Arthritis: What is it?

ARTHRITIS        
       There are over 100 rheumatic diseases, which cause pain due to inflammation, swelling, and pain in the joints or muscles. Arthritis is a rheumatic disease and one of the leading causes of pain and disability.  Prevalence of arthritis is said to increase drastically by the year 2030 due to the aging population and the continuous rise in obesity.  In the United States 22% of adults (18 years of age or older) are diagnosed with arthritis, while another 9.4% have reported to having arthritis-related activity limitations.

Two Most Common Rheumatic Diseases:  

1. Osteoarthritis: Local degenerative joint disease that can affect one or multiple joints
• Most common in hands, hips, spine, and knees
2. Rheumatoid Arthritis: chronic, systemic inflammatory disease in which there is a pathological activity of the immune system against joint tissues.  

*Other common rheumatic diseases:  fibromylagia, systemic lupus erythematosus, gout, and bursitis.

Treatment:

1. Medications: core components of arthritis treatmen 
• Ex: Analgesics, nonsteroidal anti-inflammatory drugs, disease-modifying antirheumatic drugs
2. Patient education in self-management
3. Physical Therapy
4. Occupational Therapy
5. Surgeries: For later stages of disease when pain is refractory to conservative management
• Total joint replacement and other surgeries can provide substantial relief
6. *Exercise: Although pain and functional limitations can present challenges to physical activity among individuals with arthritis, regular exercise is important for managing these painful conditions. 
• Reduces pain
• Maintains muscle strength around affected joints
• Reduces joint stiffness
• Prevents functional decline
• Improves mental health
• Improves quality of life

Exercise Testing:

• High intensity exercise is contraindicated when there is acute inflammation (i.e., hot, swollen, and painful joints). If individual experiences acute inflammation, exercise testing should be postponed until the flare has subsided.
• Although some individuals with arthritis tolerate treadmill walking, use of cycle leg ergometry alone or combined with arm ergometry may be less painful for some and allow better assessment of cardiorespiratory function. The mode of exercise chosen should be a level that is least painful for the individual being tested.
• Ample time should be allowed for the individual to warm up at a light intensity before beginning the graded exercise test.
• Pain levels should be monitored during the test.  
• There are many validated scales available including the Borg CR10 Scale and visual numeric scale.
• Testing should be stopped if the patient indicates pain is too severe to continue
• Muscle strength and endurance can be measured using typical protocols.  Note that maximal muscle contraction in affected joins may be limited due to pain. 

 

  

 

Exercise Prescription:
Pain can be a major barrier when beginning and maintaining a regular exercise program.  In order to prescribe an ideal exercise program for individuals with arthritis, the program should provide minimal pain while gradually progressing in levels that provide greater health benefits.  Overall, recommendations for exercise prescriptions are consistent with those for healthy adults, but FITT recommendations should take into account an individual's pain, stability, and functional limitations.




(Lippincott, Williams, Wilkins. ACSM's Guidelines for Exercise Testing and Prescription, Ninth Edition. Baltimore. 2014)

FITT Recommendations For Individuals With Arthritis

Frequency:

• Aerobic exercise 3-5 days/week; Resistance exercise 2-3 days/week; Flexibility/Range of Motion (ROM) exercises are essential and are recommended to be performed daily if possible. 

Intensity:

• Light-moderate intensity physical activities are recommended because they are associated with lower risk of injury and/or pain aggravation compared to higher intensity physical activities.    40% - <60% oxtgen consumption reserve (VO2R) or heart rate reserve (HRR) is appropriate
• Very light intensity, aerobic exercise is appropriate for individuals with arthritis who are deconditioned
• Both light and higher intensity, resistance exercise have shown improvements in function, pain, and strength among patients with rheumatoid arthritis and osteoarthritis
• Patients with rheumatoid arthritis and considerable damage in weight-bearing joints should perform lower intensity resistance exercise or physical activity 

Time:

• A goal of ≥150 min./week of aerobic exercise is recommended 
• When appropriate have the patient start with short bouts of 10 minutes (or less if needed), according to the individual's pain levels

Type:

• Aerobic exercises with low joint stress such as walking, cycling, or swimming are appropriate
• High-impact activities such as running, stair climbing, and those with stop and go actions are not recommended if limited by lower body arthritis
• Resistance exercises should include all major muscles groups as recommended for healthy adults
• Include flexibility exercise with range of motion exercises of all major muscle groups 

Progression:

• Progression of aerobic, resistance, and flexibility exercises should be gradual and individualized based on an individual's pain and other symptoms

*FITT Recommendations should accommodate the individual's pain levels.

Special Considerations for Individuals with Arthritis

Special Considerations:

• Avoid strenuous exercises during acute flare ups and periods of inflammation. 
• Adequate warm-up and cool-down periods of 5-10 min are essential for minimizing pain. These activities can involve slow movement of joints through their range of motion (ROM).
• Individuals with significant pain and functional limitation may need interim goals of lower than the recommended ≥150 min/week of aerobic exercise activity. They should be encouraged to undertake and maintain any amount of physical activity that they are able to perform. 
• Inform individuals with arthritis that a small amount of discomfort in the muscles or joints during or immediately after exercise is common, and this does not necessarily mean joints are being further damaged. However, if the patient's pain rating 2 hours after exercising is higher than it was prior to exercise, the duration and/or intensity of exercise should be reduced in future sessions. 
• Encourage individuals with arthritis to exercise during the time of day when pain is typically least severe and/or in conjunction with peak activity of pain medications
• Appropriate shoes that provide shock absorption and stability are particularly important for individuals with arthritis. 
• Incorporate functional exercises such as the sit-to-stand and step-ups as tolerated to improve neuromotor control, balance, and maintenance of activities of daily living (ADL).
• For water exercise, the temperature should be 83° to 88° F because warm water helps to relax muscles and reduce pain. 

*Moderate aerobic activities with low joint stress are appropriate. Adequate warm-up, cool-down, and stretching are important for minimizing pain.