1. Exercise Management Arthritis

2. Exercise Management Pathophysiology There are more than 100 rheumatologic diseases, each having varying degrees of articular and systemic involvement. (See Table 34.1, next slide, for the most common rheumatologic diseases.)rheumatologic Arthritis is a chronic and often debilitating disease caused by inflammation of one or more joints, resulting in pain, swelling, stiffness, and limited movement. An estimated 46 million U.S. adults currently have at least one of the more than 100 different forms of arthritis including the two most common: osteoarthritis arthritis (OA) and rheumatoid arthritis (RA)

3. Exercise Management

4. Pathophysiology Osteoarthritis, which is also known as degenerative joint disease (DJD), results from the deterioration or loss of cartilage in synovial joints, particularly in weight-bearing joints, followed by formation of bone spurs and subchondral cysts. Osteoarthritis is further characterized by its etiology; primary OA is associated with the normal wear and tear of aging whereas secondary OA is associated with injury, heredity, obesity, or other causes. Age is the strongest predictor of OA, in addition to obesity, injury, and heredity.

5. Exercise Management Pathophysiology Rheumatoid arthritis is a chronic and debilitating disease characterized by inflammation and swelling of the synovial membrane; the formation of pannus tissue ( an inflammatory exudate overlying synovial cells on the inside of a joint capsule) within the joint; and the eventual deterioration of bone and cartilage, which causes swelling, pain, deformity, and the movement within the joint. RA is associated with higher than normal levels of the antibody rheumatoid factorantibody rheumatoid factor and as such is referred to as an autoimmune disease.

6. Rheumatoid arthritis can affect nearly every part of the body. Complications may include: Damage to the lung tissue (rheumatoid lung)rheumatoid lung Increased risk of hardening of the arteries Spinal injury when the neck bones become damaged Inflammation of the blood vessels (rheumatoid vasculitis), which can lead to skin, nerve, heart, and brain problems Swelling and inflammation of the outer lining of the heart (pericarditis) and of the heart muscle (myocarditis), which can lead to congestive heart failurepericarditismyocarditiscongestive heart failure Exercise Management

7. Effects on the Exercise Response Vigorous exercise is contraindicated in the presence of acute joint inflammation (red, hot, swollen, painful) or uncontrolled systemic disease. Inflammatory rheumatic diseases can affect cardiac and pulmonary function, as well as cause widespread vasculitis, so this must be considered before anyone with a systemic rheumatic disease performs vigorous exercise.vasculitis

8. Exercise Management Effects on the Exercise Response Persons with joint involvement tend to be less active and less fit (cardiovascular and musculoskeletal) than their unaffected peers. Resting energy expenditure may be elevated in persons with systemic inflammatory disease, even when the disease clinically appears inactive or under control. Pain, stiffness, biomechanical inefficiency, and gait abnormalities can increase the metabolic cost of physical activity by as much as 50%. Joint range of motion may be restricted by stiffness, swelling, pain, bony changes, fibrosis, and ankylosis.ankylosis

9. Exercise Management Effects on the Exercise Response Inability to perform rapid, repetitive movements may affect exercise performance in terms of walking speed and cycle revolutions/min. Site and severity of joint involvement determine exercise mode for aerobic and strength tests. Deconditioned and poorly supported joints are at high risk for injury from high-intensity exercise or poorly controlled movement.

10. Exercise Management Effects of Exercise Training Improved aerobic capacity, endurance, strength, and flexibility are associated with improved function, decreased joint swelling and pain, increased social and physical activity in daily life, and reduced depression and anxiety. The most immediate benefit of conditioning exercise in this population may be to diminish effects of inactivity.

11. Exercise Management Recommendations for Exercise Testing In spite of the challenges presented by joint pain and dysfunction in arthritis, exercise testing is safe and should be performed when indicated. Submaximal and subjective symptom- limited treadmill tests requiring < 3 mph walking speed and common cycle ergometer protocols are well tolerated and informative of aerobic capacity.

12. Exercise Management Recommendations for Exercise Testing Early-onset muscle fatigue may reduce the prognostic value regarding cardiopulmonary disease; thus if someone is suspected of having coronary artery disease, other diagnostic tests are recommended. Range of motion measurements (goniometry) are useful for persons who have limited flexibility and need stretching programs. Gait analysis may be necessary for those who have severe disease, altered biomechanics, and a need for orthoses (see table 34.2, next)

13. Exercise Management

14. Recommendations for Exercise Testing Special considerations for exercise testing include the following: Pain or swelling may reduce performance. Vigorous, highly repetitive exercise should not be performed with unstable joints. Some arthritis’ involve cardiopulmonary systems, which may decrease performance. Spinal involvement may cause radiculopathy.radiculopathy. Morning exercise should be avoided in clients with RA because of morning stiffness. Variable-speed protocols should be available. Cycle ergometers should have loose-fitting toe straps to accommodate genu valgum.genu valgum

15. Exercise Management Recommendations for Exercise Programming The major impact of joint disease on exercise programming is the need for joint protection. Thus, the following recommendations apply: Select low-impact activities Avoid stair-climbing, contact sports and activities requiring prolonged one-legged stance or rapid stop-and-go actions in persons with symptomatic hip or knee involvement. Condition muscles prior to increasing exercise intensity Include flexibility and ROM in the general exercise program

16. Exercise Management Recommendations for Exercise Programming Overstretching and hypermobility should be avoided. If pain or swelling appears or persists, reduce load on joint (reduce exercise duration or intensity; exercise in a pool, or cycle or row). Shoes and insoles should be selected for maximum shock attenuation during weight- bearing activities; and if hip or knee pain occurs with weight bearing activities, evaluate for rigid or semirigid arch supports for mechanical support or joint unloading.

17. Exercise Management Recommendations for Exercise Programming Encourage exercise as a component of a fitness routine that is part of self management: Stretching/warm-up should be used daily, even on days when the disease flares and vigorous activity is undesirable Use aerobic activities that incorporate alternative forms of exercise (multimodal) Promote flexibility and strengthening programs Avoid activities that promote joint pain.

18. Exercise Management Exercise programs should also be designed with an individualized progression of intensity and duration (see Table 34.3): Use low intensity and duration during initial phase of programming. If necessary, exercise dose should be accumulated during several sessions throughout the day. Recommend alternate exercise modes and interval or cross-training methods to allow for changes in disease status. Set time goals, rather than distance goals, to encourage self-management to pace activity. Choose an appropriate exercise or fitness goal, and recommend that the person not exceed intensity, duration, and frequency guidelines for training.

19. Exercise Management

21. Encourage exercise as a component of a fitness routine that is part of self-management: Stretching and warm-up should be performed daily, even on days when the disease flares and vigorous activity is undesirable. Use aerobic activities that incorporate alternative forms of exercise (weight bearing, partial weight bearing, and non- weight bearing) to allow for migrating joint symptoms and changes in disease activity. Recommend that individuals learn a strengthening routine. Avoid activities that cause increased joint pain. Some post-exercise soft tissue discomfort may be expected.

22. Exercise Management End of Presentation