ARTHRITIS AND EXERCISE OVERVIEW

Exercise is known to have benefits for people with arthritis. However, many people with arthritis do not exercise, often because of joint or muscle pain, weakness, fatigue, or joint swelling. This can lead to loss of joint motion, stiffness, and muscle weakness and tightness. These problems can worsen fatigue and can cause joints to become unstable.

However, exercise can decrease pain and can enhance quality of life. Exercise is most beneficial if it is done on a regular basis. Most people can find a way to exercise without increasing their symptoms.

This topic describes the benefits of exercise for people with arthritis, including disease-specific exercise recommendations.

SUCCESS WITH EXERCISE

Stick with it — A number of factors can improve the chances of sticking with an exercise program long-term, including:

• Follow a simple regimen
• Set attainable goals
• Understand the importance and benefits of exercise
• Interact with others while exercising (ie, with exercise groups)
• Follow up regularly with a healthcare provider, such as a physical therapist or personal trainer, to provide encouragement and to make adjustments to the regimen

Exercise in a supervised setting may improve the chances of continuing long term, compared with unsupervised, home-based programs. However, people who are self-motivated and exercise at home may enjoy the benefits of equal effectiveness, lower costs, and more convenience.

Information on general exercise can be found elsewhere. (See "Patient information: Exercise (Beyond the Basics)".)

Benefits of daily activities — Some people are not interested in a formal exercise program but are able to perform daily activities such as light housework, shopping, gardening, clearing walks and driveways, caring for a child or grandchild, caring for an older person, leisure walking, or exercising in a pool. There are health benefits (largely cardiovascular) from these activities.

Exercise can be broken up into three or four 10-minute sessions per day; it does not need to be continuous to produce health benefits. Moderate intensity exercise is most effective if it is performed on most days of the week. However, exercising only one or two days per week is better than not exercising at all.

HOW CAN I PREPARE TO EXERCISE?

All people, especially those with arthritis, benefit from a balanced program of flexibility, strengthening, and endurance or aerobic exercise.

Talk to your doctor — Many people with arthritis can successfully exercise on their own. Before beginning an exercise program, contact your doctor or other healthcare provider to be sure it is safe. Specific questions to ask include the following:

• Are there specific exercises or movements that should be avoided? For example, after hip replacement, patients often have hip movement restrictions early in the recovery; patients with inflamed joints may be told to do range of motion exercises only.
• Are there specific exercises that should be included to maintain optimal health? For example, people with rheumatoid arthritis benefit from regular hand and wrist exercises to maintain range of motion and function. (See 'Disease-specific exercise suggestions' below.)
• Do I need to be evaluated by a physical or occupational therapist before starting to exercise? If you answer "yes" to the questions below, an evaluation may be helpful.

• Do stiffness, limited motion, or joint deformities make it difficult or painful to move?
• Have past exercise attempts been unsuccessful due to pain that does not go away with rest or a reduced exercise program?

Pain, stiffness, and fatigue are barriers to exercise success for many people with arthritis. Preparing for exercise can minimize these issues. Some people benefit from a warm shower prior to exercise. Cardiovascular warm-ups and cool-downs are recommended for all exercisers.

Warm up — The purpose of the warm-up is to improve circulation and to increase the temperature of muscles and joint structures so that the body is less stiff, movement is easier, and risk of injury is decreased. If you are successful, your body will feel slightly warmer than when you started. Stretching is best done after your exercise session as part of your cool down. Some people like to stretch after their warm-up.

People with arthritis may need a longer warm-up and cool-down. A three to five minute warm-up is recommended for the general population, while 10 to 15 minutes is optimal for people with arthritis. However, if you are walking slowly or exercising less than 10 minutes, you do not need a separate warm up-and cool-down.

Sample warm-up activities:

• Walk or bike at half normal speed
• Sit and perform range of motion exercises/flexibility exercises starting at the head and neck and progressing to the feet and ankles (ideally using the same muscles that will be involved in the exercise)
• March in place

Cool down — The purpose of the cool-down is to return your heart rate to a few beats above normal. This prevents a sudden drop in blood pressure, feelings of nausea, fainting, and dizziness.

Sample cool-down activities:

• Slowing down your walking or biking etc, gradually
• Lifting light weights
• Range of motion activities
• Stretching exercises

Stretching — Stretching returns muscles to their full length and reduces soreness after exercise. People with arthritis need to be more cautious if they have lax joints (extra mobility or hyperflexibility) or malaligned joints (eg, hand deformities, bowlegged). Flexibility exercises can include modified yoga and tai chi, as well as stretches.

ARTHRITIS EXERCISES

Exercises to improve muscle strength and build endurance are important components of an arthritis treatment program. Aquatic exercise and land-based exercise are effective at improving strength, function, and physical fitness.

Strengthening exercises — Strengthening exercises can help to improve joint stability and decrease pain. Examples of exercises that build strength include the use of free weights, weight machines, or body weight (eg, modified squats to build knee strength).

People with lax or malaligned knees should use caution with certain strengthening exercises because improving quadriceps strength (the muscles in the thighs) may speed the progression of preexisting arthritis. A physical therapist who specializes in treating arthritis-related knee problems can provide specific advice and can recommend exercises to balance strength building. Treatment may include modified exercises and appropriate bracing.

Tips for success

• Movements should be smooth, not jerky.
• Care should be taken to avoid gripping the weight or exercise machine handle too tightly.
• The weight should be light enough that the movement can be performed 8 to 10 times (one set) without pain or excessive fatigue.
• To avoid fatigue and joint stress, alternate one set of arm exercises with one set of leg exercises (eg, one set of biceps curls, one set of quadriceps curls, one set of triceps curls, one set of hamstrings curls, then repeat the circuit).
• The weight can be increased when 10 repetitions can be performed with ease and when the increased weight does not increase joint pain.
• People with inflammatory arthritis should err on the side of caution, and they should start with a lighter weight and increase slowly. For example, arm exercises can start with as little as 1 to 2 pounds (0.5 to 1 kilogram).

Endurance exercises — Endurance exercises work to increase the heart and breathing rates, which can improve heart health, lower blood pressure, and improve fitness. Exercise does not need to be strenuous; during moderate intensity endurance exercises, you should be able to carry on a conversation.

The type and amount of endurance exercise recommended depends upon a person's current fitness level. A person who has avoided exercise due to pain or lack of success might need to begin with just five minutes of slow walking. Low-impact exercises are preferable to minimize stress on the joints. Swimming and biking are low-impact or no-impact forms of endurance exercise that can be safely performed by most people with arthritis.

Aquatic exercises are of particular benefit for those with severe disease and/or a low fitness level, especially rheumatoid arthritis. The buoyancy provided by water decreases pressure on joints and allows a person to exercise without the constraints imposed by body weight. Aquatic exercise programs often include group exercises in the water or walking in water. If you like to swim but have shoulder or neck issues that make it difficult to turn the head, you may need to consult with a therapist to design a successful swimming program. Some people can successfully reduce neck movement by using a snorkel and mask.

In general, exercise should start at a low intensity and for a short time. It is normal to feel some joint or muscle soreness after exercising, although soreness should not last more than two hours. If pain or fatigue lasts into the next day, the exercise was probably too long or too vigorous.

Protect the joints — People with arthritis need to take a few extra precautions to protect their joints while exercising. The following tips are recommended.

• Walk on flat level surfaces, especially if prone to hip, knee, foot, or ankle problems
• Wear supportive footwear such as athletic shoes and use a shoe insert that supports the arches and provides cushioning (eg, Spenco) to reduce impact on hips, knees, and feet. The shoe's original liner may be fine, although an insert with additional cushioning is often helpful for people with foot or knee pain.
• Avoid jarring movements and high impact activities such as running
• Respect pain, do not ignore it, and monitor for pain during exercise
• Start slow and increase activity gradually
• Pay attention to posture and alignment
• Do not take excess pain medication prior to exercise; this can mask pain and cause you to over-exercise
• Caution is recommended after a knee or hip replacement. High impact sports such as running, football, baseball, basketball, and soccer are not recommended. However, participation in non-impact or low-impact sports such as swimming, cycling, or walking is encouraged.

Specific exercise instructions — Instructions for specific exercises for people with arthritis are available from the following resources:

• The National Institute on Aging website
  (http://www.nia.nih.gov/health/publication/exercise-physical-activity-your-everyday-guide-national-institute-aging-1)
• The Arthritis Helpbook [1]

DISEASE-SPECIFIC EXERCISE SUGGESTIONS

Inflammatory arthritis — Inflammatory arthritis is a condition that causes swelling and pain in joints. Examples of inflammatory arthritis include rheumatoid arthritis, psoriatic arthritis, spondyloarthropathy, and ankylosing spondylitis. (See "Patient information: Arthritis (Beyond the Basics)", section on 'Inflammatory arthritis'.)

• During an acute flare-up, reduce intensity and exercise time
• Many people need to rest during the day; long naps should be avoided to preserve nighttime sleep
• Avoid resistance exercise involving affected joints during acute flare-ups
• Do daily range of motion/flexibility as tolerated
• Avoid high-impact activities, especially while taking oral steroids
• Protect the joints, as described above (see 'Protect the joints' above)

Rheumatoid arthritis (RA) — Rheumatoid arthritis is a chronic inflammatory condition that can affect many tissues throughout the body. The joints are usually most severely affected. The number and type of joints affected by rheumatoid arthritis can vary widely, although joints on both sides of the body are usually involved. (See "Patient information: Rheumatoid arthritis symptoms and diagnosis (Beyond the Basics)" and "Patient information: Rheumatoid arthritis treatment (Beyond the Basics)", section on 'Exercise' and "Patient information: Rheumatoid arthritis treatment (Beyond the Basics)", section on 'Physical and occupational therapy'.)

• Morning stiffness related to RA often improves after performing stretching exercises, taking a warm shower, and/or using warm-up exercises. Performing flexibility exercises before sleeping can reduce morning stiffness (picture 1 and picture 2 and picture 3 and picture 4 and picture 5).
• Avoid extreme neck movements and do not put pressure on the back of the neck. Yoga positions such as the plough, headstands, and shoulder stands should not be performed. A safe stretch for the neck is shown here (picture 1).
• Avoid overstretching or applying too much force over malaligned joints, especially knees and fingers (most common for people with RA). Modify “all-fours” exercises (positioning on hands and knees) by using towel rolls or yoga blocks to avoid overstretching the wrists.
• Be sure to include hand and wrist exercises in your daily routine (picture 6 and picture 7). After doing dishes or after showering is a good time to do these exercises because hands are warmer and more flexible.

Ankylosing spondylitis (AS) — Ankylosing spondylitis (AS) is a chronic, inflammatory disease that primarily affects the back, neck, and sometimes hips. The most common symptom of AS is pain in the low back and hips. Pain, stiffness, and limited mobility in other joints also occur in some patients. (See "Patient information: Ankylosing spondylitis and spondyloarthritis (Beyond the Basics)".)

• Flexibility exercises for the neck, back, shoulders, and hips are especially important to maintain range of motion (picture 1 and picture 2 and picture 3 and picture 4 and picture 5 and picture 8).
• Be sure to include breathing and chest expansion exercises in your exercise program.

• Take a deep breath, allowing the chest to expand as much as possible
• Hold the breath for a count of three
• Exhale slowly through the mouth; rest for a count of three

• Muscle strengthening for the extensor muscles of the back and hips is needed to maintain erect posture (picture 8 and picture 9 and picture 10).
• Pay attention to keeping the neck aligned with the trunk to minimize pain during activity.
• Swimming is an excellent form of exercise if you are feeling stiff. A snorkel and mask can allow you to swim without turning your head to breathe.

Systemic lupus erythematosus (SLE) — SLE is a chronic inflammatory disease that affects various organs of the body. Joint symptoms occur in almost all patients and are often the earliest sign of SLE. The arthritis tends to occur in different parts of the body and does not usually affect both sides of the body the same way. Only a few joints are affected at any time. (See "Patient information: Systemic lupus erythematosus (SLE) (Beyond the Basics)".)

• Fatigue, shortness of breath, and pain with a deep breath (pleurisy) are common in people with SLE
• Pace yourself and break up exercise sessions into short sessions.
• Begin with breathing exercises and pay attention to breathing during exercise

• Take a deep breath, allowing the chest to expand as much as possible
• Hold the breath for a count of three
• Exhale slowly through the mouth; rest for a count of three

• Protect the joints during exercise (see 'Protect the joints' above)
• If you start to have pain in your hip or groin, check with your clinician. These can be signs that the head (top) of the femur is not receiving adequate blood flow, which can quickly destroy the joint and can potentially require joint replacement surgery.
• Performing stretching or flexibility exercises at night may help to reduce morning stiffness (picture 1 and picture 2 and picture 3 and picture 4 and picture 5).

Osteoarthritis (OA) — Osteoarthritis (OA) occurs as a result of a gradual loss of cartilage from the joints. OA can affect almost any joint, although it is most commonly seen in the hands, knees, hips, and spine. Common symptoms include pain, stiffness, some loss of joint motion, and changes in the shape of affected joints. (See "Patient information: Osteoarthritis symptoms and diagnosis (Beyond the Basics)".)

• Cartilage, which is worn down with OA, needs motion to help the joints stay healthy. People with OA generally benefit from a general exercise program that promotes healthy cartilage.
• Painful joints should be moved through a full range of motion every day to maintain flexibility and to slow deterioration of cartilage. For example, if the knees are affected, bend and extend the knees as far as comfortably possible several times per day.
• If you have knee OA, knee strengthening exercises can reduce pain and make it easier to walk, get up and down from a chair, and climb stairs (picture 10 and picture 11). Be sure to keep the joints in line by avoiding twisting motions or moving at an angle.
• Low impact activities (biking, swimming) are recommended when knees, hips, and spine are affected.
• Knee braces or other supports (eg, a Neoprene sleeve) may be helpful if there is pain while walking.

However, some knee braces are of little value for people who have active arthritis, significant joint instability, malaligned knees (bow-legged), or knees that “give out” as a result of arthritis. With a clinician's referral, an orthotist can provide an appropriate brace for these conditions and can provide instructions for wearing the brace correctly.

Fibromyalgia — The most common signs and symptoms of fibromyalgia are fatigue; tender points around the shoulders, back, hips, and knees; and generalized aching and stiffness. Joints do not become swollen as a result of fibromyalgia alone. (See "Patient information: Fibromyalgia (Beyond the Basics)".)

• Exercise, especially endurance exercises and gentle strengthening, is key to managing this condition
• Avoid very prolonged or vigorous exercise as this may worsen symptoms

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Arthritis and exercise (The Basics)
Patient information: Osteoarthritis (The Basics)
Patient information: Exercise (The Basics)
Patient information: Psoriatic arthritis in adults (The Basics)
Patient information: Psoriatic arthritis in children (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Exercise (Beyond the Basics)
Patient information: Psoriatic arthritis (Beyond the Basics)
Patient information: Rheumatoid arthritis symptoms and diagnosis (Beyond the Basics)
Patient information: Ankylosing spondylitis and spondyloarthritis (Beyond the Basics)
Patient information: Systemic lupus erythematosus (SLE) (Beyond the Basics)
Patient information: Osteoarthritis symptoms and diagnosis (Beyond the Basics)
Patient information: Fibromyalgia (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Nonpharmacologic and preventive therapies of rheumatoid arthritis
Nonpharmacologic therapy of osteoarthritis
Overview of joint protection
Overview of the benefits and risks of exercise
Overview of the therapy and prognosis of systemic lupus erythematosus in adults
Assessment and treatment of ankylosing spondylitis in adults

The following organizations also provide reliable health information.

• National Library of Medicine
  (www.nlm.nih.gov/medlineplus/healthtopics.html)
• National Institute of Arthritis and Musculoskeletal and Skin Disease
  (www.niams.nih.gov)
• American College of Rheumatology
  (www.rheumatology.org)
• Arthritis Foundation
  (www.arthritis.org)
• Spondylitis Association
  Phone: 1-800-777-8189
  (www.spondylitis.org)

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