At age 46 yr, Mrs. PJ, a nurse and mother of two young c ldren,… At age 46 yr, Mrs. PJ, a nurse and mother of two young c ldren, who was generally physically active, started experiencing pain and stiffness in her hands, feet, and left knee. Accompanying t s joint pain was profound fatigue. Over the ensuing 3 mo as her condition deteriorated, she found it progressively more difficult to perform ADLs, and she was forced to abandon her normal recreational pursuits, Which included playing social tennis with friends every Wednesday evening. Particularly difficult were mornings, when her joint stiffness was at its worst, and she needed to prepare her c ldren for school. An inability to fulfill her role as a working mother and to enjoy her usual recreation activities led over time to feelings of inadequacy and not being able to cope. Eventually, the combination of fatigue, diminished physical function, and depression forced Mrs. PJ to take extended leave from work. At the insistence of her family, Mrs. PJ booked an appointment with a rheumatologist.Objective and Laboratory DataA rheumatologic evaluation revealed swollen proximal interphalangeal, metacarpophalangeal, and metatarsophalangeal (PIP, MCP, and MTP, respectively) joints and effusion of the left knee. Blood lab values included erythrocyte sedimentation rate (ESR) = 65 mm · h-1; C-reactive protein (CRP) = 52; positivity for rheumatoid factor and ACPA (anti-CCP) = 92 units · mL-1 (normal: <5 units · mL-1); and hemoglobin (Hb) = 11.0 g · dL-1.Assessment and PlanA diagnosis of RA was made based on t s information, and Mrs. PJ was prescribed combination therapy of etanercept (anti-TNF-a) and methotrexate (ETN + MTX). The rheumatologist also advised that she remain off work and continue taking t ngs easy. At 8 wk follow-up, the joint pain and swelling had mostly resolved (two slightly swollen MCPs); blood tests showed ESR = 16 mm · h-1, CRP = 6, and Hb = 12.2 g · dL-1; and X-rays gave no indication of significant joint damage. The rheumatologist was satisfied that the prescribed DMARDs were effectively controlling disease activity, and consequently t s pharmaceutical treatment regime was continued. W le Mrs. PJ was d that her joint pain and stiffness had diminished and that her physical function had been partially restored, she was still experiencing difficulties coping with the demands of daily living, including the worry of lost income if she was unable to return to work. Additionally, she was upset at her inability to resume her usual recreational activities and attributed t s reduced physical activity to the fatigue and feeling of diminished muscle strength she had experienced over the last year. Additionally, w le her weight had not substantially changed (an increase of 4 lb [1.8 kg]), she was aware of an increase in adiposity, Which greatly concerned her as she was normally quite lean and took pride in t s. The inability to perform activities she was accustomed to doing, and the adverse changes in her body composition, had caused a further loss of self-esteem, persisting depression, and a reduced QOL. Specifically to address these consequences of impaired physical functioning, the rheumatologist referred Mrs. PJ to a clinical exercise physiologist who was experienced in prescribing exercise for RA patients.Exercise Test ResultsA submaximal treadmill walk test was performed and predicted a peak aerobic capacity (estimated V?O2max) of 27 mL O2 · min-1 · kg-1. Objective physical function tests (30 s sitto-stand test (SST), 50 ft walk, hand-grip strength) indicated performance levels significantly poorer than for healthy sedentary reference women of the same age (206). Assessment of body composition showed Mrs. PJ to have a % body fat of 36% and to be muscle wasted relative to age- and sex-specific population norms (by ~10%). Exercise PrescriptionTo improve body composition, aerobic capacity, and strength, Mrs. PJ was prescribed 8 wk of supervised gym-based combined aerobic and progressive resistance training (PRT) three times a week. Aerobic training initially involved cycling for 10 min at 30% HRR, but t s gradually progressed to 20 min continuous cycling at 65% HRR. Resistance training involved six different exercises (upper and lower body, using large muscle groups) and commenced at 60% 1RM (one set of 15 repetitions). The intensity progressed gradually, initially to two sets of 15 reps at 60% 1RM, before progressing to two sets of 12 reps at 70% 1RM, and then, at the start of week 6, to two sets of 8 reps at 80% 1RM. When supervision was withdrawn after 8 wk, Mrs. PJ was encouraged to continue training at the gym and to supplement t s training with regular walking (i.e., replacing short driving trips with walking) and taking a long walk (30 min or more) 1 d/wk.When reassessed 6 mo after commencing exercise training, Mrs. PJ's estimated V?O2max was 34 mL O2 · min-1 · kg-1; she had gained 3 lb (1.4 kg) in lean body mass and lost 6 lb (2.7 kg) in fat mass (including 5 lb (2.3 kg) in trunk fat mass). Performance in the objective physical function tests had improved from 21% to 40%, and strength, as assessed by predicted 1RMs, had increased on average by 110%. The improvement in objectively assessed physical function indicated that she was now performing these tests as well or better than age-matched, healthy reference women.DiscussionAs a consequence of her improved aerobic capacity and strength, Mrs. PJ was now able to perform ADLs generally without difficulties, had resumed playing midweek social tennis, and had returned to nursing, albeit only on a part-time basis. With the resumption of most of her previous activities and the knowledge that she was able to reduce, and in some cases eliminate, many of the consequences of her chronic disease, Mrs. PJ's selfesteem, self-efficacy, and enjoyment of life was largely restored. On the other hand, even though her fatigue had attenuated, periodically it remained debilitating, and maintenance on immune suppressors was notable for a slight increase in the incidence of opportunistic infections (e.g., upper respiratory tract infections). The challenge for Mrs. PJ will be sustaining her motivation to exercise and thus maintain the benefits of training that she has acquired.1.    What exercise advice should the rheumatologist have given Mrs. PJ when she was initially diagnosed with RA?2.     Which comorbid conditions are elevated in an individual with RA such as Mrs. PJ? What are the contributory factors to t s increased comorbidity risk?3.    What are the anticipated benefits of exercise training for Mrs. PJ?American College of Sports Medicine. (2018). ACSM's guidelines for exercise testing and prescription (10th ed.). Lippincott Williams & Wilkins. Ehrman, J. K., Gordon, P. M., Visich, P. S., & Keteyian, S. J. (2019). Clinical exercise physiology (4th ed.). Human Kinetics. Health Science EXSC 637