Arthritis and seniors and exercise and back pain
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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Arthritis is the most common cause of disability in the United States, and osteoarthritis (OA) the most common kind of arthritis.
While the cause of the disease remains controversial, its prevalence increases with age. Among older individuals, symptomatic OA is extremely common, affecting an estimated one third of those at least 60 years of age or older.
The disease process tends to affect mostly weight-bearing joints—knees, hips, and spine. Degeneration of cartilage accompanied by synovial inflammation appears to be the primary event, accompanied by secondary changes around the affected joint, such as muscle weakness and the growth of new bone, osteophytes, with resultant loss of mobility and function.
Generalized immobility is the end result of long-standing OA. Pain leads to a reduced level of activity and the disability associated with the disease is largely an outcome of this process.
Some consequences of inactivity, including loss of muscle strength and reduced production of proteoglycans in the cartilage, appear to accelerate the disease process. But other effects are more global including declines in aerobic fitness and functional capacity.
Reduced mobility increases the risk of weight gain (which in itself can accelerate OA of weight-bearing joints and worsen symptoms). Ultimately, patients are likely to become less independent and more socially isolated.
Here's the conundrum: The less the joint is used, the weaker and stiffer it grows, the more overall aerobic capacity declines, and the more resistant the patient becomes to increasing activity. A well-designed program of exercise, applied as early as possible in the course of OA, would seem to be a treatment of choice for this condition.
Research has shown exercise to be beneficial in several ways, helping patients with osteoarthritis with mobility and strength, and improving overall functioning.
Because articular cartilage lacks both a nerve as well as blood supply, it receives nourishment by the diffusion of joint fluid through the cartilage matrix, a process that is driven mechanically. Movement of the joint is critical to ensuring proper nourishment and maintain integrity of the cartilage.
Physiologic loading of the joint increases the rate of proteoglycan synthesis by mature cartilage cells, and inactivity decreases it. Clinically, mobilization is known to accelerate joint healing after trauma or surgery, whereas immobilization interferes with the healing process.
Loss of mobility in an osteoarthritic joint makes it work at a biomechanical disadvantage. This leads to fatigue and increases mechanical stress on the joint. Stretching and active and passive range-of-motion exercise are key to maintaining mobility and abrogating this process.
Resistance training protects and stabilizes the joint, improving shock absorption and reducing mechanical stress that can accelerate cartilage degeneration.
Exercise may protect osteoarthritic joints indirectly by helping control body weight. OA progresses more rapidly in overweight individuals. Researchers have consistently identified obesity as a risk factor for OA of weight-bearing joints. In addition, fat cells produce inflammatory cytokines (leptins)thereby aggravating arthritis through both mechanical as well as inflammatory processes.
In addition, strength training may play a key role in maintaining functional capacity in older persons.
Aerobic exercise for patients with OA has been shown to improve cardiovascular fitness, reduce pain, and improve functional capacity. One study found that 12 weeks of aerobic-level walking or aquatic exercise significantly improved exercise capacity and mood. The aerobic gains were maintained at 9-month follow-up, and improvements in flexibility and grip strength were also manifest at that time.
At least one recent study suggested that beneficial effects in functional capacity occur with all exercise types, that is, the kind of exercise is less important than the fact that a person exercises at all. In the Fitness Arthritis and Seniors Trial , 439 adults with x-ray evidence of OA of the knee, pain, and physical disability were randomized to a program of aerobic exercise, resistance exercise, or health education. Three hundred sixty-five participants completed the 18-month trial. Those in the exercise groups showed modest but significant improvements in tests of physical performance (climbing and descending stairs, lifting and carrying 10 lb, getting in and out of cars), compared with the health-education group. They scored lower (better) on assessments of physical disability and self-reported knee pain. While this study looked at patients with OA of the knee, an argument could be made that these results may be valid for patients who have OA involving other areas.
On the flip side, exercise that stresses joints abnormally hard has been linked to OA. In a survey of 117 former elite athletes, ages 45 to 68, OA of the knee was more prevalent in former soccer players and weight lifters than in runners or shooters. The authors speculated that the difference might reflect the deleterious effects of knee injuries (in soccer players) and high body mass (in weight lifters).
Overall, the data suggests that in the absence of joint abnormalities, physical activity that remains within the limits of normal range of motion should not lead to joint injury.
It should come as no surprise that the guidelines for the treatment for knee arthritis recently published by the American College of Rheumatology advocate exercise as part of initial management. Also, the American Academy of Orthopaedic Surgeons, as part of its "Keep Moving for Life" program, recommends exercise as part of the overall treatment strategy for arthritis.
The exercise prescription should have four aims: cardiovascular conditioning, improvements in strength, enhanced flexibility, and increased joint mobility.
Aerobic exercise should aim to increase heart rate to the training range, ie, 60% to 80% of maximum, and keep it there for 30 minutes, at least three times a week. Low-impact exercise is generally best because it entails less risk of joint damage. Examples would be a stationary bike or swimming.
In one study, patients with OA or rheumatoid arthritis improved equally with water-based aerobics and walking. The pool group had fewer sore and swollen joints and less morning stiffness.
Aerobic exercise should be matched to the patient's capacity. A seriously de-conditioned individual should start with walking sessions of 5 minutes or less, lengthened by no more than 10% per week. Patients may tolerate an exercise program if workouts are divided into short sessions. It has been found that three 10-minute aerobic sessions seem to be as effective in improving fitness and health risk profiles as a single 30-minute session.
Strength training should work major muscle groups of the whole body, not only those that support affected joints. Muscles respond when given a load greater than accustomed.
Whole-body strength training should be done at least twice a week, but no more than four times: a day must be allowed for recovery between sessions. One study showed significant strength and function gains in 90- and even 100-year-old nursing home residents.
Stretching exercises for flexibility can safely be done every day. These should target all the major muscle groups, with particular attention to the calves, hamstrings, lower back, and the shoulders--the muscle groups that most commonly lose flexibility with age. Initially tight muscle groups may require special attention.
Joints affected by osteoarthritis require range-of-motion exercises. Stretching and range-of-motion exercises are especially helpful when limited motion is the result of tightened muscles, tendons, and capsular structures.
Range-of-motion exercises can restore or increase mobility of affected joints beyond the results of simple stretching.
The exercise prescription for OA should be flexible, geared to the individual's capacity and modified for his or her specific deficits. With older, de-conditioned patients particularly, the program should begin at a very low level of intensity, progressing as the patient improves to maintain a level that balances challenge and comfort.
It is always important to keep individual impairments in mind, and to modify specific exercises accordingly.
Strength and Flexibility Training for Older Patients
1.Begin with a gentle warm-up to increase the heart rate and breathing. A 5- to 10-minute walk is effective. Stretch major muscles, like legs and back, for 5 to 10 minutes after the warm-up.
2.Concentrate on working large muscle groups such as the quadriceps (thighs), gluteus muscles (buttocks), hamstrings, hip muscles, deltoids (shoulders), biceps, triceps, back, and abdominal muscles. Standing up from a chair with arm rests using the arms and legs is a good way to work many of these muscles. Repeat this 12 to 15 times. Work up to two to three sets of these. Using these large muscle groups burns many more calories.
3.Dumbbells are an alternative. Use light weights that can be lifted 12 to 15 times with moderate exertion. Make sure to breathe. When that amount of weight becomes easy, increase the weight slightly, but keep the number of repetitions the same, between 12 to 15. Lift the weight slowly in 2 seconds and gently lower it in 4 seconds, working the muscles through the normal range of motion.
4.Rest for 1 to 2 seconds between repetitions and 1 to 2 minutes between sets of exercises. Eventually work up to two to three sets of each exercise.
5.Allow 1 to 2 days' rest between workouts so that muscles can recover.
6.Stop immediately lie down if you experience chest pain or pressure, dizziness, abnormal heartbeats, or unusual shortness of breath. Call 911 if the symptoms don;t go away within a minute or two.
7.Yoga is an excellent method of stretching.
8.Drink plenty of fluids during your workout.
9.Don't skip the post-exercise stretching.
The other principal therapies for OA such as weight loss, medication, surgery, and physical therapy, should be coordinated with exercise for best results.
Recent evidence suggests that OA worsens more rapidly in overweight individuals. Also, stress on weight-bearing joints decreases significantly with weight loss: even small reductions make a big difference.
Timing of analgesics and anti-inflammatory drugs can help patients get through exercise sessions more comfortably, and in some instances will help control joint inflammation.
Some patients need physical therapy to get them started with an exercise program. The ultimate goal, of course, is to have the patient exercise at home.
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