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.

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