DPT-402.6- Exercise Prescription: Special Considerations – Arthritis

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Arthritis is a term used to describe inflammation of a joint. It may be due to an abnormality in one joint, or to a widespread condition affecting several joints. Although there are more than 100 variations of rheumatologic diseases, the two main types are rheumatoid arthritis and osteoarthritis (Minor and Kay, 1997). 

Rheumatoid arthritis

Rheumatoid arthritis, or R.A., is an ‘autoimmune’ disease where the body’s immune system attacks itself, causing inflammation of the lining (synovium) of the joints. The inflammation in rheumatoid arthritis is unusual because it does not stop of its own accord – it becomes a long-lasting (chronic) process. It can start at any age, from children to those in their 90s. The most common age for the disease to start is between 30 and 50 years of age (ARC, 2004), and women are about 7 times more likely to be affected than men (Symmonds, Barrett and Benkhead, 1994). Research shows that rheumatoid arthritis can not be passed on from parent to child (The Arthritis Research Campaign [ARC], 1998).

In its mildest form, the illness can last for only a few months and disappear creating no disability. It may also come and go with episodes of illness (exacerbation) interspersed with periods of normal health (remission). In most people, the disease starts slowly with the joints of the fingers, wrists or the balls of the feet becoming uncomfortable and swollen; joints often feel stiffer in the mornings.  In about 1 in 5 people the disease will develop very rapidly with a rapid onset of pain and swelling causing everyday activities to become difficult (ARC, 1998).  

Pathophysiology

The process of inflammation begins with some sort of foreign substance invading the body. The exact cause is still unknown, and finding out why is the key to discovering a cure for rheumatoid arthritis. The inflammatory changes that take place in rheumatoid arthritis occur within the synovium. This inflammation causes a number of symptoms:

  • redness and warmth
  • swelling
  • pain

The redness and warmth are due to an increased blood flow. The swelling is because the joint secretes more synovial fluid. The swelling can cause the tough capsule, which supports the joint, to stretch. When the swelling goes down the capsule remains stretched and fails to hold the joint in its proper position. As a result the joint becomes less stable and can move into unusual or deformed positions. Initially, the disease involves the smaller peripheral joints of the hands and feet spreading later into the wrists, knees, elbows, and cervical spine (Minor and Kay, 1997).

Osteoarthritis

Osteoarthritis (OA) is a disease where inflammation and damage of the joint (arthritis) affects the surrounding bone (‘osteo’), causing it to grow thicker. Other words used to describe osteoarthritis are ‘osteoarthrosis’, ‘arthrosis’ and ‘degenerative joint disease’. Osteoarthritis is by far the most common joint disease, with about 8 million people in this country affected and about 1 million of these asking for treatment (ARC, 2004). Knee osteoarthritis is more common than hip osteoarthritis, but taken together they affect 10–20% of people aged over 65 (ARC, 2004). Many people never realise they have osteoarthritis, or suffer any pain, although it is very common to spot it on x-rays.  

Unlike RA, which is an autoimmune disease, the mechanisms contributing to OA make it more of a ‘wear and tear’ type of disease. Degenerative changes in joints are normally due to repeated overloading in ageing tissues; therefore, in the elderly some degree of osteoarthritis is present in all weight-bearing joints. If this process is exaggerated, symptoms may arise. The hips, knees and hands are most likely to be affected, but osteoarthritis can occur in any joint.

Pathophysiology

Osteoarthritis is a slow process that develops over many years. In most cases, there are only small changes that affect only part of the joint, but sometimes osteoarthritis can be more severe and extensive. Osteoarthritis is, fundamentally, an attempt by the body to repair itself that goes wrong. When a joint develops osteoarthritis, the cartilage gradually roughens and becomes thin and, the bone underneath thickens. The bone at the edge of the joint grows outwards (this forms osteophytes or bony spurs).

In many cases, especially in small finger joints, this attempt at repair is successful and the person experiences few or no problems. If the repair is not successful then it may seriously affect the joint, making it painful and difficult to move.

This occurs particularly in large joints such as the knees and hips. In these cases, the synovium swells and may produce extra fluid, which then makes the joint swell slightly. The capsule and ligaments slowly thicken and contract, to try to protect and stabilise the joint. Muscles that move the joint may weaken and become thin or wasted. In severe osteoarthritis, the cartilage can become so thin that it no longer covers the thickened bone ends. The bone ends touch and start to wear away.

People suffering from osteoarthritis usually complain of:

  • pain, stiffness and loss of movement in the joints affected
  • muscle spasm
  • muscle atrophy and weakness
  • joint enlargement and deformity
  • crepitus and loss of function

Risk Factors

Like most other conditions, there are many factors that can increase the risk of getting osteoarthritis. Usually, several of these have to be present before osteoarthritis develops. These important risk factors include the following:

Age:
Osteoarthritis usually starts in the late 40s, 50s or 60s and is uncommon before the age of 40. We do not fully understand why it is more common in older people. It is probably due to several factors that accompany growing older – muscles become weaker, weight increases, and our body is less able to heal itself.
Gender:
For most joints, especially the knees and hands, osteoarthritis is more common and severe in women.

Obesity:

For many people, this is an important factor in causing osteoarthritis, especially at the knee. Being overweight also increases the chances of osteoarthritis worsening once it has developed.

Joint injury:

A major injury or operation on a joint may lead to osteoarthritis at that site in later life. Excessive stress on certain joints, as with elite athletes, may also injure joints, for example professional footballers (osteoarthritis of the knee).

Heredity:

There is one common form of osteoarthritis (nodal osteoarthritis) that strongly runs in families. This particularly affects the hands of middle-aged women. 

Other types of joint disease:

Sometimes osteoarthritis is caused by injury and damage from a different kind of joint disease that occurred years before. For example, people with rheumatoid arthritis can develop ‘secondary’ osteoarthritis in those joints in which the rheumatoid inflammation has largely burnt out but where the joint remains damaged by the disease.

There are some myths concerning the causes of osteoarthritis, which are addressed by the ARC (1998):

  • osteoarthritis is not caused by exercise, the weather or from shock (although the symptoms of osteoarthritis may be felt more in cold, damp weather)
  • it is not caused specifically by diet; however, poor nutrition will not help, as it is detrimental to the formation and maintenance of bone, cartilage, ligaments and muscle

Cycle of Arthritic Degeneration

Osteoarthritis and a lack of activity can give rise to a gradually depreciating spiral. The affected joint is painful so the joint is used less causing an individual to reduce their total amount of activity. The joint then becomes stiffer and ultimately weaker, making an increase in their activity levels more difficult.

 Exercise Recommendations 

Although hard and repetitive activity may injure joints, normal activity and exercise is a protective factor against osteoarthritis. The type of exercise prescribed for an arthritic will vary daily according to the person’s physical condition, medical history, pain threshold and fitness level.

The increased risk of musculoskeletal damage and the implications of working with de-conditioned individuals must be addressed, to ensure safe and effective programming.  Weight-bearing or high impact activity is a relative contraindication as it may accelerate changes in articular cartilage that has already been damaged.  Non-weight-bearing or minimal weight-bearing activities are ideal (e.g. swimming, aqua-aerobics, cycling).  Where appropriate walking has the added benefit of bone loading and more natural, less stressful joint alignment, but it is not possible or desirable for severe arthritis.  

Aerobic Exercise Recommendations
Frequency·    3-5 x/week
Intensity40-60% VO2max (or 60-80% of peak HR), RPE 11-16
Time5 minutes, building to 30 as tolerated
Type          aerobic physical activity

Minor and Kay (1997), make the following recommendations for aerobic programmes: 

  • include low impact activities
  • avoid stair climbing, running or jogging in people who have arthritis in the hip or knee
  • reduce the load on a joint by exercising in a pool or an exercise bike
  • base exercise on a cross-training approach, e.g. swimming, hand cycle, treadmill, cycle etc.
  • follow an interval training approach that includes periods of rest
  • omit an exercise if there is any flare up or other contraindications
  • select shoes appropriate for shock absorption during weight-bearing activity
Resistance Training Exercise Recommendations
Frequency2-3 x/week
Intensity2-3 repetitions, building to 10-12
Timeisometric holds, up to 6 seconds, or isotonic as tolerated
Type          isometric contractions for affected joints, normal recommendations for unaffected joints

Muscles that move the joint may weaken and become wasted or atrophied (ARC, 1998).  Although the disease has an effect, inactivity is the main contributing factor.  Both isometric and isotonic exercises are useful in the improvement of joint function but they need to be approached and monitored carefully. Isometric exercises that are held for a maximum of six seconds are of particular value for painful joints – they cause the least rise in pressure inside the joint, the least inflammation and the least effect on the bone ends.

The benefits of isotonic exercises, developing strength through the full range of movement and showing greater strength gains overall, have to be weighted against the amount of movement at the joint.  Therefore, selective, well performed isometric work is used initially in preference to isotonic work for joints that are moderately painful or inflamed.  It may then be possible to progress to isotonic exercises.

Flexibility Recommendations
Frequencydaily or twice daily
Intensityto a position of mild discomfort
Time10-15 seconds per hold for maintenance10-15 seconds repeated with 6-8 second contractions for development3-4 repetitions for each stretch
Type          all major muscle groups used in the sessions

It is important to begin with specific posture work to maintain an upright, well-aligned posture in lying, sitting and standing.  Progress the size and intensity of movement gradually (e.g. shoulder, elbow, full arm) and target minor joints (i.e. hands and feet) as well.  Aim to include a full range of two and three-dimensional movements that relate well to everyday tasks, e.g. combing hair, pushing window open, putting on a jacket and so on.

Stretching should be supported, performed from a stable base and controlled. Extra time should be allowed for getting into position and for transitions. It is important to monitor for pain both during and following the exercises, stopping immediately if necessary and identifying the exercises that caused the pain. 

In particular, consider the following (Minor and Kay, 1997):

  • mobility and stretching is to be recommended daily (and even twice daily) even if the disease has flared up or if the rest of the programme is not possible
  • avoid the overstretching of muscles and the development of hypermobility at joints
  • avoid medial or lateral forces
Special Exercise Precautions

Programme planning:

  • investigate implications of any drug treatment for different types of exercise
  • assess the degree of functional capacity and fitness level
  • allow a longer warm up and cool down
  • allow a longer stretching and relaxation component in the cool down
  • repeat the cool down stretches two to three times for muscles around affected joints 
  • follow all stretches with mobility work to release tension and prevent stiffness
  • all training work should have an interval training approach

Guidelines for giving advice:

  • listen to the body and never disregard pain. Learn to know the extent of the regular level of joint pain and how exercise affects the joints
  • never exercise the affected joint if it is inflamed or if there is redness, swelling, tenderness or warmth
  • rest – a vital part of any programme
  • take it very slowly at first. Never overdo it and never be over ambitious
  • find the time of day when medication and arthritis symptoms are at their best and  the body is at its most mobile. This may be later in the day when joints are fully warmed up
  • always wear purpose-built exercise shoes for extra joint protection and balance
Additional Lifestyle Recommendations

A balanced diet can help to reduce the symptoms of arthritic conditions as well as promoting weight loss, if that is a goal. Certain nutrients or supplements include:

  • antioxidants – vitamin C, E and A (or beta carotene)
  • essential fatty acids (EFAs) – omega 3 (oily fish, such as salmon, mackerel, pilchard and herring) and omega 6 (evening primrose oil)
  • glucosamine sulphate  (Airola, 1988; ARC, 2004).

Weight loss is also advised to reduce stressful forces on the knees and hips. Each actual pound of weight lost reduces forces at the knees to the tune of 3 to 4 pounds (DiNubile, 1997).

Examples of Drugs Used to Treat Arthritis
Painkillersparacetamolco-proxamol
Non-steroidal anti-inflammatory drugs (NSAIDs)aspirinibuprofen
Rheumatoid arthritiscyclosporinazathioprine
Summary of Exercise Recommendations
Warm UpEvery session10-15 minutesUp to AeTlow impact and mobility
Main SessionCV3-5 x/week5 min building to 30 minutesAerobic exercise(AeT) RPE 11-16
Resistance2-3 x/week2-3 reps initially building to 10-12Circuit format, using isometric or isotonic ex.
Cool DownEvery session10-15 minutesSlow decrease in intensity
Flexibility 1-2 sessions/dayFocus on maintaining flexibility, and combine stretching with mobility work.

References

Airola, P. (1988). There is a Cure for Arthritis. Prentice Hall Press.

Arthritis Research Campaign (1998). Arthritis: An information booklet.  The Arthritis Research Campaign. 

Arthritis Research Campaign (2004). Arthritis. http://www.arc.org.uk. 

DiNubile, N A, MD, (1997). Osteoarthritis: How to make Exercise Part of your Treatment Plan, The Physician and Sports Medicine.

Minor, M. A. and Kay, D. R. (1997). Arthritis. In ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities (J. L. Durstine, ed.). pp. 149-152. Human Kinetics.

Symmonds, D., Barrett, E., and Bankhead, C. (1994). The prevalence of rheumatoid arthritis in the United Kingdom: Results from the Norfolk Arthritis Register. Br. J. Rheumatol., 33, 735-739.

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