I firmly believe that quality strength training is an absolute must for ALL populations. This view is generally supported by anecdotal evidence and an ever growing body of research. However, there is one population group where the benefits of strength training are not as well researched, those experiencing inflammatory conditions. While the benefits of strength training for mechanical arthritic conditions is more well known (e.g. Osteoarthritis), exercise prescription and strength benefits for conditions such as Psoriatic Arthritis, Rheumatoid Arthritis and Ankylosing Spondylitis are somewhat limited. Other conditions such as gout, asthma, allergies, coeliac disease, and hepatitis also fall under inflammatory disorders.

Along with localised inflammation, pain and stiffness associated with these conditions, comes additional challenges. These include, but are not limited to, states of severe fatigue, challenges to maintain full time employment, withdrawal and isolation from socialisation, depression and anxiety.

Having coached many clients with inflammatory based conditions, I wanted to delve deeper and educate others on just how important strength training is for this population. Unfortunately, a lot of the research around exercise and inflammation is limited and focuses on prevention of low grade inflammation for metabolic conditions like diabetes.  The aim of this article is to share as much information as I can on the subject.

Before moving on, I must state that these conditions MUST be managed with medication, and always under the guidance of your GP and specialists, I am merely going to comment on the role strength training can play to assist.

So, What is Inflammation?

Chronic inflammation in short, is a system wide problem with the immune system which is designed to fight off viruses, bacteria, and infection. Putting it simply, it results when your immune cells attack your body by mistake. Inflammation is one of the body’s natural defences against infections from bacteria, viruses, and other invaders, and is also a key process involved in adaption to training stress. Inflammation is usually the process in which the body produces and deploys white blood cells to flush out and destroy any foreign bodies in the bloodstream or to repair damage from muscle contraction (different mechanisms involved here). However, there are certain conditions such as those mentioned above or stressful situations, in which the body can trigger inflammatory responses without any invaders being present, and there becomes an imbalance in cytokine profiles.

Cytokines are cell signalling molecules that aid cell to cell communication in immune responses and stimulate the movement of cells towards sites of inflammation, infection and trauma. Cytokines can be pro-inflammatory and anti-inflammatory; the key is to have a favourable profile of anti-inflammatory vs pro-inflammatory cytokines. There are many, but the key anti-inflammatory ones I found in my research are interleukin (IL)-1ra and IL-10 which are induced by up-regulation of IL-6, a pro-inflammatory cytokine.

See below left a great photo from ESSA (Exercise & Sports Science Australia) of a joint affected by inflammatory arthritis, and on the right, an illustration showing the difference between a healthy synovial lining (LHS) and an inflamed synovial lining (RHS).

Common Symptoms and Issues, and How Strength Training Can Help

Psoriatic Arthritis, Rheumatoid Arthritis and Ankylosing Spondylitis are some of the more common inflammatory conditions, yet are quite confusing, and complex by nature regarding their pathophysiology, however they have large crossovers in their symptoms. I will now detail some of the more common symptoms and issues associated with these inflammatory conditions, and how strength training can play a key part in management. Unfortunately, as I mentioned earlier, a lot of the research around exercise and inflammation focuses on low grade inflammation for metabolic conditions like diabetes, so ensuring conditions have drug management from a specialist is vital.

Inflammation and pain –

Strength training promotes better anti-inflammatory profile balance and physical performance simultaneously ⁽¹⁾ as it increases the production of anti-inflammatory cytokine IL-10, key for a positive inflammatory profile.

Even moderate exercise has major effects on muscle-derived IL-6 which induces a greater release of anti-inflammatory cytokine (IL)-1ra & IL-10. In a study by Fischer (2004) ⁽²⁾, young healthy individuals performed 3 hours of dynamic two-legged knee-extensor exercise at 50% of their individual maximal power output. This exercise induced a 16-fold increase in IL-6 mRNA, a 20-fold increase in plasma-IL-6, and a marked IL-6 release from working muscle, thereby improving their anti-inflammatory profile. In another study about the anti-inflammatory effects of exercise by Peterson (2005) ⁽³⁾,  it states “During exercise, IL-6 is produced by muscle fibers via a TNF-independent pathway. IL-6 stimulates the appearance in the circulation of other anti-inflammatory cytokines such as IL-1ra and IL-10 and inhibits the production of the pro-inflammatory cytokine TNF-α”. Imagine if you had healthier muscle from quality barbell training with squats, deadlifts, presses’ and pulls!

Medication side effects –

Medication prescribed by specialists play a key role in the management of inflammatory conditions. Some commonly used medications include:

• Disease-modifying anti-rheumatic drugs (DMARDs), which are used to decrease inflammation, but unlike standard over the counter anti-inflammatory drugs that only temporarily ease pain and inflammation, DMARDs can slow the progression of the disease. Also falling under this group are Anti-TNF therapy, which are a key pro-inflammatory cytokine. It plays a crucial role in the pathogenesis of inflammatory diseases.
• Biologics, they work by blocking specific inflammatory pathways made by immune cells.
• Better known to public would be the use of Non-Steroidal Anti-Inflammatory Drugs (NSAIDS), which is the most commonly used drug.

Side effects of the above drugs, NSAIDs in particular, include ulcers, kidney injury, bleeding in the gastrointestinal tract ⁽⁴⁾, headaches, dizziness and high blood pressure. I am going to focus on the musculoskeletal area of the side effects as the others are beyond my scope of practice, and advice should be sought by experts in those areas.

Inflammation plays a vital role in remodelling of tissue, so it has been seen that with the use of anti-inflammatory drugs that the initial steps of tendon healing, through protein synthesis, are inhibited with NSAIDS and the proliferation of tendon cells is blocked ^{(5, 6)}. Several studies have demonstrated that the use of NSAIDs led to a lower load-to-failure and reduced tensile strength of tendons ⁽⁷⁾, which therefore increases the risk of injury. Clinical evidence also indicates that NSAID therapy can impair bone fracture healing and tendon-to-bone (enthesis) healing ⁽⁸⁾. I want to be clear that most research in to the risks of NSAID’s use is in far lower dosages and looking at sporting injuries. Also to note, if the dosage is well controlled, as it usually is under guidance of a specialist, anything that facilitates earlier return to strength training specifically (as opposed to normal sports), with the training load appropriately modified for the first few sessions back, then they are likely to be of net benefit rather than harm.

So, what does strength training do? It plays a significant role in mitigating the long-term effects such as tendon weakness, and therefore higher injury and disability risks. Strength training increases the tendons ability to absorb and utilise tensile forces through stiffness, and obviously increases the strength of the musculature surrounding the tendons and joints. Increases in tendon stiffness in response to resistance training have been identified in both animal and human studies following long term resistance training ^{(9, 10, 11, 12)}. In addition, tendons respond to strength training by increasing total number of collagen fibrils, increasing the diameter of collagen fibrils, and increasing in fibril packing density ^{(13, 14, 15, 16, 17)}, all reducing injury risk and rupture while increasing performance.

However, because of the risks involved for someone with already weakened tendons from long term inflammation and detraining effects, all strength training must be well planned, supervised and controlled individual, avoiding explosive ballistic training (at least through early phases).

Joint and bone degeneration –

There is greater risk of joint degeneration for those with inflammatory conditions, particularly if they are not addressed very early on through diagnosis and drug management. Strength training provides appropriate stressors to the skeletal system, stimulates the body to increase bone density, and significantly slows the decline in bone and joint health that comes with chronic inflammation and the natural processes of ageing ^{(18, 19)}. Planned and productive strength training, providing increasing yet controlled stress over time, causes your body to adapt with stronger and healthier bones and joints, hence why it is so critical in preventing osteoarthritis and other mechanical forms of degeneration.

 

Muscle wastage –

With pain, fatigue and withdrawal from physical activity (side effects of chronic inflammatory diseases), comes increasing rates of sarcopenia, which is essentially muscle wastage. While this does happen naturally as we age, lack of strength training and other disease factors significantly increases the rate of loss of muscle cross sectional area. So, to put it simply, get under the barbell regularly, with well-planned training structure from a skilled coach, and you can effectively address this issue. High-intensity strength training has been effective and well-tolerated method to increase or maintain muscle strength in patients with rheumatoid arthritis, with NO deleterious effects on disease activity and pain being observed ⁽²⁰⁾.

The increases in lean muscle tissue strength training gives you (which cardio does not) helps to decrease risks of many other co-morbidities that are associated with low levels of lean tissue. Quality lean tissue (muscle) helps you to avoid metabolic syndromes such as obesity and the associated diabetes & cardiovascular disease to name a few, improves your ability to respond and recover from illness & injury, and increases whole body metabolism. More details and references are in my previous article HERE.

 

Fatigue –

Fatigue is a disabling symptom of inflammatory diseases.  It often hits hard for sufferers during flare ups. Strength training however, can significantly counteract these symptoms and results in improving self-reported fatigue and health ⁽²¹⁾. By improving the bodies tolerance to load, and the forces of gravity itself through greater base strength, means that simple day to day tasks become that much less stressful for your systems in general. So, while the strength training is doing all that great stuff reducing system wide and tissue specific inflammation, it is also reducing fatigue and improving overall quality of life, helping you get back to enjoying a lifestyle most people take for granted ^{(22, 23)}.

Isolation from socialising & mental wellbeing – With pain, fatigue, and challenges during day to day activity, comes a range of mental wellness problems. These are just as important as the physical ones already mentioned. Socialisation, autonomy, self-mastery & self-efficacy all play critical roles in mental wellness, and these key components can be stripped away from day to day life for those managing inflammatory conditions. Strength training provides everyone, not just this population group, the opportunity meet all these needs.

Interacting with a coach and other clients (if in a small group session), the freedom of choice to do something beneficial for you, the feeling of elation in successfully progressing with your well-structured strength program and hitting a PB, knowing within yourself that because of your strength you can approach any physical task and succeed, it doesn’t get any better than that! Please see more details and research references in my article HERE on mental wellbeing and exercise, and HERE on exercise and quality of life from Coach Michael Velianis.

What About When I Have a Flare Up?

Unfortunately, there still will be occasions when you have flare ups in your condition, no matter how well managed it is with medication and training. But, the stronger and healthier you are, the less severity, frequency and overwhelming affect the flare ups have. Removing yourself completely from strength training won’t help you in the long term, you need to be well controlled, monitoring fatigue and symptoms with your coach/EP/allied health professional, and always consulting your specialist if it’s long lasting. The sooner you get back to moving the better you will be.

Some more information for you:

For those interested in finding out a bit more and hearing from the experts in the field, I encourage you to click on the below youtube clip, featuring Drs. Austin Baraki, Jordan Feigenbaum, and Shom Bhattacharjee, discussing all things strength training for arthritic and inflammatory conditions. It is nearly an hour long so I draw your attention to minute 30:26 for a discussion on the anti-inflammatory effects of more lean muscle, as well as minutes 42:40-49:00, around the benefits strength training has for inflammatory conditions such as Ankylosing Spondylitis, and minutes 54:30-58:30 for detail on how tendon weakness from chronic steroidal use and other myopathic effects of drug interaction are mitigated through quality strength training under a highly skilled coach.

I had the opportunity to speak with Dr Shom Bhattacharjee, who is a specialist in Rheumatology and General Internal Medicine at the Alfred Hospital and the Western Hospital, when he came to visit us here at Absolute. I feel a quote from such an expert in the field is a great way to finish this article off, now go get under that barbell under guidance!!

“It is my opinion, however, that in patients with axial or peripheral spondyloarthritis, on treatment, increasing muscle mass through a suitably supervised, programmed and progressed resistance training regimen, in concert with an appropriate nutritional prescription to facilitate the above, has a panoply of long term benefits – anti-inflammatory, motor control, possibly improved response to drug therapy, almost certainly decreased cardiovascular morbidity, and preservation of bone mass, to name a few.” Dr Shom

 

Written By Head Performance Coach David Smith

 

References:

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