Häkkinen A, Sakka T, Kotaniemi A, Hannonen P. A randomized two-year study of the effects of dynamic strength training on muscle strength, disease activity, functional capacity, and bone mineral density in early rheumatoid arthritis. Arthritis Rheum. 2001;44:515-522.