1. Copyright 2005 Lippincott Williams & Wilkins Chapter 12 Therapeutic Exercise for Arthritis

2. Copyright 2005 Lippincott Williams & Wilkins Goals of Exercise Intervention  Slow or reverse body’s response to joint pathology by increasing strength, flexibility, endurance & by decreasing pain.  Improve impairments, functional limitations, and disabilities resulting from arthritis.  Lead to overall improved health status as an effect of cardiovascular, strengthening, ROM, and stretching exercises.

3. Copyright 2005 Lippincott Williams & Wilkins Review of Anatomy and Kinesiology  Ligaments, muscles, tendons, capsule, cartilage, subchondral/trabecular bone.

4. Copyright 2005 Lippincott Williams & Wilkins Joint Structures – Knee

5. Copyright 2005 Lippincott Williams & Wilkins Osteoarthritic Knee

6. Copyright 2005 Lippincott Williams & Wilkins Inflammatory Response to Rheumatoid Arthritis

7. Copyright 2005 Lippincott Williams & Wilkins Pathology Osteoarthritis (OA) Nonsystemic, mostly noninflammatory, localized pathology. Rheumatoid Arthritis (RA) Systemic, inflammatory disease that usually involves multiple joints and often affects organ systems.

8. Copyright 2005 Lippincott Williams & Wilkins Articular Cartilage FunctionShock absorption, joint congruence Effects of osteoarthritisThickening to softening, to thinning to loss Effects of rheumatoid arthritis Erosion of cartilage

9. Copyright 2005 Lippincott Williams & Wilkins Synovium FunctionSecretes synovial fluid for nutrition of cartilage, lubrication, and stability Effects of osteoarthritisAbnormal joint alignment stresses Effects of rheumatoid arthritis Microvascular lining cells activated by inflammatory process, pannus formation

10. Copyright 2005 Lippincott Williams & Wilkins Ligaments FunctionStability, reinforce capsule and limit movement, guide movement Effects of osteoarthritisAbnormal joint alignment stresses Effects of rheumatoid arthritis Erosion weakens

11. Copyright 2005 Lippincott Williams & Wilkins Muscles FunctionReinforce joint capsule, reflex joint protection, move joints Effects of osteoarthritisImmobility shortens pain, causes guarding and reflex inhibition, leading to weakness Effects of rheumatoid arthritis Joint deformity interferes w/ peak torque, immobility shortens; myositis weakens; pain & effusion cause guarding & reflex inhibition leads to weakness

12. Copyright 2005 Lippincott Williams & Wilkins Bone FunctionStructural support Effects of osteoarthritisSubchondral bone remodeling changes shock- absorbing properties, joint- margin spurring leads to bony blockade and pain Effects of rheumatoid arthritis Erosion leads to joint deformity, bony blockade, pain

13. Copyright 2005 Lippincott Williams & Wilkins Extra-articular System Function Effects of osteoarthritisIncreased energy expenditure from abnormal movement patterns Effects of rheumatoid arthritis Myositis, anemia, sleep disruption, fatigue, increased energy expenditure from abnormal movement patterns

14. Copyright 2005 Lippincott Williams & Wilkins Classification of Functional Status of Patients with RA Class I: Completely able to perform usual activities of daily living. Class II: Able to perform usual self-care and vocational activities, but limited in avocational activities. Class III: Able to perform usual self-care activities, but limited in vocational and avocational activities. Class IV: Limited in ability to perform usual self- care, vocational, and avocational activities.

15. Copyright 2005 Lippincott Williams & Wilkins Classification of Progression of RA Stage I (Early)  No destructive changes on roentgenographic examination.  Roentgenologic evidence of osteoporosis may be present.

16. Copyright 2005 Lippincott Williams & Wilkins Classification of Progression of RA Stage II (Moderate)  Roentgenologic evidence of osteoporosis, with or without slight subchondral bone destruction; slight cartilage destruction may be present.  No joint deformities, although limitation of joint mobility may be present.  Adjacent muscle atrophy.  Extra-articular soft tissue lesions, such as nodules and tenosynovitis.

17. Copyright 2005 Lippincott Williams & Wilkins Classification of Progression of RA Stage III (Severe)  Roentgenologic evidence of cartilage and bone destruction in addition to osteoporosis.  Joint deformity, such as subluxation, ulnar deviation, or hyperextension, without fibrosis or bony ankylosis.  Extensive muscle atrophy.  Extra-articular soft tissue lesions, such as nodules and tenosynovitis, may be present.

18. Copyright 2005 Lippincott Williams & Wilkins Classification of Progression of RA Stage IV (Terminal)  Fibrous or bony ankylosis.  Criteria of stage III.

19. Copyright 2005 Lippincott Williams & Wilkins Exercise Recommendations for Prevention and Wellness Appropriate exercise regimen should emphasize:  Maintaining appropriate body weight.  Sustaining good postural alignment.  Developing good muscular strength and length.  Correct movements during functional activities.

20. Copyright 2005 Lippincott Williams & Wilkins Therapeutic Exercise Intervention for Common Impairments Osteoarthritis  Decrease pain and any inflammation.  Re-establish muscle length and strength around the joint.  Address adaptive changes in proximal and distal joints.  Performance of basic functional tasks.

21. Copyright 2005 Lippincott Williams & Wilkins Therapeutic Exercise Intervention for Common Impairments Rheumatoid Arthritis  Considerations are similar to osteoarthritis  Patients must be taught how to recognize symptoms, to modify activity according to symptom development and stage of illness

22. Copyright 2005 Lippincott Williams & Wilkins Pain Pain, swelling, and splinting Disuse atrophy Reduce protective reflexes Further cartilage breakdownDisruption of soft tissue balance Inefficient movement/muscle patterns Activity reduced further Decrease in cardiovascular activity

23. Copyright 2005 Lippincott Williams & Wilkins Pain  Exercise is used to restore muscle balance, joint ROM, CV conditioning.  Thermal modalities and electrical stimulation (TENS, etc.) for management.

24. Copyright 2005 Lippincott Williams & Wilkins Impaired Mobility and Range of Motion Can be diminished by:  Stiffening and shortening of muscles or tendons from spasm, guarding, or habitual postures.  Capsular stiffness or contracture.  Loss of joint congruity because of bony deformity.

25. Copyright 2005 Lippincott Williams & Wilkins Impaired Muscle Performance Rheumatoid Arthritis  1-2 daily applications of PROM (large joints) and AROM (small joints).  Single submaximal isometric contractions (2/3 of MVC) 6 sec work/20 sec rest (acute and subacute phases).  Caution should be used during MVC efforts.  Repetitions at various angles.

26. Copyright 2005 Lippincott Williams & Wilkins Osteoarthritis  Isometric contractions in acute phase.  As pain and swelling decreases, graduating into a routine containing dynamic contractions is appropriate.

27. Copyright 2005 Lippincott Williams & Wilkins Impaired Aerobic Capacity CV training should be a major part of therapy programs with osteoarthritis or Class I, II rheumatoid arthritis. Aquatic Therapy is an excellent tool – benefits include:  Allowing performance of movement patterns that may not be possible on land because of balance or strength deficits.  Providing muscle relaxation.  Modifying pain perception through sensory stimulation.

28. Copyright 2005 Lippincott Williams & Wilkins Special Considerations in Exercise Prescription and Modification  Protect joints during strengthening when ligament or capsular laxity exists.  Restore muscle balance when splinting, postural habit, pain inhibition has weakened muscle groups around one or more joints.

29. Copyright 2005 Lippincott Williams & Wilkins Special Considerations in Exercise Prescription and Modification (cont.)  Normalize specific joint movement patterns.  Restore functional activities.  Treat pain during and after exercise.

30. Copyright 2005 Lippincott Williams & Wilkins Summary Exercise can mitigate impairments that lead to functional deficits in patients with arthritis and has positive effect on quality of life. Disease process of OA and RA attack joint parts and affect joint integrity. Pathology of one joint affects joints proximal and distal in chain and contralateral joints. Management of pain (common impairment) using therapeutic modalities, safe alignment, bracing, and pacing are necessary components of exercise prescription.

31. Copyright 2005 Lippincott Williams & Wilkins Summary (cont.) Joint movement is necessary for joint health. PROM and AROM are chosen depending on the severity of involvement of joint(s). Isometric exercises can be useful in maintaining strength around the joint. Cautious dynamic training offers the advantage of strengthening periarticular musculature through full range and increasing cartilage nutrition.

32. Copyright 2005 Lippincott Williams & Wilkins Summary (cont.) CV training is frequently necessary for patients with RA or OA and has a positive impact on life. Because of inflammation, precautions must be taken when considering exercise prescription.