RA Exercise Guide · The Holistic Rheumatologist
Rheumatoid arthritis

Exercise as medicine.

Your evidence-based movement guide — every exercise matched to the research that supports it.

Resistance training reduces disease activity. Pilates reduces pain. Tai Chi quiets the stress-inflammation axis. Aerobic training protects your heart. Exercise snacks keep all three pathways active throughout the day. This page teaches you how to do each one safely.

The evidence. A meta-analysis of 17 RCTs (Ye 2021, Medicine) found resistance training reduced RA disease activity (DAS28) by SMD −0.69 — the strongest effect of any exercise modality. The included trials ranged from 30% to 100% of 1-rep max. Your contracting muscles produce exercise IL-6, which stimulates your body's own version of anakinra (IL-1ra) — a built-in anti-inflammatory response.

Lower body

Bodyweight squat

3 sets · 10–12 reps · 60s rest
▾
Video coming soon
Feet shoulder-width apart, toes turned slightly outward
Sit back and down as if reaching for a chair behind you
Keep chest lifted — eyes forward, not at the floor
Knees track over toes, never collapsing inward
Lower until thighs are parallel to the floor (or as far as comfortable)
Push through your whole foot to stand — squeeze glutes at top
RA note: If knee swelling limits depth, squat to a chair or box and sit briefly before standing. The movement pattern matters more than the depth.
Sets
1:00between sets
Lower body

Reverse lunge

3 sets · 8 each leg · 60s rest
▾
Video coming soon
Stand tall with feet together, hands on hips or at sides
Step one foot backward — land on the ball of the back foot
Lower back knee toward the floor, both knees near 90°
Front knee stays stacked over the ankle — not past your toes
Push through the front heel to return to standing
RA note: Reverse lunges are easier on the knees than forward lunges — the deceleration happens in the hip, not the knee joint.
Sets
1:00between sets
Posterior chain

Hip hinge (deadlift pattern)

3 sets · 10 reps · 60s rest
▾
Video coming soon
Feet hip-width apart, soft bend in the knees
Slide hands down your thighs as you push hips backward
Keep back flat — imagine a broomstick along your spine from head to tailbone
Lower until you feel a deep hamstring stretch, then drive hips forward to stand
Why this movement: This is the deadlift pattern. Master it here before adding any load. The Lemmey 2009 RCT used loaded deadlifts at 80% 1RM — this is where that movement starts.
Sets
1:00between sets
Upper body

Wall push-up → floor push-up

3 sets · 8–12 reps · 60s rest
▾
Video coming soon
Start at a wall (easiest), progress to a countertop, then knees, then full floor
Hands slightly wider than shoulder-width, fingers spread
Lower chest toward the surface — elbows at about 45°, not flared wide
Keep body in one straight line from head to heels (or knees)
Push away to return to start — exhale as you push
RA note: If wrist involvement limits flat-palm push-ups, use fists on a padded surface or push-up handles to keep wrists neutral.
Sets
1:00between sets
Upper body

Overhead press (bodyweight)

3 sets · 10 reps · 60s rest
▾
Video coming soon
Stand tall, arms in goalpost position — elbows at shoulder height, bent 90°
Press hands straight overhead until arms are fully extended
Lower back to goalpost with control — 2 seconds down
Keep ribs down, core braced — no arching the lower back
Progression: Once bodyweight is easy, add 3–5 lb dumbbells. This pattern progresses to the loaded shoulder press used in the Häkkinen and Flint-Wagner protocols from the Ye 2021 meta-analysis.
Sets
1:00between sets

Adding load · 60–70% of your 1-rep max. This matches the intensity used in the majority of the 17 RCTs in the Ye 2021 meta-analysis — including Häkkinen 2001 (50–70% 1RM, 2x/week, 104 weeks) and van den Ende 2000 (60% 1RM). The ACSM classifies 60–70% 1RM as moderate intensity — sufficient to build strength in beginner-to-intermediate lifters.

Lower body · loaded

Goblet squat

4 sets · 8 reps · 90s rest · 60–70% 1RM
▾
Video coming soon
Hold a dumbbell or kettlebell at your chest with both hands, elbows tucked
Same squat pattern — sit back, chest up, knees tracking toes
The weight in front acts as a counterbalance, making depth easier
Control the descent (3 seconds down), drive up with intent
How to find 60–70% 1RM: If the heaviest single squat you can do with good form is 50 lb, your working weight is 30–35 lb. Retest every 6–8 weeks as you get stronger.
Sets
1:30between sets
Posterior chain · loaded

Romanian deadlift

4 sets · 8 reps · 90s rest · 60–70% 1RM
▾
Video coming soon
Hold dumbbells in front of thighs, palms facing you
Push hips back (same hip hinge pattern), sliding weights down your legs
Stop at deep hamstring stretch — typically mid-shin
Drive hips forward to stand, squeeze glutes at lockout
RA note: Use lifting straps if hand/wrist involvement limits grip. The target is glutes and hamstrings, not grip endurance.
Sets
1:30between sets
Lower body · loaded

Dumbbell walking lunge

3 sets · 10 steps each leg · 90s rest
▾
Video coming soon
Hold dumbbells at your sides, shoulders back and down
Step forward into a lunge — both knees to approximately 90°
Push off the front foot to step into the next lunge
Keep torso upright throughout — no leaning forward
Sets
1:30between sets
Upper body · loaded

Dumbbell shoulder press

4 sets · 8 reps · 90s rest · 60–70% 1RM
▾
Video coming soon
Seated or standing, dumbbells at shoulder height, palms forward
Press straight overhead until arms are fully extended
Lower with control — 2 seconds down to shoulder height
Brace core and keep ribs down to protect your lower back
Shoulder caution: If shoulder involvement limits overhead range, substitute a high incline dumbbell press (bench at ~70°) to reduce the overhead demand.
Sets
1:30between sets

High intensity · 80–90% of your 1-rep max. This matches the Lemmey 2009 (80% 1RM, 2x/week, 24 weeks), Flint-Wagner 2009 (90% 1RM, 3x/week, 16 weeks), and Siqueira 2017 (90% 1RM, 3x/week, 16 weeks) protocols from the Ye 2021 meta-analysis. At this intensity, train 2x/week with full recovery between sessions. Always use a spotter or safety equipment.

Compound · barbell

Barbell back squat

5 sets · 5 reps · 2–3 min rest · 80–85% 1RM
▾
Video coming soon
Barbell across upper back (not neck), feet shoulder-width
Brace core as if bracing for a punch, then descend with control
Full depth if mobility allows — hip crease below the knee
Drive up explosively — the intent to move fast recruits more motor units even if the bar moves slowly
Safety: Always use a squat rack with safety bars set just below your lowest depth. Never train to failure without a spotter.
Sets
2:30between sets
Compound · barbell

Barbell deadlift

5 sets · 5 reps · 2–3 min rest · 80–85% 1RM
▾
Video coming soon
Bar over midfoot, feet hip-width, hands just outside knees
Flat back, chest up, shoulders over or slightly in front of the bar
Push the floor away with your legs — the bar rises with your hips
Lock out by standing tall — hips forward, shoulders back, glutes squeezed
RA note: Use mixed grip or lifting straps if hand involvement limits double overhand grip. The target is posterior chain, not grip.
Sets
2:30between sets
Compound · barbell

Overhead press

5 sets · 5 reps · 2–3 min rest · 80–85% 1RM
▾
Video coming soon
Bar at collarbone height in the rack, grip just outside shoulders
Brace core, squeeze glutes, press bar straight overhead
Move head back slightly to let the bar pass, then push head through once bar clears
Lock out overhead with bar directly over midfoot — stack the joints
Shoulder caution: If shoulder involvement limits overhead range of motion, substitute a landmine press or high incline barbell press.
Sets
2:30between sets

The evidence. The Ye 2022 aerobic meta-analysis (17 RCTs) showed VO2max +2.41 mL/kg/min and HAQ-DI −0.25 (exceeding the MCID of 0.22). The Bilberg 2024 HIIT RCT showed VO2max +3.71 mL/kg/min and waist circumference −2.6 cm. Aerobic exercise improves cardiovascular fitness and function but does NOT significantly reduce DAS28 disease activity — that's resistance training's job. These two modalities are complementary, not interchangeable.

Cardiovascular

Moderate aerobic training

3–5x/week · 30–40 min · 50–70% max heart rate
▾
Video coming soon
Options: Brisk walking, cycling, swimming, elliptical — choose what your joints tolerate best
Intensity check: You should be able to hold a conversation but not sing. If you can sing, go faster. If you can't talk, slow down
Heart rate target: 50–70% of your maximum heart rate. Estimate max HR = 220 minus your age. For a 45-year-old: max 175, target zone 88–123 bpm
Duration: Start at 15–20 minutes if deconditioned, build to 30–40 minutes over 4–6 weeks
RA note: If weight-bearing cardio aggravates lower extremity joints, cycling or swimming are excellent alternatives — they provide the same cardiovascular benefit with less joint stress.
30:00workout timer

The Bilberg 2024 protocol. The Bilberg RCT tested HIIT specifically in well-controlled RA. The fitness gains were superior to moderate aerobic training: VO2max +3.71 mL/kg/min and waist circumference −2.6 cm. However, DAS28 did not improve — HIIT is a fitness intervention, not a disease-modifying one. Combine it with resistance training for the full effect.

High intensity intervals

HIIT protocol

2–3x/week · 20–25 min total · 85–95% max heart rate during intervals
▾
Video coming soon
Warm-up: 5 minutes at easy pace (walking, light cycling)
Intervals: 4 rounds of 4 minutes at 85–95% max heart rate, with 3 minutes active recovery between rounds
Active recovery: Keep moving at very low intensity — walk, pedal slowly. Don't stop completely
Cool-down: 5 minutes at easy pace, then stretch
Mode: Bike, rower, or elliptical are preferred — less joint impact than running
RA note: HIIT should only be attempted once you have a base of 4–6 weeks of moderate aerobic training and your disease is well-controlled. If you are in a flare, drop to moderate intensity until it resolves.
4:00high intensity

The evidence. The 2025 network meta-analysis of 34 RCTs ranked Pilates highest for pain reduction in RA — above all other exercise modalities. The mechanism is likely a combination of core stabilization (reducing compensatory strain on inflamed joints), mind-body awareness (breaking the pain-tension-guarding cycle), and gentle progressive loading (building strength without high joint forces).

A beginner Pilates flow for RA · 20–25 minutes · 3× per week · no equipment
Position 1 · 3 minutes

Lateral breathing + pelvic floor

8–10 breath cycles · Foundation of every Pilates movement
▾
Video coming soon
Lie on your back, knees bent, feet flat on the floor. Place hands on your lower ribs
Inhale through the nose — feel ribs expand laterally (sideways), not belly rising upward
Exhale slowly through pursed lips — draw navel gently toward spine
On each exhale, lightly engage your pelvic floor (as if stopping the flow of urine)
8–10 breath cycles. This lateral breathing pattern is the foundation of every Pilates movement that follows
3:00breathing practice
Position 2 · 3 minutes

Pelvic tilts + bridge

8 tilts → 8 bridges · Spinal articulation
▾
Video coming soon
Same position. Exhale and tilt your pelvis — press lower back flat into the floor
Inhale and release to neutral (slight natural curve in the lower back)
8 tilts, then progress: on the exhale/tilt, peel hips off the floor into a bridge
Roll spine up one vertebra at a time — hold 3 seconds at top, squeeze glutes
Lower back down one vertebra at a time. 8 bridges total
3:00tilts + bridges
Position 3 · 4 minutes

Single leg stretch + toe taps

8 each leg · Core stability under movement
▾
Video coming soon
Tabletop position — both knees bent 90° over hips, shins parallel to floor
Maintaining core engagement, slowly lower one toe to the floor
Return to tabletop. Alternate sides. 8 each leg
If easy: extend the lowering leg fully straight before returning
RA note: Keep lower back pressed into the floor throughout. If it arches, you've gone too far — reduce range of motion.
4:00core sequence
Position 4 · 4 minutes

Cat-cow + thread the needle

8 cycles + 15s hold each side · Spinal mobility
▾
Video coming soon
Hands and knees — wrists under shoulders, knees under hips
Inhale: drop belly, lift chest and tailbone (cow). Exhale: round spine upward, tuck chin (cat)
8 slow cycles — match each movement to a full breath
Then: thread one arm under the opposite arm, lowering that shoulder to the floor
Hold 15 seconds each side. This releases the thoracic spine and shoulders
RA note: If wrist involvement limits weight-bearing on flat palms, make fists or use forearms on a bolster.
4:00spinal mobility
Position 5 · 4 minutes

Side-lying leg series

10 circles + 10 clamshells each side · Hip stability
▾
Video coming soon
Lie on your side, hips stacked, bottom arm extended under head
Lift top leg to hip height. 10 small circles forward, 10 backward
Then: bend both knees 90° (clamshell position). Open top knee, keeping feet together
10 clamshells each side. This targets hip abductors — critical for knee stability in RA
4:00hip series
Position 6 · 4 minutes

Spine stretch + saw

6 stretches + 6 saws each side · Flexibility
▾
Video coming soon
Seated tall, legs extended wider than hips, feet flexed
Inhale to sit taller. Exhale: round forward, reaching past toes
Stack back up one vertebra at a time. 6 reps
Then the saw: twist torso and reach opposite hand toward outside of opposite foot
Exhale as you reach, inhale as you return to center. 6 each side
4:00flexibility

The evidence. The 2025 network meta-analysis of 34 RCTs ranked Tai Chi highest for DAS28 disease activity reduction in RA. The mechanism is top-down rather than bottom-up: slow, controlled movement with meditative focus reduces sympathetic nervous system tone, lowers cortisol, and quiets NF-κB inflammatory signaling. Resistance training fights inflammation through your muscles. Tai Chi fights it through your nervous system. Together they address both pathways.

Daily practice · 10–15 minutes · slow, continuous, and flowing

I recommend learning Tai Chi from a qualified instructor or following an established video series. Below is a curated beginner Yang-style sequence I recommend for my patients, with key movements explained.

Curated Tai Chi video
YouTube embed goes here
Replace with: <iframe src="YOUTUBE_EMBED_URL">
Opening · 2 minutes

Wuji standing + commencement

3 repetitions · Settle into stillness first
▾
Stand with feet shoulder-width, knees slightly bent, weight evenly distributed
Hands at sides, shoulders relaxed and dropped. Tongue resting on roof of mouth
Breathe deeply for 30 seconds — settle into stillness
Inhale: raise both arms slowly to shoulder height, palms facing down
Exhale: press palms gently downward, bending knees slightly deeper
3 repetitions. Each one slower than the last
2:00opening form
Movement 1 · 3 minutes

Parting the wild horse's mane

3 each side · Continuous flowing movement
▾
Hold an imaginary ball — one hand on top, one underneath
Step forward on the same side as the top hand
Top hand sweeps upward and outward; bottom hand presses down
Shift weight fully onto the front foot — back foot pivots naturally
Switch sides: gather a new ball and step forward with the other foot. 3 each side
Key principle: Power comes from your legs and waist rotating — arms are carried by the torso, not moving independently. This is what distinguishes Tai Chi from arm waving.
3:00flowing practice
Movement 2 · 3 minutes

Wave hands like clouds

6 repetitions · Meditative weight shifting
▾
Face forward, weight shifting smoothly left and right. Feet step together and apart
As weight goes left, left hand rises to face height while right drops to hip
As weight goes right, hands trade — right rises, left drops
Hands trace slow, continuous circles in front of your body
Eyes follow the upper hand. Waist turns with each weight shift. Let thought quiet
3:00meditative flow
Movement 3 · 3 minutes

Brush knee and push

3 each side · Coordinated upper/lower body
▾
Step forward. One hand sweeps past the knee (as if brushing something aside)
The other hand pushes forward from beside the ear — palm facing outward
Shift weight onto the front foot as the push completes
Step forward on the other side and repeat. 3 each side
RA note: Keep stances shorter if ankle or knee involvement limits range. The benefit comes from the flow and the breath, not the depth of the stance.
3:00flowing practice
Closing · 2 minutes

Cross hands + closing

3 breaths · Gathering and settling
▾
Bring feet together to shoulder width, arms opening wide to each side
Cross wrists in front of your chest — right over left, palms facing you
Hold for 3 deep breaths — this is a moment of gathering energy
Uncross and lower hands slowly to your sides as you exhale
Stand quietly for 30 seconds. Notice how your body feels compared to when you started
2:00closing form

The evidence. Fenton 2017 showed that sedentary time increases cardiovascular risk in RA independently of how much formal exercise you do — even if you meet the 150-minute weekly guideline. A 2025 systematic review of 26 studies confirmed exercise snacks improve glucose metabolism, blood pressure, endothelial function, and cerebral blood flow. Your morning workout cannot undo 8 hours of sitting. These can.

One movement every 30 minutes of sitting · 60–90 seconds each
60 seconds

Stand and sit × 10

Pathway: GLUT4 translocation → glucose clearance (insulin-independent)
▾
From your chair, stand fully and sit back down 10 times without using your hands
This triggers the contraction-mediated glucose uptake pathway — your muscles pull sugar out of the blood without needing insulin
1:00snack time
90 seconds

Brisk walk across the room × 3

Pathway: Shear stress → eNOS → nitric oxide → vasodilation
▾
Walk briskly across the longest room available and back, three times
Restoring blood flow creates shear stress on your artery walls, which triggers nitric oxide production — your blood vessels open up and your endothelium stays healthy
1:30snack time
60 seconds

Bodyweight squats × 10

Pathway: Myokine release → exercise IL-6 → IL-1ra (endogenous anakinra)
▾
10 full squats at your desk — same form as the beginner resistance section
Muscle contraction releases exercise IL-6, which tells your liver to produce IL-1ra — the same receptor antagonist your rheumatologist prescribes as anakinra (Kineret)
1:00snack time
90 seconds

Staircase climb × 1–2 flights

Pathway: Cardiac output → cerebral blood flow → brain perfusion
▾
Walk up 1–2 flights of stairs at a moderate pace, then walk back down
The increased cardiac output drives a pulse of blood flow to your brain — delivering glucose, oxygen, and clearing metabolic waste. This is the neuroprotection pathway
1:30snack time

Your RA exercise prescription

Resistance training 2–3× per week — the disease-modifying backbone. Aerobic or HIIT 2–3× per week — cardiovascular protection. Pilates or Tai Chi 2–3× per week — pain management and neuroendocrine regulation. Exercise snacks every 30 minutes of sitting — vascular, metabolic, and brain health. Three pathways. One prescription.