For a number of years now I have given a presentation on how physiotherapy can help me self manage rheumatoid arthritis to University of British Columbia physiotherapy students. Each year I appreciate being able to speak candidly about how physiotherapy has been a crucial part of my self management with RA. I create blog posts out of these presentations so others can learn from my presentation, patients or clinicians!
Physical Activity and Rheumatoid Arthritis: How Physiotherapy Has Helped Me Move
A decade with rheumatoid arthritis has taught me something surprising: when people ask what helps most, I don’t start by talking about medications. Yes, the drugs have gotten better over the years, and they help tame this aggressive disease. But that’s not the whole story.
The real game-changer? Exercise or Physical Activity. Research shows that regular movement actually makes our medications work better. This matters a lot to someone like me who’s cycled through more than a dozen different drugs for RA alone, not counting the medications for everything else that often comes along with RA.
Living with RA means dealing with unwanted guests – in my case, that’s osteoarthritis, fibromyalgia, anxiety, depression, ADHD, premenstrual dysphoric disorder (PMDD), and high blood pressure. Each one makes exercise harder, yet each improves with the right movement. The tricky part is knowing how to safely and effectively exercise with RA while balancing the appropriate amount of rest I need. Physiotherapists have been invaluable in helping me navigate this balance.
Finding the right help Is Critical for self managing rheumatoid arthritis
Since 2018, I’ve served on Arthritis Research Canada‘s patient advisory board, participating in studies that have transformed how I manage my rheumatoid arthritis and connected me to clinicians who really understood arthritis. Finding the right guidance hasn’t always been easy though, and I am privileged to live so close to Arthritis Research Canada and The Mary Pack Arthritis Clinic Vancouver Location. Not everyone is so lucky to have this type of care and information within 20 minutes of where they live.
I’ve worked with various personal trainers and physiotherapists, but many lacked the specific knowledge needed for someone with severe seropositive RA. They couldn’t offer tailored advice for exercising through fatigue or managing inflammatory arthritis’s unique challenges. Looking back, I can see their hesitation when discussing my condition – a clear sign they needed more specialized training.
What’s made the real difference? Working with physiotherapists and kinesiologists who have taken advanced training in rheumatic diseases. Their deep understanding of RA has been invaluable and taught me more about my condition, not just how to navigate it. My advice to other patients is ask your rheumatologist to recommend physiotherapists who specialize in inflammatory arthritis. In my experience, they’re just as crucial to your care as your rheumatologist.
At one point I was seeing a pain specialist who was doing myofascial release and lidocaine injections in my back. I got minimal relief from these and actually dropped seeing the pain specialist when I met my new physiotherapist who I found more helpful for my pain. One of the treatments he does that has significantly helped me is Dry Needling. He also has a deeper understanding of rheumatic diseases as he works in a hospital and has advanced training through the Mary Pack Arthritis Program. Another reason I chose to go to him instead is because he is significantly closer to my home, less than a five minute walk, where the pain specialist took me 40 minutes to get to. When you live with fairly severe chronic fatigue, how far your treatments are from you really does matter. He was also the first and only clinician of mine to ever address how brain fog affects me.
In my opinion, the right care will listen to me, engage with me and educate me.
Important Questions I’ve Asked My Physiotherapists
I have been going to physiotherapists for about 9 years now into my diagnosis, these would be some of the most important questions I have asked my physiotherapists or topics they have addressed to me.
- What are the best exercises to do to improve my posture?
- What exercises can help me reduce pain?
- What should I look for in footwear to help with avoiding pain?
- Is it safe to exercise in a flare? How can I exercise in a flare without causing pain and irritating my joints?
- What pain should I be looking out for and what pain should I expect?
- How can you help me memorize my exercises with cognitive dysfunction?
- How do I exercise with fatigue?
- What exercises should I avoid?
- How can I protect my joints with exercise?
- What time of day is the best time to exercise?
- What counts as physical activity?
- What are some signs I am over doing it with my physical activity?
My Personal Barriers to Physical Activity
Exercising and being physically active with rheumatoid arthritis (RA) presents unique challenges. Physical barriers include fatigue, pain, medication timing, surgeries, infections, depression, anxiety, mobility issues, hand pain and strength, cognitive dysfunction, and “painsomnia” (pain-related insomnia). Additionally, time constraints, balancing activities (especially as a single mother who recently went back to work after years of being on disability from RA), safe exercise practices, suitable equipment, weather, environment, costs, and location also pose challenges.
For me, depression and fatigue are my biggest barriers. Both are common in those with inflammatory arthritis. Fatigue saps my energy, making everyday tasks like showering, dishes, laundry, and meal prep physically and emotionally draining. It feels like a heavy weight. Depression further reduces the joy in simple activities, turning them into massive chores. It impacts my confidence and motivation to exercise. The combination of the two is even more difficult to navigate than chronic pain.
- 2023 EULAR recommendations for the management of fatigue in people with inflammatory rheumatic and musculoskeletal diseases
- Research progress on rheumatoid arthritis-associated depression
What Happens When I Exercise vs What Happens When I Don’t Exercise
How I feel when I am physically active compared to how I feel when I am not physically active is definitely something to keep me motivated to stay physically active. This is what I experience and my concerns about not being physically active or the nature of my disease:
| When I Am Not Physically Active | When I Am Physically Active |
|---|---|
| -Increase in stiffness and pain -Handle less in a day -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 -Weight gain – especially depending on what medications I am on like prednisone | -Improvement with sleep -Increased stamina and ability to do more in a day -Balance improves -Pain Reduction – Reduces inflammation and joint stiffness -Corrects Posture -Mental Health and Cognitive Health improve -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 |
Further reading:
- Benefits of exercise in patients with rheumatoid arthritis: a randomized controlled trial of a patient-specific exercise programme
- The Effect of Exercise on Sleep and Fatigue in Rheumatoid Arthritis: A Randomized Controlled Study
Learning Curves To Being Physically Active With Rheumatoid Arthritis:
Learning how to exercise on the good days, the bad days and the in between days – Living with rheumatoid arthritis means accepting that consistency isn’t always possible – Because of how bumpy this chronic disease is. More often than I like, my disease forces me to start over. What matters is getting back up, not dwelling on setbacks I often experience. Life with chronic disease throws inevitable hurdles my way – surgeries, infusions and medication disruptions, infections, injuries, trauma, mental health, even my menstrual cycle can throw me off immensely. I feel like I am constantly having to pick myself back up with this chronic progressive disease. That first week back to exercise is particularly challenging – the fatigue hits hard, but it usually improves as my body adapts. I need to carefully balance how I get started into adding exercise back into my routine due to the heightened fatigue at first. If I know I have too much on my plate at the moment, I need to make very small steps at an arthritic pace.
Knowing when not to exercise is just as crucial as knowing when to move. I always follow my healthcare providers’ instructions after procedures or treatments. Being immunocompromised means I often need longer recovery periods than suggested. After my recent surgery, even though I was cleared at 12 weeks, my body needed more time. Exercising at the wrong time of the day
Originally I looked for influence and information in the wrong places – Trying to exercise like someone without rheumatoid arthritis and taking advice from people who don’t know much of anything about rheumatoid arthritis and would suggest me high impact exercises best suited for a body builder. Navigating unsolicited bad advice with chronic disease is another chapter of the difficulties we have to go through. My confidence hit rock bottom during a supposedly “all-abilities” exercise class. On a gray, exhausting day, I struggled through 45 minutes without breaks while older participants breezed through the routine. When the instructor called me out for falling behind, I wanted to disappear. Public exercise became my new fear. Having credible resources and the right advice is critical to safely exercising with rheumatoid arthritis. Find a list of resources here.
At first I did not allow myself to build up to high intensity exercise – At first I thought I had to exercise like someone who wasn’t dealing with chronic pain or fatigue. Meaning I would go into the gym and expect myself to do a minimum of 30 minutes on the elliptical 5 or 6 times a week and then strength train after. I was often left feeling pretty burnt out after this. I require rest after physical activity but If I need more than a few hours to recover from a workout, that’s my body telling me I’ve pushed too hard. Since then I have learned that doing a little bit each day, listening to my body and allowing myself to build up to higher intensity when my chronic illness drags me down is most important. 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.
Focusing on cardio before strength training – Something that made navigating an exercise routine quite challenging when living with RA was not knowing what muscles or part of my routine to start with first. I never really considered how important warming up to exercise was until a kinesiologist pointed out to me why.
What Helps Me Be Physically Active With Rheumatoid Arthritis
Understanding that exercise is not one size fits all – Learning that my daily house work, gardening, or running errands also contributes to my daily physical activity. This helps me plan my day better when living with rheumatoid arthritis because often a work out at the gym and then running errands or doing house work can be too much in a day for me. Knowing that my regular activities also contribute to me being physical active helps me pace myself and eliminates emotions of guilt when I can not make it to the gym or do a full work out on a busy day. Exercise for how I feel that day.
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 to prevent more 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 and another set later in the 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.
Variety of physical activity that I enjoy doing – Doing only one exercise routine gets boring so having a mix of physical activity I enjoy keeps me interested. These include hiking, swimming, or biking outdoors, especially during warmer months.
Timing is everything – I prefer to focus on my exercise routine during my best hours, which are usually in the morning though that is not always possible. I’ve learned to weave movement into my day rather than forcing myself into rigid workout schedules when not an option for me.
Medications and their role – I make a point to plan my exercise when medication is most effective, this means I will take my medication before something strenuous to prevent further inflammation. When it comes to my biologic infusion I know that getting closer to my infusion date my ability to handle more strenuous exercise goes down. I refer to this period of time as the Nightmare Before Infusion Day.
Home Gym – Being that I am immunocompromised, some times I am forced to keep my physical activity at home or out in nature. Having the equipment I need at home helps me stay active when it is better I avoid crowds of people.
Visuals and organization – I often struggle to remember things for a variety of reasons, cognitive dysfunction from rheumatoid arthritis is one. So having visuals and neatly organized routines helps me memorize the movements with more confidence.
Equipment I Use To exercise with rheumatoid arthritis
| Equipment I Use | What Else I Use |
|---|---|
| -Treadmill with handrails (own) -Elliptical (gym) -Step -Loop resistance bands -Resistance bands with handles and a door anchor -2 lbs, 5lbs, 8 lbs, 10 lbs, 15lbs dumb bells – Having multiple weights for good days, bad days and in between days or different joints with varying strength and ability -10 lbs and 15lbs kettlebells -20 lbs plate -2 lbs Cuff weights -Nordic Walking Poles by Urban Poles -Yoga mat | –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 and half size up. 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 opening are beneficial. -Sauna -Ice Packs and Heating Pads |
The Strength Training Exercises I Am Comfortable Doing and Find Relief From
| Core | Push | Pull | Hinge | Squat |
|---|---|---|---|---|
| -Bird Dog -Plank -Dead Bug -Flutter Kicks -Russian Twists -Superman | -Chest Press -Shoulder Press -Arnold Press -Side Raises -Front raises | -Seated Row -Lat Pulldown -Reverse Fly | -Romanian Deadlift -Glute Bridge -Kettlebell Swings | -Reverse Lunge -Curtsy Lunge -Goblet Squats -Side Lunge -Squat |
Good Days, Bad Days, In Between Days
Good Days – I can get through my entire strength training routine doing three sets and/or do some sort of cardio. These days I aim for 10,000 steps.
In Between – I might only focus on rest and range of motion exercises, maybe some light strength training doing only 1 set of as many ST exercises as I can do and feel comfortable doing,. This might also include a walk around my neighborhood or a swim and sauna session.
Bad Days – Some days I need multiple naps and mostly just need to focus on getting through the day with light movement.
Conclusion/Recommendations
As physiotherapists it is important for you to understand all the symptoms of rheumatoid arthritis and how to help us navigate them. Think outside of pain, how can you help us move easier with the complex symptoms and barriers that get in the way of physical activity with RA. The first step is to listen to us.
RA is one of the most common forms of inflammatory arthritis and with arthritis being incredibly common in Canada and the world, with over 100 forms and the main cause of disability I highly recommend you continue your education and training in this field. There is always work and you can help a wide range of the population.
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