Pilates guide
Exercise is part of treating rheumatoid arthritis (RA), alongside your medicines: it improves everyday function and eases pain by moderate amounts, helps tiredness and mood a little, and doesn't make the disease more active. Pilates is one gentle way to do the strength, flexibility and balance parts. Only three small trials have tested Pilates itself in RA, so we can't say it beats other exercise, but it's easy to adapt for sore hands, feet and necks.
Pilates sits beside your rheumatology team, never in place of it, and you keep taking your medicines as prescribed. This guide covers what RA means for exercise, what the trials found, how to work around flares, the hands, feet and neck, steroids and bones, which moves to start with and which to change or leave out, and the warning signs that need help the same day. Our 25-minute Pilates for arthritis class has no kneeling and no weight on your hands.
The National Institute for Health and Care Excellence (NICE) says adults with RA should have specialist physiotherapy to "improve general fitness and encourage regular exercise". The European Alliance of Associations for Rheumatology (EULAR) says everyday activity guidelines are "feasible and safe" in inflammatory arthritis. Neither names Pilates, but it's one gentle way to do the strength, flexibility and balance work.
Across the trials behind the American College of Rheumatology's guideline, exercise improved everyday function and eased pain by moderate amounts, with about 1 in 6 people helped. It eased tiredness a little and low mood a bit more, and it didn't make the disease more active.
Three trials of 30 people each. In the best reported, Pilates, walking and both together didn't differ, and the Pilates group's tiredness, mood and walking improved but its pain didn't. No trial has tested reformer or hot Pilates in RA.
Do less than usual, keep your joints moving through a comfortable range, and leave strengthening until hot or swollen joints settle. A flare that won't settle needs your rheumatology advice line.
A hand exercise programme improved hand function a little in a large trial. Most people with RA have foot problems, so stand in supportive shoes. Long-standing RA can affect the top of the neck: leave out moves that put weight on it, and know the warning signs.
RA raises fracture risk even without steroids, so with long-term steroids or thin bones use bone-safe versions of the moves. RA also raises heart and stroke risk by about half: add walking, cycling or swimming, because Pilates alone isn't enough for your heart.
RA is an autoimmune condition: the immune system attacks the lining of the joints, which become painful, swollen and stiff. It usually starts in the small joints of the hands and feet, and it can flare up unpredictably. Arthritis UK says it affects around 450,000 people in the UK, most are diagnosed at around 50, and it's much more common in women. It isn't the same as osteoarthritis, which our Pilates for arthritis guide covers.
Disease-modifying medicines control RA, with physiotherapy, occupational therapy and foot care (podiatry) beside them. Exercise is used alongside these medicines, never instead of them. NICE uses short courses of steroids for flares, and long-term steroids only after other options and their side effects have been discussed.
In a National Rheumatoid Arthritis Society (NRAS) survey, 89% of people with RA said they had fatigue, and 40% of them said it was persistent and severe. EULAR recommends tailored physical activity for it, so pacing matters: short sessions on tired days, longer ones on good days.
Across 14 studies of 41,490 people, RA raised the risk of heart and circulation problems by 48%, of heart attack by 68% and of stroke by 41%. Your rheumatology team manages that risk, and regular aerobic exercise is part of it.
Slow, controlled strength for the trunk, hips and shoulders, movement for stiff joints, balance, and breathing that helps you pace effort. It can be done lying, side-lying, seated, standing or on spring-loaded equipment such as the reformer. It's low in aerobic effort, so it covers the strength, flexibility and balance parts of EULAR's advice, not the heart part.
Re-analysing the American College of Rheumatology's trials (20 comparisons in 1,487 people for function, 14 studies in 998 people for pain), exercise improved function and pain by moderate amounts, and about 1 in 6 people were helped. The authors say more trials could still shift the size of the effect, and not every programme will help everyone.
EULAR found side effects in exercise trials were "transient and mild", such as muscle soreness and tiredness, and that there are "no disease-specific contraindications". A review for EULAR found activity "did not affect disease activity", and aerobic trials reported no harm to the disease.
Across 11 trials, high-intensity training didn't improve function more than gentler training, though it built a little more strength and fitness. A 2026 analysis of 44 trials found bigger doses didn't consistently help more. Everyday activity and sitting less eased fatigue too.
Physical activity eased RA fatigue by a small amount, about 14 points on a 100-point scale (6 trials, 388 people, moderate quality). In 15 trials, exercise reduced symptoms of depression by a moderate amount (moderate certainty) and may ease anxiety; mind-body exercise did about as well as other exercise.
In 30 people with RA (10 per group), 8 weeks of Pilates, walking, or both didn't differ from each other. The Pilates group's tiredness, mood, walking distance and quality of life improved, but its pain didn't. There was no group that did no exercise, so it can't show Pilates beats doing nothing.
Source 8
In 30 Iranian women with RA in the hips and knees, 8 weeks of Pilates eased pain and strengthened the knees more than in a control group, but the paper is in Persian, and what the control group did, and some details, are unclear to us. A trial in 30 men reported only before-and-after changes, and a registered trial has published no results.
A 2025 analysis of 34 trials ranked Pilates first for pain, but its Pilates result rests on one group of 10 people, its printed range of results doesn't contain its own estimate, and its authors rate the evidence low. We don't rely on it.
Source 10
We found no trial of reformer Pilates, chair Pilates or hot Pilates in RA. The trials used mat Pilates.
Source 11
In 5 yoga trials (718 people), disease activity and function improved, but pain didn't clearly. Tai chi trials found fewer people dropped out, without clear changes in function. No trial has compared Pilates with yoga in RA.
Our editorial starting point: our 25-minute Pilates for arthritis class 2 or 3 times a week. The Pilates trials in RA used 3 sessions a week for 8 weeks. Add repetitions first, then range, then load.
EULAR's dose is the general one: 150 minutes a week of moderate activity, such as brisk walking, cycling or swimming, plus regular strength, flexibility and balance exercise. The NHS asks for strength on at least 2 days a week; a Pilates class counts.
Some pain when you start is common and isn't a sign of harm if it settles. A hot, swollen joint is different: rest it from strengthening.
Aim for moderate effort: you can talk but not sing. If an activity makes your joints warm and swollen or causes severe pain, the NHS says stop and rest.
In a flare, rest the inflamed joints but keep them moving gently, then build back up.
Arthritis UK says to focus on "slow and gentle movement during a flare up, rather than stopping altogether", and to avoid intense or jarring movement. NRAS suggests rest and relaxation at the first signs of a flare, and gentle exercises to help with stiffness.
Leave strengthening until hot or swollen joints settle, and keep to breathing and gentle range, such as heel slides, ankle circles and hand glides.
Our flare-up routine and the stretches in our hand routine fit a bad day; save the strengthening moves for when the joint has settled.
NICE says everyone with RA should have rapid access to specialist care for flares. If a flare doesn't settle, or comes with feeling unwell, call your rheumatology advice line rather than pushing through.
Source 1
NICE suggests considering a tailored stretching and strengthening hand programme, taught by a trained practitioner, if you're not on RA medicines or your medicines have been stable for at least 3 months. In the SARAH trial of 490 people, 5 supervised sessions and daily home exercises improved hand function by 4.3 points on a 0 to 100 scale at a year, but not pain. By about 26 months the difference had faded as people stopped. A Cochrane review calls the benefit small.
Weight on flat hands (the knee hover, leg pulls, push-ups and side bends) loads the wrists and fingers most (our reading). Make fists, use your forearms, or choose the hands-free moves below when they're sore. Our hand routine follows the SARAH programme.
Most people with RA have foot pain or foot problems, says NRAS (on a page past its review date), and most of 413 people in one survey had a current foot problem. NICE says everyone with RA and foot problems should see a podiatrist, with insoles and footwear if needed. Do standing moves in supportive shoes.
In 13 studies (548 people), foot and ankle exercise eased pain and improved function and walking distance, at moderate certainty, though the review's reporting is a little inconsistent. Ankle circles and calf raises are simple places to start.
Source 48
RA can loosen the joints at the top of the neck, where the first two bones meet. How often depends on the study: X-ray signs of neck instability were found in 17% to 86% of people with RA, and signs of pressure on the nerves or spinal cord in 7% to 34%. Neck surgery for RA has fallen as treatment has improved. The NHS calls the spinal cord problem (cervical myelopathy) uncommon but serious.
No trial has tested which Pilates moves are safe for an RA neck, so this is our reading of the NHS's warning. If RA affects your neck, keep your head down in curl-up moves such as the hundred, and leave out moves that put weight on your neck: the roll-over, jack knife, control balance and boomerang. Gentle neck movement within comfort is fine unless your team says otherwise.
Our editorial advice: leave out headstands, shoulderstands and the plough pose, and don't force neck circles. Gentle neck movement is fine unless your team says otherwise.
Source 17
Long-standing RA can affect the joints at the top of the spine, which can slip and press on the spinal cord (cervical myelopathy). It is uncommon but serious: NICE asks for an urgent MRI scan and a surgeon's opinion for symptoms such as pins and needles, weakness or unsteadiness, and you may need a neck check before a general anaesthetic.
Arthritis UK asks you to tell your healthcare team about neck pain, loss of balance, trouble walking, or weakness or numbness in your arms or legs.
The UK osteoporosis guideline says rheumatoid arthritis raises fracture risk even without steroids and whatever your bone density. Across 29 cohorts, people with RA were about 1.5 times as likely to break any bone and 2.2 times as likely to break a hip. In 57 studies, 28% of people with RA had osteoporosis.
The guideline starts bone protection alongside steroids for some people, including those aged 50 or over taking 7.5 mg or more of prednisolone a day for 3 months, without waiting for a scan. If you take steroid tablets, ask your team about your bones. Never stop or change steroids yourself.
The UK consensus on osteoporosis says to modify or avoid "sustained, repeated or end-range flexion" and to consider alternatives to the Pilates roll-down and curl-up, and it recommends Pilates at least twice a week for balance and strength.
Leave out loaded rounding: the roll-up, roll-over, rolling like a ball and jack knife. Keep your head down in the hundred, chest lift, single-leg stretch and criss-cross, and twist and side-bend smoothly, as the move pages say.
Source 21
Because RA raises heart and stroke risk, add aerobic activity towards 150 minutes a week. Walking, cycling, swimming and water exercise are easy on the joints.
The RA trials used mat Pilates. Chair Pilates suits days when getting down to the floor is hard; the NHS has a chair-based Pilates video.
No trial has tested it in RA. The springs can lighten or add load, but the foot bar and straps can press on sore feet and hands, so a teacher who knows inflammatory arthritis helps (our suggestion).
There's no evidence for it in RA. NRAS suggests a warm bath or shower for morning stiffness, and a warm-up does the same job in a normal room.
Lateral breathing, 5 to 8 breaths; heel slides, 10 slow repetitions each side; ankle circles, 5 slow circles each way; tendon glides, 4 to 6 of each position held 5 seconds (the moves' pages); shoulder rolls, 10 slow circles each way, and slow breathing, 2 minutes (our lupus class).
3D demoLateral breathing (Pilates breathing)Beginner · No equipment
3D demoSupine heel slideBeginner · No equipment
3D demoAnkle CARs (controlled articular rotations)Beginner · No equipment
3D demoTendon glides (hand tendon gliding exercises)Beginner · No equipment
3D demoShoulder rollsBeginner · No equipment
3D demoSlow breathing (6 breaths a minute)Beginner · No equipmentPelvic tilt into bridge, 8 slow reps; hundred, 50 beats with your head down; clamshell, 10 each side; seated knee extension, 2 sets of 10 each leg; sit to stand, 5 slow reps (our arthritis class), building to 2 sets of 10 (our lupus class); knee folds, 2 sets of 5 to 10 each side; side kick, 8 to 10 each side; wall side leg lift, 10 to 12 each side (the moves' pages); dead bug heel taps, 6 each side, and swan, 5 small lifts with your arms by your sides (our lupus class).
3D demoPelvic tilt into bridgeBeginner · No equipment
3D demoKnee foldBeginner · No equipment
3D demoDead bug heel tapsBeginner · No equipment
3D demoHundred (Pilates)Intermediate · No equipment
3D demoClamshellBeginner · No equipment
3D demoSide kick (Pilates side kick series)Beginner · No equipment
3D demoSeated knee extension (chair)Beginner · A bench or box + Something with weight
3D demoSit to stand from a chairBeginner · A bench or box
3D demoWall side leg lift (standing side kick at the wall)Beginner · A wall
3D demoSwan (Pilates swan dive)Intermediate · No equipmentWrist and forearm flow, 5 finger spreads and 5 palm turns; reverse wrist curls, 10 reps; ball squeezes, 10 of 2 seconds (our hand routine); calf raises, 10 holding a counter (our lupus class); seated calf raises, 10 to 15 (our seated chair class); single-leg stand, up to 30 seconds each side with a hand near a wall (our arthritis class).
3D demoWrist & forearm flowBeginner · No equipment
3D demoReverse wrist curlBeginner · A dumbbell + A bench or box
3D demoBall squeezeBeginner · Other / check instructions
3D demoSlow calf raiseBeginner · A wall
3D demoSeated bent-knee calf raise (soleus raise)Beginner · A bench or box
3D demoSingle-leg standBeginner · A wallSpine twist, 3 to 4 each side, on a chair if you like; mermaid, 3 each direction, each side (the moves' pages); side-lying open book, 5 each side with your head on a cushion (our lupus class).
With rheumatoid arthritis that affects your neck, leave this out: the NHS says long-standing rheumatoid arthritis raises the risk of an uncommon but serious problem at the top of the spine (cervical myelopathy).
That applies to the roll-over, jack knife, control balance and boomerang. Also leave out the neck pull and rolling like a ball, and keep your head down in the hundred, chest lift, single-leg stretch and criss-cross.
Source 17
Swap the knee hover, leg pull front, side bend and push-up for the hands-free moves above, or use fists or your forearms, as the move pages suggest.
Leave out loaded rounding: the roll-up, roll-over, rolling like a ball and jack knife. Keep your head down in the hundred, chest lift, single-leg stretch and criss-cross, and twist and side-bend smoothly, as the move pages say.
Do the wall roll-down only with your hands resting on your thighs.
Source 21
Pad your knees or swap all-fours moves for lying or standing versions; our arthritis class has no kneeling. A hot, swollen joint gets gentle range only until it settles.
If a joint is hot and swollen, do the stretches only, gently, until it settles.
Start with our 25-minute Pilates for arthritis class: it has no kneeling and no weight on your hands, and if RA affects your neck, keep your head down throughout. Add the hand routine on most days while your hands are a problem, and use the flare-up routine on bad days. The lupus class is a hands-free 30-minute alternative.
A gentle 25-minute Pilates class for arthritis: lying, side-lying, chair and standing moves, with no kneeling or weight on your hands, and flare-day options.
25 minBeginner16 movesA bench or box, Something with weightThe daily stretches and strengthening moves from the SARAH hand trial and NHS hand therapy leaflets: finger bends, finger walking, wrist circles, squeezes and pinches.
15 minBeginner7 movesA dumbbell, A bench or boxA 10-minute routine for a pain flare-up: slow breathing, small gentle moves lying and sitting, a short stroll if you can, then rest. Repeat later in the day.
10 minBeginner10 movesA band, A bench or boxA 30-minute Pilates class for lupus with no weight on your hands: a gentle warm-up, balance at a counter, standing and mat strength, and a stretching cool-down.
30 minBeginner16 movesA wall, A bench or boxA 20-minute chair Pilates workout for beginners and older adults: breathing, sitting tall, gentle spine and leg moves, and a standing finish at the chair.
20 minBeginner14 movesA bench or box, Something with weightA 30-minute joint-friendly circuit built like the GLA:D and ESCAPE-pain programmes: a gentle warm-up, chair, step and band strength moves, balance, then stretches.
30 minBeginner14 movesA bench or box, A stepA 25-minute Pilates workout for osteoporosis and osteopenia: the Royal Osteoporosis Society's swaps for rounding moves, plus back strength and balance.
25 minBeginner16 movesA wall, A bench or boxA 30-minute joint-friendly yoga class for arthritis: seated breathing and joint warm-ups, standing poses with a chair, gentle lying poses and a long relaxation.
30 minBeginner17 movesA bench or box, A wallOnce your RA is stable, the beginner Pilates plan builds a routine over 4 weeks; swap any move this guide asks you to change.
A free 4-week, 3-day Pilates plan for complete beginners. Two mat days and one wall day, with clear rules for when to move each exercise to its harder version.
3 training days25 minBeginner3 days a weekA 12-week exercise plan for over-65s: strength and balance three times a week, short balance sessions and daily walks, based on falls-prevention trials.
3 training days40 minBeginnerThese are the warning signs from our rheumatoid arthritis and neck pain guides. A&E means accident and emergency. In the US, call 911 for 999, and use your doctor's urgent line or urgent care for NHS 111.
Call 999 if:
Call 999 or go to A&E (accident and emergency) straight away for severe difficulty breathing (gasping, choking or not able to get words out), a chest that feels tight or heavy, pain that spreads to your arms, back, neck and jaw, lips or skin turning very pale, blue or grey, or sudden confusion. If you're more short of breath than usual, or your heart is racing, fluttering or skipping beats, contact NHS 111.
Source 54
Call 999 or go to A&E: new problems walking, loss of bladder or bowel control, or a sudden loss of coordination, such as difficulty doing up buttons. These can be signs of pressure on the spinal cord.
Long-standing RA can affect the joints at the top of the spine, which can slip and press on the spinal cord (cervical myelopathy). It is uncommon but serious: NICE asks for an urgent MRI scan and a surgeon's opinion for symptoms such as pins and needles, weakness or unsteadiness, and you may need a neck check before a general anaesthetic.
Contact your rheumatology advice line, GP or NHS 111 the same day for:
Get help the same day for a hot, swollen joint with a fever, or severe pain and swelling that came on suddenly in one joint.
Source 14
Unexplained back pain with muscle spasms, loss of height, or a curved spine or change in posture: a possible osteoporotic spinal fracture, more likely with older age or long-term steroid tablets.
Source 20
The NHS advises getting advice from a healthcare professional first if you have a health problem, an injury or symptoms, or have recently had a heart attack or an operation.
Never stop or change your RA medicines because of exercise or a flare without your team.
Source 55
Trials found side effects were mild and short-lived, activity didn't make the disease more active, and function and pain improved.
Relative rest, not bed rest: keep your joints moving gently, then build back up.
The ranking that says so isn't reliable, and the only head-to-head trial found Pilates no different from walking.
No trial measured flares. Medicines control the disease; exercise helps you function and feel better alongside them.
The RA trials used mat Pilates, and no trial tested reformer or hot Pilates in RA.
It can be: exercise of any kind improves function and eases pain in RA by moderate amounts, and Pilates is a gentle way to do the strength, flexibility and balance parts. Only three small Pilates trials exist, so we can't say it's better than other exercise.
For most people, yes: European rheumatologists found no condition-specific reason to avoid activity, and side effects in trials were mild. Adapt it: keep your head down if RA affects your neck, keep weight off sore wrists, and use bone-safe versions if you take steroids or have thin bones.
Do less, not nothing: gentle breathing, heel slides, ankle circles and hand glides, and leave strengthening until hot or swollen joints settle. Call your rheumatology advice line if a flare won't settle or you feel unwell.
No trial has tested it. The springs can lighten or add load, which some people like, but the foot bar and straps can press on sore feet and hands, so a teacher who knows inflammatory arthritis helps.
There's no evidence for it in RA. A warm bath or shower beforehand, or a good warm-up, eases stiffness in a normal room.
Neither has been shown to be better. Yoga trials improved disease activity and function but not clearly pain; choose the one you'll keep doing, and see our yoga for arthritis guide.
With RA in your neck, leave out the roll-over, jack knife, control balance and boomerang, and keep your head down in curl-ups. With sore wrists, avoid weight on flat hands; with steroid-thinned bones, avoid loaded rounding such as the roll-up.
Exercise eases fatigue a little, about 14 points on a 100-point scale, and in one small trial the Pilates group's tiredness improved. Pace yourself: shorter sessions on tired days, and build up slowly.
Pilates itself hasn't been tested for RA hands. A tailored hand programme improved hand function a little in a large trial, and our hand routine follows it; NICE suggests a trained practitioner teaches it.
Our suggestion is our 25-minute class 2 or 3 times a week; the Pilates trials used 3 sessions a week for 8 weeks. Add walking, cycling or swimming towards 150 minutes a week for your heart.
Long-term steroids and RA itself thin bones, so ask your team about a bone check and use the bone-safe versions of the moves. Never stop or change steroids yourself.
Get advice the same day for pins and needles, weakness, unsteadiness or clumsy hands, especially with neck pain, a hot, swollen joint with a fever, or a flare that won't settle. Call 999 for chest pain, fainting or new problems walking.
Exercise education, not a personal prescription, and clinical review of these guides is pending. If you are pregnant, have a health condition or have had recent surgery, check with a doctor, midwife or physiotherapist before starting, and stop for sharp or increasing pain. Health disclaimer.
