**5. Conclusion**

300 Rheumatoid Arthritis – Treatment

favour programs which feature short rest periods, whilst strength and power athletes generally employ longer rest intervals. Whether these differential effects of rest period duration also operate in middle-aged and elderly previously untrained exercisers is unclear. As such, and given that training benefit is unlikely to be significantly compromised but training time will be markedly reduced if short rest periods are preferred to long rest

For safety, training on resistance machines with incremental weight stacks rather than using free weights is recommended (ACR, 2002; Pollock et al., 2000). Machines are also easier and quicker to set up. On the other hand, free weights allow more variety in the exercises performed and are better able to simulate ADL's. As mentioned previously, an optimal PRT program will feature exercises that collectively involve all the major joints and muscle groups. Such whole-body programs, as well as being more effective in increasing overall strength and muscle hypertrophy, also produce significant improvements in aerobic capacity (VO2max) and endurance performance. For example, Vincent et al. (2000) noted that 6 months whole-body PRT increased peak VO2 by 22% and treadmill time to exhaustion by 26% in elderly (60-85 years) men and women. Similarly, 10-12 weeks of HI PRT has been shown to improve time to exhaustion while cycling (47%), running (12%) and walking (38%)

Exercises should be performed rhythmically, in a slow, controlled movement (≈2 secs to lift and ≈4 secs to lower the weight) and, to avoid a Valsalva's manoeuvre and the resultant rises in blood pressure (BP), breathing should be continuous. When proper technique is observed, systolic BP during weight lifting is considerably lower than it is during aerobic exercise of similar intensity, and CV stress is minimal (Pollock et al., 2000). Naturally, with RA patients attention to affected joints is essential and joint pain, instability, poor proprioception, or reduced ROM may necessitate modification or substitution of prescribed

Gains in strength are usually rapid and substantial following commencement of PRT, with 10-15% increases in strength typically observed each week for the first 8 weeks of training in healthy, previously untrained individuals (Evans, 1999). Initially these improvements are due to enhanced neural factors i.e. improved motor unit recruitment, firing rate and synchronisation (Sale, 2003), with muscle hypertrophy contributing from about week 4 onwards (Sale, 2003). In order to maintain the maximal muscle fibre recruitment necessary for optimal increases in strength and muscle hypertrophy to occur, progressively higher loads need to be lifted. This increase in resistance (in accordance with increases in strength) to maintain a constant relative intensity is termed "progressive overload", and is a

Whilst marked responses to training are expected in untrained or deconditioned individuals, after an extended period of training the "law of diminishing returns" applies i.e. as an individual's fitness improves and he/she approaches their genetic ceiling it becomes harder to achieve further fitness gains. Consequently, when PRT is prolonged, plateaus in training response should be anticipated. The usual way of dealing with this

periods, allocation of 1-2 min rest between sets appears optimal.

**4.4 Type (modality)** 

(Ades et al., 1996; Hickson et al., 1980).

fundamental principle of all exercise training regimes.

exercises (ACSM, 2010c).

**4.5 Progression** 

This chapter has described important consequences of RA which are usually untreated (i.e. diminished muscle mass and high fat mass, particularly central obesity; rheumatoid cachexia) or are still prevalent despite enhanced pharmaceutical treatment (disability, CVD, osteoporotic fractures), and then reviewed the research into the efficacy and safety of PRT in treating these conditions. The evidence indicates that PRT is an appropriate adjunct therapy for RA patients. In particular, its efficacy in positively affecting body composition and physical function is almost unique, particularly when accessibility and the lack of negative side effects are considered. As such, rheumatologists and allied health professionals overseeing the management of RA patients should be encouraging them to undertake PRT, ideally in conjunction with aerobic training. To better inform clinicians in their exercise

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**15** 

*USA* 

**Molecular Effects of Exercise** 

*Department of Orthopaedic Surgery and Radiation Oncology, Oncophysics Research Institute, Albert Einstein College of Medicine/Montefiore Medical Center, New York* 

Rheumatoid arthritis (RA) is an autoimmune disorder that affects approximately 1% of adults in the United States (Alamanos and Drosos 2005). Clinically, RA is manifested by pain and swelling of joints, disability, and diminished overall patient well-being (Scott et al. 2010). The etiology of RA remains enigmatic, but a range of genetic and environmental factors closely associated with RA have been identified over the past two decades. It is now known that the pathogenic process of RA involves the initiation and establishment of autoimmunity, followed by an inflammatory response, angiogenesis to maintain the chronic

Despite the advances in the pharmacological therapies of RA over the past years, most patients (85-90%) do not achieve full remission, with up to 15% showing little clinical improvement in outcomes (Geborek et al. 2002; van der Woude et al. 2009). Accumulating studies have demonstrated the effectiveness of non-drug treatment modalities, e.g. exercise and physical activity, as an adjunct to drug therapy in patients with RA (Stenstrom and Minor 2003; Lundberg and Nader 2008). As a result, physical training is now a standard part

This chapter will first review results from randomized clinical trials which investigated the effects of exercise on RA disease activity. In RA patients, exercise was demonstrated to improve physical performance, cardiorespiratory fitness and muscle strength without worsening joint inflammation (Ekblom et al. 1975). Subsequent clinical studies have not only shown that exercise leads to meaningful effects on physical performance and fitness, but exercise can also reduce RA disease activity, measured by the number of swollen or tender joints (Stenstrom and Minor 2003). At the systemic level, there are several reports indicating a reduction in circulating levels of inflammatory biomarkers following long-term physical exercise (Dekker et al. 2007; Olson et al. 2007). These beneficial effects of exercise have been observed following different types of physical activity, after short-term and long-term (>2 years) exercise programs, at different phases of the disease course, and even in patients with

Next, by focusing on the effects of exercise, delivered in the form of physiologically relevant mechanical loading, this review will provide updated insights into exercise at both the systemic and local (e.g. cartilage and synovium) levels. Studies indicate that exercise

inflammatory state, and tissue degradation of the joint (Scott et al. 2010).

high disease activity (van den Ende et al. 2000; Stenstrom and Minor 2003).

**1. Introduction** 

of treatment for RA patients.

 **in Rheumatoid Arthritis** 

Daniel J. Leong and Hui B. Sun


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