Pain-Free Living

Managing Morning Stiffness in RA

by Maura Daly Iversen, PT, DPT, SD, MPH

Waking in the morning to the sound of a blaring alarm can cause any good-natured person to get up on the wrong side of the bed. If you are one of the 1.3 million Americans with rheumatoid arthritis (RA), managing your early-morning routine may be especially challenging. That’s because many people with RA must deal with particularly achy and hard-to-move joints at the start of the day — a condition called “morning stiffness.”

RA is a chronic inflammatory condition that mainly affects the joints, causing them to grow swollen, painful, and stiff. These symptoms tend to be more pronounced in the morning, and people with RA often feel that the first hour or two of their day is the most difficult. Fortunately, there are effective ways to reduce the severity of morning stiffness using medicines and gentle exercise.

What is morning stiffness?

Morning stiffness is a type of joint stiffness, a general term used to describe difficulty moving your arms, legs, and other parts of your body. Stiffness is often described as a tight, rigid feeling in the joints. Stiffness caused by RA can occur at any time, but it is most common after waking in the morning and following other times of prolonged inactivity (for example, after sitting for a while). In addition, stiffness is usually worse during RA “flares” — temporary periods when RA is very active. Stiffness can occur in any joint of the body, although the joints most commonly affected are the hands, feet, hips, knees, and spine. In RA, morning stiffness typically lasts more than one hour. Because it lasts so long, it can make it difficult to carry out simple morning routines such as dressing, eating, and showering.

In RA, pain and stiffness are brought on by an overactive immune system that mistakenly attacks the joints, inflaming the thin layer of cells that surround them (called the synovium, or joint lining) and causing the joint fluid to thicken. As a result, the joint becomes swollen, painful, and increasingly difficult to move.

If this immune-system attack continues unchecked, the result can be damage to the cartilage and bone within the joint and eventual joint deformity. For this reason, medicines that address the disease process of RA are the first line of treatment for RA and the joint pain and stiffness it causes. Disease-modifying antirheumatic drugs (DMARDs), which include methotrexate (Rheumatrex, Trexall) and leflunomide (Arava), and biologic response modifiers such as etanercept (Enbrel) and adalimumab (Hu­mira) are commonly used. Both these types of drugs can slow or even stop the progression of RA within the body. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil and others) may be used to reduce joint swelling and pain but do not affect the underlying disease process in RA. Corticosteroid drugs, including prednisone, are extremely effective at reducing stiffness and inflammation, but because they can cause many side effects, they are typically used only for short periods and under specific conditions.

Sometimes RA medicines are used alone and other times in combination with one another. Your doctor — preferably a rheumatologist, a physician who specializes in treating rheumatic conditions such as RA — is best able to help you decide which RA medicines are appropriate for you. When you speak with your rheumatologist, be sure to ask about potential side effects of your medicines, how best to take them, any interactions they may have with other medicines, and how long it will take before they are effective. Knowing you must take a medicine for two weeks before your symptoms improve can help you feel more confident about the medicine and stick with it even if it doesn’t seem to be working at first.

Range-of-motion exercises

Besides medicines, there are a number of simple exercises you can do to keep your joints moving and reduce morning stiffness. After you reach over to shut off that nagging alarm clock in the morning, consider doing some simple range-of-motion exercises in bed before you get up. In range-of-motion exercises, you move a joint through its full range of motion without using any weight or resistance. (Range-of-motion exercises are different from stretching, in which the goal is to elongate muscles to their full potential.) Studies show that gentle range-of-motion exercises can improve flexibility and maintain joint movement. See “Bed Exercises for Morning Stiffness” for a full program of simple range-of-motion exercises. You can also do these exercises at night before going to sleep to reduce joint stiffness and pain when you wake up the next morning.

Taking a hot or warm shower can also help reduce joint and muscle stiffness and improve joint range of motion. The warmth from the water is thought to increase the elasticity of collagen, a fiber found in muscles and other tissues in the body, and therefore make range-of-motion and stretching exercises more effective. Gentle range-of-motion exercises can also be used in the shower to reduce stiffness. (See “Range-of-Motion Exercises” for a few exercises you can do in the shower.)

A general recommendation is to have two or three range-of-motion “sessions” every day to maintain joint health and mobility. It is particularly important to do range-of-motion exercises during RA flares, when you may be unable to do more strenuous exercise. Integrating exercises into your routine — for example, doing a few neck exercises before brushing your hair or rotating your wrists before putting on your socks — can help you remember to do these exercises.

While range-of-motion exercises can go a long way toward relieving joint stiffness, it’s also important to get other types of exercise. Rounding out your exercise program with strengthening and aerobic, or cardiovascular, exercise can help you keep your body strong and your joints functioning well.

Strengthening exercises

In addition to stiffness, joint inflammation and swelling produce joint pain, and many people find that keeping their joints in a flexed or bent position helps to relieve that pain. Unfortunately, maintaining joints in a flexed position allows the muscles surrounding the joints to shorten, and shortening of muscle fibers can eventually lead to muscle contractures, loss of muscle mass, and muscle weakness. It is especially important for people with RA to avoid muscle loss and weakness because the inflammatory process of RA can itself cause these symptoms.

It is therefore essential to incorporate strengthening exercises into your routine to improve joint motion, muscle strength, and joint function. Strengthening exercises come in two main types: dynamic and static. Each of these provides specific benefits and can help to reduce joint stiffness.

Static exercises. Static strengthening exercises are useful when your joints are inflamed, as during a flare. The tension created by contracting the muscles without changing the muscle fiber length can maintain muscle strength without putting additional stress on the joints. These exercises should be performed multiple times a day. (See “Two Static Exercises” for examples.) Do not hold your breath when performing static exercises, as this can increase your blood pressure. In addition, you should talk with your doctor or physical therapist before doing these exercises if you have any changes in your joint alignment due to joint deformities.

Dynamic exercises. Dynamic strengthening exercises have been shown to improve muscle strength and function. These exercises are most effective when performed for many repetitions and with low resistance (2–5 pounds). Lifting dumbbells and using elastic exercise bands are well-known types of dynamic strengthening. The key to successful dynamic exercise is to pay attention to your body’s response afterward. It is common to feel some muscle discomfort with exercise, but the discomfort should not last more than half an hour after exercising. Doing the exercises at a slow pace and building intensity gradually can also lead to better results and make it easier to stick with your exercise program.

Tai chi and yoga combine the benefits of strengthening and range-of-motion exercises and can also help to improve balance and coordination. Recent studies suggest that both tai chi and yoga can help improve balance, strength, endurance, and joint function while reducing joint pain and stiffness. In addition, tai chi and yoga can both be modified so that they don’t place too much stress on the joints. Your local Arthritis Foundation chapter may offer classes teaching these exercises; call (800) 283-7800 or go to the Arthritis Foundation Web site for information.

Aerobic exercise

Fatigue is a common symptom of RA and often accompanies morning stiffness, making it even more difficult to handle pain and stiffness early in the day. Aerobic exercises, which are defined as those that cause an increase in your heart and breathing rate, can help to address fatigue and other symptoms of RA. Cycling on a stationary bike, swimming and other water exercises, and brisk walking are examples of aerobic exercises that are suitable for people with RA. Water exercises are especially helpful for easing joint movement and reducing joint pain and stiffness. Your local Arthritis Foundation chapter can help you locate a water exercise program near your home. Before you begin an exercise program, check with your doctor or physical therapist to find out what level of aerobic intensity is safe for you.

Range-of-motion, strengthening, and aerobic exercise can all help improve the health of your joints, making them less stiff and better able to function properly. While joint stiffness is a common and to some extent unavoidable symptom of RA, these exercises can help you reduce its impact. Start with simple range-of-motion exercises in bed before you fall asleep and incorporate a few exercises before you get out of bed. Next, add in some strengthening and aerobic exercises to your routine. Soon you will be on the move again.

Last Reviewed December 15, 2010

Dr. Maura Daly Iversen is Professor and Chair in the Department of Physical Therapy at Northeastern University and Senior Lecturer in Medicine in the Division of Rheumatology, Immunology, and Allergy at Harvard Medical School in Boston.

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