Exercise-based and mind-body rehabilitation strategies to improve cardiovascular autonomic control in rheumatologic diseases

Rheumatologic diseases (RDs) are chronic autoimmune and inflammatory conditions associated with increased cardiovascular risk and autonomic nervous system dysfunction, typically characterized by sympathetic predominance, reduced vagal tone, and persistent inflammation. This narrative review synthesizes current evidence on exercise-based and mind-body rehabilitation strategies aimed at improving cardiovascular autonomic control in RDs, including rheumatoid arthritis, ankylosing spondylitis, osteoarthritis, systemic sclerosis, and fibromyalgia. We examine the physiological mechanisms linking these interventions to autonomic regulation and inflammatory modulation, drawing upon the inflammatory reflex framework. Aerobic exercise training demonstrates consistent benefits for cardiovascular autonomic control, including enhanced heart rate variability, improved heart rate recovery, and reduced inflammation, though effects are reversible upon cessation. Resistance training improves pain and physical function but shows equivocal effects on autonomic outcomes. Balneotherapy and aquatic exercise may enhance parasympathetic activity, though responses are temperature-dependent and highly individualized. Mind-body interventions, including yoga, mindfulness, and breathing exercises, show promise for improving symptom burden and cardiac vagal modulation, with slow-paced breathing demonstrating particularly consistent acute and chronic autonomic benefits. Emerging evidence supports transcutaneous auricular vagus nerve stimulation as a non-invasive modality capable of modulating inflammation and reducing pain, though effects on cardiac autonomic control remain inconsistent across RDs populations. Key challenges include high inter-individual variability in treatment responses, poor long-term adherence, and frequent dissociation between subjective clinical improvement and objective autonomic measures. This review identifies critical knowledge gaps and proposes future research directions to optimize rehabilitation protocols for cardiovascular protection in RDs.