Arthritis and seniors and exercise and back pain
The disease process can affect many joints, with the weight-bearing joints—knees, hips, and spine--most often involved. Degeneration of articular cartilage appears to be the primary event, accompanied by secondary changes around the affected joint, such as muscle weakness and the growth of new bone, with resultant loss of mobility and function. Generalized immobility is a frequent result of 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 the reduced production of proteoglycans in the cartilage within the affected joint, appear to accelerate the disease process itself. But other effects are global: declines in aerobic fitness and functional capacity. Osteoarthritis and inactivity together lead to a vicious cycle: 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 the disease, would logically seem to be a treatment of choice in this condition. Research has shown exercise to be beneficial in several ways, helping osteoarthritic joints both directly and indirectly, and improving patients' overall functioning. Among the direct effects are increased mobility of the joints and greater strength of the muscles that support and protect the joint, ameliorating pain and stiffness. Regular exercise has been associated with significant declines in joint swelling caused by arthritis. These improvements should not be surprising, in view of the known effects of physical activity on joint physiology. Lacking blood vessels and nerves, the articular cartilage of the joint surface is nourished only by the diffusion of joint fluid through the cartilage matrix, a process that is driven mechanically. Movement of the joint is necessary to ensure proper nourishment and maintain integrity of the cartilage. Loading pressures within the physiologic range increase 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 the osteoarthritic joint forces it to work at a biomechanical disadvantage, which in turn promotes fatigue and increases mechanical stress. Stretching and active and passive range-of-motion exercise are highly beneficial in improving or maintaining mobility and circumventing this process. Resistance training to strengthen muscle around affected joints protects and stabilizes the joint, improving shock absorption and reducing stresses 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, strength training (of lower body musculature in particular) 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 symptoms, 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 on functional capacity cut across exercise type, that is, the kind of exercise is less important than the fact of exercise per se. In the Fitness Arthritis and Seniors Trial , 439 adults with radiographically confirmed 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. Exercise that subjects joints to abnormal stress, however, 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 weight of data suggests that in the absence of joint abnormalities, physical activity that remains within the limits of comfort and normal range of motion does not lead to joint injury. Given the formidable base of research, it should come as no surprise that the guidelines for the treatment for knee arthritis (and this can probably extrapolated to other areas of OA involvement) 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. One might go further and propose that exercise of some sort, whether it is limited to a single involved joint or extends to a balanced, overall program for general fitness, should have a role in treating virtually every patient who has OA. The exercise prescription should have four aims: cardiovascular conditioning, improvements in strength, added flexibility, and increased joint mobility. As with healthy individuals, 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 orthopedic complications and encourages compliance. The reduced cardiovascular risk may also be a consideration. A workout on a stationary exercise bicycle may be ideal. When disease of weight-bearing joints is severe, swimming or water exercise has proven an excellent choice. 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 must be matched to the patient's capacity. A seriously deconditioned individual may well start with walking sessions of 5 minutes or less, lengthened by no more than 10% per week. Patients may be more accepting of 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. This has important implications in getting sedentary individuals motivated to become more active. Strength training should work major muscle groups of the whole body, not only those that support affected joints. Muscles respond when given a load higher than accustomed, and any number of means may be used to this end: ankle weights and dumbbells, calisthenics, and simple devices constructed with elastic tubing, as well as more sophisticated machines. Patients can benefit without enrolling in a gym or spending heavily on equipment. 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. Exercises to strengthen the muscles surrounding affected joints, however, are typically lighter, at least in the early stages, and in many cases--especially when there is extreme weakness or low exercise tolerance--may be prescribed every day. It is never too late to strengthen muscle. 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 front of 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 particularly 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. These may require heat, ice, or other physical therapy modalities or assistance, at least in early stages. With severe joint involvement, gains may be slow. However, preventing further motion loss can be helpful. Forceful maneuvers must be avoided. It is always important to keep individual impairments in mind, and to modify specific exercises accordingly. Strength and Flexibility Training Guidelines for Older Patients
1. Start with a gentle warm-up. A 5- to 10-minute walk with active arm swinging can be effective. Stretch your major muscles, like legs and back, for 5 to 10 minutes after the warm-up. Your healthcare provider can give you handouts or a list of resources to guide you.
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