Arthritis - Part 1

As life expectancy increases coupled with a higher incidence of obesity in society, arthritis is emerging as one of the most common ailments for the human population. Statistics show that approximately 90 percent of individuals over the age of 40 develop arthritis. More people are turning to exercise, either attending fitness classes, completing strength and cardiovascular exercise or employing the help of a personal trainer. These are all successful methods to cut down the side effects of a sedentary lifestyle and poor diet. But because people have ignored their health and body for so long before taking up exercise, most are unaware about their physical limits.

The problem becomes escalated in those over age 40 because not only do they have to offset years of no exercise or poor diet, the majority are most likely unaware they have some form of arthritis. Their health is not helped by gym instructors using generic exercise programs that are designed for a 20-year-old male with no history of degenerative joint diseases. Often, arthritic patients can be seen attempting high intensity, high impact workouts or performing free weight sessions with little direction or training. Such workouts challenge even elite athletes and are not appropriate for those who are unfit or who have some form of arthritis.

We really need to ask ourselves, "What are we really trying to achieve with these individuals?" Most clients aren’t ever going to need to get to an elite level of performance. Their goals are often focused on improving their activities of daily living, and therefore their programs should reflect this. Again, I have often witnessed new and enthusiastic gym members who show determination in persisting with the programs they are given in an effort to improve their health and wellbeing, only to see they cannot cope with it. The natural response for these individuals is to lose interest because they are not achieving what they set out to do, and they often find themselves in the very same place they were before they started.

In this article series, I am hoping to raise the awareness of arthritis, debunk the myths surrounding arthritis and exercise, discuss the management of an arthritic client in terms of strength and cardiovascular training and provide you with the foundations for developing a program that will allow your arthritic clients to achieve their goals.

Arthritis can be defined as “inflammation of a joint, usually accompanied by pain, swelling and stiffness and resulting from infection, trauma, degenerative changes, metabolic disturbances or other causes. It occurs in various forms, such as bacterial arthritis, osteoarthritis or rheumatoid arthritis.” The two most common forms of arthritis we need to consider are osteoarthritis (OA) and rheumatoid arthritis (RA). Both affect joints in very different ways, and due to this, they must be looked at individually in regards to exercise advice.

Osteoarthritis, otherwise known as degenerative joint disease, can be defined as “chronic degenerative changes to joint cartilage.” The exact cause of osteoarthritis is unknown; however, the risk factors leading to an increased chance of developing osteoarthritis include heredity, excess weight, injury and past history of joint damage. OA is usually associated with stiffness, especially after inactivity. The joints commonly involved are the weight bearing joints such as the knees, hips and spine as well as the hands and toes. The clinical features of OA include pain worsened by physical activity (excessive) and relieved by rest, morning stiffness, tenderness, swelling (mild), crepitus, restricted movement and joint deformity. Those over the age of 40 years are most likely to develop OA; however, previous history of trauma and other lifestyle/work factors can also contribute.

When training a client with OA, there are certain factors that also need to be considered. It has been shown that those individuals with OA who either do too much or too little exercise are more likely to develop symptoms. Finding the right balance between exercise and rest requires communication between you and your client.

Exercise helps to increase functional independence by increasing pain control, proprioception, strength, stability and endurance. Strong muscles are able to act as shock absorbers for the joints and distribute the pressure to reduce stress being placed on joints. Those with mild to moderate OA are the only individuals that I would advise to continue exercising through pain. Often, the patient might not experience huge reductions in pain, but functionally speaking, their abilities will improve dramatically.

Rheumatoid arthritis on the other hand is a systemic arthritis in which the body’s immune system attacks the joints, typically effecting symmetrical joints. RA is the most common inflammatory arthritis, affecting approximately three percent of the population. It can vary from mild to severe, and pain is often persisting rather than fleeting. In 25 percent of cases, a single joint such as the knee can be affected. The joints most commonly involved include the hands, wrists, elbows, feet, knees and hip, glenohumeral joint and neck. The clinical features of RA include an insidious onset, peak at ages 30 to 50, female 3:1 ratio, joint pain, morning stiffness and stiffness with rest. Typically signs include soft tissue swelling, warmth, tenderness and restriction of movement and muscle wasting. Later stages include deformity, subluxation, instability or ankylosing. Rest is very important for those individuals suffering from an acute attack of RA. However, regular exercise is important (i.e., walking, swimming), and each joint should be put through full range movements to reduce stiffness and maintain mobility. Diet and education are also important in the management of RA.

There are certain misconceptions among arthritis sufferers who think exercise will be detrimental to their health. Others may think that pain is a sign you should rest and not aggravate it. While these myths have some degree of truth in them, for the majority of individuals, this is not so black and white. While it is not recommended to exercise when there is an acute bout of arthritis, in those individuals with mild to moderate arthritis, it has been proven that exercise is just one of the key elements to managing it effectively. The problem with arthritis is that those individuals will develop behavioral and motor compensation patterns that create problems elsewhere. One of the best ways to counteract this is to strengthen the muscles around the area so that the individual is able to cope better.

When it comes to exercising and arthritis, there has been extensive research conducted. Exercise in general is a great way to control or reduce weight as well as produce feelings of wellbeing. When training a client with RA, there are several factors you need to take into consideration. Exercising goals for clients with RA should focus on maintaining and increasing strength to prevent muscle contraction and fibrosis. RA is a chronic condition where periods of acute bouts of inflammation occur. Exercising when RA is in a controlled state is fine; however, in an acute stage of inflammation, exercise should be restricted. During these stages, passive range of motion exercises are preferred. In less acute stages, isometric exercises are recommended to help maintain strength. Hydrotherapy is also a good alternative to strength and cardiovascular training in these less acute stages. In a non acute RA sufferer, active exercises are good with an aim to increase strength and resistance training.

Always remember exercise is just one part of a comprehensive arthritic treatment plan. Other forms of treatment include rest, diet modification and medication. Part 2 of this series will look at prescribing exercises for clients with OA and RA and adapting specific training principles to suit their needs.

References:

1. Adams, M. Bogduk, N., Burton, K. & Dolan, P. The Biomechanics of Back Pain, Churchill Livingstone, Sydney, 2002.
2. Kover, P.A, Allegrante, J.P, MacKenzie, C.R, Peterson, MGE, Gutin, B, Charlson, M.E, Supervised from walking in patients with osteoarthritis of the knee. Ann Intern. Medical 1992. 116:529 – 534
3. Minor, MA. Sanford, MC. Physical interventions in management of pain in arthritis. An overview for research and practice. Arthritis care. Res. 1993 – 6: 197 – 206.
4. Murtagh, J. General Practice, 3rd Edition, The McGraw-Hill Companies, Sydney, 2003.
5. Pao – Feng, Tsai. Kathy Richards & Richard Fitz Randolp. Feasibility using quad strengthening exercises to improve pain and sleep in a severely demented elder with OA – A case report BMC Nursing, 2nd Oct. 2002, Biomed. Central
6. Robert, I. Petrella. Is exercise effective treatment of osteoarthritis knee. British J. Sports. Med, 2000, 34: 326 – 331
7. Conservative management of rheumatoid arthritis. Medical staff conference – University of California. San Francisco, Journal Medicine, 129: 121 – 125, August, 1975

Web Pages:

1. http://www.thefreedictionary.com/arthritis
2. http://www.arthritis.org/conditions/exercise/default.asp
3. http://www.arthritisaustralia.com.au/
4. http://www.arthritis.com/osteoarthritis.asp
5. http://www.pubmedcentral.nih.gov/
6. http://medlineplus.gov/
7. http://www.rheumatology.org/public/factsheets/exercise
8. http://www.arthritisvic.org.au
9. http://www.niams.nih.gov/hi/topics/arthritis/ff_osteoarthritis.htm