Arthritis is a chronic disease affecting joints, muscles, and sometimes other body systems. Because of the resulting pain and disability, arthritis is the leading cause of impaired functioning in adults and affects more than 52.5 million Americans. There are more than 100 forms of arthritis, though the most common forms are osteoarthritis (OA), rheumatoid arthritis (RA), fibromyalgia, and the spondyloarthropathies (SA) (6). Osteoarthritis is primarily joint specific while the others are systemic and affect more than just the joints, although even OA has systemic inflammatory responses.
The most common symptoms of arthritis, regardless of the type, are stiffness, joint or muscle pain, and fatigue. Unfortunately, you may have stopped exercising when you started to have this joint or muscle pain, believing that the activity would make your pain worse or speed up the degenerative process. However, proper exercise actually decreases pain. Exercise does not speed up the joint degeneration; rather it helps you maintain normal function.
Causes of Arthritis
Trauma to a joint, abnormal biomechanics (movement), or repetitive joint stress can damage the articular cartilage (the special covering within the joint that absorbs stress and smooths motion) (9, 34). As the damage progresses, the joint space narrows and the bone underlying the cartilage experiences abnormal stresses and deforms. However, for some people, there is no identifiable cause for their arthritis; and with the systemic forms of arthritis, an abnormal immune system response is often the cause of the joint destruction.
There are several risk factors for arthritis. Although some, such as age and sex, cannot be altered, addressing some of the other risk factors may help to control the discomfort of arthritis. Risk factors include the following:
· Age. Your risk increases with advancing age.
· Sex. Females are at higher risk for most types of arthritis.
· Overweight and obesity. Increased body weight may result in increased stress on the joints and may alter biomechanics.
· Previous joint injury. Joint injuries usually cause long-term changes to the joint surface and lead to the development of arthritis. In addition, muscle strength may decrease after an injury, transmitting more force through the joint and altering biomechanics.
· Occupation. Jobs that require sustained positions or repetitive motions place increased stress on the involved joints (e.g., butchers must use sustained grips, with repeated impact, and thus have a higher incidence of hand arthritis).
· Smoking. Smoking is a risk factor for RA and can also lead to complications following joint replacement.
Arthritis is often self-diagnosed during the initial stages. Most people do not go to the doctor until the pain and perhaps loss of motion limit their activity. Diagnosis of arthritis is done by correlating a health history and a physical examination to X-ray and various laboratory test results (1, 4, 7). Some people have little joint damage but significant pain, whereas others have significant damage and little pain. Regular activity appears to diminish the presence of pain. Laboratory tests are most helpful in diagnosing the systemic arthritis diseases.
Types of Arthritis
The two most common forms of arthritis are OA and RA (1). Osteoarthritis is most common (85 percent of arthritis is in this form). It is a local degenerative joint disease and as such most commonly affects the hands, hips, knees, and spine. One or more joints may be affected. Damage to the joint may be due to trauma, infection, mechanical stress, or often an unidentified cause (27). For many with OA, initial symptoms include aching within a joint or stiffness after prolonged sitting. Cartilage damage within the joint is the main problem with OA, and over time the joint may become deformed and lose motion.
Rheumatoid arthritis is the second most common form (1 to 2 percent of the adult population, although it can occur at any age). The cause is unknown, but risk factors include age and being female. Unlike OA, which is more localized, RA is body-wide (systemic) and affects tissues throughout the body. Symptoms develop slowly and include fatigue, weight loss, weakness, and general joint pain. Similar to what occurs with OA, joints become deformed and motion becomes difficult.
Two other common systemic conditions are fibromyalgia and SA (a category). Fibromyalgia is an arthritis-related condition found more often in women than in men that causes widespread muscle tenderness. With fibromyalgia, numerous “tender points” occur in various places (e.g., neck, shoulders, back, hips, arms, legs) when pressure is put on the area. Several forms of SA exist; ankylosing spondylitis is the most common. This condition causes back pain and eventually complete immobility in joints of the spine.
As noted previously, stiffness is the most common symptom of arthritis, and thus its presence is used to help diagnosis the disease. Generally, if morning stiffness lasts less than 30 minutes, the condition is OA; most of the systemic forms result in stiffness that lasts at least an hour. Osteoarthritis is initially limited to one or two distinct joints, whereas RA is diagnosed by the presence in multiple joints, and fibromyalgia has distinct muscle tenderness at points all over the body.
Healthy Approaches to Managing Arthritis
Physical activity and diet are two important lifestyle factors over which you have control. This section explains how both improved nutrition and regular exercise can help you manage your arthritis while also improving your health and fitness.
Focusing on Nutrition
Maintaining an appropriate body weight decreases the risk of developing arthritis; it also helps lessen pain if you already have arthritis (27). Experts speculate that decreased weight results in less force to the joint. If you are overweight, you can use exercise and proper nutrition to control your weight. A loss of as little as 10 pounds (4.5 kg) has been shown to decrease the pain associated with arthritis (26). Because obesity is a risk factor for arthritis, you may want to consult chapter 18, which focuses on weight management. The nutritional guidelines outlined in chapter 3 provide a solid plan for ensuring optimal nutrition. Some nutritional supplements may be helpful and are discussed in “Influence of Supplements” later in this chapter.
Focusing on Physical Activity
In general, the benefits of exercise are similar across all types of arthritis. A proper exercise program can diminish the associated pain and disability. Some studies have shown an immediate decrease in joint pain after gentle exercise, whereas participation in a regular exercise program results in more significant reductions in pain (10, 28). In addition to reducing the pain associated with arthritis, you may also be able to reduce the amount of medication you take to control pain. As noted in the section on medications, many medications have some associated risks, so reductions in dosage are considered a very positive benefit.
Decreased muscle strength and joint motion often result in functional limitations and disability. Regular exercise improves strength and joint motion, thus improving function (21). Additionally, some studies have shown that even low-intensity exercise slows the progression of functional loss, although more intense exercise confers even more benefits (15, 17, 22, 29, 35). A common myth is that those with arthritis should participate only in low-intensity activities. In reality, more intense exercise does not speed the joint degeneration or worsen symptoms as long as you have progressed your program gradually and are protecting your joints appropriately.
If you have one of the systemic forms of arthritis, such as RA, you have a higher risk of heart disease and other systemic complications. Participating in a regular exercise program will help decrease these risks as well.
Precautions for Arthritic Conditions Before Exercise
To maintain a safe and effective training program, you may have to make some modifications. One problem you may have is flare-ups—periods in which the joint swells more than it does normally and the pain is worse. These are more common with the systemic forms of arthritis. During a flare-up you may need to alter your program, reducing the intensity or temporarily eliminating a specific activity if it makes your symptoms worse. Balancing activity and rest is important, especially with systemic arthritis, because of the involvement of the immune system. However, it is not good to stop all activity.
Another concern with arthritis is joint instability and laxity (32). As the joint becomes more degraded and the joint space narrows, the tissues that normally stabilize the joint become slack. When this happens, they are no longer able to properly control the joint movement. In addition, the joint often becomes slightly deformed and out of alignment. Instability is the sensation of the joint “giving way” when you are active and is not necessarily related to laxity, though it is related to a decrease in function.
You may need a brace to provide stability and alignment if you are engaging in activities that stress a joint prone to laxity or joint instability. If joint alignment is the primary problem, especially for the lower extremity, you may benefit from an orthotic, which is an insert placed in a shoe to correct the alignment of the foot (33). Correction of foot position has been shown to decrease knee pain.
If you are having any of these issues, consider consulting with a health professional with expertise in orthopedics or sports medicine. In particular, a professional evaluation is a good idea if you are experiencing your knee giving way with pain, clicking, or catching. Shoulders also are a joint at risk for being unstable.
If you have arthritis in the lower extremity, proper shoes are a must. Your shoes should provide support as well as cushioning. Good shoes can help with minor alignment problems, whereas worn shoes can turn minor problems into major discomfort.
Q&A
What type of shoes are recommended?
The right shoes can have a major impact on your enjoyment of exercise. A good shoe does not have to be the most expensive. These are some qualities to look for in a shoe:
· A sole that provides shock absorption and cushioning.
· Good arch support.
· A roomy toe box that accommodates toe deformities.
· A snug fit along the width of the shoe, especially in the heel counter. When purchasing, walk or jog around the store in the shoes—the heels should not slip.
· Secure closure. Lace-up is preferable, but Velcro may be necessary if you have trouble managing laces because of arthritis in your hands.
· A design appropriate for the activity.
Also, if you have orthotics, be sure to bring them along when you shop for shoes so you can try them in the shoes before making your purchase.
Physical Activity Recommendations
Exercise comes in many forms, and you should tailor your program to your current health status. A complete exercise program includes aerobic activities, resistance training, flexibility, and neuromotor training.
For the primary components of aerobic and muscular fitness, you can safely set up a program following the Physical Activity Guidelines as endorsed by the ACSM and as described in chapters 5 and 6 (3). If walking is difficult, biking is an excellent alternative that can be very effective (24). You will require more flexibility activities than in a typical program (as described in chapter 7); depending on the severity of your arthritis, you should do range of motion activities on a daily basis, and perhaps several times a day.
Aerobic Exercise
Aerobic fitness is often lower in people with arthritis than in those of the same age without arthritis. Much of this is likely due to decreased activity. Furthermore, some of the systemic forms of arthritis such as RA bring a higher risk of heart disease, implying that aerobic activity is important to help to reduce the cardiac disease risk. Not only does aerobic exercise improve circulation to the muscles and joints, but also the rhythmic nature of the activities helps lubricate joints and provides nutrition to the joints, thereby decreasing pain. Aerobic exercise is one of the easiest ways to reduce the stiffness associated with arthritis. You can safely follow the guidelines for aerobic activity outlined in chapter 5, though you may want to make a few modifications (3).
If you have not been doing much physical activity, you should start at a lower intensity (e.g., two to three 10-minute sessions a day) until your joints get used to the increased activity. This will also allow you to develop your lower extremity (thigh and leg) strength before engaging in higher-intensity or longer-duration sessions. Increased strength helps absorb forces around your joints, such as the knees, which should help decrease the stress through the joint and the pain.
Although walking is often the easiest and most functional aerobic activity, if you are a runner, there is no reason to give up running. Running does not increase the speed of joint breakdown; many regular runners report less pain with regular training. If you have severe joint instability (the sensation of the knee giving way or buckling), you might want to start with cycling or pool activities until you can decrease the instability. Some exercise ideas to address joint instability appear at the end of this chapter.
Q&A
Does running cause arthritis?
Although running affects joints more than walking does, scientists have not found evidence that links running, in itself, with arthritis. Actually, moderate levels of running may decrease the symptoms and loss of function associated with arthritis compared to being inactive.
If your arthritis is more advanced and you have access to a pool, aquatic activities are an option to consider, although the cardiovascular benefits are not as good as with land exercises (11). The buoyancy helps to unload your weight-bearing joints and allows you to work on joint motion as well. Because the shoulder joint is less stable, if you have arthritis in your shoulders, you should start shoulder stability exercises before swimming. Water activities in general are great for arthritis, but not everyone with arthritis in the shoulders tolerates swimming laps.
Aquatic activities are an excellent option for individuals with arthritis.
If you prefer group activities, many facilities have special classes for people with arthritis. Such classes may not be rigorous enough to build aerobic fitness, but they may be good for alternate training days. Tai chi can help improve lower extremity strength, improve flexibility, and provide some aerobic benefits (18). Aquatic classes are another alternative, especially if you are looking for activities with reduced weight bearing. Other group aerobic classes can be good as long as you make sure to modify movements that seem to stress your involved joint(s) and start at an appropriate intensity based on your level of fitness.
Warm-up activities are particularly important for people with arthritis, especially those who are very stiff. Before your exercise session, loosen up the joints and muscles that are stiff. A good way to warm up is to do some gentle rhythmic activities, starting with small movements and increasing the range of the movements as you loosen up. The objective is controlled movement with a slowly increasing range of motion.
Resistance Training
Resistance training may be one of the most important fitness activities you can do to reduce symptoms and protect your joints (5, 13). When there is pain around a joint such as your knee, the nervous system can also inhibit muscle contraction. For many, this results in a knee buckling unexpectedly, usually secondary to pain. After starting a strengthening routine, people with this concern have less pain and fewer problems with their knees giving way. Some have found that strengthening alone does not decrease their joint instability. In such instances, combining strengthening with some balance and movement activities has proven effective (14, 32).
You can safely follow the guidelines for resistance training outlined in chapter 6. A program of two to three days per week that emphasizes the major muscle groups is appropriate (3). Start at a lower level of exertion and gradually work up to a moderate level in order to allow your body time to adapt. A resistance that allows you to do one set of 10 to 15 repetitions in a controlled manner is a good start and is adequate for obtaining some strength benefits.
If you prefer to exercise at home, you can start with a few dumbbells and cuff weights or use resistance bands. Many resistance bands have handgrips and cuffs so you can do upper or lower extremity exercises (see figure 17.1 for an example of a shoulder-strengthening exercise using a resistance band). Resistance bands allow you to progress the resistance with the use of different densities of tubing (see chapter 6 for more information).
Figure 17.1 A shoulder-strengthening exercise using a resistance band.
You can also do resistance training without equipment by simply using your own body weight. For example, the wall sit, as shown in figure 17.2, is an easy way to strengthen the front of the thigh, or the quadriceps. This exercise decreases the amount of pressure on the knee while still working the muscle. Stronger quadriceps can help distribute forces that are being transmitted through the knee and also improve function, such as going up and down stairs. You can do the wall sit as a timed activity by holding the position for 15 seconds, returning to an upright stance, and then repeating three to five times (progressing the time as you get stronger). You can also do repetitions by using a towel (something that will allow your body to slide up and down against the wall) or a ball behind your back. Another way to increase the resistance is to use tubing with a partial squat.
Figure 17.2 Wall sit for strengthening the quadriceps (thighs).
Flexibility
Joint motion is usually lost as arthritis progresses, but regular stretching and range of motion activities can help slow this loss. Furthermore, if you do not move an involved joint, you may lose joint motion more quickly, with an associated increase in pain. Flexibility and joint range of motion can be restored if the loss is temporary, but the longer the impairment lasts, the more difficult it will be to regain your motion. Regular motion of each joint decreases the stiffness and associated pain. Although the typical recommendation is to do flexibility exercises three days per week, you will benefit from daily stretching and range of motion activities (3, 27).
Stretching focuses on increasing the extensibility of tight muscles. Stretching techniques include static and dynamic, as well as those that use assistive devices. You can use any of these safely as long as you follow a few guidelines. You should never hold a stretch that is causing increased pain; rather, stretching should be gentle. Because arthritis can cause laxity in a joint, you should not stretch beyond what is considered normal for that joint. Several factors can affect your response to stretching. With age, muscles tend to lose elasticity, which means that the tissues do not respond as easily to stretching even though much of a stretching response is neural (i.e., nervous system control of the resting tension in the muscle).
You can improve the response to stretching by warming your muscles, which improves elasticity. You can do this by increasing the blood flow to a muscle with a repetitive activity or by using external heat. Some people find that an elastic support not only provides a sense of stability to an affected joint but also helps to keep the joint warm.
Staying hydrated is also important, because dehydration decreases the elasticity of your muscles. The use of a prolonged stretch (several minutes) may be helpful if you are extremely tight—just make sure to find a comfortable, supported position. For example, if you have tight hamstrings, you might lie on the floor with one foot on a wall (see figure 17.3). You should find a position that puts a gentle but tolerable stretch on the hamstring.
Figure 17.3 Hamstring stretch using a wall.
Range of motion is simply moving a joint through its entire range without holding it at any one position. This type of activity may be even more important than stretching because you can use it to prevent loss of motion and throughout the day to decrease stiffness. You should be moving every joint through its full range every day. If a joint stiffens with sitting or lack of activity, simply moving that joint through its range a few times helps to decrease the pain and stiffness. For example, if you work at a desk and have arthritis in your knees, you might slide your feet back and forth (moving the knees) in the middle of a long session of work. Five to 10 repetitions will help to lubricate the joint and prevent discomfort. Most aquatic classes emphasize joint motion in the comfort of the water; thus they are a nice way to work on flexibility. Yoga and tai chi are popular activities that are beneficial for improving flexibility and have the added benefit of improving balance (8, 18).
Neuromotor Training
A typical result of arthritis is the loss of proprioception, which is the feedback to the brain regarding joint position and motion. This loss also contributes to the instability noted earlier. You will need to do some specific activities to address the problem. Neuromotor training addresses joint proprioception and includes agility, balance, and other types of activities that stimulate feedback between the muscles and the brain (15).
Although general guidelines suggest two to three days per week, you will benefit from a more frequent program of five to seven days per week (3, 14). Tai chi is an excellent activity to train the connection between the nervous system and the muscles; it addresses all of the necessary components (18). Tai chi focuses on slow, controlled movements throughout the range of motion with limited impact on the lower extremities. Tai chi decreases pain, improves function, and has the side benefit of relaxation. If you don’t want to take a class, you may elect to get a DVD and participate in the comfort of your home. Some people like starting their day with tai chi because it helps reduce morning stiffness. Yoga has also been shown to improve function and balance (8).
You can also design your own neuromuscular training program (14). Because this is the most distinctive component of the training program, a sample is provided in figure 17.4, which includes both land- and water-based activities. Note that if your knees give way frequently, you might want to start balance and agility activities in the pool to remove the influence of gravity on the joint and decrease the chance of the knee buckling while doing the activity. Furthermore, if the knee does give way, you are protected by the water against falling. Once you are not having pain with the activities and can do them without your knees giving way, you can progress to land activities or alternate between water- and land-based activities.
Influence of Medications
Acetaminophen is recommended for people with mild to moderate pain due to arthritis. The most common, though still rare, side effects are upper gastrointestinal (GI) bleeding and liver damage. Nonsteroidal anti-inflammatories (NSAIDs) are the next type of medication taken to help control the pain of arthritis. The strength ranges from medications that are available over the counter (aspirin and ibuprofen) to stronger forms that require a prescription and have different modes of action within the body. As with acetaminophen, GI bleeding is a possible side effect. Naproxen sodium also has the potential of raising blood pressure and lower extremity swelling. Some of the prescription anti-inflammatories have a decreased risk of GI bleeding but may have some cardiovascular-related risks (20).
If you have a systemic form of arthritis, you are likely to be on a disease-modifying antirheumatic drug (DMARD), glucocorticoid (steroid), or biologic drug (2). Possible side effects include liver and kidney damage and, with the steroids, a risk for infections. On the positive side, these drugs are the most effective for pain relief and for slowing the associated joint deterioration. Because these drugs affect the immune system, you may need to slightly decrease the intensity of your program. A summary of the benefits and possible side effects of common arthritis medications is presented in table 17.1.
Influence of Supplements
A few nutritional supplements have been shown to decrease the pain associated with arthritis. A positive aspect of these supplements is that they do not have the health risks associated with some of the medications. For this reason, they could be worth trying. When considering use of various supplements, it is recommended that you check with your health care provider regarding your particular situation. This section discusses glucosamine and chondroitin, fish oil, flaxseed, and antioxidants. Although other supplements have been identified in the popular literature, the research is still lacking on many. See Potentially Risky Supplements to Watch Out For to read about supplements that you may want to avoid.
Potentially Risky Supplements to Watch Out For
Dietary supplements are not tested as rigorously as medicines are and thus may have harmful effects. They are not necessarily labeled properly, and they may interact with medications you take. Some have been linked to heart irregularities, increases in blood pressure, seizures, and even death. Steer clear of the following risky substances:
· Ephedrine or ephedra (used in weight loss or energy supplements)
· Kava (purported to produce relaxation and reduce sleeplessness)
· Prohormones or herbal anabolic supplements, such as androstenedione or yohimbine
Even vitamins and minerals can be toxic if taken in excessive quantities. Consider the following:
· Vitamins B6 and B12 can cause liver damage.
· Vitamin C can cause stomach upset and interfere with copper and iron status.
Check with a knowledgeable person who is qualified to give you information about a supplement before you try it, such as a physician, pharmacist, or Registered Dietitian.
Also, the National Institute of Health’s Office of Dietary Supplements provides summaries of many supplements at http://ods.od.nih.gov/HealthInformation/makingdecisions.sec.aspx.
One of the most common nutritional supplement therapies is a combination of glucosamine and chondroitin. These compounds are normally found in body tissues, and it is thought that increased levels might protect and even improve the joint cartilage. Although the advertised promises are overwhelmingly positive, the research findings are varied. Some studies have shown decreased pain for those with OA, whereas others have not shown any benefit (25). Some of the studies reporting positive effects used supplements in addition to glucosamine and chondroitin, such as manganese ascorbate (a compound formed from ascorbic acid, or vitamin C, and the mineral magnesium) (19, 28). Typical daily dosage recommendations are 1,500 milligrams for glucosamine and 1,200 milligrams for chondroitin. Benefits are typically seen within a few weeks and may be related to the severity of the arthritis and your body’s ability to respond to the supplement.
Fish oil, which contains omega-3 fatty acids, has been shown to reduce the pain associated with arthritis (19, 30). In several studies people were able to reduce the amount of NSAIDs or other medications they were taking when they consumed fish oil. Another positive side benefit of fish oil may be a reduced risk for heart disease and reductions in blood pressure that are associated with omega-3 fatty acids. The primary side effect is GI discomfort, which one can address by reducing the dosage and taking the supplement with foods. The recommended daily dosage varies between 3 and 8 grams per day, usually divided into two or three doses (2.6 grams two times per day for RA).
Flaxseed contains both omega-3 and omega-6 fatty acids, but research related to arthritis has been limited, and there are some side effects. Flaxseed can alter the absorption of some medications and thins the blood, so you should check with your physician if you are considering this supplement.
Newer research has looked at the use of other antioxidants that can be found in different types of foods (12). Cherry juice has been shown to decrease inflammatory markers in the blood for some individuals (23). Supplementation of vitamin C (ascorbate) or vitamin E (α-tocopherol) reduced the progression of OA and had anti-inflammatory effects (31).
Exercise is important for people with arthritis. A balanced exercise program that includes aerobic activities, resistance training, stretching, and neuromuscular training (i.e., balance and agility) can help you maintain normal function. Medications used for arthritis can have side effects in addition to the intended benefits. Exercising may allow you to reduce the amount of medication you take to control pain. Although supplements are widely advertised, few have proven to be beneficial. Some people benefit from a combination therapy of glucosamine and chondroitin or from fish oil (omega-3 fatty acids). In addition to physical activity, a healthy diet helps to maintain an appropriate body weight; overweight and obesity are concerns related to risk of developing arthritis as well as the pain associated with arthritis.