• Fitness & Health
• Sport & Exercise Science
• Physical Education
• Strength & Conditioning
• Sports Medicine
• Sport Management
• Dance

Clinical exercise prescription for clients with arthritis

This is an excerpt from Clinical Exercise Physiology 6th Edition by Jonathan K Ehrman,Paul Gordon,Paul S. Visich,Steven J. Keteyian.

By George S. Metsios, PhD

The following are goals of exercise specific for the treatment of arthritis:

• Maintain or improve physical function by maintaining or improving muscle strength, cardiorespiratory fitness, and ROM
• Improve body composition (i.e., restore muscle mass and reduce fat mass) and, when appropriate, reduce body weight
• Reduce the risk of comorbidities such as CVD, type 2 diabetes, metabolic syndrome, and osteoporosis
• Reduce inflammation and pain
• Prevent contractures and deformities

Immobilization and inactivity amplify the negative systemic and psychological manifestations that accompany arthritis.^{93, 197} The effects of inactivity include rapid reductions in strength (approximately 3%-8% per week) and aerobic capacity, muscle loss, reduced bone mass, and loss of cartilage matrix components.^{68, 108, 172} Because cartilage is avascular, it depends on normal repetitive loading of the joint for its nutrition and normal physiological function.⁷⁹ Moreover, joints with effusions may develop synovial ischemia attributable to elevated intra-articular pressure. Walking and cycling increase synovial blood flow in inflamed knees.⁸⁶ Additionally, in both healthy and OA joints, the intra-articular oxygen partial pressure increases during joint movement, although the increase is diminished in arthritic joints.¹⁴⁵

A person in an exercise program, whether supervised or unsupervised, requires education, skill acquisition, and reinforcement.^{6, 124} In any case, behavioral change interventions have become the forefront of enhancing exercise participation in people living with arthritis,⁵⁴ with excellent results.²⁰⁵ Supervised group settings may be beneficial for this patient population because they provide peer social support, facilitate training compliance, help decrease anxiety,²¹¹ and enhance attendance.⁶⁴ These are key considerations because exercise training compliance is associated with training response and improved physical function.^{65, 108, 124} Moreover, supplementing supervised classes with home-based exercise may boost improvements in pain and function.^{36, 129, 171} Regular monitoring by clinical exercise professionals also helps ensure safety and appropriate progression of the exercise.

Many exercise options are available for unsupervised programs. Walking is an excellent cardiorespiratory exercise, although performing a variety of cardiorespiratory activities (e.g., cycling, swimming, rowing) may help maintain interest and compliance and reduce the likelihood of overuse injuries. The American College of Sports Medicine (ACSM) has also produced informational handouts encouraging home exercise regimens in patients with OA and RA through their Exercise Is Medicine campaign (www​.exerciseismedicine.org).

Following the Arthritis Foundation’s YMCA Aquatic Program (AFYAP), available nationally in YMCAs and in private facilities, has been shown to increase hip ROM, isometric strength, and flexibility when performed two or three times a week over 6 to 8 wk.^{198, 199} In a meta-analysis that included data from 1,092 individuals with lower limb OA, Waller and colleagues²¹² concluded that aquatic exercise achieved small but statistically significant improvements in pain and self-reported function comparable to those gained by land-based exercise or use of NSAIDs. This reported benefit concurs with the findings of the Cochrane review by Bartels and colleagues.¹⁵ Similarly, Dunbar and colleagues⁴³ observed that aquatic exercise performed 5 d/wk for 4 wk significantly attenuated pain and improved QOL in AS patients. However, like numerous other researchers, Bartels and colleagues15 did not find a benefit regarding muscle strength. This lack of efficacy of aquatic exercise is generally explained by the failure of this form of training to achieve sufficient intensity to increase strength,¹¹⁷ which in turn has led to the recommendation that aquatic exercise be supplemented by more intense strength training performed on land.

Nonfacility-based activities and exercises that can be performed throughout the day include chin tucks, corner pectoral stretches in a doorway, abdominal tightening, checking posture throughout the day in the mirror, and extending walking time by taking the stairs or parking farther from a destination.

The sequencing of exercises for individuals with arthritis is similar to that for the general population, beginning with a warm-up and ending with a cool-down. A warm-up should be performed to increase tissue temperature, and as a consequence tissue compliance, throughout the body. As decreased stiffness and greater ROM ensue, patients should be taught to judge whether increasing the range through which they are exercising is safe.¹⁸² Strengthening and cardiorespiratory conditioning exercises should be performed after a warm-up and should be followed by a cool-down period. Flexibility training is best performed during the cool-down, because muscles and connective tissue are more pliable when body temperature is elevated. Laliberte and colleagues¹⁰⁰ provide extensive and useful examples and illustrations of various sequences of exercise appropriate for people with arthritis.

Exercise loads should be progressed as indicated by the training response and when symptoms do not increase for two or three consecutive sessions. Conservative increments are recommended. In general, after 1 wk of consistent exercise without an exacerbation of symptoms, the training demands should be increased toward the maximum recommended. However, some people living with arthritis may require more time when progressing their exercise intensity, to enhance self-confidence and avoid injury. The exercise principles have to be appropriately monitored, and regular evaluation is necessary to understand the effects of specific exercise dosages on arthritic symptoms.¹³⁶ To ensure that progression in aerobic, resistance, or combined training programs is safe, initially increase the volume (i.e., total duration of exercise, the number of exercises performed, or the time spent exercising with the use of shorter rest periods) and then gradually increase the intensity (e.g., increasing the percent heart rate reserve for aerobic exercise, or the percent one-repetition maximum for resistance training). An increase in symptoms may require lowering the intensity or volume of exercise, especially for an affected joint. Once the patient is accustomed to exercising (i.e., muscle soreness is not simply due to unaccustomed activity), the “2 h pain rule” is a helpful maxim for regulating exercise intensity: Localized increase in pain that lasts more than 2 h after an activity suggests the need to decrease the exercise intensity or volume for the next training session.

Collecting outcomes data serially to objectively monitor response to therapy is useful. Table 27.4 lists a variety of physical function measures that can be used to evaluate strength, aerobic capacity, physical function, ROM, balance, and body composition in arthritis patients. In addition, a number of standardized and validated instruments (questionnaires) are available for assessing arthritis pain, stiffness, and subjective function, as well as response to therapy, for OA, RA, and AS.^{17, 109, 132, 161, 178, 180}

More Excerpts From Clinical Exercise Physiology 6th Edition

---