**1. Introduction**

330 Rheumatoid Arthritis – Treatment

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Historically, the recommendation of exercise for patients with rheumatoid arthritis (RA) has been avoided by clinicians due to fears that such activity may contribute to joint damage and result in worsening of disease. Hence, previous treatment of active RA has included bed rest and splinting of the affected joints (Partridge & Duthie, 1962). Over recent decades however, the numerous physiological advantages of exercise have become well-established and include improved cardiovascular health, increased muscular hypertrophy and increased bone mineral density. Enhanced physical function and psychosocial advantages have also been shown in followers of a continued exercise programme (Baillet et al., 2009; Bilberg et al., 2005; de Jong et al, 2003, 2004; Hakkinen et al., 2001; Lemmey et al., 2009; Marcora et al., 2005; Melikoglu et al., 2006; Van Den Berg et al., 2006; van den Ende et al., 1996, 2000). Importantly, it has also been found that high-intensity exercise training is of superior effectiveness, with no detrimental effect on disease activity. This has been confirmed in patients with controlled (Ekdahl et al., 1990; Lemmey et al., 2009; van den Ende et al., 1996) and active RA (van den Ende et al., 2000). Furthermore, as advances in pharmacological treatment work to effectively control disease, this patient group are now able to tolerate regular, progressive and intensive exercise (Lemmey, 2011). A recent systematic review also provides further information as to the benefits, effectiveness and safety of exercise in RA (Hurkmans et al., 2009).

Patients with RA are also at an increased risk for cardiovascular disease (Metsios et al., 2008), cachexia (Walsmith & Roubenoff, 2002) and osteoporotic fracture (Van Staa et al., 2006). Therefore, the aforementioned improvements associated with exercise are vital in limiting the negative consequences inherent to the disease. Furthermore, physical activity has been found to be a significant predictor of the number of hospital admissions and the length of hospitalisation in RA (Metsios et al., 2011). In light of this evidence, exercise is now considered an essential component within the management of this condition. However, despite this it is apparent that RA patients are less physically active than the general population (Sokka et al., 2008), and greater medical costs are coupled with this inactivity (Wang et al., 2001). Therefore it is important for those involved in the care of RA patients to be aware of factors that may positively and negatively affect the uptake and maintenance of an exercise prescription for this patient group.

Fig. 1. Analytical model of the issues relating to exercise and joint health in RA patients

(Law et al., 2010).

This chapter will discuss the perceptions of patients and health professionals in relation to exercising with RA, alongside the implications and recommendations for patient care. Many of these issues have been highlighted as part of our continuing research and it is the findings from these novel investigations, alongside others, which form the basis of this chapter. Illustrative quotes from patients and practitioners have been included to facilitate description of these issues.
