PT on the Net Research

Arthritis - Part 2


Before you can commence any cardiovascular or strength training program, it is important to understand and know your clients' individual issues and concerns. Taking a short history of current situations and past history can reveal valuable information about their physical and psychological states. Always remember if you are uncertain about anything in your clients' history or presentation, refer them to their doctor and/or therapist. That way, you are not only looking after your clients' best interests, but you are also developing a good business relationship with the therapist.

Based on what we already know about arthritis and its impact on the body, there are certain areas we need to address to improve functional capacity and overall wellbeing. Key abilities that need addressing include flexibility, strength, endurance, balance, co-ordination and also cardiovascular fitness. Having identified these areas, the next biggest challenge is selecting the right exercises to improve them. Qualifying the client’s ability before doing this will help you to determine what movements and exercises may or may not be suitable.

When selecting exercises for your arthritic clients, you should always ask yourself the following questions:

  1. Does the exercise I have chosen challenge my client's motor abilities?
  2. Does the exercise challenge the client’s nervous system effectively?
  3. Does the exercise isolate or integrate the body? Exercises that train integration ensure one's motor patterns and neurological pathways are challenged.

This is not to say you should never put an isolation exercise in your programs. Rather, it will probably be more beneficial to choose exercises that challenge the motor and neurological systems before moving to more strength based exercises. Your clients will only have you to thank when their activities of daily living improve because the exercises you have chosen closely match the skills and movements that assimilate real life activity.

What good does it do for clients to perform hamstring curls when they will probably never do this type of movement in this position in any real life situation? Unless they introduce hamstring curls as a new Olympic sport at China in 2008, it virtually has no functional purpose at all. Instead, wouldn’t it be better to train hamstrings lying on your back with the legs on a Swiss ball or in a simple bridge position that will not only strengthen both hamstrings but will also train the stabilizing muscles around the knee and hip joint and challenge stability? Activities that involve challenging multiple abilities and train motor patterns result in greater neurological firing, greater ability to adapt and improved day to day function.

You should always be aiming to achieve the clients' goals by training them with functional and practical exercises. The most common thing I hear gym instructors and personal trainers say is that if they don’t do the exercises that will produce muscles or make clients "feel the burn," they will lose clients. The trick is being able to make clients feel and think they are getting what they want when in fact you are giving them both what they want and what is best for them. Often, this involves a little bit of careful planning and lateral thinking.

Supervision or instruction is also an important aspect to training an arthritic client. Having a basic understanding of arthritis and how it affects an individual is imperative to achieving a good outcome. You must observe and listen to your clients and learn to recognize any of the contra-indicated signs of exercise. Often, the biggest challenge to the personal trainer is slowing clients down once they have started.

Some of the more obvious things you should look for as warning signs that your clients are possibly over doing it include:

  1. Unusual or persistent fatigue
  2. Increased weakness
  3. Decreased range of motion
  4. Increased joint swelling
  5. Pain lasting longer than two hours after exercise

Often, I get asked, "Should pain be felt during and after exercise?" Osteoarthritis is the only arthritic condition I would say to continue exercising with pain (only in mild to moderate non acute cases of OA). It is very important to thoroughly explain to clients that mild soreness following exercise is a normal physiological response. As your clients fitness improves, their tolerance to exercise and pain will gradually increase.

The Arthritis Foundation suggests following the two hour pain rule when training. If the individual has more arthritis pain two hours after exercise then they did before, they have probably done too much and should reduce the training. If you only take one thing away from this article, it is this. Make sure you have thoroughly explained to your clients what they should expect and what to look out for. Without an understanding of the how the body can react to exercise, clients may have a negative outcome. You have to keep in mind this might be the first time your clients have ever done any exercise before. If you overdo it on your first session, you may lose clients and potentially put them off exercise forever. For those with OA, this is probably one of the worst things you can do to them in terms of managing their condition. Exercise is one of the key elements to managing osteoarthritis.

When designing an exercise program, the arthritis foundation suggests that you should set realistic goals and choose activities that the client likes. Ensure that your client has an adequate warm up and good flexibility for strength training.

Starting an Exercise Program for Someone with Osteoarthritis

  1. Discuss exercise plans with GP or physical therapist if possible
  2. Advise the client to perhaps to apply heat to sore joints prior to exercising
  3. Stretch and warm up with range of motion exercises
  4. Select functional exercises that assimilate real life activities
  5. Start strengthening exercises slowly.
  6. Progress slowly
  7. Include aerobic exercise (low impact is preferable)
  8. Ease off training it joints become sore.
  9. Use cold damp towel if the areas become sore.

How to Maximize Training and Avoid Injury

  1. Get all the muscles involved. Some people will find some exercises more enjoyable than others. It is important to train all muscles to maintain balance. This is especially important in those with OA knees, hips and backs.
  2. Work within range. Depending upon the severity of the arthritis present, be aware of the patient’s limitations. Range of motion exercises help to maintain normal joint movement and relieve stiffness.
  3. Slow and controlled is better. Full range activities if possible will ensure that the client is functionally efficient and less susceptible to injury.
  4. Follow the 10 percent rule. Never increase your program more than 10 percent a week.

Remember that during acute bouts of arthritis, clients can still continue to perform some exercise. Simple isometric contractions are good for slowing down the process of atrophy and helping to maintain muscle strength.

Aquatic exercise can be a good cross training tool when arthritis is acute because it can relieve arthritic pain, raise body temperature and increase circulation. Plus, it encourages free movement and provides mild resistance.

Aerobic or endurance exercises also good improves cardiovascular fitness, helps control weight and improve overall function. Weight control is important to people who have arthritis because extra weight puts pressure on many joints. Cardiovascular training should focus on low impact activities such as swimming, bike riding, rowing, cross training to minimize force on the joints. However, some impact is necessary for our joints in order to maintain bone strength and prevent osteoporosis.

Often clients will have difficulty with walking, squatting, walking up and down stairs, kneeling, getting in and out of bed, etc. Therefore, focus your training on functional exercises such as lunges, step ups and squats that will improve these daily activities. Be sure to train both the right and left sides of the body as well as the upper and lower. Common areas affected by OA that will benefit from strength and cardiovascular training include the knee, hips and lower back. A good example is that if your client has trouble walking up stairs, start a program with easy steps ups onto a low level platform, initially aided by support, progress to step ups without support, then higher platform or perhaps greater reps. To challenge the brain and the body’s balance, you can add multiple movements (upper and lower body) or perhaps multiple plane movements (i.e., shoulder press or lateral raise with a step up). Always be aware of your client’s abilities and train them to this accordingly. Making your client do an advanced exercise they are not ready for only increases the likelihood of injury and reduces the benefit of the exercise.

Exercise Progressions for Arthritic Clients

I have included some basic exercises and progressions that might be suitable for your arthritic client. Remember that range of movement is dependent upon the severity of the arthritis and the patient's confidence. In exercises like step ups, lunges and squats, you should be endeavoring to train through full range of movement as this is what is required in everyday life. Remember that all people won’t be able to get to every level of difficulty. For examples of each exercise, see the PTN Exercise Library.

Step Ups

  1. Half step up – Balance assisted (hanging onto a rail or pole)
  2. Full step up – Balance assisted (hanging onto a rail or pole)
  3. Full step up – no assistance
  4. Full step up moving into a calf raise – Balance assisted (hanging onto a rail or pole)
  5. Full step up with a calf raise – No assistance
  6. Full step up with dumbbells
  7. Full step up with dumbbells and a calf raise
  8. Full step up with no weights and shoulder press
  9. Full step up with dumbbells doing a shoulder press

Benefits: Improves balance, co-ordination and muscle strength and endurance of the lower legs. It serves as a good platform for walking up and down stairs.

Lunges

It is important to train throughout all ranges of motion. However, for clients with arthritis, it might be more appropriate to start with smaller ranges of movement and progress to larger ranges once they have reached an acceptable level of performance. For exercises that require greater range of movement, a good level of flexibility is required.

  1. Partial lunge
  2. Partial lunge with small pulses or static hold (isometric contraction)
  3. Full lunge (with pulses, static hold or alternating legs)
  4. Lunge with dumbbells
  5. Dynamic lunge in multiple directions (no dumbbells)
  6. Dynamic lunge in multiple directions with Swiss ball out in front
  7. Dynamic lunge in multiple directions with Swiss ball above head height
  8. Lunging in multiple directions can involve forward, backwards, to the side and horizontal lunges

Benefits: Improves balance, flexibility, co-ordination and muscle strength and endurance of lower legs. It serves as a good platform for lunging in everyday life.

Squats w/Swiss Ball

Perform with a Swiss ball against the wall and progress to free weight. Follow the same principles of lunges in regards to range of movement. Start small and work towards greater range.

  1. Quarter squat
  2. Half squat
  3. Full squat
  4. Squat with dumbbells
  5. Squat challenging stability (Bosu ball) and no dumbbells

Benefits: Improves balance, flexibility, co-ordination and muscle strength and endurance in lower legs. It serves as a good platform for lifting and squatting exercises.

Bridges (Hip extension)

  1. Bridge – Static hold or repetitions
  2. Bridge – Arm movements (over head)
  3. Bridge – One leg
  4. Bridge – One leg and arm movements

Benefits: Improves stability, strength and endurance of lower limbs. Trains core stabilizers and gluteals.

Seated Bend Pull on Swiss Ball and Rowing with Back

  1. No weight
  2. Weight
  3. No weight and one leg
  4. Weight and one leg

Benefits: Improves stability, strength, co-ordination and endurance. Trains back and core stabilizers.

Cable Pull or Push (Chest and Back)

  1. Standing cable push – no weight
  2. Standing cable push with weight
  3. Standing cable push with weight and step forward

Benefits: Improves stability, strength, co-ordination and endurance. Trains chest and core stabilizers.

Woodchop

  1. Woodchop with arms (no weight) – From above and below
  2. Woodchop with weight (cable) – From above and below

Benefits: Improves stability, endurance, co-ordination and strength. Trains core stabilizers and obliques.

Wall/Ground Push Up

  1. Half wall push up
  2. Full wall push up
  3. Wall push up standing on one leg
  4. Half push up on ground
  5. Full push up
  6. Push up on one leg

Benefits: Improves stability, endurance, co-ordination and strength. Trains chest and core stabilizers.

Often, if you have very able bodied clients, you can skip some of the progressions and move onto the more advanced exercises. That way, you will ensure you are achieving the goals of your clients while also looking after their health. Remember that there are many arthritic clients out there wanting to get fit and stay healthy. Often, many of your clients may already complain of aches and pains, and they may have osteoarthritis. So when training your clients, listen to them, educate them and work with them to achieve the results they desire.

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
    Conservative management of rheumatoid arthritis. Medical staff conference – University of California. San Francisco, Journal Medicine, 129: 121 – 125, August, 1975
  7. How to Eat, Move and Be Healthy! Paul Chek, 2006.
  8. American Journal of Preventive Medicine, May 2006. Reuters Health

Web Sites:

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