Introduction
Rheumatoid Arthritis (RA) is a chronic, systemic disease, with local
inflammatory action and which directly affects individuals’ quality of life
affected by it. People with RA suffer the increase of morbidity and mortality
from cardiovascular diseases, due to a high rate of atherosclerosis (Cairns
& McVeigh, 2009). In relation to Osteoarthritis (OA), this a chronic
disease, degenerative and disabling, characterized by deterioration of the
articular cartilage, synovitis and changes in subchondral bone periarticular
structures (Goldring & Goldring, 2007).
Physical exercise has been used as a helping factor in the treatment of RA
patients (Cairns & McVeigh, 2007; Germanou et al., 2013; Burrows et
al., 2014). Among many benefits, reduction in pain levels, increase aerobic
capacity and improvement in levels of muscle strength can be highlighted
(Germanou et al., 2013; Wilcox et al., 2015). Therefore, this
brief review aims to point out some of the main effects of the different forms
of physical exercise as a helping factor in non-pharmacological treatment of
individuals with RA and OA. Also, this review briefly indicates the effects of
physical-motor intervention in reducing the pain and the benefits provided by
aerobic activity and resistance exercises as well.
Physical
exercises and pain in RA and osteoarthritis patients
In a study carried out by Germanou et al. (2013), the authors examined
the influence of isokinetic exercises in acute inflammatory responses of
middle-aged obese women with knee osteoarthritis. The participants were divided
into two groups, a control group and the group that performed the isokinetic
exercise protocol. The torque of the knee (extension/ flexion), delayed onset
muscle soreness (DOMS), knee flexibility and pain have been evaluated. Blood
samples were taken pre-exercise, post-exercise and 24h post-exercise. Blood
tests were conducted in order to verify the activity of creatine kinase (CK),
lactate dehydrogenase activity (LDH), CRP, leukocytes, uric acid, IL-6, TBARS,
lipid hydroperoxide (LPX), protein carbonyls (PC) oxidized (GSH) and reduced
glutathione (GSSG), total antioxidant capacity (TAC), the activity of catalase
and glutathione peroxidase activity (GPX). The authors found that the isokinetic
exercise induces only a mild inflammatory response of short duration (<24h)
without impairment of physical function and pain in patients with knee
osteoarthritis, suggesting that moderate physical exercise, strengthening type
can be safe for this group of patients. Isokinetic exercises can improve the
quality of life in patients with knee osteoarthritis as in the regulation, the
antioxidant system provides the patient with little inflammation pain because it
is light and of short duration. Therefore, it is quite interesting in patients
who are becoming active again, and the possibility of holding sessions every
rest period of 48 hours.
In another study, Burrows et al. (2014) used three groups of 11
people: a group with knee osteoarthritis, another group of elderly but healthy
people, and a final group of healthy young ones. The goal was to determine
whether a single session of resistance exercise can produce analgesic effect in
individuals with knee osteoarthritis. The research results showed that the
pressure pain thresholds increased after exercise for the three groups,
indicating reduced sensitivity to pain. This reduction of sensitivity to pain
after resistance exercise can be assigned to changes in the pain threshold, not
to a greater tolerance of it. Therefore, it can be seen that physical activity
may be an effective factor in the constant struggle of RA and osteoarthritis
patients against pain, and regardless the age group, exercise can bring
significant improvements in long-term in people with this diseases.
Modalities
of exercise and its implications in the treatment of RA and osteoarthritis
The benefits of physical exercise for an individual with RA go far beyond from
the treatment of osteo-articular pathology in case, it is about the individual
functionality before society. RA not only compromises skeletal muscle
performance, but also prevents the practice of physical exercise, but in
general, the physical exercises are recommended and safe for patients with RA
and other rheumatic diseases (Silva et al., 2008; Gualano et al., 2011).
RA patients present an increased risk for cardiovascular disease. Studies show
that exercise restrictions for RA patients are mainly related to the significant
deterioration of the articular symptoms, impeding the training of aerobic
capacity, with consequences for the increased cardiovascular risk (Teixeira et
al., 2012).
According to Oliveira et al. (2012), osteoarthritis results from
degeneration in the joints causing changes in the mechanoreceptors and muscle
strength, triggering pain and affecting functional capacity, which can cause
damage and affect the joint functionality while performing the movements.
Carriers of the condition are likely to live with muscle pain and a poor quality
of life (Rosa, 2012).
Aerobic
and strength exercise
Looking at an individual with RA in a perspective of quality of life (QOL), it
can be considered that aerobic training works significantly in reducing
depressive symptoms in people with this disease. Depression and mood disorders
are commonly reported, and fighting against them influences on the QOL of this
population (Pincus et al., 1996; Blixen & Kippes, 1999; Rejeski &
Mihalko, 2001; Pennix et al., 2002).
In a study carried out by Harkcom et al. (1985) the authors investigated
the response of aerobic exercise in women diagnosed with rheumatoid arthritis.
The experimental design of the study consisted of three low intensity aerobic
exercise protocol (15, 25 and 35 minutes) 3 times per week for 12 weeks. A group
who did not train was used as control one. All groups who followed the exercise
program increased aerobic capacity, exercise time and joint counts. The study
participants reported improvements in their daily activities, reduction of joint
pain and decreased fatigue. In this study, the authors report that aerobic
exercise performed up to 35 minutes may be a therapeutic alternative in the
treatment of rheumatoid arthritis, and also conducted exercises in less time (15
minutes) 3 times a week may be enough to improve aerobic capacity in patients
with rheumatoid arthritis and severe constraints.
In a systematic review with meta-analysis by Baillet et al. (2010), the
authors performed a search in Medline, Embase, and Cochrane. Screenings which
used intervention with aerobic exercise in patients with RA were included.
Outcomes studied were post intervention quality of life, function evaluated by
the Health Assessment Questionnaire (HAQ), the visual analog scale pain (VAS),
joint count, the Disease Activity Score in 28 joints (DAS28), and radiological
damage. Efficacy was evaluated by standardized mean differences (SMDs;
difference between groups of mean outcome variation from baseline/ SD at
baseline) of aerobic exercises. Fourteen randomized controlled trials were
included, in which it was obtained a total of 1040 patients who met the
inclusion criteria of the meta-analysis. Exercise improved the post intervention
quality of life (SMD 0:39, p<0.0001), HAQ score (SMD 0:24, p=0.0009), and
pain VAS (SMD 0:31, p=0:02). Exercise in this RA population seemed to be safe,
since global compliance, DAS28, and joint count were similar in both groups. The
authors concluded through this study that aerobic exercise in stable RA seems to
be safe and may increase some of the most important variables related to health,
quality of life and pain in this specific population.
Studies have shown that strength exercises also help to reduce the problems
related to RA. According to the study Beckwée et al. (2013), in its
qualitative analysis of several studies related to RA, it was found out that the
conclusions of these ones converge to the positive role of an exercise
intervention to reduce problems related to RA. The energy absorption capacity,
stability, joint components, bone connective tissue, intra-articular components,
cartilage, inflammation reducing, joint lubrication, bone loss, functionality
increase, and welfare have been improved with the exercise program.
The aerobic exercise is being used as a non-pharmacological treatment in
patients with OA of the knee, recent research showed the benefits of aerobic
exercise on the functional quality of life for individuals with OA. In a study
by Freitas et al. (2012) showed health parameters of the population and
physiological benefits of aerobic exercise in the treatment of OA, in other
study made by Dadalto et al. (2013), the authors used resistance exercise
for increasing of the muscle strength of knee extensors muscles in patients with
OA, the authors found improvements in motor mobility and muscle strength in this
patients.
Conclusion
Based on the statements above, it can be seen that there are still gaps in
knowledge with regard to the most effective training program in the treatment of
RA and other degenerative diseases, but actually, physical exercise acts as a
non-pharmacological tool effective in reducing symptoms related to RA.
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