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Training Clients with Arthritis
Johndavid Maes, M.S. and Len Kravitz, Ph.D.

Introduction
Arthritis is a health problem which affects approximately 42.7 million Americans (CDC 1999). It is projected that 60 million people will be impeded by arthritis by the year 2020 (CDC 1999). Commonly characterized by stiffness, pain, and loss of joint function, arthritis may imperil the physical, psychological, social and economic well-being of individuals, depriving them of their freedom and independence (CDC 1999). Unfortunately, exercise program adherence for many arthritic clients often takes a back seat to rest and inactivity, due to the complications associated with this disorder. Physicians now do commonly prescribe exercise as a modality for treatment of arthritis. However, there is a great deal of confusion pertaining to the appropriate type and dose of suitable exercise. This article presents a review of the pathophysiology of arthritis, benefits of exercise to arthritis sufferers, and exercise prescription suggestions for the personal trainer and fitness professional. With a better understanding of the health issues and manageable exercise options associated with arthritis, the personal trainer will be more equipped to improve the health, functional capacity, well-being and quality of life of afflicted clients.

What is Arthritis?
Arthritis is a broad term referring to greater than 100 rheumatic diseases (CDC 1999). It affects people of all ages, genders, and ethnic groups. Arthritis is second only to cardiovascular disease as a leading cause of disability in the United States (Porth 1998). Of the many types of arthritis, osteoarthritis (a degenerative joint disease) and rheumatoid arthritis (an inflammatory disorder affecting multiple joints) are the two most prevalent (ACSM 1997). Osteoarthritis affects 21 million people and another 1.2 million have rheumatoid arthritis (CDC 1999). Common to all forms of arthritis are the symptoms of joint pain, swelling, inflammation and loss of physical function (Porth 1998). As health advocates, it is important to realize that arthritis not only negatively impacts the sufferer with painful symptoms and disability, but it also burdens the lifestyle for his/her family (CDC 1999). In addition, when incurring the costs of treatment, complications and resulting treatment, arthritis costs the Unites States approximately 65 billion dollars per year; $15 billion is for 39 million physician visits and the rest of the money represents indirect costs resulting lost wages (CDC 1999).

Osteoarthritis
Osteoarthritis (OA), also known as degenerative joint disease is the most common form of arthritis (Sharma 2003). It stems from the degeneration of joint cartilage and changes in the underlying bone structure and supporting tissues leading to stiffness, pain, movement problems, and limited physical activity (CDC 1999). OA commonly affects joints of the hands, knee, hip, foot, and spine (Porth 1998). Traditionally, OA has been regarded as a consequence of the aging process (Porth 1998). Commonly referred to as “wear and tear” arthritis, OA is an acute metabolic disorder of the articular cartilage and underlying bone of diarthrodial (freely movable) joints. Diarthrodial joints typically exhibit a balance between mechanical stress and the ability of the joint tissues to resist that stress (Porth 1998, Marieb 1998). OA begins with a deterioration of the cartilage (articular cartilage) surrounding bone endpoints within the joints (Porth 1998). This deterioration is caused by a physiologic imbalance between the stress applied to the joint tissues and the ability of the joint tissues to withstand this stress (Porth 1998). Muscle weakness, frequently surrounding the knee joint, is a common phenomenon in people with OA, and this may even be a risk factor for developing OA (Bischoff 2003).

Rheumatoid Arthritis
Rheumatoid arthritis (RA) can be characterized as a chronic systemic inflammation of the joint capsule inner lining (Porth 1998, CDC 1999). Between .3% and 1.5% of the population is affected by rheumatoid arthritis, with women being more afflicted than men (Porth 1998). While RA is known to increase between all age groups, its incidence increases with age (Porth 1998). Symptoms of RA include pain, stiffness, and swelling of multiple joints (CDC 1999). The inflammation observed in RA is also known to spread to tissues surrounding a joint, causing bone and cartilage erosion, joint deformities, movement problems, and limitations in activity (CDC 1999). In severe cases, RA can effect connective tissue and blood vessels throughout the body, setting off an inflammatory response in a variety of organs such as the lungs and heart, which would in-turn increase mortality due to respiratory and infectious disease (CDC 1999). Of particular importance to the fitness professional are the effects RA has on functional capacity, such as decreases in range of motion, muscle strength, and aerobic capacity. Of the various treatments for RA, exercise has emerged as an essential aspect of rehabilitation (Stenstrom 2003).

What are some common misunderstandings of arthritis?
There are some key myths and misunderstandings associated with arthritis. Table 1 disproves some of these false assertions and clarifies the known facts.

Table 1. Common myths about arthritis

Arthritis only affects the elderly Arthritis does affect a great amount of people age 65 or older, however most people (nearly three out of five) with arthritis are younger than age 65. Arthritis can affect people of all ages including children and teens. One of the most common chronic illnesses in children is juvenile rheumatoid arthritis.

Arthritis is a normal consequence of aging If this myth was correct, most mature adults, and no children would be affected by arthritis. Subsequently, close to half of the elderly population never experience arthritis, and an estimated 285,000 children do experience arthritis. It is also known that some types of arthritis, such as osteoarthritis of the knee, can be prevented.

There is no cure for arthritis While no “magic pill” exists for all types of arthritis, research has shown that early diagnosis along with appropriate management can help reduce the complications associated with many types of arthritis. Physical activity, medication, education and surgery are four effective treatments shown to improve this limiting health condition.

Rest is best There is a common misconception in the medical community that exercise is not feasible in the treatment of arthritis. Research has made it clear that the right types of exercise, performed correctly, in fact restore people’s function while dramatically cutting down on their pain.

Some joints are too far gone to make a difference Many afflicted people feel that their arthritis is too far advanced to be treated. The fact is that people of all ages have made tremendous improvements in their disability by taking the proper steps to care for arthritic joints.
Adapted from the CDC’s National Arthritis Action Plan: A Public health strategy, and Strong Women and Men Beat Arthritis by Miriam E. Nelson

Obesity Strikes Again
Another associated benefit of exercise as a treatment for arthritis is its positive effect on facilitating weight loss. Being overweight and/or obese may have a deleterious effect on arthritis. Obesity has been found to increase disability and pain in patients with established OA (Bischoff 2003, DiNubile 1997). Furthermore, researchers in the Framingham Osteoarthritis study found that a weight loss of approximately 11 pounds decreased the risk for pain and stiffness by 50% (Neslon 2002). Additionally, the knee is prone to an increase equal to three times a person’s body weight during walking, and five times body weight while going up or down stairs or when running (DiNubile 1997). These factors provide consequential implications for exercise program design with overweight/obese clients affected with arthritis.

A Strong Case for Aerobic and Resistance Training
A regular exercise program has proven to be effective in improving both muscular strength and cardiovascular fitness in healthy persons and those affected with chronic diseases. As a consequence of inactivity, patients with arthritis are at greater risk than their non-affected counter parts (de Jong 2003). This supports the notion that a gradually progressive cardiovascular and strength training program can be beneficial for individuals with arthritis. In a recent publication, researchers from Leiden University Medical Center sought to investigate the effects of a long-term challenging exercise program, and the effectiveness on patients with RA. Subjects in the study participated in an exercise program consisting of 75-minute sessions involving 20 minutes of bicycle training, 20 minutes of circuit training, and 20 minutes of sport and game activities performed 2 times a week for 2 years (de Jong 2003). The researchers found that the exercise program proved to be effective and safe. Subjects showed great improvements in functional capacity and emotional status with no observable negative side effects in their disability (de Jong 2003).

In another recent study, patients affected with RA underwent a dynamic strength-training program for 2 years. Subjects performed a program which trained all major muscle groups of the body. The exercise program consisted of 2 sets of 8-12 repetitions using elastic bands and dumbbells as resistance, 2 times per week (Hakkinen 2003). Exercise prescriptions were evaluated and progressed every 6 months. Subjects showed an average of 19-59% increase in strength (Hakkinen 2003). Along with significant improvements in physical function, study results provide evidence-based research for the safety and efficacy of strength training in patients with RA.

In yet another investigation, researchers from the University of Tennessee Memphis and Wake Forest University compared aerobic exercise and resistance exercise to an education program in older adults with OA of the knee (Ettinger et al., 1997). In this study subjects were assigned to either an aerobic exercise program consisting of 1 hour of walking 2 times per week for 18 months, or a resistance-training program consisting of 2 sets of 12 repetitions two times a week for 18 months. The control group consisted of an educational (only) program for 18 months only. The 9 exercises in the resistance training program consisted of leg extension, leg curl, step-up, heel raise, chest fly, upright row, military press, biceps curl, and a pelvic tilt. The researchers found that both the aerobic and the resistance training groups reported less disability at the end of the study than the education group. Both exercise groups also reported significantly less pain than the education group, as well as increased measures of strength during knee flexion. This study documents that both aerobic and resistance exercise programs are not only safe in older adults with OA, but they can lead to reasonable and consistent improvements in self-reported pain, disability and muscular fitness.

Exercise to the rescue
Exercise has been proposed to have a pain-relieving effect similar to that of a pharmacological treatment (Bischoff 2003). Inactivity, a consequence of arthritis, leads to a negative shift in body composition (muscle wasting and increased body fat percentage), increasing in the risk of hypertension, obesity, osteoporosis, type 2 diabetes, cardiovascular disease, and cancer of the colon (ACSM 6th ed. Pg 5 2000). Fitness related problems common to arthritis such as loss of flexibility, muscle atrophy, weakness, osteoporosis, elevated pain threshold, depression and fatigue are found to respond favorably to a low-to-moderate, gradually progressing exercise program (ACSM 1997). Up until the mid 1970’s, most physicians prescribed rest and reduced physical activity for patients with arthritis (Robenoff 2003). Since this “era of physical inactivity” research has shown that patients treated with aerobic exercise and progressive strength training have shown improvements in strength, function, and joint symptoms (Roubenoff 2003). It has also been noted that both aerobic and strength training seem to be equally effective in treating the symptoms of pain and loss of function in patients with osteoarthritis (Bischoff 2003). Additionally, physical activity is shown to decrease pain, improve self-efficacy and physical function, and delay disability in people with knee osteoarthritis (Macera 2003). The 90’s were a noteworthy decade for the impact and use of exercise for the arthritis. Types of exercise tested and found to be beneficial include low-intensity isokinetic training, low-intensity physical therapy, intermediate intensity circuit training, and high-intensity strength training (Roubenoff 2003). In a recent review article entitled “Exercise and Inflammatory Disease”, Ronnen Roubenoff M.D. of Tufts University states “Almost any form of exercise, if done carefully, will help to reverse the catabolic effects of inflammatory disease on muscle, improve function, and decrease the risk of disability”.

The fact is that persons with either OA or RA are able to participate in a regular exercise program to improve cardiovascular status, muscular fitness, flexibility, and overall health status (ACSM 1997). Improvements in these components of fitness observed in persons with arthritis are associated with improved function, decreased pain and swelling, increase in social and physical activity in daily life, and lessened depression and anxiety (ACSM 1997).

Exercise prescription
In designing a safe and effective exercise program for clients with arthritis, the personal trainer and fitness professional must be mindful of many factors. Exercise programming for clients with arthritis should focus on improvements in cardiovascular conditioning, improvements in strength, increased flexibility, increased joint mobility, and joint protection (DiNubile 1997, ACSM 1997). Arthritis presents many issues in the design of and exercise prescription. Table 2 presents some overall considerations in the design of an exercise program for persons with arthritis.

Table 2. Exercise prescription considerations for persons with arthritis
When designing an exercise program for a client affected by arthritis, important factors to consider include the following:
Clients affected by arthritis tend to be less active and less fit (cardiovascular and musculosleketal) than their unaffected counterparts
The metabolic cost of physical activity can increase by as much as 50% due to pain, stiffness, biomechanical inefficiency, and gait abnormalities
Range of motion in affected joints may be restricted by pain, stiffness, swelling, and bony changes
The repetitive movements in activities such as walking and cycling may inhibit the ability of arthritic sufferers in these activities
Exercise mode for both aerobic and strength training are largely determined by the site and severity of affected joints
Poorly controlled exercises and high-impact movements present a high risk for injury in deconditioned and poorly supported joints
* Adapted from the ACSM’s Exercise Prescription for People With Chronic Diseases

The Aerobic Exercise Prescription
When designing an aerobic exercise program (see Table 3.), mode selection is of utmost importance. Emphasis should be placed of modes of exercise that are predominantly non-weight bearing and utilize large muscle groups. If possible, a multi-mode approach to aerobic exercise may be a worthwhile recommendation. Since high-impact exercises are relatively contraindicated, some appropriate modes of aerobic exercise include water walking, swimming, aquatic exercise, dance, cycling, and brisk walking (ACSM 1997, Finckh et al 2003). Note that for some arthritic sufferers the repetitive nature of cycling may be contraindicated. The goals of an aerobic exercise program should be to increase cardiovascular endurance and peak work (which means optimal effort for physical activity) (ACSM 1997). Guidelines for intensity, frequency, and duration should include 60-80% maximal (or estimated maximal) HR, 3-5 days per week, and 5 minutes per session progressing to 30 minutes duration per session (ACSM 1997). Progression should evolve in a manner that emphasizes duration over intensity (ACSM 1997). Modes of exercise to avoid include stair climbing, jogging, and running with persons who are affected by arthritis of the lower body (ACSM 1997). Proper warm-up should be incorporated to condition muscles prior to the activity. Pre-exercise joint range of motion exercises, to prepare the joints for the more challenging demands of the workout, should be emphasized. The resistance setting (such as with cycling, rowing and elliptical training) of an exercise should be reduced when exercising affected joints. When prescribing weight-bearing activities, shoes and insoles with maximum shock attenuation are recommended (ACSM 1997). A low-intensity and reduced duration should be employed in the initial phase of programming to allow for graduate adaptation to the exercise program.

Table 3. Cardiovascular exercise guidelines for persons with arthritis
Obtain medical clearance from client’s physician prior to beginning exercise

Incorporate smooth, rhythmical activities use large muscle groups

Avoid high impact exercise that stress affected joints

A frequency of 3-5 days per week is suitable

Set an intensity of 60-80 % of maximal heart rate

Aerobic activity may last from 5 minutes initially to 30 minutes, depending on initial fitness level of client

When progressing exercise, first increase duration, followed by intensity

Some suggested modes of exercise may include walking, rowing, swimming, cycling and aquatic exercise

The Strength Training Exercise Prescription
Benefits of a resistance-training program include strengthening muscle groups around affected joints, offering protection and stabilization of affected joints, improved shock absorption, and reducing mechanical stresses that hasten cartilage degeneration (DiNubile 1997). A sound strength-training program should incorporate all major muscle groups, not just those supporting joints affected with arthritis. Appropriate modes of exercise selection for strength training include free weights, weight machines, isometric exercises, elastic bands, and ankle weights (ACSM 1997, DiNubile 1997). The goals of a resistance exercise program should be to increase muscular strength, peak torque, power and joint stabilization (ACSM 1997). Intensity for a strength-training program should be individualized to suit the client’s needs and abilities, and will vary between clients. A total body strength-training program can be performed 2 times per week, and no more than four. It is appropriate to allow 24 hours between sessions to allow for recovery (DiNubile 1997). Exercises involving strengthening muscles of affected joints should be lighter in the early stages of an exercise program. A severely deconditioned client, or one who has an advanced state of arthritis, may only be able to start off with 2-3 repetitions initially (ACSM 1997). A recommended progression would be to increase to 10-12 repetitions for 1-3 sets, 2-3 days per week. Proper care must be taken to insure affected joints are protected at all times during strength training. Many common exercises must be modified in order for a client to perform the exercises through a pain free range of motion.

Table 4. Resistance exercise guidelines for persons with arthritis
Ensure client’s physician has cleared client to exercise

Begin each strength training session with an adequate joint range of motion warm-up

Avoid strength training exercises that cause increased joint pain

A frequency of 2-3 days per week is suggested

Many client’s may need to initiate a program with 2-3 repetitions, progressing to 10-12 repetitions

Acceptable modes of resistive exercise include free weights, weight machines, isometric exercises, and elastic bands

Avoid high repetition, high resistance, and strength training exercises that cause a greater force impact on affected joints

Flexibility Guidelines
Integrating from the publications reviewed for this article, Table 5 summarizes some key guidelines with flexibility training for persons with arthritis.

Table 5. Flexibility exercise guidelines for persons with arthritis
Precede flexibility sessions with a thorough warm-up in order to increase internal body temperature and circulation

Daily flexibility sessions targeting the major muscle groups can be safely done

Special attention to be given to the lower back, hamstrings, calves, and front of the shoulders as these areas frequently lose flexibility with age

Flexibility exercises should include static stretches held for 10-30 seconds

The static stretch should not cause pain, but rather a mild tension, typically felt by taking a joint to its optimal range of motion

Use caution not to overstretch unstable joints

Stretching should be performed through a pain-free range of motion, avoiding bouncing and ballistic style stretches

Final Thoughts
Arthritis has contributed to inactivity for many individuals. The good news is that exercise is not only possible, but also highly beneficial for the treatment of arthritis. As a fundamental part of the treatment for individual’s suffering from arthritis, exercise is a cost-effective alternative to medication and surgery. Research has supported that both aerobic exercise and strength training are beneficial for clients affected by arthritis. With a broader knowledge of arthritis and the benefits of proper exercise interventions, the personal trainer may better help his/her clients who are affected with this disability.

References

American College of Sports Medicine (ACSM). (1997). ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities. Champaign: Human Kinetics.

American College of Sports Medicine (ACSM). (2000). ACSM’s Guidelines For Exercise Testing and Prescription 6th ed. Philadelphia: Lippincott Williams & Wilkins.

The Arthritis Foundation, Association of State and Territorial Health Officials, Centers for Disease Control and Prevention (1999). National Arthritis Action Plan: A Public Health Strategy. Accessed at http://www.cdc.gov/nccdphp/pdf/naap.pdf.

Bischoff, H.A.,& Roos, E.M. (2003). Effectiveness and safety of strengthening, aerobic, and coordination exercises for patients with osteoarthritis. Current Opinion in Rheumatology, 15, 141-144.

de Jong, Z., Munneke, M. Zwinderman, A.H. et al. (2003). Is a Long-Term High-Intensity Exercise Program Effective and Safe in Patients With Rheumatoid Arthritis? Arthritis & Rheumatism, 48, (9), 2415-2424.

DiNubile N.A. (1997). Osteoarthritis: How to Make Exercise Part of Your Treatment Plan. The Physician and Sports Medicine, 25, (7), 47-58.

Ettinger, W.H., Burns, R. Messier, S., et al. (1997). A Randomized Trial Comparing Aerobic Exercise and Resistance Exercise With a Health Education Program in Older Adults With Knee Osteoarthritis: The Fitness Arthritis and Seniors Trial (FAST). Journal of the American Medical Association, 277, (1), 25-31.

Finckh, A., Iversen, M., & Liang, M.H. The Exercise Prescription in Rheumatoid Arthritis: Primum non Nocere. Arthritis & Rheumatism, 48, (9), 2393-2395.

Hakkinen, A., Sokka, T., Lietsalmi, A., Kautiainen, H., & Hannonen, P. (2003). Effects of Dynamic Strength Training on Physical Function, Valpar 9 Work Sample Test, and Working Capacity in Patients With Recent-Onset Rheumatoid Arthritis. Arthritis & Rhuematism, 49, (1), 71-77.

Macera, C.A., Hootman, J.M., & Sniezek, J.E. (2003). Major Public Health Benefits of Physical Activity. Arthritis & Rheumatism, 49, (1), 122-128.

Marieb, E. N. (1998). Human Anatomy & Physiology 4th edition. Menlo Park, CA: Addison Wesley Longman Inc.

Nelson M.E., Baker, K.R., Roubenoff, R, & Lindner L. (2002). Strong Women and Men Beat Arthritis. New York, NY: The Berkley Publishing Group.

Porth, C.M. (1998). Pathophysiology: Concepts of Altered Health States. Philadelphia, PA: Lippincott.

Roubenoff, R. (2003). Exercise and Inflammatory Disease. Arthritis & Rheumatism, 49, (2), 263-266.

Sharma, L. (2003). Examination of Exercise Effects on Knee Osteoarthritis Outcomes: Why Should the Local Mechanical Environment Be Considered? Arthritis &Rheumatism, 49, (2), 255-260.

Stenstrom, C.H. & Minor, M.A. (2003). Evidence for the Benefit of Aerobic and Strengthening Exercise in Rheumatoid Arthritis. Arthritis & Rheumatism

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