Exercise Prescription in Arthritis Management Flashcards
Those w/ _______ belong to the MOST sedentary chronic disease population
- Highest proportion of overweight/obese than other chronic diseases
- At risk for developing other comorbidities - diabetes, HTN, metabolic syndrome, CV disease, early mortality
In IA: Can develop osteoporosis due to inflammation & immobility, or corticosteroid use
In RA specifically: >60% have rheumatoid cachexia (lean muscle loss replaced by fat, can have normal BMI), ↑ w/ advanced age
Muscle physiology/activation is impaired during joint pain/flares = residual weakness post flares
- Progressive resistance training & biologic medications are important for these patients
Arthritis
Individuals w/ RA up to 60% more likely to suffer CV event
Individuals w/ axial spondylitis (including AS) up to 50% ↑ risk of CV events
Systemic inflammation is key driver (need medication!!) compounded by inactivity
Inflammatory Arthritis CV Risk
↑ muscle strength may modify biomechanics = ↓ joint loading rate or localized stress in the articular cartilage
Strengthening exercises play an important role in delaying progression of knee OA
Improved fitness may enhance quality of life by allowing a greater range of available daily tasks, thereby improving physical function
OA Exercise Benefits
Non-surgical management of knee OA
Core tx:
- Land-based exercise
- Weight management
- Strength training
- Water-based exercise
- Self-mgmt & education
OARSI Guidelines
High intensity exercise in _______ _______ - SAFE!
Resistance training, biking, stepping & stair walking
↓ progression of radiologic small joint damage (more pronounces in feet vs hands)
Less disease activity & use of glucocorticoids, improved function & aerobic fitness
Rheumatoid Arthritis
Ages 18-64 should accumulate at least 150mins of mod-to-vig intensity aerobic physical activity per week, in bouts of 10mins or more
Muscle & bone strengthening using major muscle groups at least 2x/week
Canadian Physical Activity Guidelines
Aerobic Activity:
- 150-300 mins/week of mod-intensity OR
- 75-150 mins/week of vig-intensity OR
- Equivalent combo of mod-and-vig intensity
+
Muscle Strengthening:
- At least moderate or greater intensity 2+ days/week
- Involve major muscle groups
When adults w/ chronic conditions/disabilities are not able to meet the above key guidelines, they should engage in regular physical activity according to their abilities
& should avoid inactivity
American Physical Activity Guidelines
Current recommendations: Get up every 20-30mins
Public Health England Recommendations - Desk Workers:
- Seated-based work should be regularly broken up w/ standing- based work (sit-stand desks or short active standing breaks)
- Initially work to accumulate 2hr/day of standing & light activity (light walking) during working hours, goal 4h/day
Education, self-monitoring, problem solving, restructuring social/physical environment most promising behaviour change techniques
Sitting Breaks
↑ aerobic capacity ↑ function (self-reported & performance) ↑ strength ↑ bone density ↓ joint damage ↓ pain, depression ↓ fatigue ↓ disease activity ↓ morbidity & mortality May improve efficacy of meds
Benefits of Physical Activity
Precautions & red flags
Current guidelines
Modifications
Monitoring
Progression
Adherence
Exercise Considerations
Inappropriate exercise can ↑ pain & reduce exercise confidence & adherence
- Exercise cannot make IA disease activity worse, but will aggravate symptoms if too much
In RA, unstable joints are vulnerable to deforming forces
Swollen joints at risk for capsular stretching; ligamentous rupture w/ uncontrolled inflammation
Tendinopathies common
Osteoporotic bones are risk for #s
Exercise Precautions
Sudden severe pain and/or joint deformity, or inability to move joint (#, tendon rupture)
Unable to weightbear (#)
Neurological signs in extremities (C1-C2 instability in longstanding RA) or progressive weakness despite exercise
SOB/chest pain w/ minor exertion (CV distress, RA lung)
Exercise Red Flags
Worsening pain, fatigue or AM stiffness
Joint becomes swollen, hot or red soon after doing exercise (within 24hrs)
- Re-Ax. whether exercise at appropriate intensity
- IA flare? Can be purely coincidental. Modify based on energy & what can tolerate
- In OA - may require better pain control to ↑ activity
Chronic pain
- highly associated w/ depression, anxiety
- activity avoidance, expectation of passive Rx, catastrophization
Low motivation, fear of making joints worse
Rx w/ education & reassurance, patient-identified functional goals
Exercise Yellow Flags
Greatest issue with the arthritis population is __________ behaviour & lack of physical activity, second to ________ adherence - Need to be ACTIVE & SELF MANAGE
Arthritis pt’s should never be treated with solely passive approaches
Individuals w/ arthritis & pain become rapidly, severely deconditioned, particularly in IA if multi-joint flares past/present
Sedentary; Medication
Include:
- ROM
- Strengthening
- Aerobic
- Flexibility
- Balance & Coordination
FITT principles
Exercise Prescription
Maintains/restores joint movement
Reduce stiffness in the morning & after inactivity, warming up
F: Daily
I: Full, pain free range
T: 5-10 reps
T: Active or self-assisted, non-WB
ROM
Increases energy & stamina; improves long-term function; releases endorphins to reduce pain
F: 4-7 days/week (most days)
I: Moderate
T: 150mins/week, bouts of 10min or more OR high intensity interval training, if tolerated
T: Whole body, dynamic
Moderate intensity: 50-7-0% HRmax (60-85% for CV fitness) or RPE 3-5 on 10 point scale; talk test
Aerobic Exercise
2 HOUR PAIN RULE: If post-exercise pain lasts more than 2-3 hours, probably over-did it
Do not quit; advise client to change HOW they do things:
- Slower progression, more breaks
- Different exercise
- Pre-medicating (more effective vs taking meds after activity when in pain)
- Ice/heat
- Difference between joint pain & muscle soreness
After Exercise
Occurs w/ articular swelling, inflammation, pain, joint laxity & structural damage
Caused by change in the discharge of sensory receptors in damaged joint = ↓ motor neuron excitability
Contributes to muscle atrophy
- If severe, may need NMES/high frequency TENS to activate
Most severe in acute stages of joint damage
- e.g. if ongoing swelling = continuous AMI even if no pain
Well documented in knee, applies to ALL joints
Arthrogenic Muscle Inhibition (AMI)
Consistent evidence for quads weakness in knee OA/RA, but clinically very often also hamstrings & glute max/med weakness
Hip pain = abductor, extensor, & rotator weakness
Can develop secondary mechanical orthopedic issues w/ weakness
- Knee: PTFPS secondary to gluteal weakness
- Shoulder: impingement, tendinopathies, burtisits
AMI & Muscle Dysfunction
Provide support & stability to the joint, reduce force through the joint
Prevent injuries/falls, maintain function
F: 2-3 days/week, non consecutive days
I: Moderate (3-5 on 10point scale)
T: 8-15 reps, 1-2 sets, work to fatigue
T: Major muscle groups, dynamic, functional
Protect other affected joints
Closed chain > Open chain
Strengthening
F: Min 2-3days/week, daily for problem muscle groups
I: “Feel” resistance, no pain
T: 20-30s hold, 2-3 reps
T: Static or dynamic
Caution w/ effused joints - avoid prolonged stretch
Common problem areas: hamstrings, hip flexors
Flexibility
Poor joint proprioception & AMI affects balance
F: 4-7 days/week
I: Moderate (challenging)
T: 10mins/day or more
T: Static, dynamic
Balance
Start slow
- Allow self-paced progression based on symptoms/tolerance
Painful, unstable joints
- ↓ load/intensity, incorporate proprioception, wear brace/splint
Restricted, fused joints
- Pain free ROM, if concentric painful, try eccentric/lower load/isometric
Recent joint surgery - Knee or Hip Arthroplasty
- Follow precautions
Falls & Low BMD
- WB balance & proprioception
Minimize joint stress
- Newer supportive/cushioned shoes, avoid stress balls (hand squeezing exercises), avoid hopping/jumping or twisting on fixed foot even in pool
- Apply resistance proximal to painful/unstable joints, sit rather than stand
Minimize impact if joints are damaged
- Avoid high-impact activities
Exercise Modifications
MSK: Teach pt to monitor pain & other symptoms
- During & after exercise
- Type of pain: DOMS vs joint pain lasting >2-3hrs
- Pain/activity diary
CV: Self monitor to ensure at mod intensity
- RPE, talk test, HR
Track functional changes
PA monitors/Apps (fitbit, track & react) - technology
Evolve intensity, complexity & functional challenge over time
Exercise Monitoring
Educate about benefits & risks
Enhance self-efficacy
- short term SMART goals/action plan
- Problem solve barriers in advance
- Exercise w/ a friend
- Communication
Keep exercise log
Follow up/booster sessions
Provide support resources; refer to community resources/classes
Promoting PA & Exercise Adherance
