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Medicine Matters rheumatology

Hello, and welcome to the fourth Medicine Matters podcast in a series on quality of life. Today, we will be talking to Dr Dana DiRenzo, from Johns Hopkins University in Baltimore in the USA, about physical activity in patients with rheumatic diseases.


Firstly, Dana, why is exercise important for patients with rheumatic diseases?


Exercise is important for patients with rheumatic disease because it has very few negative side effects and essentially all positive side effects. So any type of physical activity, especially if you do it on a routine basis, is going to improve disease activity and that has been found in a number of different studies in patients with inflammatory arthritis. It improves cardiovascular health, it improves bone health, decreased bone loss, and improves overall quality of life, fatigue, pain. And it also improves joint disease, so you have slower radiographic progression and joint space narrowing for patients who routinely engage in physical activity. I would say that overall, in review of the literature, the most effective and the safest exercise protocol remains unclear, it’s really tailored to the individual. So again, it would have to come down to the individual trying several different programs or modalities and finding out what is the best fit for them. The data is clear that having an exercise program is going to improve outcomes.


What types of physical activity are best for patients with rheumatic diseases, and are there any activities that should be avoided?


No activity is perfect, but also no activity is strictly off the table in terms of exercise. Certainly, if you have severe arthritis in your knees, you should avoid something like high impact aerobics or long distance running, but if you do not have any specific “problem” joints, then there are not necessarily activity restrictions. So I recommend talking to your rheumatologist about your joints in detail, and you could come up with a plan with the rheumatologist in terms of activities might be best. I am a huge fan of a variety, a mix of both aerobic and core strengthening activities. So combinations may include a walking routine, or practicing yoga several times weekly. It is important for those with arthritis to improve core strength which improves stability in the body. So, I could just touch upon a few different options.


First of all I’ll talk about yoga. So, there are many different styles of yoga, each optimal for different populations. Performing the physical poses can improve fitness by increasing strength, flexibility and balance, and of course, there is added benefit of stress-reduction during the guided meditation portions. If you are starting a yoga regimen for the first time, it is important to discuss this with your doctor and the instructor. If you’re starting for the first time I would say to avoid hot yoga or high intensity flow classes. Trying gentle yoga, restorative yoga, or chair yoga is a good way to start.


Another type of modality is aerobic exercises. Examples of this include walking, running or cycling. If you are an individual who has a lot of knee problems then cycling would be best as it is lower impact. So if you are having any problems with the joints in your legs to begin with, then I would actually recommend doing more of a combination of things. So if you wanted to find the cardio equipment at the gym, this is a great way to improve on strength that is typically lower impact. So this would be something like the elliptical machine. Again, I recommend meeting with a trainer for a session or two to design a workout regimen that is tailored, and then they can watch you operate the equipment and make recommendations on how to optimize your form. A physical therapist can also help you come up with a different regimen as well.


And then another type of modality would be resistance training. So this is going to build up muscle strength and endurance. If you have joint limitations, let’s say if you have limitations in your grip or your range of motion in your upper extremities, it may be a good idea to meet with a physical therapist or trainer to discuss ways to modify the equipment that’s going to help with the different activities and exercises you’re going for.


What challenges do patients face when participating in physical activity?


I think the biggest challenge may be modifying the physical activities to your body. Therefore, it is important to keep an open dialogue with your physician as well as your trainer or instructor. For example, we just touched upon yoga. If you have limitations in your joints, some of the poses may be challenging and it may be better to modify or adjust the different postures. So talking to your yoga instructor prior to class to come up with solutions or modifications for your joints will be key. Another challenge that that many patients with rheumatic disease face is fatigue. Although it is easier said than done, exercise is absolutely one of the best ways to improve energy levels. It releases endorphins and it elevates your mood. It also helps with sleep.


How can rheumatology healthcare professionals address patient physical activity in general appointments?


You want to tell them that different exercise programs are safe, and that they actually improve disease activity. If you are a rheumatologist and you are not quite familiar with the different resources available in the community, you want to educate yourself. So you want to know what are the different programs available to you, and you want to know the different trainers and physical therapists who are going to help you. And this is going to be able to facilitate meeting goals for your patients. And then, related to physical activity, there are several different modalities that we were touching upon, so patients can go in person to get this one-on-one training. They can even do group based programs that may not be supervised, and then they can even watch things that are online. So monitoring your patients throughout their exercise program, having them check in with you and tell them and discussing how they are doing, that’s going to be key.


I like to ask my patients what activities they do throughout the day, including exercise, and what activities they WISH they could be doing but their disease is holding them back from. It is at this point in the conversation when I begin to suggest different types of exercise depending on interest. You can also do simple questionnaires to gauge physical function- which may be a segway to discuss physical activity. This might be something like the health assessment questionnaire, the PROMIS physical function form, or the physical function scale on the short form of the SF-36.


Finally, are there any tools or strategies to help patients monitor and improve their activity levels?


There are multiple tools to monitor activity levels. Smartphone apps, Fitbits, smart watches. These can vary in price. But likely the easiest way to monitor your activity would be with a smartphone application, counting steps for example. If smart technology is not available to you, there is nothing wrong with a good old fashion pen and paper. So keep a log, keep yourself on track. This may also allow for goal setting. For example, yesterday I did 5000 steps, today I want to do 6000. Or I rode the bike for 20 minutes at the gym and my goal today is 30 minutes.


You don’t have to work out every day to gain benefit, every little bit counts. You can also incorporate exercise into your work day, for example take the stairs, or park at the end of the parking lot. You can even do chair yoga to break up your work day, and you could do that at your desk. It is also important to note that exercise is not “damaging” to your joints, so exercise is encouraged. Weight bearing activities strengthen bone and decrease your risk for osteoporosis.


The important thing is that exercise is very specific to the individual. 10 minutes of walking may be a great goal to get started for someone who may be very ill, and then you could build upon this, you could build up your stamina. But goal setting and discussing these plans with your doctor is key. Also having friends or work-out buddies helps as well.


So, exercise has many benefits for patients with rheumatic diseases, including improvement in disease activity and quality of life. While patients may face challenges in increasing their level of physical activities, there are several tools and strategies that can help patients to improve this.


Thank you very much to Dana for sharing her thoughts with us on this topic. You can find links to the other podcasts in this series on Medicine Matters rheumatology.