Welcome Back Rheumatology Fans,

Recently we explored high-intensity exercise in Rheumatological Diseases with insights from Jean-Pascal Grenier. The conversation challenged a belief that has lingered in rheumatology forever That people with inflammatory arthritis should exercise gently.

Moderate exercise? Yes. Gentle strengthening? Of course. Hydrotherapy? Yes Please!

But high intensity? Long duration? Pushing physiological limits? This has been where clinicians have become nervous. It is natural of course, an assumption that utilising inflamed joints will cause that inflammation to increase or an acceleration of joint damage leads to caution. Especially if there is also an associated increase in pain levels.

Which is why it is worth talking about Natalie Dau - Follow her Instagram here.

Natalie is an ultrarunner who holds the Guinness World Record for crossing Peninsular Malaysia on foot. In the process she ran roughly 700 km in just over eight days as part of a 1,000 km endurance project from Thailand to Singapore. (I once got a train from London to Edinburgh and thats 630km and I was absolutely exhausted).

Natalie Dau has Rheumatoid Arthritis.

For many clinicians trained even 10–15 years ago, that combination of facts would have sounded contradictory. RA was traditionally framed through the lens of protection: protect the joints, protect the energy envelope, protect against flare.

And yet here we have someone running the equivalent of two marathons a day.

Now, before anyone concludes that this is a prescription rather than an observation, it’s worth being clear: Natalie’s story is not an argument that everyone with RA should become an ultramarathon runner.

But her story is useful because it forces us to interrogate our assumptions.

One of the themes Jean-Pascal raised was that the human body – even with inflammatory disease – is often far more adaptable than we think. With appropriate training progression, recovery, and load management, people can tolerate much higher intensities than traditional guidance might imply.

Graded individualised exposure, consistency, individualised adaptation and a good amount of reassurance. This can enable people to achieve a lot more than they thought they might be able to.

I used to run a version of this for people newly diagnosed with RA in the NHS, they were offered to attend an exercise group and we started every session with static bike. The person had control, I gave them the instruction to bike at a 5-6/10 on an effort scale. The difference between session 1 and session 2 was STAGGERING. I tracked their settings in super none-vigorous manner and they increased their settings a lot more than you would anticipate.

So to conclude, no you can’t exercise “too much” with Rheumatoid Arthritis, the amount you SHOULD exercise is variably individual but a good starting point is to aim for 150 minutes of moderate intensity per week. Some is better than none, more is usually better and enjoying it is probably the most important ingredient.

Welcome Back Rheumatology Fans,

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We got ANOTHER media request, I am starting to wonder who is giving out my email address, if it is you then can you tell them I would like paying next time… haaaaaa.

Ok, so back to being serious, this request was advice for returning to tennis or squash when arthritis had stopped the person from playing. This was actually a new one for me so here we are with an expansion on my responses.

You can get access to this article but upgrading your subscription, enrolling in my online course or becoming a member of Physio Matters Advanced Practice

Welcome Back Rheumatology Fans!

Swimming is often recommended for people with arthritis, but is it actually better than other types of exercise? The short answer: it depends on the individual.

Swimming and water-based exercise can be helpful because the buoyancy of water reduces the amount of weight going through the joints. For example, when standing in water up to belly-button depth, the body is only bearing around 40% of its usual weight . This reduction in joint loading can allow people with painful hips, knees, or feet to move more comfortably and exercise for longer.

Water immersion also provides a cardiovascular benefit. The pressure of the water increases venous return — meaning more blood is pushed back to the heart — which makes the heart work slightly harder and therefore provides a cardiovascular training effect . In addition, buoyancy can make it easier to move stiff joints and take them through their range of motion.

However, swimming is not without downsides. Many barriers are logistical: travelling to the pool, changing clothes, slippery surfaces, cold environments, and cost. Some people also accidentally overdo activity in the water because the reduced joint loading masks normal pain signals.

Ultimately, swimming is a good exercise option for arthritis, but it is rarely the only or “best” option. The most effective exercise is usually the one a person can do consistently and safely.

* Water reduces joint loadingBuoyancy can significantly decrease the weight passing through painful joints, making movement easier.

* Swimming provides cardiovascular benefitsWater pressure increases venous return, which places a mild training demand on the heart.

* Movement can be easier in waterBuoyancy can help people move joints and the spine through their range of motion with less discomfort.

* Logistics often limit swimming as exerciseTravel, changing facilities, cost, and cold environments can be significant barriers.

* Exercise choice should be individualisedSwimming is helpful for some people with arthritis, but it is not inherently superior to other forms of exercise.

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