Running with rheumatoid arthritis: a qualitative study of Australian rheumatologists’ perceptions and recommendations

Abstract

Objective

To explore how Australian rheumatologists perceive and recommend running for individuals with rheumatoid arthritis (RA), including their clinical experiences, observations and personal views.

Design

Qualitative exploratory study using semistructured interviews. Interviews were conducted via Microsoft Teams, transcribed verbatim and analysed thematically using NVivo software.

Setting

Australia; interviews were conducted remotely via Microsoft Teams with participants joining from either clinical or home environments.

Participants

13 practising Australian rheumatologists recruited through purposive and snowball sampling.

Results

Five themes were identified from thematic analysis: (1) perceived benefits of running, (2) risks and clinical cautions, (3) criteria required for discussing running, (4) barriers to running and (5) facilitators to running. Participants acknowledged various benefits of running for individuals with RA, such as improved mental health, lifestyle changes and support for joint health. Concerns included risks of running during active disease phases and overly rapid progression of training loads. Key criteria for recommending running included good disease control, the patient’s running history and personal goals. Barriers included patient concerns around joint harm, lack of guidelines and socioeconomic challenges. Facilitators included stable disease, symptom-guided pacing, gradual load increases, allied health referral and appropriate footwear.

Conclusion

Rheumatologists acknowledged both the potential benefits and risks of running for people with RA. Individualised recommendations based on disease status and patient preferences could enhance the integration of running into care plans. Further research is needed to develop specific guidelines and understand patient outcomes.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Exploratory qualitative design enabled in-depth insights from Australian rheumatologists.

• The semistructured interview method allowed flexibility while ensuring coverage of key topics.

• Interviews were brief (20 min), potentially limiting depth of discussion.

• Snowball sampling may have led to self-selection bias favouring prorunning perspectives.

• Findings may not represent the full spectrum of rheumatologist views across Australia.

Introduction

Rheumatoid arthritis (RA) is an autoimmune disorder characterised by synovial joint inflammation leading to the destruction of bone and cartilage in affected joints.¹ This disorder is associated with joint pain, fatigue, increased incidence and progression of cardiovascular disease and accelerated loss of muscle mass which ultimately leads to impaired physical function.²

Exercise has been found to be safe and effective for people with RA, enhancing functional ability, cardiovascular fitness, muscle strength and mitigating joint damage.3,7 Furthermore, there have been no adverse events reported for people with RA engaging in various modes of exercise, including high-intensity exercise.^{3 7}

While the protective effects of recreational running on the development of osteoarthritis (OA) have been well-documented, the implications of running for RA remain relatively unexplored.^{8 9} Despite their different aetiologies, both OA and RA share the common feature of inflammation as a contributing factor in their pathogenesis.¹⁰ Acute bouts of running have been demonstrated to reduce the intra-articular concentration of proinflammatory cytokines (granulocyte-macrophage colony-stimulating factor and interleukin-15), which are implicated in joint disease pathogenesis.^{11 12} The immediate effect of long-distance running has also been evaluated, suggesting protection against chronic systemic inflammation possibly through the modulation of cytokine levels and other anti-inflammatory mechanisms.¹³ Running does not worsen symptoms or structural progression with knee OA and may reduce knee joint pain.¹⁴ These findings support previous literature on using exercise to reduce inflammatory pathways and support its role in alleviating symptom burden in inflammatory arthritis, including RA.^{15 16}

While progress has been made in understanding the impact of running on OA, there is comparably less knowledge concerning RA. One study found that high-intensity exercise can improve disease outcomes and slow bone mineral density loss.^{3 17} Only two other small studies have incorporated running into the interventions for individuals with RA; however, participants had alternative options in both studies to complete the protocol.^{18 19} This protocol inconsistency makes it unclear how running affects RA. Promising data from animal models show that treadmill running inhibits joint destruction and synovial hyperplasia in rats with collagen-induced arthritis if completed during periods of decreased disease activity.²⁰ These findings suggest that running may inhibit arthritis and prevent joint destruction if completed during phases of reduced disease activity. Further research, particularly in human populations with RA, is required to support these findings and explore the potential benefits and risks of running as an intervention.

Despite growing evidence showing the benefits of physical activity in the management of RA, fear of joint harm remains a barrier.²¹ As running is often regarded as harmful to joint health, there is a need for greater dialogue and consideration for individuals with RA.²² Addressing concerns around the safety and efficacy of such exercise is essential for promoting physical activity in this population. Improvements in fatigue, pain reduction, enhanced ability to perform daily activities and overall improvements in general health, fitness and mental health all serve as facilitators to physical activity.²³ Promoting running as a safe and beneficial exercise for individuals with RA could help overcome misconceptions and further encourage physical activity in this population.^{7 24}

Given the limited evidence and guidance available for running with RA, it is important to explore how clinicians currently perceive and approach this activity. As there are no established clinical recommendations specifically addressing running for individuals with RA, it is worthwhile exploring the perspectives and professional insights of rheumatologists in relation to the effects of running on people with RA. Rheumatologists can provide expert opinion in the management of rheumatological conditions. Subsequently, their insights, experiences and recommendations may provide valuable insight into the benefits, considerations and risks of incorporating running as a form of physical activity for people with RA.

Research aim

The aim of this study was to understand how Australian rheumatologists perceive the impact of running on joint health for individuals with RA. This perception includes rheumatologists’ clinical observations, their recommendations to patients and their personal views and experiences related to running for people with RA.

Materials and methods

Design

This was an exploratory study using a qualitative research method of semistructured interviews.

Recruitment

Purposive and snowball sampling strategies were used. Rheumatologists were identified through the Australian Rheumatology Association’s practitioner directory and invited via email to participate in the study. Participants were also encouraged to forward the invitation to colleagues. In total, 128 rheumatologists were contacted, with 14 agreeing to participate and 13 completing an interview. Demographic data were obtained from the Australian Health Practitioner Registration Agency to categorise participants (table 1).

Table 1. Participant characteristics.

Characteristic	Participants (N=13)
Male, n (%)	10 (76)
Years of clinical practice (mean, range)	27 (10–54)
Location (State), n (%)
VIC	4 (31)
NSW	3 (23)
QLD	1 (8)
SA	3 (23)
WA	2 (15)
Current runner, n (%)
Yes	6 (46)
No	1 (8)
Unknown	6 (46)

NSW, New South Wales; QLD, Queensland; SA, South Australia; VIC, Victoria; WA, Western Australia.

Interviews and data collection

Written informed consent was obtained from all participants in this study. 20 min semistructured interviews with consenting participants were completed between March 2024 and May 2024 (see online supplemental file 1). While interviews were relatively brief, participants provided detailed insights reflecting the targeted nature of the questions and their clinical expertise. Individual interviews were conducted via Microsoft Teams, with the interview being recorded for accurate documentation and transcribed verbatim. The interviews were all conducted by one investigator (SS). All data was stored securely as per Australian Catholic University’s Research Data Management Policy. Each participant was assigned a unique identifier by one investigator (SS), to maintain their confidentiality in the study. The other researchers (AH, JB) did not have access to the participants’ identity. The videos were then deleted after they had been transcribed for the safety and protection of the participants. Theme saturation appeared to be reached by the 13th interview, implying that there were no new narratives about the effect of running on RA. However, we acknowledge that snowball sampling may have favoured rheumatologists with more positive views of running, potentially narrowing the range of perspectives captured.

Data analysis

All 13 finalised transcripts were uploaded to NVivo (V.14, QSR International) for analysis. The coded thematic framework and supporting quotes are available in the Dryad Digital Repository.²⁵ An inductive thematic analysis was conducted following Braun and Clarke’s six-phase framework to analyse data in relation to the research question being investigated.²⁶ This process involved reviewing and familiarising with the content, generating initial codes, searching for patterns and organising content into themes that reflected the views and experiences of participants.²⁶

Braun and Clarke’s guidance on good practice in thematic analysis was incorporated to ensure that theme development was data driven, reflexivity was maintained and the analytical process remained transparent and coherent.²⁷ Following this, codes were generated to label and organise segments of data according to their meaning and relevance to the research question.²⁶ The data was then synthesised into the existing themes to form a narrative that summarises the experiences and perceptions of rheumatologists.

The content analysis was undertaken by SS and AH separately to ensure a fair representation of the interview topics and to minimise bias. Subsequently, coinvestigators SS and AH then reviewed the codes together and discussed any discrepancies; any disagreements were adjudicated by co-investigator JB. Key quotations from transcripts were selected to highlight major themes.

Patient and public involvement

Patients or the public were not involved in the design, conduct, reporting or dissemination plans of our research.

Results

Thematic analysis

Five themes were identified from thematic analysis: (1) perceived benefits of running, (2) risks and clinical cautions, (3) criteria required for discussing running, (4) barriers to running and (5) facilitators to running.

Theme 1: perceived benefits of running

Most participants highlighted a range of physical and psychological benefits associated with running for patients with RA. These included improvements in pain management, mental health, confidence and overall well-being. Several participants observed that individuals who ran adopted healthier lifestyle behaviours such as improved cardiovascular fitness, leaner body composition and reduced reliance on analgesia. This was described by one participant:

They’re leaner, their mental health is better, their muscle bulk is better. Their requirement for analgesia is less and their rheumatoid is generally better. So their overall health is better physically, but also mentally. And you know, they get addicted to it. So it’s a really nice thing to see that they’re empowered to do that.

Some participants suggested that running may benefit joint health, although the mechanisms were not fully explained and were often drawn from OA literature. As one participant noted:

I can’t speak for my colleagues, but we have some pretty good data that we can borrow from the osteoarthritis literature that suggests that running protects the joints long term.

Additional benefits included better coping, a sense of achievement and a perceived sense of control over the disease. One participant also suggested that running may help mitigate osteoporosis risk.

Theme 2: risks and clinical cautions

Concerns about potential risks were also expressed by nearly all participants. These included the advisability of running during active disease and the suitability for running for individuals with coexisting OA in weight-bearing joints. A specific concern was raised regarding the metatarsophalangeal joints. Participants emphasised the importance of timing and gradual progression, especially for individuals returning to running after a disease flare. As one participant explained:

As they start to pick back up after protracted periods of time of not running, none of them have done any resistance either because often I guess the problem is for a patient without rheumatoid arthritis who isn’t tired, who isn’t feeling sick because of their medications who isn’t anything else, you can point them in the direction of resistance and cross-training. Whereas our rheumatoid patients, you can't because we’ve made them unwell with their medication side effects.

Several participants highlighted the risk of injury from rapid load progression, citing examples such as stress fractures. One participant also described how corticosteroid use, such as prednisone, could create a false sense of energy while negatively affecting collagen structure, further increasing vulnerability to joint injury.

Theme 3: criteria for discussing running

When considering the suitability of running for individuals with RA, three main criteria arose; good disease control, the individual’s history of running and the individual’s personal goals.

All participants advocated the importance of good disease control before recommending running. They emphasised that managing inflammation and symptoms effectively was essential to prevent exacerbating symptoms. This was described by one participant;

If they’ve got very active disease, they’ve got like active inflammation, very high inflammatory markers and they're having pain doing just normal daily activities. Then I'd suggest that running at that time might not be a good idea because it’s likely to be very painful for them at that time.

Participants only discussed running if it aligned with their patient’s goals. They described the need to tailor recommendations to individual preferences and readiness. As one participant described;

I’m very encouraging towards exercise, but I usually try and tailor it towards what are their goals and what are what are they actually going to do. So running is just one of many things, but unless they specifically mention the word running, I'm not going to mention it to them specifically.

An individual’s history of running was an important consideration. Participants shared that advocating for more demanding modes of exercise can be challenging if an individual is quite deconditioned. As one participant explained;

Many people, when they come to us with inflammatory arthritis have been unwell for a while and are quite deconditioned. The thought of going from often relatively close to zero physical exercise through to something that’s considered to be quite a demanding form of exercise by many people, seems like a big barrier.

A number of participants also agreed that running can be difficult to advocate for if the patient is unfamiliar with it. Another participant highlighted the challenge of encouraging patients to exercise in general, let alone more challenging activities such as running. One participant suggested that such patients might find running daunting and recommended cycling as a gentler introduction to physical activity for those who are unfit.

Theme 4: the barriers to running

Barriers to running for individuals with RA reflected challenging experiences by both patients and clinicians. A key theme was patient concern that running may harm joint health or worsen disease outcomes. Participants described this as a common misconception that can be difficult to address. As one participant shared:

I think there is a general fear amongst people with any form of arthritis that a form of exercise that’s perceived as high impact exercise may be detrimental to joint health.

Participants also expressed that a lack of clinical guidelines or RA-specific evidence made it challenging to confidently recommend running. One participant expressed concern that many rheumatologists lack the knowledge or experience to support patients with greater athletic goals:

Very few of my colleagues have an understanding on how you should look after a recreational or semi-elite or elite athlete who has inflammatory arthritis … many of my colleagues are quite content [if patients] can go to the shops and … see [their] grandkids … They don’t have any concept of how to coach to the next level, let alone nail the disease to another level … that’s the bit that really disappoints me in my colleagues as they actively discourage people from doing it, and that’s a reflection of the fact they don’t know what to do with them.

A few participants reflected on how their own limited experience or knowledge of running impacted their ability to provide recommendations. Others perceived that their colleagues were generally conservative when it came to recommending high impact exercise. As one participant stated:

I’ve met some patients recently who had been advised previously by other doctors to not run, and I asked them how do you feel and actually they said they don’t feel better and they miss running and they didn’t feel better for not doing it.

Time constraints during consultations were also viewed as a barrier, limiting the opportunity to explore exercise options in depth. Medication side effects, which can make a patient feel unwell, were also seen as limiting a patient’s capacity or motivation to engage in more vigorous intensity exercise.

Socioeconomic factors further influenced engagement in running and other forms of exercise. One participant stated;

Overall I think it’s a fantastic form of exercise and I think is underutilised, particularly in certain populations. The population that I serve in a public hospital setting, in a relatively socioeconomically deprived area, includes very few people who either run or are open to the concept of running, despite the fact that it’s a low-cost, easily accessible form of exercise.

Theme 5: facilitators to running

Participants identified a range of strategies to facilitate safe running for individuals with RA. Key recommendations included ensuring disease stability, progressing load gradually and monitoring symptoms to guide activity.

As one participant described;

Listen to your body. Run and it’ll hurt you a little bit likely. But if the pain settles within an hour or two of stopping, then you keep doing it. But if you have a bad night the night after, or if you’re really sore the next day, then you need to back off.

Gradually building up distance slowly over time was also frequently highlighted, with some participants recommending following structured plans, such as ‘Couch-to-5km’. Referral to physiotherapy and exercise physiology was also frequently encouraged, with participants recommending professionals who have an interest in inflammatory arthritis or in running, respectively. Recommendations for good footwear, consideration of custom-made orthotics through podiatry and gait analysis were discussed to aid pain-free running. Education and reassurance were key themes, with participants emphasising the importance of reducing patient fears that running could worsen their disease. Encouraging patients to consider vigorous intensity exercise was recommended, with one participant stating:

Everyone likes the idea of natural therapies and they normally er towards curcumin and fish oil and glucosamine and rosehip. And you know dietary restriction. And we try and impress upon them that actually exercising regularly, vigorous aerobic exercises is more powerful than all of those things. And so if they’re honest about doing natural therapies, that’s where they should focus their attention.

Parkrun was noted by one participant as a flexible and inclusive entry point;

I think the thing for Parkrun… you could walk it if you want to start, and it’s not competitive in the sense of, you know, it’s not lot like an Athletic Club. So you can do everything from running to running hard to walking slow. So there’s a place for everyone there. Not just people who would perceive it as being turned off because it was overly competitive.

Strength training and cross-training during periods of increased disease activity were also discussed to complement running.

Finally, the consultants’ personal activity preferences were seen as influential, with those interested in running more likely to discuss it in depth:

…because I run myself we can go pretty deep into a kind of anecdotal account of running, but I don’t have any hard and fast rules that - I’m not prescriptive about it.

In contrast, others reported limited confidence in discussing running due to lack of personal or clinical experience;

Not being an athlete myself, I don’t have a lot of experience with people who run those distances, like running marathons, doing marathon training, running mountain roads.

Key recommendations for facilitating running are presented in online supplemental file 2.

Discussion

The aim of this study was to explore Australian rheumatologists’ perspectives on recommending running as part of the overall management for people with RA. Despite a growing body of evidence demonstrating the potential beneficial effects of recreational running, and more importantly no reported significant adverse effects, there appears to be a reluctance for running to be prescribed by rheumatologists for their patients with RA.28,30 Determining the most effective form of overall management for people with RA to promote physical activity and enable community participation is therefore an important issue for both rheumatologists and healthcare professionals.

The framework for this qualitative study was to conduct individual semi-structured interviews. Thematic analysis of the interview data revealed five main themes: (1) perceived benefits of running, (2) risks and clinical cautions, (3) criteria for discussing running, (4) barriers to running and (5) facilitators to running.

Consistent with existing literature around high-intensity exercise, participants recognised the potential benefits of running as a valuable strategy for improving physical and psychological outcomes in RA.^{7 31 32} Furthermore, there was a consensus that while running is considered beneficial for joint health, participants did not elaborate on mechanisms and explanations were often derived from OA literature. It has been previously identified that running may benefit joint health through nutritional penetration into the cartilage and removal of metabolic substances such as water, thereby enhancing cartilage regeneration.^{33 34} A reduction in osteoporosis risk was also mentioned, which aligns with previous research suggesting that high-intensity impact exercise can slow down the loss of bone mineral density for individuals with RA.¹⁷ Participants spoke positively about how running can empower individuals with RA, allowing them to regain independence and a sense of achievement. Participants noted that running was often a high priority for those already engaging in it.

All participants emphasised the significance of good disease control and cautioned against rapidly increasing training loads, particularly if a patient has gone through a period of offloading due to disease management. Medications were also noted as influencing exercise tolerance, both by making patients feel unwell and at a cellular level to negatively affect collagen structure and thereby increasing the risk of injury. A clinical example provided by one participant described an instance of a patient developing stress fractures due to an overly enthusiastic resumption of running. While running with concurrent OA was cautioned against by some participants, current literature suggests that running may not exacerbate symptoms or structural progression in knee OA.¹⁴ However, more research is needed to understand whether these findings extend to other affected joints. Care of the metatarsophalangeal joints was discussed, underscoring the importance of considering joint-specific factors for individuals with RA and supporting the need for appropriate footwear and orthoses.

In exploring the criteria for discussing running with their patients, all participants reiterated the importance of effective disease management as a prerequisite. Participants highlighted that running should align with their patients’ personal goals and history of physical activity prior to discussing the feasibility of running. It was suggested by some participants that individuals who lack a history of running are unlikely to want to adopt it as a form of physical exercise, despite its accessibility and low cost. One participant also identified the need for physicians to exert greater effort in preparing to discuss running with their patients. They underscored a prevailing tendency to discourage more physically demanding forms of activity, potentially due to a lack of knowledge in managing athletic patients.

Several barriers to recommending running as a form of physical activity were identified. There was recognition that there is a lack of RA-specific guidelines and evidence complicating participants’ ability to provide confident recommendations. Limited time in rheumatology consultations was also identified as a barrier to discussing running. Patient concerns regarding the potential for exacerbating joint issues, coupled with challenges in altering public perceptions, were frequently cited. Additionally, socioeconomic factors emerged as influential determinants affecting participants’ willingness to engage in running.

Key recommendations to facilitate running included adequate disease control, gradually increasing running volume, adjusting running volume in response to pain and following structured plans such as ‘Couch-to-5k’. Referral to physiotherapy and exercise physiologists was frequently encouraged. Recommendations for good footwear, custom-made orthotics through podiatry and gait analysis were discussed to aid pain-free running.

Participants also discussed the importance of creating realistic goals and encouraging patients to consider vigorous-intensity exercise, particularly those with a greater baseline of fitness. The role of vigorous-intensity exercise in inflammatory arthritis disease management has been identified, suggesting the benefits of reduced disease activity, fatigue and pain.^{3 35 36} Strength training, as well as cross-training during periods of increased disease activity, was recommended to complement running.

Community engagement through initiatives like Parkrun was suggested to make running more accessible and enjoyable. Parkrun is a free, weekly 5 km walk/run event held every Saturday in parks worldwide. It is considered a successful physical activity promotion initiative due to its inclusivity, catering for all running levels and abilities, and its accessibility, with no fees and convenient timing and location.³⁷ Parkrun also fosters social support, community spirit and friendship building.^{37 38} These factors collectively may contribute to improved health and fitness outcomes.³⁹

The personal activity preferences of participants were seen as influential, with those interested in running more likely to discuss it. This suggests that patients might be more encouraged to run if their consultants share a similar interest. This is consistent with prior research, which indicates that physically active physicians and healthcare professionals are more inclined to provide physical activity counselling to their patients.⁴⁰

The primary limitation of this study is related to the sampling method. Snowball sampling may have introduced self-selection bias favouring participants with a pre-existing interest in running, potentially weighting the findings towards more favourable views of running for individuals with RA. This bias could limit the generalisability of the results to the broader population of rheumatologists who may have differing views. Additionally, the brief duration of interviews may have limited the depth and variability of responses. While theme saturation was reached, it is possible that more critical or alternative views were underrepresented. Furthermore, references by some participants to colleagues who discourage running highlight the potential narrowness of the sample captured in this study and underscore the need to interpret the findings with caution.

The findings of this study have implications for clinical practice and future research. First, they underscore the need for patient-centred care and individualised recommendations when discussing physical activity options, particularly running, for people with RA. Rheumatologists play an essential role in addressing concerns, providing education and promoting physical activity to improve health outcomes. Clinicians also require greater confidence, resources and RA-specific guidance to translate recognition of running’s potential benefits into safe, tailored advice. Second, further clinical trials and longitudinal research are needed to better understand the effects of running on RA and help inform the development of RA-specific exercise guidelines, thereby reducing uncertainty and enabling rheumatologists to provide more consistent evidence-based recommendations.

Conclusion

Despite the rheumatologists engaged in this study acknowledging that running may be beneficial for individuals with RA, this study reveals important barriers including lack of guidelines and evidence, time constraints and patient concerns about joint health. Based on the perspectives of this small sample, suggested strategies include achieving adequate disease control, being guided by symptoms, following structured plans and referring patients to physiotherapists and exercise physiologists. Prioritising patient-centred care and further research could enhance the integration of running into RA management plans, ultimately improving patient outcomes.

Data availability statement

Data are available in a public, open access repository. All data relevant to the study are included in the article or uploaded as supplementary information.