Rheumatism and CrossFit

CrossFit and rheumatism. Not an obvious match. But with the right approach, CrossFit can help alleviate symptoms and contribute to a healthier and stronger life. In this article we explain how.

Rheumatism explained

Rheumatism is a chronic disease that includes several disorders of the musculoskeletal system and sometimes of organs. The cause is unknown, and the disease is not yet curable. In The Netherland, one in nine people at any age are diagnosed with a type of rheumatism and almost two million people suffer from this disease today. There are five groups of rheumatism, with specific disease symptoms and concerns regarding treatment and exercise:[1]

1. Osteoarthritis

The most common group of rheumatic disorders in The Netherlands is osteoarthritis, a condition of the cartilage and bone of joints. The cartilage becomes thinner and worse in quality. It can disappear completely,and damage or disform the underlying bone.

Inflammation can occur with osteoarthritis, but it is not an autoimmune reaction. Although over time, inflammatory rheumatism, as explained later, can lead to osteoarthritis. Osteoarthritis is not necessarily or exclusively a result of ageing. Although it is more common in elderly, it also occurs at a young age. It is also not necessarily a result of wear and tear. Other factors also play a role in its development such as genetics, being overweight, and a previous injury of the joint. Exercise does not make osteoarthritis worse, although very intense heavy loading and heavy physical work can contribute to its development.

Symptoms of osteoarthritis are pain and stiffness after rest; pain when the joint is heavily loaded; pain or swelling in the joint in case of inflammation; an unstable feeling in the joints; cracking joints; and nerve impingement. Furthermore, osteoarthritis is often accompanied by other chronic conditions such as cardiovascular diseases, obesity and diabetes.[2]

2. Inflammatory rheumatism

Inflammatory rheumatism is an autoimmune disease that causes inflammation in joints, tendons, muscles, or organs. Some forms include rheumatoid arthritis (RA) and spondylo- arthritis which is inflammation of the pelvis, spine, and/ or large joints in the arms or legs and the gut.

Although the exact cause is unknown and the disease is not hereditary, RA sometimes occurs in several members of a family. People who smoke are more likely to get it, stress can worsen symptoms, and hormones also seem to play a role. During the menstrual cycle and menopause, symptoms are often worse.

Symptoms of inflammatory rheumatism include pain, swelling, stiffness and limited range of motion of joints. Also, fatigue is a common symptom in auto- immune disorders as well as bowel issues. This can be a direct effect of the disease or a side effect of medication. Other symptoms are stiff or weak muscles and a higher risk of cardiovascular disease, osteoarthritis, (secundary) osteoporosis, and diabetes. Complications such as tendon rupture, carpal tunnel syndrome, nerve disorders, synovial cysts and osteoporosis may also occur. Axial spondylo-arthritis (inflammation of the pelvis and spine) can be accompanied by intestinal discomfort and inflammation of the eyes.[3]

3. Soft tissue rheumatism

Soft tissue rheumatism is a chronic disease with unexplainable pain in muscles connective tissue. Often this pain is accompaniedby (morning) stiffness, chronic fatigue, sleep disturbances, mood swings and brain fog. Exercise, rest, and pain killers can sometimes alleviate symptoms. Abnormalities in the body cannot be found and the cause of this disease is unknown. There are hypotheses about the possible cause, such as disturbances in the brain- muscle connection, or in the mechanism by which stimuli are filtered from the outside world, or in the processing of pain stimuli.[4]

4. Gout

Gout is a form of rheumatism caused by excessive uric acid levels in the body. Uric acid levels in the blood increase because the body's metabolism is not working properly. This might be due to several reasons such as impaired kidney function. Stress and the consumption of alcohol and purine-rich food such as legumes and meat can trigger symptoms. Also, heredity seems to play a role.

The high levels of uric acid can cause uric acid crystals which precipitate in joints. This often leads to sudden intense painful attacks of joint inflammation. The first attack often occurs in the joint of your big toe or in the instep of your foot. Symptoms are sudden pain; swelling; reditchy skin; limited movement of the joint; fever; and sometimes kidney stones. Also, people with gout have a 30 percent higher risk of cardiovascular diseases.[5]

5. Osteoporosis

Osteoporosis is a form of rheumatism in which the bones become weak and spongy, and the bone density decreases. Most common symptoms are bone fractures and changes in bodily posture. Postmenopausal women as well as anyone over the age of 50; those who use corticosteroids; and people with rheumatoid arthritis and axial spondylo- arthritis have an increased risk of osteoporosis.[6]

Heavily underestimated disease

The tricky thing of rheumatism is, you often can't tell from the outside if someone suffers from rheumatism. This can lead to a lack of understanding of patients, of their behavior, their mental and physical state, and their capabilities and limitations in daily live. Furthermore, many patients have a hard time accepting the disease and want or think they can do more than their body allows.

Research shows that 68 percent of patients in The Netherlands have problems performing daily activities and experience limitations due to pain, fatigue or reduced mobility. This affects their perceived quality of life. Half of all rheumatic patients experience a lack of understanding at work, and with friends and family. Of all people with a rheumatic disease in The Netherlands, 54 percent report they feel lonely. More than half of all patients between the age of 40 to 65 are not employed.

This makes rheumatism a heavily underestimated disease with physical, mental, emotional and social components.[7] 

Rheumatism and exercise

Exercise is important for people with rheumatism. It strengthens bones and muscles, and it increases joint mobility. Although pain, and the fear of worsening symptoms may lead to the avoidance of exercise and starting exercise can lead to a temporary flair up of symptoms, exercise does not damage muscles or joints. It can actually relieve symptoms, especially in the long run. In osteoarthritis for example, the rubbing of bones against each other due to a lack of cartilage can cause pain or swelling, making exercise harder. Nevertheless, exercise can help to decrease stiffness and prevent further weakening of the muscles, tendons and ligaments. Exercise does not cause any further damage of the joint. In soft tissue rheumatism, research has shown that regular exercise leads to a reduction of symptoms.[8]

General points of attention

The mail goal of exercise should be to increase confidence in exercise or any type of activity, and to increase trust in your body. Although exercise is highly recommended and all types of activity are great, not all types of exercise are suited for everyone with rheumatism. Five aspects need to be taken into account, before and during exercise:

1. Medical indications

As goes for anyone starting exercise, overall physical fitness and medical indications both play a role in choosing the appropriate form of exercise. There are no globally recognized exclusion criteria for rheumatism. Therefor, the generally applicable medical, physical, mental exclusion criteria for exercise apply.

Rheumatism is associated with a higher risk of (chronic) diseases such as cardiovascular disease, diabetes, COPD, and obesity. Osteoporosis comes with a higher risk of fractures. Medical indications need to be taken into account when starting an exercise program. A tailor made training plan and a medical risk assessment and supervision by a physical therapist or qualified fitness professional are advised.

2. Energy levels

Fatigue and sleeping disorders are symptoms of rheumatism. This affects the taxability of the body and mind and thus the ability to exercise. An assessment of current energy levels needs to take place at the start of every training session, in order to adjust the exercise to what is feasible, practicable and wise to do at that time.

3. Load capacity

With rheumatism, the load capacity of the joints is crucial. This is determined, among other things, by the condition of the joint and the extent to which a person suffers from inflammation. The load capacity of joints can be increased by increasing muscle strength and muscle endurance. This should be done gradually and with a solid approach under the supervision of a physical therapist or qualified fitness professional, to avoid overloading and severe joint pain after training. Muscle soreness is perfectly fine of course.

4. Inflammation grade and levels of pain

Rheumatoid arthritis and spondylo- arthritis both involve active phases in which inflammation flares up, and non- active phases in which inflammation is only latently present. The intensity of exercise needs to be adjusted to the current phase.

During a flare up of inflammation, if the person with rheumatism does not have a base level of fitness yet or is in a lot of pain, low intensity exercise such as yoga or walking are recommended. The exercise should focus on functional movements and mobility. The goal is to stay active, to relax and to prevent further stiffness of muscles and joints. Keep in mind that this type of exercise does not improve cardiovascular endurance, muscle strength or musche endurance. It should be considered as a way to at least do somethingm which is always better than doing nothing.

During low levels of inflammation and pain, and once the person has a base level of fitness, the intensity of the exercise can be increased to a moderate level, even if joints still feel a bit sore or stiff. Exercise such as regular fitness, swimming or biking are appropriate. This types of exercise improve mainly cardiovascular endurance and muscle endurance, but not muscle strength.

5. Age

For people over the age of 70 with rheumatism, the focus should be on longevity by increasing muscle mass, improving balance and coordination and training functional movements. This requires an exercise program focussed on cardiovascular endurance, muscle endurance and muscle mass.

Specific points of attention

In addition to the general ponts of attention, there are four specific points of attention during and after exercise:

1. Longer warmup

People with osteoarthritis need a longer warmup phase, sometimes up to 30 minutes, due to morning stiffness and stiffness after rest. The joints need more time to  lubricate in order to exercise.

2. Sub- maximal loading

Increasing the load capacity of the joint, and increasing muscle endurance and muscle strength requires a gradual approach in which maximum loading must be avoided. The approach should be characterized by sub-maximal loading, a variety of functional movements, and little prolonged static loading and sudden twists and turns.  A sub- maximal approach also applies to endurance training.

3. Recovery capacity

Rheumatism can lead to decreased recovery capacity, and this can also fluctuate over time. Especially in cases of RA, adequate recovery time during a training session is important. When someone is new to exercise, a recovery time of 72 hours between two training sessions is recommended.

4. Insight in effects

The effects after training should be monitored closely. Exercise may lead to a temporary flare up of symptoms, but can be very beneficial in the longer run. Severe joint pain or increased stiffness are indicators of overloading. And it might take some time of experimenting to figure out what the types of exercise are appropriate, and to learn to distinguish pain from exercising versus pain from rheumatism. Keeping a diary can help to get more insight.

Rheumatism and CrossFit

In some cases, and/ or at some point of time, a person’s load capacity, pain level and inflammation grades allow high intensity exercise such as CrossFit. This type of exercise increases cardiovascular endurance, muscle strength and muscle endurance, but can be more taxing for the joints compared to low or moderate intensity exercise.

Research has shown that in the case of spondyloarthritis (SpA) heavy load strength training in combination with a healthy diet, as described later, can lead to significant improvements in the quality of life of patients. Additionally, high intensity exercise can improve fatigue, sleep and mood.

In treatment, diet and nutritional supplementation are often prescribed but strength training and high intensity training are not and are often discouraged. Yet, low intensity exercises are limited in their effectiveness and long-term adherence. Strength training, (even with high loads) in a progressive and supervised way, can be a valid alternative. A healthy diet supports a healthy body weight and body composition, supports the athletic performance and helps to limit inflammation.

A case description:

A 50-year-old woman was diagnosed with axial SpA when she was 44. She received medication from 2016 to 2017 but still suffered from pain, difficulty sleeping and performing some daily tasks. She used a crutch to walk. She started a treatment plan of strength training and nutritional adjustments under professional supervision. At the beginning of the plan, she perceived walking on a treadmill at 5 km/h with a 5% gradient as tiring on a scale of 7 out of 10. The strength training program focused on gradually increasing joint mobility, muscle endurance and muscle strength. The nutritional adjustments among which fiber, vitamin D and omega 3 supplements, supported a healthy body composition and athletic performance, and limited inflammation. After three years she won the Italian master deadlift championship and powerlifting championship and was no longer in need of medication. A few years later, she had a setback with symptoms flaring up. She had been absent from training for months, did not stick to her diet and experienced stress during the Covid-19 lockdown. After picking up her training and nutritional routine, her health and strength improved again [12].

Keys for success

Self- management

On of the keys for success in dealing with rheumatism in daily life and during exercise is self-management. Learning to recognize and understand one's own strength, load capacity, endurance, and energy levels is crucial. Also, being able to distinguish the difference between muscle pain and stiffness due to sports versus and joint pain and rheumatic stiffness. The (new) athlete must learn to recognize disease symptoms and signals of the body, and how to intervene in a timely manner. This means for example being able to speak up tocoaches, colleagues, family and friend what is needed at that moment in time to stay active and keep functioning, or what specific needs and wants are.

Especially RA is known to have an erratic course, and sometimes the mind wants more than the body allows. Exercising with rheumatism, especially high intensity exercise like CrossFit, requires cooperation with the fitness professional in charge, and close monitoring of training effects. Both parties need to have disease knowledge and be able to act on findings at the time. This means, for example, that a CrossFit WOD has to be adjusted on an ad hoc base, in types of exercise or intensity.

Lifestyle adjustments

Lifestyle adjustments, part of self- management, can contribute to dealing with rheumatism.[9] Such as taking the prescribed medication (treatment adherence). Some people with rheumatic arthritis benefit from NSAID’s or DMARDs. In some cases of osteoarthritis, the supplement glucosamin has a mild analgesic effect.

Stress is a trigger for the flare up of rheumatic symptoms. It is known that, for example in soft tissue rheumatism, techniques such as mindfulness are helpful. Knowing your limits and standing up for yourself are important. A supportive environment can be helpful in dealing with the stressful aspects of the disease. Sharing information about the impact of the disease with others can help to gain greater understanding. Speaking up is important.

Nutrition

The role of nutrition in rheumatism is not fully clear. Ther eis little convincing evidence for rheumatoid specific foods, i.e. foods that are good or bad exclusively for people with rheumatism. However, patients may find, based on their own experiences, that certain foods have a good or bad effect on them at an individual level.

There are general dietary guidelines that contribute to the health of the general population, and to the prevention of chronic diseases such as obesity, diabetes and cardiovascular disease. These guidelines are also relevant for people with rheumatism who are at higher risk of such chronic diseases.[10]

Mediterranean diet

There is clear evidence that the Mediterranean diet provides health benefits. It contributes to a healthy gut microbiome (Read more about the importance of a healthy gut in this article) and to the functioning of the immune system, which is relevant for people with rheumatism. Alterations of the gut microbiome and of body composition are one of the mechanisms of how a diet can influence rheumatism. For example, the Mediterranean diet contains nutrients with an anti- inflammatory and antioxidant effect, that have a protective role in the onset and progression of rheumatism. There is also plenty of evidence that a Western diet is harmful for the health of the general population and therefor also for people with rheumatism. Red meat and salt for example have a harmful effect on rheumatism.[11]

"Extensive research has shown that a Mediterranean diet, in combination with exercise and three cups offiltered black coffee every day, can have positive health effects in terms of morbidity and mortality. The Mediterranean diet includes a great variety of foods, which are eaten in moderation and within a positive social environment. It contains a high intakeof fruits and vegetables, whole grains, legumes, nuts, fish, white meats and olive oil, a moderate consumption of fermented dairy products and a low intake of red meat. The diet is low in saturated fats and animal protein. It is high in antioxidants, fiber, and mono-unsaturated fats, and exhibits an adequate omega-6/omega-3 fatty acid balance. The health benefits can be explained by antioxidants, fiber, mono- unsaturated and omega-3 fatty acids, phytosterols from plants, and probiotics."

A Western diet is characterized by chronic overconsumption of calory rich food; a high intake of refined sugar, salt, and saturated fat; and especially a high intake of fructose. This dietary pattern is associated with metabolic dysfunctions, fatty liver, disruptions of the immune system; increased rates of cancer; increased risk of allergic and auto- inflammatory disease; and chronic metabolic inflammation. This is inflammation of tissue in body fat, skeletal muscle, liver, pancreas, intestine and in the brain, often seen in obesity. Because a Western diet can negatively impact our genes, the consequences of unhealthy food choices today are passed on to the next generation.

More info about these types of diets can be found in this article.

‍Conclusion and advice

Exercising with rheumatism is a matter of experimenting: What is doable at this moment in time, given aspects such as the inflammation grade and levels of pain. Any type of activity, done regularly and consistently, is beneficial for health and wellbeing.

Experimenting requires a close cooperation between the athlete with rheumatism, the fitness coach and other health professionals concerned. Acknowledgement of the disease and its erratic course are important.

Consistency and discipline, a gradual build-up, and rather underloading than overloading in training are aspects that contribute to the intended training effects and moreover to gaining confidence in exercise with rheumatism. Self- management, lifestyle adjustments and healthy nutrition are key.

It is recommended that people with rheumatism who start with exercise are coached by a physical therapist or trained exercise professional. In The Netherlands NL Actief Prevention Centers such as CrossFit Eudokia accredited by the Dutch health and fitness association NL Actief can provide professional advice and coaching.

Create your own health!©‍

References 

[1] Reuma Nederland, NL Actief, Ambaum Brandmakers. (2021). eBook Fitness en reuma.; Reumanederland. Wat is reuma. Geraadpleegd op 18 maart 2023 via: https://reumanederland.nl/reuma/wat-is-reuma/

[2] idem

[3] idem

[4] idem

[5] Reumanederland.Wat is reuma. Geraadpleegd op 18 maart 2023 via: https://reumanederland.nl/reuma/wat-is-reuma/;Reumanederland. Vormen van reuma. Geraadpleegd op 18 maart 2023 via: https://reumanederland.nl/reuma/vormen-van-reuma/jicht/; Maxima MC. Regionaal Reumacentrum. Geraadpleegd op 18 maart 2023 via: https://www.mmc.nl/regionaalreumacentrum/aandoeningen-en-behandelingen/jicht/

[6] Reumanederland. Vormen van reuma. Geraadpleegd op 18 maart 2023 via: https://reumanederland.nl/reuma/vormen-van-reuma/osteoporose/

[7] Nivel. Kennis voor betere zorg. Impact reuma zwaar onderschat. Geraadpleegd op 18 maart 2023 via: https://www.nivel.nl/nl/nieuws/impact-reuma-zwaar-onderschat; Reuma Nederland, NL Actief, Ambaum Brandmakers. (2021). eBook Fitness en reuma. 

[8] Reuma Nederland, NL Actief, Ambaum Brandmakers. (2021). eBook Fitness en reuma.; Reumanederland. Wat is reuma. Geraadpleegd op 18 maart 2023 via: https://reumanederland.nl/reuma/wat-is-reuma/

[9] Ornish Lifestyle medicine. Nutrition. Geraadpleegd 22 maart 2023 via https://www.ornish.com/proven-program/nutrition.; Reade. Plants for joints. Geraadpleegd 22 maart 2023 via: https://reade.nl/wetenschap/onderzoek/plants-for-joints;

[10] Gwinnutt JM, Wieczorek M, Rodríguez-Carrio J, Balanescu A, Bischoff-Ferrari HA, Boonen A, Cavalli G, de Souza S, de Thurah A, Dorner TE, Moe RH, Putrik P, Silva-Fernández L, Stamm T, Walker-Bone K, Welling J, Zlatković-Švenda M, Guillemin F, Verstappen SMM. Effects of diet on the outcomes of rheumatic and musculoskeletal diseases (RMDs): systematic review and meta-analyses informing the 2021 EULAR recommendations for lifestyle improvements in people with RMDs. RMD Open. 2022 Jun;8(2):e002167. doi: 10.1136/rmdopen-2021-002167. PMID: 35654458; PMCID: PMC9096533.; Thomas S, Browne H, Mobasheri A, Rayman MP. What is the evidence for a role for diet and nutrition in osteoarthritis? Rheumatology (Oxford). 2018 May 1;57(suppl_4):iv61-iv74. doi: 10.1093/rheumatology/key011. PMID: 29684218; PMCID: PMC5905611.; Reumanederland. Leven met reuma. Voeding. Geraadpleegd 22 maart 2023 via: https://reumanederland.nl/leven-met/voeding.; Reumanederland. Rheumatoide artritis en voeding. Geraadpleegfd 22 maart 2023 via: /https://reumanederland.nl/reumatoide-artritis-en-voeding

‍[11] Gioia C, Lucchino B, TarsitanoMG, Iannuccelli C, Di Franco M. Dietary Habits and Nutrition in RheumatoidArthritis: Can Diet Influence Disease Development and Clinical Manifestations?Nutrients. 2020 May 18;12(5):1456. doi: 10.3390/nu12051456. PMID: 32443535;PMCID: PMC7284442.; Ornish Lifestyle medicine. Nutrition. Geraadpleegd 22 maart 2023 via https://www.ornish.com/proven-program/nutrition.; https://www.ornish.com/zine/nutrition-for-a-healthy-strong-immune-system.; Paolino S, Pacini G, Patanè M, Alessandri E,Cattelan F, Goegan F, Pizzorni C, Gotelli E, Cutolo M. Interactions betwee nmicrobiota, diet/nutrients and immune/inflammatory response in rheumaticdiseases: focus on rheumatoid arthritis. Reumatologia. 2019;57(3):151-157. doi:10.5114/reum.2019.86425. Epub 2019 Jun 28. PMID: 31462830; PMCID: PMC6710844.; Reumanederland. Vormen van reuma. Geraadpleegd op 18 maart 2023 via: https://reumanederland.nl/reuma/vormen-van-reuma/osteoporose/

[12] Cannataro R, Di Maio L,Malorgio A, Levi Micheli M, Cione E. Spondyloarthritis and Strength Training: A4-Year Report. J Funct Morphol Kinesiol. 2021 Jun 24;6(3):58. doi:10.3390/jfmk6030058. PMID: 34202441; PMCID: PMC8293414.; Sveaas SH,Dagfinrud H, Berg IJ, Provan SA, Johansen MW, Pedersen E, Bilberg A.High-Intensity Exercise Improves Fatigue, Sleep, and Mood in Patients WithAxial Spondyloarthritis: Secondary Analysis of a Randomized Controlled Trial. PhysTher. 2020 Aug 12;100(8):1323-1332. doi: 10.1093/ptj/pzaa086. PMID: 32367124;PMCID: PMC7439225.