Exercise Programs for Your Arthritis Patients:

As the population ages, osteoarthritis and rheumatoid arthritis are becoming increasingly common complaints in primary care practices. These disorders affect 27% of adults in the United States and are leading causes of physical disability.¹ The annual total cost of arthritis (including both direct and indirect costs) exceeds $80 billion.² By 2020, it is estimated that over 60 million adults will have arthritis.³

Exercise is a recognized, inexpensive, and effective therapy for arthritis. In this article, we enumerate the benefits of exercise for patients with arthritis, outline the elements of an effective program, and describe a variety of appropriate exercises.

OVERVIEW

Osteoarthritis is especially common in the elderly; it affects more than 68% of persons over the age of 65 years.⁴ This degenerative arthritis typically affects the knee, hip, and hands and results in decreased strength, reduced flexibility, diminished proprioception, and joint pain.

Rheumatoid arthritis is less common than osteoarthritis; it occurs in about 1% of adults, two thirds of whom are women.⁵ This autoimmune, inflammatory process tends to affect joints in the hands, wrists, and elbows.

Both osteoarthritis and rheumatoid arthritis cause muscle atrophy and weakness that often lead to physical inactivity, which then exacerbates muscle wasting. As a result, both types of arthritis lead to reduced lean body mass.

Although there is effective drug therapy for arthritis, regular exercise is also an important part of treatment. Healthy People 2010-the list of US health objectives developed by federal agencies and non-federal partners-advocates participation in an exercise program as an effective self-management strategy for persons with arthritis.⁶

BENEFITS OF EXERCISE

The benefits of exercise to patients with arthritis are numerous. Direct benefits include reduced pain, improved flexibility, and increased strength (Table). Additional benefits include reduction of cardiovascular risk, improved lipid management, and increased bone mass. In overweight patients with osteoarthritis, a further benefit is weight loss, which lessens the load on joints and ultimately facilitates greater success with an exercise regimen.

• Increased flexibility
• Reduction of pain
• Prevention of deconditioning
• Increased muscle strength
• Protection of joints
• Reduced stiffness
• Improved gait
• Improved mood
• Less fatigue

An extensive body of literature demonstrates the effectiveness of exercise for patients with arthritis. Van den Ende and colleagues⁷ reviewed exercise studies and concluded that exercise was effective at increasing aerobic capacity and muscle strength in patients with rheumatoid arthritis and had no detrimental effects on disease activity, disease progression, or pain levels. Ekblom and associates⁸ studied patients with rheumatoid arthritis who underwent 6 weeks of daily physical rehabilitation that consisted of muscle strength and joint mobility training. At the end of the study, the participants' cardiovascular fitness, physical performance capacity, and leg muscle strength was significantly improved. In a follow-up study 6 months later, the participants were retested; those who had continued regular physical training maintained their functional improvements, while those who had discontinued their training showed a decrease in the factors studied.⁸

Long-term studies confirm the effectiveness of exercise. Nordemar⁹ studied 23 patients with moderate disease activity who underwent physical training for 4 to 8 years. The program consisted of home-based regimens, such as swimming, jogging, or bicycling, as well as hospital-based training. After 5 years of training, progression of radiographic erosion was slower in the patients who participated in physical training than in the control group. Moreover, outcomes in activities of daily living and in overall attitude were better in the training group.

Messier and colleagues¹⁰ randomized 316 adults with osteoarthritis of the knee into 4 groups. Therapy for the first group consisted of a healthy lifestyle; for the second, an appropriate diet; for the third, exercise; and for the fourth, diet plus exercise. (Exercise therapy consisted of 60-minute sessions performed 3 days per week.) After 18 months, participants in the diet-plus-exercise group had significant improvement in physical function and reduction in pain compared with participants in the other 3 groups. Exercise was also shown to increase mobility.

Ettinger and colleagues¹¹ randomized 439 elderly adults with radiographic evidence of knee osteoarthritis, pain, and self-reported disability to an aerobic exercise program, a resistance training program, or a health education program. At the end of 18 months, participants in both the aerobic exercise and resistance training programs showed modest improvements in measures of disability, physical performance, and pain compared with participants in the health education program.

SAFETY OF EXERCISE

Both patients and clinicians sometimes fear that exercise will exacerbate arthritis. Studies do not support this fear. In fact, significant data show that exercise is safe as well as effective for patients with arthritis.^12,13

Relative contraindications to exercise include recent joint replacement, significant joint damage, or an actively inflamed joint. Such conditions may necessitate avoidance of certain ranges of motion so as not to increase pain or cause additional damage. However, these conditions are often transient.

Lyngberg and colleagues¹⁴ studied patients with rheumatoid arthritis who were taking low-dose corticosteroids. One group of patients underwent progressive interval training (bicycle riding, step climbing) for 3 months. At the end of the study, disease activity in the trained group had not increased, and the patients who underwent training had fewer swollen joints than those in the control group.

Rall and colleagues¹⁵ studied high-intensity resistance exercise in patients with rheumatoid arthritis and compared its effect with that on healthy young patients and healthy elderly patients. Eight patients with arthritis, 8 healthy young patients (aged 22 to 30 years), and 8 healthy elderly patients (aged 65 to 80 years) underwent 12 weeks of total-body, high-intensity, progressive-resistance strength training. In addition, 6 healthy elderly patients were randomly assigned to non–strength training regimens, such as swimming. At the end of the study, all participants in the strength training groups demonstrated significant improvement in strength compared with those in the non–strength training group; participants with rheumatoid arthritis demonstrated a greater percentage increase in strength than those in the other 2 strength training groups. There was no change in the number of painful or swollen joints in the patients with arthritis, but there was a significant reduction in self-reported pain and fatigue, as well as improvement in balance and gait.

OVERCOMING RESISTANCE TO EXERCISE

Despite the benefits, the majority of patients with arthritis do not engage in regular exercise.¹⁶ It can be challenging to motivate patients with arthritis to initiate and/or adhere to an exercise program.

There are numerous reasons why patients are not physically active. Many patients do not exercise because of fear of injury. You need to recognize and address this fear. In addition, weakness, fatigue, stiffness, and joint pain can cause patients with arthritis to remain inactive and become weaker, thus initiating a cycle of reduced physical activity and muscle atrophy.

The key to successfully motivating patients with arthritis to initiate and adhere to an exercise program is to educate them about the benefits. If patients better understand the rationale for exercise, they are more likely to incorporate it into their daily routine.

It is also useful for patients to have goals. Both short-term and long-term goals need to be specific. For instance, long-term goals might include reduction of daily pain or use of less medication. Instead of simply suggesting that patients "be more active," help them to formulate a more tangible short-term goal, such as walking/hiking farther on a weekly basis, swimming for 30 minutes twice a week, or playing ball with their grandchildren several times a month.

Make sure patients understand that they do not need any special equipment or need to go to a gym. An effective routine can easily be completed in their home.

In addition, educate patients about normal responses and realistic expectations. Early on, some patients may experience soreness as they become more physically active. This soreness should be transient. It is important that patients be able to distinguish between soreness and pain. During the beginning weeks of an exercise program, it is critical that patients not become discouraged.

Encourage patients to commit to a routine for at least 6 to 8 weeks, the minimum time needed to appreciate significant results. Caution them not to expect immediate change; the benefits will come in time, typically after a few months. Reassess their progress at each office visit, so you can address any questions or concerns as well as reinforce the importance of this therapy. Some patients, such as those with low fitness levels or those who need significant encouragement, may be helped initially by several sessions with a physical therapist.

A large number of patients stop exercising after a few months. Therefore, it is important to stress the benefits of long-term adherence and to find ways to help patients "stick with it." First, eliminate any problems of miscommunication and make sure patients understand that long-term adherence is the goal. Explore their expectations and make sure these are realistic. Finally, provide frequent encouragement; patients often need positive feedback to continue with exercise.

AN EFFECTIVE EXERCISE PROGRAM FOR PATIENTS WITH ARTHRITIS

The goals of an exercise program for patients with arthritis are slightly different from those for the general population. They include:

• Improving joint flexibility.
• Preventing the deconditioning of muscles that keep the joints stable.
• Enhancing overall fitness while maintaining good joint protection.

Thus, a comprehensive exercise program needs to include the following 3 elements:

• Stretching.
• Strengthening.
• Aerobic exercise.

Stretching. This involves slowly lengthening the muscles. An effective stretching routine can be completed in less than 10 minutes. A brief stretching routine is particularly important for patients with inflammatory arthritis. A sampling of stretches for patients with arthritis is shown in Box I.

Strengthening. Exercises to strengthen muscles can be either isometric or isotonic.

Isometric strengthening exercises contract muscles without moving the joints. A good example of an isometric strengthening exercise is pushing against a wall. In isometric exercise, the contraction force of the muscle is equal to the resistance; consequently, the muscle neither shortens nor lengthens. ("Isometric" means "same length.") Because it involves no movement of the joint, this type of exercise is less likely to exacerbate pain. However, most patients should avoid forceful muscle contraction, which can increase pressure within the joint and thereby cause damage to the cartilage, ligaments, and joint. For this reason, instruct patients to perform multiple repetitions of isometric exercises at low intensity. A sampling of isometric strengthening exercises for patients with arthritis is provided in Box II.

Isotonic strengtheningexercises move the joint in an arc. In these exercises, patients extend the range of the joint until the full range of motion is covered. Isotonic exercises are performed using gravity or progressive weights to provide resistance. Exercises in which gravity provides resistance include push-ups and pull-ups. Most isotonic exercises, however, are performed using weights. Another common term for such exercises is "resistance training." Direct patients with arthritis to use very light weights and perform a large number of repetitions. Patients need not use actual dumbbells but can use household objects or their own body weight instead.

Isotonic strengthening exercise is particularly important for patients with arthritis because it is one of the few types of exercise that can reverse muscle wasting. Be sure patients with arthritis include isotonic strengthening exercises in their training routine. Box III contains a sampling of isotonic strengthening exercises for patients with arthritis.

Aerobic exercise. This type of exercise is important for patients because it strengthens the heart and improves overall fitness by increasing the body's ability to use oxygen. Because there is a wide range of aerobic activities from which to choose, this should be one of the easiest types of exercise to persuade patients to take up. The key is to help patients choose an activity they enjoy. Walking, light jogging, dancing, cycling, and swimming are good aerobic activities for many patients with arthritis. Cycling and swimming (Box IV) are particularly good because they are low-impact.

Putting it all together. Recommend that patients strive to exercise for at least 30 minutes, 5 days a week. They can slowly build up their stamina until they reach this goal. They can break the 30 minutes down into three 10-minute sessions or two 15-minute sessions. They can also alternate the type of exercise they do, as long as at least 50% of their exercise time is devoted to strength training.

References:

REFERENCES:

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