In This Chapter About The Authors

64 Pages·2011·4.29 MB·English

In This Chapter
Epidemiology
Physical Symptoms and Findings
Associated With Osteoarthritis
Normal Course of Symptoms in an
Osteoarthritic Joint
Osteoarthritis and Exercise
Programming Guidelines and
A b o u t T h e A u t h o r s
Considerations
Sample Exercises
John G. Aronen, M.D., FACSM, is an orthopedic sports medicine
Case Study
specialist. Retired from the Navy in 1996, Dr. Aronen is a consultant
Summary
for the Center for Sports Medicine, Saint Francis Memorial Hospital
in San Francisco. Dr. Aronen is a selected member of the American
Orthopedic Society for Sports Medicine and the American Medical
Society for Sports Medicine, and a fellow of the American College
of Sports Medicine. Following two years of specialty training in
sports medicine, Dr. Aronen founded and served as the head of the
Sports Medicine Division of the Department of Orthopedic Surgery
at the United States Naval Academy and head team physician from
1979 to 1987. Dr. Aronen then founded and directed a four-week
CME/GME course for primary care providers and second-year
physician assistant students in the “Evaluation and Management of
Musculoskeletal Injuries Commonly Seen in Military Personnel.”
Kent A. Lorenz, M.S., CSCS, NSCA-CPT, is an exercise physiologist
and program coordinator with the Center for Optimal Health and
Performance at San Diego State University. He is also a lecturer and
researcher within the School of Exercise and Nutritional Sciences,
and uses his strength and conditioning and personal training
background to develop exercise programs and classes for adults to
help them maintain functional capacity and independence.
C hApTe r 1 5
Arthritis
John G. Aronen
Kent A. Lorenz
Arthritis is a general term that refers to joint inflammation. The two primary forms
are osteoarthritis (OA) and rheumatoid arthritis (RA). OA results from a
degeneration of synovial fluid and generally progresses into a loss of articular
cartilage, which typically presents itself as localized joint pain and a reduction of range
of motion (ROM) (Buckwalter & Martin, 2006). Buckwalter and Martin (2006) report that
approximately 20 million Americans have OA, and the World Health Organization (WHO)
estimates that about 10% of the world’s population over the age of 60 has the disease.
Of those who have OA, 80% will have limitations of move- improved with exercises that are designed to maintain muscle
ment and 25% cannot perform major activities of daily living strength, joint range of motion, and cardiovascular function.
(ADL), with the most common sites affected being the knees, The exercise recommendations that are presented in this
hips, spine, hands, and feet (Buckwalter & Martin, 2006). chapter are specific to OA, but people with RA are encour-
While OA is the most common affliction of the joints, RA aged to perform low levels of activity that does not increase
is another condition the ACE-certified Advanced Health & inflammation. Certain modifications, such as the use of wrist
Fitness Specialist (ACE-AHFS) may see among his or her straps or ankle or wrist weights and the performance of lower-
clientele. RA is a chronic autoimmune disease that results intensity and higher-duration activities, may be needed to
in inflammation of the synovium, leading to long-term accommodate certain clients. Helmick et al. (2008) estimate
joint damage, chronic pain, and loss of function or disability that 1.3 million Americans suffer from RA, down from
(Arthritis Foundation, 2007). RA progresses in three stages, 2.1 million in 1995, suggesting a reduction in the prevalence
with the first being a swelling of the synovial lining, resulting of the disease.
in pain, warmth, stiffness, redness, and swelling of the joint. While this chapter introduces both forms of arthritis, the
The second phase is a rapid division and growth of cells, which focus from this point on will be on the identification and
causes the synovium to thicken. In the third and final stage, treatment of OA. As with all chronic conditions, the ACE-
the inflamed cells release enzymes that break down bone and AHFS should communicate with his or her clients to discuss
cartilage, causing the affected joint to lose structure and align- what types of activities they are able to do—and how much.
ment, leading to more pain and a further decrease in function. If someone presents with some of the signs and symptoms of
RA is a chronic disease that typically worsens with time, OA or RA, and he or she has not sought medical advice, the
resulting in further physical limitations of the involved joints. ACE-AHFS should refer the individual to a medical profes-
In comparison to osteoarthritis, RA, being an autoimmune sional before working with him or her. In more severe cases,
disease and having a more systemic effect, may manifest itself where the majority of weightbearing activity is painful or lim-
in the development of heart and lung disease and diabetes. ited, the ACE-AHFS may want to refer to a physical therapist
As with OA, the quality of life for individuals with RA can be or occupational therapist.
378 Chapter FiFteen Arthritis
Medical conditions (e.g., illnesses, injuries) are reminders to the individual that he or she no longer
typically placed into one of two categories based has an entirely healthy or normal joint. For others,
on their suspected cause, or etiology—primary the initial changes to the structural integrity of the
or secondary. The determination of a condition’s joint are not severe enough to result in the onset
category is based on whether the underlying cause of discomfort and/or swelling from the time of
for the problem can be identified. If the underly- the injury. The starting point for changes to the
ing cause for a problem cannot be identified, the structural integrity with an injury of insidious
problem falls into the primary category (i.e., the onset, as may be seen in the knees and hips with a
individual has the problem, but physicians cannot steady regimen of distance running, is ill defined, as
determine why or what is causing or contribut- it does not come on acutely, but rather over time.
ing to the problem). For primary problems, unfortunately, with the normal progression of
treatment and management must be directed degenerative changes that occurs in osteoarthritic
at the symptoms associated with the condition. joints, discomfort and/or swelling will become evi-
unfortunately, while this approach may provide dent sooner or later in the majority of cases.
resolution of the symptoms, the underlying cause Structural integrity of a joint refers primarily to
will continue to contribute to the natural progres- the following:
sion of the problem. • Articular cartilage, which consists of hyaline
If the underlying cause that contributed to cartilage, is free of pain fibers and covers the
the onset of the condition and/or continues to portions of bone that articulate with each
contribute to the condition can be identified, other within a joint. Articular cartilage is also
the condition is categorized as secondary. With referred to as chondral cartilage.
a problem that is secondary, the emphasis of • Subchondral bone, which underlies the
the treatment and management program must articular cartilage, must be healthy to provide
be directed at eliminating or minimizing the appropriate structural support to the articu-
underlying cause. Failure to recognize that proper lar cartilage overlying it.
management of a secondary condition includes • discomfort and/or swelling are the earliest
management of both the symptoms and, more symptoms or physical findings that indicate
importantly, the underlying cause(s) of the symp- that changes have occurred to the structural
toms, will result in only short-term relief from the integrity and that the joint is no longer an
presenting symptoms, as the underlying cause is entirely healthy or normal joint. Typically,
allowed to continue to contribute to the natural the amount of discomfort and/or swelling is
progression of the problem. an indicator of the severity of changes to the
Injuries to a joint occur either acutely or insidi- structural integrity of the joint.
ously (i.e., over a prolonged period of time). Any
injury to a joint that causes detrimental changes to
Epidemiology
its structural integrity becomes the starting point
P
for the onset and progression of osteoarthritic rior to the 1980s, OA, often referred to
changes. Because there are typically detrimental as degenerative joint disease (DJD),
changes to the structural integrity of the knee with was believed to occur only in men who
an acute injury, such as a sprain of the anterior suffered an injury to a joint, most commonly the
cruciate ligament, a tear of a meniscus, or patel- knee, while involved in a contact sport. Because
lar dislocation, the starting point for the onset of the onset of OA was thought to be caused by the
osteoarthritic changes is the time of the injury. In initial injury to the knee, the OA that occurred
many acute injuries, due to the severity of the initial following a documented knee injury was classi-
changes to the structural integrity of the joint, the fied as a secondary problem. Additionally, little
starting point for osteoarthritic changes is also the concern was given to the initial treatment and
starting point for the discomfort and/or swelling long-term management of the etiology, which
associated with the osteoarthritic changes, constant would have slowed down the progression of
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Arthritis Chapter FiFteen 337799
the undesirable changes to the structural integ- of attrition from sports entirely due to injuries
rity. Typically, the athlete would remain active at an early age suddenly came more into focus.
in sports, only expediting the “unavoidable” Experts had assumed that injured joints would
progression of the acute changes, resulting in a naturally degenerate with time and that lifestyle
chronically painful and functionally deficient knee. modifications of young athletes would have little
unfortunately, due to an avid desire to return an
or no effect on the outcome of the process of
athlete to all activities rather than be realistic and
degeneration.
make modifications in lifestyle that may prolong
It is slowly becoming understood that the pro-
the life of the injured joint, too little progress has
gression of the initial changes to the structural
been made in the appropriate initial treatment and
integrity of a joint can be “slowed down” through
long-term management.
alterations in the individual’s daily lifestyle and
Two other factors came into play regarding OA
through rehabilitation programs designed to regain
in the late 1970s and early 1980s, the first being
and maintain normal strength and flexibility of the
the sudden surge of adolescent and teenage girls
muscles surrounding the joint. These programs
into injury-producing sports. As the number of
are designed to slow the progression of the degen-
participants in sport dramatically increased, the
erative changes already existing in the joint. Each
number of significant acute injuries, not only to
exercise incorporated into a rehabilitation program
the knee but to other joints as well, resulted in a
for an individual with OA must be evaluated for
large increase of symptoms and findings compat-
ible with osteoarthritis in younger and middle-aged the amount of force it places on the vulnerable
athletes. Additionally, it was noted that not only joint, because, although the individual may be able
could the onset of OA [through findings noted to perform the exercise without any pain, this is no
on arthroscopy, magnetic resonance imaging guarantee that the exercise is not doing more harm
(MRI), or symptoms compatible with OA] occur than good over an extended period of time.
following an acute injury to a joint, but it could Another factor in the increase in prevalence of
also occur following persistent microtrauma to the OA was the changing of dietary and exercise habits.
structural integrity of a joint, as seen in distance Since the 1980s, the united States went from
runners. In the early 2000s (approximately 20 to being one of the leanest and fittest countries in the
25 years following the surge in female participation world to the other end of the spectrum. It soon
in sports), a dramatic increase in individuals with
became apparent that people were living longer
physical and radiographic findings compatible with
and presenting with significant arthritic changes in
significant osteoarthritic changes in the knees and
hips and/or knees that had never experienced acute
hips began to appear. The following characteristics
trauma. Although from this group it appeared that
were common in this group:
a primary form of OA was associated with normal
• A female participating in sports that were only
aging, 52% of patients who required total knee
sparsely available to the female community
arthroplasty and 36% of those who required total
prior to 1980, but sprang into popularity in
hip arthroplasty were overweight or obese (namba
the 1980s (e.g., basketball, volleyball, softball,
et al., 2005).
soccer, distance running)
Although there are some individuals who will
• An individual incurring a knee/hip injury or
develop OA with no identifiable underlying
simply having a history of following a compul-
causes, the vast majority of OA is secondary in
sive daily running regimen
• An individual treated with one of the increas- nature—secondary to trauma and/or obesity.
ing number of surgical procedures designed to Therefore, exercise programs for individuals with
address these injuries, followed by aggressive OA must keep forces on the osteoarthritic joint to
rehabilitation programs a minimum, as clients strive to retain the strength
With emphasis placed on early surgical interven- and flexibility necessary for a joint to function
tion and aggressive rehabilitation, the high rate normally.
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380 Chapter FiFteen Arthritis
Physical Symptoms and
• Because it lacks a blood supply, the role
Findings Associated With of providing nourishment to the articular
cartilage is carried out by the synovial fluid,
Osteoarthritis
which is able to enter and exit the articular
cartilage at will through microscopic pores
T
o understand the symptoms experienced in the surface.
with OA, the ACE-AHFS must have • The articular cartilage is void of pain fibers.
knowledge of the anatomical structures The contributions of the articular cartilage to
of a joint. Furthermore, the ACE-AHFS must a normal, healthy joint include the following:
understand the role each structure plays in • When the surface of the articular cartilage
normal joint functioning and the contribu-
is pristine and covered with synovial fluid,
tions each makes to the physical symptoms
the coefficient of friction between the two
experienced and the physical findings noted on
articulating surfaces is almost zero.
examination).
• Because it lacks pain fibers, the articular
The role of a joint, or articulation, is to allow
cartilage prevents the subchondral bone,
motion between bones at a specific site. Because
which has an abundance of pain fibers,
of its high frequency of injury and because it is
from experiencing pain related to the
a common site of OA, the knee will be used in
normal transmission of force across joints
this discussion.
on a daily basis. Without articular carti-
A capsule fully encloses each joint, so that
lage, the joint would be basically bone on
fluid produced in the joint is retained in the
bone—which would be very painful.
joint. lining the capsule is a synovial mem-
• It has been determined clinically that
brane that consists of synovial cells. There are
healthy articular cartilage can tolerate
two types of synovial cells, type A and type B.
approximately seven times the person’s
The lubrication system, which sounds very sim-
body weight before undesirable and often
plistic, is actually very sophisticated. The type A
silent detrimental changes begin to com-
cells are secretory in that they produce the syn-
promise the structural integrity of the
ovial fluid that acts as a lubricant for the joint.
articular cartilage, which is why it is so
The natural viscosity of the synovial fluid mini-
important to avoid activities that place
mizes the degenerative process normally seen
unnecessarily high forces on the joints
between two healthy structures that repetitively
(Repo & Finlay, 1977).
articulate with each other. The type B cells are
Initial changes to the articular cartilage
phagocytic, in that they are responsible for the
involve the changing of the once pristine surface
debridement (removal) of the “worn out” syn-
into an uneven, incongruous surface. These
ovial fluid and any excess fluid (synovial fluid
changes can occur quickly from acute trauma,
and/or blood) that may have accumulated in
such as a torn anterior cruciate ligament, menis-
the joint. The articular cartilage of the knee is
entirely separate from the two menisci, which cal tear, or dislocated patella. Each of these
are made up of fibrocartilage and function to injuries produce shear forces in the joint that
provide shock absorption and stability to the damage the articular cartilage. The rating of
knee. the severity of damage is based on the amount
The articular cartilage is unquestionably a key of articular cartilage involved and the depth of
anatomical structure. Osteoarthritis begins and the disruption, which ranges from grade 1 to
ends with changes to the structural integrity of grade 4. Grade 1 implies only superficial changes
the articular cartilage. There are a few properties to the articular cartilage, while grade 4 implies
unique to articular cartilage: damage to the point where subchondral bone is
• It has no blood supply and thus cannot heal exposed. The loss of the pristine surfaces leads to
if injured. an increase in the coefficient of friction, which
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381
Arthritis Chapter FiFteen
Normal Course of Symptoms
hastens damage due to wear and tear on the
remaining articular cartilage. in an Osteoarthritic Joint
Along with the loss of the pristine surface,
I
the once microscopic pores that allowed the n the earliest stages, there may be no symptoms
synovial fluid to flow freely into the articular or findings until continued forces are placed
cartilage become enlarged, allowing the escape of on the joint and the degenerative changes sub-
chemicals from inside the articular cartilage into sequently progress. Initial symptoms are next-day
the joint. These chemicals are direct irritants discomfort and/or stiffness of the joint from chemi-
to the synovial cells and cause them to become cal synovitis.
inflamed (chemical synovitis). Once inflamed, As the changes to the structural integrity
the cells produce soreness throughout the knee increase, the next-day discomfort and/or stiffness
will increase in intensity and frequency. As the
as well as an excessive amount of synovial fluid,
articular cartilage becomes thinner, forces are trans-
which is experienced as tightness in the knee.
mitted and experienced by the subchondral bone,
The inflammation from the chemicals, with
resulting in bone pain during and after activity.
the resultant discomfort and excessive synovial
Further progression leads to bone-on-bone contact
fluid production, typically takes 10 to 14 hours.
and constant pain.
Thus, the individual can be physically active on
Because it is relatively silent in nature in its
the knee in the evening, but will note the diffuse
early stages, OA is comparable to hypertension in
discomfort and tightness the next day.
that they are both silent diseases that continue to
With the continuous wear-and-tear changes
worsen without telltale signs. These silent changes
due to the increased coefficient of friction, the
frequently have dramatic effects on an individual’s
articular cartilage becomes thinner, allowing
health and lifestyle activities if he or she fails to
the subchondral bone to experience more of the
recognize them in the early stages. The diagnostic
forces transmitted across the joint. Forces expe-
criteria that are used to identify individuals with
rienced by the subchondral bone result in pain,
OA of the knee as outlined by the Agency for
the amount and frequency of which is depen-
Healthcare Research and Quality are joint pain plus
dent on many factors:
five of the following criteria (Samson et al., 2007):
• The location of the site of exposed
• Client over 50 years of age
subchondral bone (weightbearing vs. non-
• less than 30 minutes of morning joint
weightbearing areas)
stiffness
• The amount of force placed on the site with
• Crepitus
physical activity (e.g., minimal with swim-
• Bony tenderness
ming, highest with weightbearing activities)
• Bony enlargement
• The weight of the individual, as higher
• no palpable warmth of synovium
body mass can increase joint compressive
• Erythrocyte sedimentation rate (ESR)
forces that are excacerbated by misalign-
<40 mm/hr
ment of the femoral-tibial joint (Felson et • Rheumatoid factor <1:40
al., 2004) • non-inflammatory synovial fluid
The pain can start out as minimal follow- It is highly recommended that the ACE-AHFS
ing activity, but progresses in accordance with speak in detail with his or her client to get a full his-
the amount and frequency of undesired forces tory before developing an exercise program. If the
placed on the site, typically to the point where ACE-AHFS or the client is unsure of the status or
the individual’s lifestyle is greatly altered by the progression of OA, the client should be referred to
pain. unfortunately, most individuals will not a medical professional.
consider making changes in their level of physi- The task for an ACE-AHFS is to recommend
cal activity until they are experiencing constant specific exercises for clients with OA that will allow
bone pain. them to remain physically active without doing
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382 Chapter FiFteen Arthritis
harm to their existing problem. The ACE-AHFS Osteoarthritis and Exercise
must understand which individuals are at risk for
B
osteoarthritis and who will therefore need exer- y increasing muscular strength and endur-
cise programs designed to protect the joints. ance, enhancing the stability of the joints,
Any individual who has had surgery on a joint improving range of motion, and reducing
involved in the exercise program: The initial passive tension of the soft tissue surrounding joints,
injury requiring surgical intervention in the an ACE-AHFS can help his or her clients improve
vast majority of cases disrupts the structural their quality of life, maintain normal function, and
integrity of the joint (i.e., the articular cartilage prevent deconditioning. One of the secondary
and subchondral bone). This situation must be outcomes of OA is a development of other diseases,
recognized in the development of an exercise such as coronary artery disease, diabetes, and
hypertension, as physical activity becomes too pain-
program for these individuals.
ful to attempt, cardiovascular function declines, and
Individuals who state that they experience
the client becomes sedentary. For the high number
discomfort and/or tightness the day following
of overweight or obese clients with OA, a further
physical activity: Chemical synovitis is the num-
reduction in physical activity can increase the risk
ber-one reason for these symptoms to occur
for the development of comorbidities. By encour-
and persist. Temporary relief can be achieved
aging clients to maintain cardiovascular fitness by
with over-the-counter anti-inflammatory
doing exercise that does not increase joint pain,
medications, but the symptom and not the
combined with exercises and treatments to help
etiology itself is being treated. Also, the con-
reduce joint pain, an ACE-AHFS can reduce the
cern over the possible significant side effects
impact of OA on pain, day-to-day function, cardio-
of all anti-inflammatory medications often
vascular health, and quality of life.
outweighs the palliative benefits. A safer route
Of the randomized, controlled trials explor-
to control the discomfort may be the use of a
ing the effects of exercise on OA symptoms,
glucosamine sulfate with a low-molecular chon-
some have used hydrotherapy, tai chi, or other
droitin (only found in CosamindS®). A study
low-impact exercises to reduce the stress on the
by the national Institutes of Health (Clegg et
joints (Ettinger et al., 1997; Fransen et al., 2007;
al., 2006) reported better relief of pain and no
Hinman, Haywood, & day, 2007; lund et
known side effects with the use of the ingredi-
al., 2008; Wang et al., 2007). This outcome is
ents found only in CosamindS when compared
certainly recommended for individuals who expe-
to Celebrex® 200 mg a day or a placebo.
rience pain throughout the day, but for those who
Overweight individuals: The excessive forces
are relatively pain free, weightbearing exercise and
associated with overweight and obesity result
resistance training can be beneficial in not only
in undesirable changes to the articular cartilage.
reducing pain and disability, but also in maintain-
The ACE-AHFS must not do anything to
ing normal everyday function. A study examining
hasten these changes.
the effects of different exercise modes on pain,
Individuals who walk with an altered gait, espe- disability, and performance measures found that
cially following participation in a weightbearing 60 minutes of light- to moderate-intensity walking
activity: This can result in an asymmetrical load- three days per week [50 to 70% heart-rate reserve
ing of the joint, which increases the risk of joint (HRR)], or light- to moderate-intensity resistance
degeneration (Buckwalter & Martin, 2006). training three days per week (two sets of 12 repeti-
Individuals who feel the need to wear a brace tions of nine exercises) had significantly better
with activity: Bracing is often a result of a previ- results than the control group over an 18-month
ous injury or current joint pain, which may have intervention (Ettinger et al., 1997). Similar results
resulted in alterations of the articular structures were obtained in a study that showed that indi-
and can increase the risk of the development of viduals performing three days per week of light- to
OA (Buckwalter & Martin, 2006). moderate-intensity resistance training (three sets of
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Arthritis Chapter FiFteen
eight to 10 repetitions) had lower pain scores and • Reduce volume and intensity if next-day tight-
higher functional abilities compared to those who ness or pain is present.
performed only passive range-of-motion exercises • More frequent, lower-intensity exercise is
(Mikesky et al., 2006). There was also a dose- preferred to a single longer or higher-intensity
response relationship between those who did more session.
exercise (75 to 100% of programmed sessions) and Guidelines
those who did less activity (<40% of programmed • Clients should always perform an adequate
sessions), with those in the former group experi- warm-up (10 minutes) to ensure joint
encing lower pain and disability scores and having lubrication and increased elasticity of tissues
greater performance and fitness scores (Ettinger et (Hedrick, 1992).
al., 1997). However, as with all exercise programs 4 They should start with light aerobic exercise
for individuals with limitations, the ACE-AHFS to increase systemic blood flow and body
must always be cognizant of the client. If the client temperature.
is hurting, he or she will not do the exercise, so the 4They should perform activation exercises
ACE-AHFS must base decisions on individual to target specific areas (knees, hips), such as
feedback, not general guidelines. unloaded knee flexion and extension focus-
unfortunately, exercise is not a cure for OA, but ing on full ROM.
maintaining a regular exercise program of resis- 4dynamic flexibility exercises should be per-
tance and aerobic training can reduce the pain and formed to maintain elasticity and further
rate of decline in functional capacity (Ettinger et increase lubrication (static stretching will
al., 1997; Mikesky et al., 2006). no evidence exists cool the body down; the goal is to keep it
that properly programmed and managed exercise warm and moving).
will increase the rate of joint degeneration, as Progressions and recommendations
measured by joint-space narrowing (Mikesky et al., • Aerobic exercise: Three to five days per week of
2006) or pain scores (Ettinger et al., 1997; van Baar light- to moderate-intensity training (50–70%
et al., 1999). Exercise can help reduce some of the HRR) of lower-impact exercises (e.g., walking,
risk factors associated with the progression of OA, swimming, cycling, inline skating, rowing) for
including weak quadriceps (Bennell & Hinman, 30 to 60 continuous minutes
2005; Mikesky et al., 2006), valgus or varus knee 4 Multiple, shorter sessions per day may help
alignment (knock-kneed or bow-legged), weak reduce joint pain.
hip abductors, and obesity (Issa & Sharma, 2006). 4 Aqua-therapy or swimming can reduce
By selecting exercises or developing programs that joint stress while maintaining cardiovascular
address these conditions, an ACE-AHFS can help function and muscular endurance.
reduce pain and functional limitations, as well as 4 Clients should gradually progress to
slow the progression of OA to keep clients active. longer sessions (increases of 5–10% in
Further reductions in quadriceps strength, as well duration) when able to comfortably
as in the hip abductors and extensors, will acceler- exercise without any fatigue or increasing
ate the deterioration of the joint by reducing the joint pain, keeping intensity low to avoid
ability of the individual to control anterior-pos- higher joint forces.
terior motion of the knee, as well as exacerbating 4 If exercising on consecutive days, clients
structural alignment problems that may lead to should switch modes to avoid overuse
asymmetrical wear on the articular cartilage. injuries.
4 The ACE-AHFS should remind clients
Programming Guidelines and that proper footwear and softer terrain are
Considerations important to reduce joint forces during
Contraindications and precautions weightbearing exercise.
• Stop immediately if any feelings of joint pain • Resistance training: Two to three days per
occur during exercise. week of light- to moderate-intensity training
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384 Chapter FiFteen Arthritis
4 Clients should perform one to three sets of These exercises can be performed in a pool to
eight to 12 repetitions. further reduce joint pressures.
4 They should follow a full-body program • Clients can move to bodyweight bilateral
using machines or free weights. exercises (e.g., squats) to develop overall mus-
4 The program should include functional cular and joint control while encouraging full
exercises to develop synergists as well as ROM.
overall coordination of the musculature to 4 Clients can add external resistance to
control and stabilize the joint. increase muscular strength and endurance
4 Clients should begin with isometrics and if they are pain free.
unloaded movements to increase ROM • Clients can progress to unilateral exercises
and develop proper movement patterns. (lunges, step-ups) to develop muscular con-
4 Exercise in the water allows for light resis- trol of the joint complex.
tances to help condition muscles through 4 They should focus on proper control and
a full, pain-free ROM, while also reducing technique to make sure the patella and
joint stresses. femur track correctly.
4 Clients can progress to light resistance Osteoarthritis of the hip
(cuff weights, tubing/bands, dumbbells) or • Clients can begin with passive ROM exer-
bilateral exercises (bodyweight squats). cises to increase circulation and synovial
4 Clients should work toward moderate- lubrication, which helps reduce joint com-
resistance exercises with as much ROM as pression. Also, aqua-therapy can be used to
can be tolerated, or to unilateral exercises reduce pressure on the joint.
(lunges, step-ups). • Clients can perform exercises lying on the
• Flexibility and stress reduction: ROM ground to avoid putting too much load on
exercises daily to keep joints mobile and the hips. They should begin with limited-
compliant ROM lying hip abduction and extension
4 Clients should perform dynamic flexibility exercises, plus ROM exercises to strengthen
exercises to increase ROM and keep joints the hip and increase flexibility.
lubricated, and static stretching to decrease • Clients can progress to bilateral weightbear-
passive tension (emphasis on the ham- ing exercises with limited ROM (e.g., wall
strings, quadriceps, gluteals, gastrocnemius, slides, bodyweight squats) to develop the hip
soleus, and adductors for the lower extrem- complex. They can perform ROM exercises
ity, and the pectorals, trapezius, latissimus at the end of the session to keep the joint flex-
dorsi, deltoids, rhomboids, rotator cuff ible and reduce joint compression and passive
muscles, biceps, and triceps for the upper tension.
extremity). • When the client is able to perform bilateral
4 pilates, yoga, tai chi, and meditation can exercises with limited pain through a larger
improve overall flexibility, reduce stress, ROM, he or she can progress to unilateral
improve mood or psychological outlook, exercises (e.g., single-leg squat) to further
and reduce pain. develop the gluteals and hamstrings.
4 Myofascial release (foam rollers, massage)
Sample Exercises
can decrease passive tension and break
A
down soft-tissue adhesions that impair ll programs should be tailored to meet the
normal muscular function. individual needs and experiences of each
Osteoarthritis of the knee client, but free-weight or body-weight
• Clients can begin with isometric exercises or exercises are generally preferred for clients with OA,
light resistance (ankle weights) to strengthen as they allow for the development of neuromuscu-
the quadriceps, hamstrings, and gluteals lar control and conditioning of antagonists and
without putting undue pressure on the joint. synergists to help control and stabilize the joint.
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Arthritis Chapter FiFteen
note that this list of exercises is not meant to be a knee extension. This exercise places tremendous
complete exercise program, but is instead intended compression forces on the underside of the patella,
to provide sample exercises that can be beneficial accelerating the degeneration of the joint.
in reducing symptoms of OA and ameliorating the Once the client has progressed to where he
progression of the disease. or she can create adequate force and endur-
At the beginning stages of exercise, individu- ance to sustain the contraction shown in
als need to increase quadriceps strength without Figure 15-1 for 15 to 30 seconds, the client
increasing the risk of joint degeneration. The open- can progress to the closed-chain terminal knee
chain terminal 30 degrees knee extension exercise extension (Figure 15-2). This exercise allows
(Figure 15-1) is an effective means of doing just for the development of the quadriceps, but also
that. This exercise allows for the strengthening of develops the hip extensors and abductors in a
the knee extensors, but by performing only the final stabilizing capacity.
30 degrees the client avoids the high compression As the client progresses, the addition of body-
forces of the full-ROM knee extension. Note: One weight exercises to condition the lower body is
exercise that should be removed from all exercise recommended. The isometric or small-ROM
programs of those with OA (and for those who wall slide or wall squat (Figure 15-3) is the first
want to avoid developing OA) is the full-ROM exercise that should be added to the program, as
it develops the strength of the knee extensors,
hip extensors, and abductors, and also helps the
client develop the neuromuscular control to
help move on to dynamic exercises.
After the client is able to perform the wall
slide comfortably, he or she can progress to the
bodyweight squat to develop the musculature sur-
rounding the hips and knees (Figure 15-4). The
Figure 15-2
Figure 15-1 Terminal knee extensions (closed chain). The
Terminal 30-degrees knee extension (open chain). client starts by standing on one leg with the non-
Starting the knee at 30 degrees of flexion and supporting leg resting toes-down for support. The
moving to full extension reduces the compression client then moves the support leg into 30 degrees
forces on the underside of the patella, minimizing of flexion, keeping the shoulders and hips over the
wear and preventing further degeneration of the heel, and then presses the knee of the supporting
articular cartilage. This exercise can be performed leg backward, actively contracting the quadriceps
with ankle weights or as an isometric hold at the to move into full extension. Resistance bands can
terminal range of motion. be added to increase difficulty.
ACE AdvAnCEd HEAlTH & FIT nESS SpECIAlIST MAnuAl