A presentation on exercise with RA I gave to University of British Columbia kinesiology students in March 2023

Nearing 8 years into my diagnosis I’ve learned a few things to self manage my rheumatoid arthritis. 

When people ask me what helps with my disease, I don’t respond first with my medications, even though those have advanced over the years, help reduce the symptoms of this aggressive disease and make exercise a lot easier.

Research actually suggests that regular exercise can improve the efficacy of our medications. 

My answer to what really helps me will be exercise because movement really is lotion when living with this creaky disease. 

Exercise also doesn’t just help with my arthritis but my overall well being, important when RA tends to come with friends (comorbidities). Not only do I live with RA but I also have osteoarthritis, fibromyalgia, anxiety and depression. Each adds an extra barrier to my ability to exercise but are improved by exercise. 

There was a time where exercise was not suggested for people living with arthritis, instead patients were told to not exercise and only focus on bed rest. 

However now research shows exercise can help reduce the symptoms of arthritis and reduce the risk of serious comorbidities associated with arthritis or not enough physical activity. 

Excessive rest can worsen arthritis – Sitting too much is now the new smoking, but also excessive exercise can aggravate rheumatoid arthritis.

It is a challenge finding the right balance of appropriate amount of exercise and rest when living with RA but after some trial and error, participation in research and consulting with health care professionals, I found my stride and understanding of rheumatoid arthritis. I now understand  strength training is safe for people with arthritis. They just need to be educated on it properly.

Finding the right help

Since September of 2018 I have been partnering with Arthritis Research Canada as a member of their arthritis research patient advisory board. Through this board I joined as a patient partner in a study that truly sparked my interest as someone living with rheumatoid arthritis. 

The study,  I START – Improving Strength Training and Tailoring Among People with Rheumatoid Arthritis conducted by Arthritis Research Canada and the University of British Columbia led by Dr. Jasmin Ma (kinesiologist). The purpose of this study was developed to tackle the issue of why 86% of people with RA do not strength train and how exercise professionals can better assist RA patients with a tailored prescription in strength training. 

Now coming up to my 5th year into this partnership I have presented at conferences, webinars and even hosted an exercise class for arthritis alongside Jasmin. I think this has been a perfect example of effective patient engagement in research and program development to help patients live a healthier life. Thanks to this partnership I have learned so much and gained confidence in exercise. 

It wasn’t just this study that helped me learn to be physically active with this disease. I am grateful for the guidance on how to safely exercise that I have received from skilled physiotherapists and kinesiologists studying exercise and arthritis.

I have hired personal trainers or gone to the nearest physiotherapy clinic, only to feel I wasn’t finding the right advice I needed for my needs as someone living with inflammatory arthritis.

From my experience, unless they have a background in arthritis care, RA is often not properly understood by even many exercise experts. 

For example, the only experts who have addressed brain fog with me, a big part of living with RA, was by arthritis researchers or healthcare professionals who have taken the Arthritis Continuing Education Program through the Mary Pack Arthritis Clinic. They’ve also been the only ones who have helped me through exercising with fatigue, pacing myself and understanding RA better.

I regularly see a physiotherapist at Burnaby General who has taken the ACE program and his care helps me tremendously, especially the dry needling he does on my back. Seeing him regularly helps keep me motivated, answer any questions I have about my routine, posture and form, it helps keep me accountable for exercising. 

My advice for patients is to ask their rheumatologist if they know of any physiotherapists with extensive knowledge in inflammatory arthritis. 

Exercising with RA isn’t just a walk in the park though

There are unique barriers to exercising with RA. From fatigue, pain, medication timing, surgeries, infections, depression, anxiety, mobility issues, hand pain and strength, cognitive dysfunction, and painsomnia are just some of the physical barriers to regular exercise with this disease. The ISTART study identified over 50 different barriers unique to strength training with RA. 

There’s also time, balancing our ability with what we can handle in a day before we have done too much, knowing how to exercise safely, what equipment to use, weather, environment, costs and location. 

I had a lot to work through before exercise could become easier and consistent with this bumpy disease.

My Personal Barriers to Exercise

For me my biggest barrier remains to be depression and fatigue. Both are incredibly common in those with inflammatory arthritis.

Fatigue robs me of energy, making tasks like showering, the dishes, laundry, preparing food, all physically and emotionally draining. Fatigue weighs me down. 

Depression can significantly reduce the ability to experience pleasure and joy in simple daily activities often making things feel like a massive chore to complete. This illness can impact my confidence and my motivation to exercise. 

Regular exercise can significantly help with these emotions, however getting started is really the hardest part next to staying consistent.

How do I get through this and keep moving? Medications,therapy, knowing how exercise will make me feel after, finding things I do enjoy like painting, gardening, writing and spending time in nature. Volunteering and being an active patient advocate has done me wonders. 

What I Have Learned About Exercise Over The Years

There is no doubt that exercise can be healthy for the majority of people, but for someone living with rheumatoid arthritis, it can be critical. 

What exercise improves living with RA:

• Sleep 
• Stamina
• Balance
• Pain Reduction – Reduces inflammation and joint stiffness
• Corrects Posture
• Mental Health and Cognitive Health
• Reduces comorbidity risks – Especially cardiovascular disease, the leading cause of death of people with RA
• Assists in maintaining a healthy weight and takes a load off the joints
• Medications work more effectively
• Prevents sarcopenia – Muscle loss and strength that is common in people with RA

Consistency 

Consistency can be difficult when living with a bumpy chronic illness. I often feel like I have to go through moments where I need to pick myself back up and start over because my disease got in the way. I can experience a lot of guilt and negative emotions when this happens but the important thing is I pick myself back up and to not let myself stew in those negative emotions. 

There are events that stop me from exercising that are out of my control. Those include surgeries, tests, infusions, my menstrual cycle, or infections. 

Motivation

Finding ways to stay motivated and developing healthy habits is another way to tackle this barrier. For me, being an active patient partner in research and advocacy keeps me incredibly motivated. Working with physiotherapists and kinesiologists, having a buddy to exercise with (my son), music that gets me moving or a reward like a sauna session after keep me moving. 

Switching up my exercise can be motivating too, especially if it is something I can do outside like hiking, swimming or riding a bike. The warmer months are incredibly motivating to be more active for me. The winter is more draining and difficult to stay motivated. Regularly supplementing with vitamin D can significantly help with higher fatigue in the winter, the sauna can help warm me up. It is very common for people with RA to be deficient in vitamin D. 

Knowing the right time to exercise 

Finding ways to add exercise into my day, rather than stressing out some perfect fitness program everyday is just as good a way to exercise. If I am really busy one day and can’t spend a full hour working out, I might try adding it into my day. This is also helpful on the high fatigue days when I can only handle small amounts of exercise at a time. If I have a strenuous job around the house that day, like mowing the lawn or a deep clean of the house, I might include that as my exercise rather than focus on my tailored routine. 

I do find this extremely beneficial when living with RA because if you have a job that requires a lot of sitting at a computer, it can help alleviate pain. Another reason it is a great way to build strength over time without pushing too hard at once.

I prefer exercising in the morning when I have the most energy or throughout the day as I am working on my computer. I do not like evening exercises. I turn into an arthritic pumpkin around 5 or 6 pm, especially in the winter. Exercising regularly does help reduce my arthritic pumpkiness though.

Knowing when to not exercise

I will not exercise when one of my healthcare providers tells me not to. This could be after surgery, a cortisone injection, injury, biopsy or infusion. Chronic illness is bumpy so I do go through periods of a time when I’m told to avoid exercise. I’ve made a point to always ask if it is OK to exercise and if not how long to my doctor or healthcare provider at that moment.

Due to being immunocompromised I may take longer to heal than the suggested time to avoid exercise, so it’s important for me to listen to my body and to go slow after an extended period away from exercise. 

Finding My Stride Through Trial and Error

What happens when I exercise too much:

• Joint aggravation which feels like hot burning pain with swelling that feels like jelly under my skin 
• Sore muscles
• Increase in fatigue and cognitive dysfunction (brain fog)

Pain can happen right away from doing too much intensity or having improper form. If I have overdone it the pain or increase in fatigue can show up from 2 hours to 48 hours later, then I know I have over done it. 

Rest is as important as movement but balance is important. If I feel like I need to rest for an extended period of time, like more than two hours after a workout, I probably over did it. 

Another way I tell if I have over done it, particularly with walking or running, is when my lower legs flare up. If I spend too much time on my feet, especially with the wrong shoes, my feet, ankles, knees, hips and lower back will let me know.

The beginning isn’t easy

Many people with chronic illness can experience heightened fatigue after just about anything we do. On the bad days, a shower can wipe me out so thinking of doing a strenuous workout might not be appropriate for that day. It’s important to go slow, at your own arthritic pace. 

When I restart my exercise program I usually do experience some heightened fatigue but this goes away within the first week as I’m getting stronger from the benefits of exercise. That first week however really sucks and I need to push through it. 

I use heightened fatigue that lasts more than 3 days as a warning sign something might be going on with me. Examples have been injury, infection, nearing my menstrual cycle or my medications are wearing off. Another could be I am just overdoing it. If I have unexplained heightened fatigue for longer than 3 weeks I will contact my rheumatologist to investigate. Monitoring my blood work regularly is important, but I must exercise before, not after the blood work draw. 

What happens when I do not exercise enough

• Increase in stiffness
• Balance and posture worsen
• Require more naps in the day and an increase in fatigue
• Fragmented sleep with an early bedtime
• Putting myself at risk for serious comorbidities
• Decline in my mental health

Mistakes I Made Exercising With Rheumatoid Arthritis

At the time of my diagnosis I was living across the street from a community center which had a gym, pool and sauna. I wanted to lose weight and get healthier but I also could barely handle a 6 minute walk to the train station or around a grocery store. 

I had to muster up a lot of courage to enter the gym and start on the elliptical but I am grateful I did. I would push myself to do 30-60 minutes on the elliptical, as many days of the week I could do, followed by the sauna after my workouts. The elliptical and cardio did a lot for me. I was able to lose a significant amount of weight, gain lower body strength and improve my health. 

I relied on YouTube exercise videos, which certainly never addressed concerns like inflammation or mobility issues and were mostly taught by influencers or personal trainers, not trained healthcare professionals that knew about RA.  

I attempted to go to an exercise class at a local community center that advertised it as accessible for all abilities. That day was gray and gloomy, I was highly fatigued. The class was 45 minutes long with no break. I felt embarrassed because women older than me had an easier time with the work out than I did. At one point the instructor called me out for not being able to keep up. This crushed my confidence in exercising, especially in public. 

I was intimidated with strength training because I did not know how to, especially the weightroom in my gym. The machines seemed confusing and I felt insecure about not knowing how to do strength training, so I mostly avoided it. 

Another mistake I made was, I really had no routine or goals set. Pushing myself too much on the elliptical often left me with heightened fatigue. I was constantly overdoing it because I felt I wanted to be like a regular healthy person who can handle more. I had to accept that I was living with rheumatoid arthritis and life would look a little different for me. 

What Helps Me Exercise With Rheumatoid Arthritis 

• Get supportive footwear and comfortable clothing to exercise in. When it comes to footwear I have had the most luck with shoes that are available in wide width. Sweat makes clothing stick, which can be uncomfortable with arthritic joints, so I wear looser clothing or light fabrics. For sports bras, one’s that are a light fabric or front zip are easiest to remove when moistened. 
• Do a little bit each day until I gained more strength
• When starting a new medication it is important to give my medications time to start working. If my medications are not working I go slow and light. 
• Focus on healthy eating along with my workouts with a goal to avoid sugar and junk food that slows me down
• Allow myself to rest
• Found credible resources and education for exercising with arthritis

I have exercises for the good days, bad days and days in between. The key is to keep moving, give my body the rest it needs and listen to my body for subtle signs of what it needs. 

How I Exercise Now

After all the trial and error, consulting with healthcare professionals, participating in exercise research studies, talking with other patients, and learning to listen to my body I have learned to be confident and comfortable with exercise. Here are some tips that have really helped me exercise easier with RA:

Warm up is important

I make a point to stretch before I exercise, this can help alleviate stiffness that makes moving difficult if I don’t warm up properly. 

Doing a 10 minute warm up on my treadmill before strength training to loosen the muscles which makes strength training easier and less painful. I’ve learned this is important to activate our muscles and prevent pain. 

A warm up is also a great way to tell how I am feeling that day. On the days where I really struggle with my warm up I can tell I need to focus on rest and I’ll go slow, only doing one set of the exercises I feel comfortable with. I do make a point to try and keep moving on the bad days but very gently. On bad days I’ll do range of motion and stretching at home, or go to the pool and move around in the water. 

Exercise for how I feel that day

If my warm up was easy and I feel like I want more, I know this is a good day and will do my best to accomplish my exercise routine that day.

I make a point to plan my exercise when medication is most effective. I currently take my biologic in the evening before bed but I do take an anti-inflammatory with my breakfast before I exercise. I also take my daily supplements with my breakfast. I do find this helps with reducing pain and fatigue. I have had trouble with vitamin deficiencies before, iron, copper and vitamin D in particular which make exercise difficult. Vitamins and supplements need to be talked about with healthcare professionals before taking them though. 

Which muscles to focus on first

I start with the core or shoulders when strength training. Something Dr. Jasmin Ma taught me was that it is important when living with RA to engage the smaller muscles first to better support joints for when activating the larger muscles as it works like a wake up call for them. This also provides more stability when performing exercise.

Intensity

Some tips that really helped me understand and prevent pain that comes with exercise.

A little discomfort is ok. Muscle pain is fine, joint pain is not. I actually crave that muscle soreness that exercise creates. Watching how I feel after 2 hours, 12 hours, 24 hours and up to 48 hours can tell me when I have done too much. If I experience discomfort in my joints or more than usual muscle soreness, I know to reduce my intensity.

Pros to working out at home when living with RA

• I can move at my own arthritic pace
• I can take rests from equipment without someone else taking it over during my rest
• I know my equipment is clean and free from germs
• I can experiment without worrying people are looking at me
• I can be in tune with my body better without the distractions of others
• I can exercise exactly when I want to
• I can workout throughout the day

Cons to working out at home with RA

• More distractions
• No social connection – it’s kind of lonely
• I get less steps or fresh air
• Add Less equipment
• No staff present in the event that I need help

Equipment I Own

• Treadmill with handrails
• Step
• Loop resistance bands
• Resistance bands with handles and a door anchor
• 2 lbs, 5lbs, 8lbs and 10lbs dumb bells
• 10lbs kettlebell
• 20 lbs plate
• 2lbs Cuff weights
• Nordic Walking Poles by Urban Poles
• Pilates bar 

What my workout routine now  looks like after a lot of tailoring.

Workout A – Monday, Wednesday, Friday

Good days 3 sets of 10-15

Not so good days – 1 set of as many as I can do and feel comfortable doing

Extremely high fatigued or inflamed days – Just focus on rest and range of motion exercises

10 minute warm up

Core – Bird Dog

Push – Chest Press

Pull – Lat Pulldown

Hinge – Romanian Deadlift

Squat – Goblet Squats

10 minute treadmill

Core – Plank – On forearms, not wrists

Push – Shoulder Press

Pull – Seated Row

Hinge – Glute Bridge

Squat – Reverse Lunge

10 minute treadmill

Core – Dead Bug

Squat – Curtsy Lunge

Workout B – Tuesday, Thursday, Saturday

Good days 3 sets of 10-15

Not so good days – 1 set of as many as I can do

Full body stretch

10 minute warm up on treadmill

Core – Flutter Kicks

Push – Arnold Press

Pull – Reverse Fly

Hinge – Kettlebell Swings

Squat – Side Lunge

10 minute treadmill

Core – Russian Twists

Push – Side Raises

Squat – Squat

10 minute treadmill

Core – Superman

Push – Front Raises