Arthritis Exercise Program

Arthritis is a chronic disease affecting an estimated 43 million (20.8%) U.S. adults and is the leading cause of disability in the United States [1]. Arthritis may result in limitations in activity, work, and decreased quality of life. Promotion of arthritis self-management through weight counseling, exercise and arthritis education can reduce pain, improve function and quality of life, and delay disability among persons with arthritis.

            Regular moderate to vigorous exercise has been shown to lower the risk of myocardial infarction, stroke, hypertension, type 2 diabetes mellitus, and osteoporosis. Recent findings also suggest that regular exercise may improve arthritis symptoms. Patient compliance is a key factor in determining outcome from exercise therapy [2]. Although it appears that supervised exercise sessions are superior to home exercise, a home program is a relatively cost effective method of improving pain and disability. As you undertake your fitness program, it's important to remember that fitness is an individual quality that varies from person to person. It is influenced by age, sex, heredity, personal habits, exercise and eating practices. You can not do anything about the first three factors. However, it is within your power to change and improve the others where needed.

In general, healthy individuals may exercise without supervision. However, prior to beginning any exercise program patients should visit their primary care physician for a physical examination and laboratory studies to prevent injuries or complications.

How often, how long and how hard you exercise, and what kinds of exercises you do should be determined by what you are trying to accomplish. Different types of exercise have different effects; thus an individual approach to exercise is best. Traditionally, muscle strengthening was a key component of exercise. However the effectiveness of joint specific strengthening is maximized when combined with stretching and aerobic exercises including walking programs and aquatic exercise.

Patients with arthritis often report pain, muscle weakness, stiffness, and instability, as well as reduced physical functioning. In order to safely improve these symptoms your exercise program should include a warm up, muscle strengthening, cardio respiratory endurance, flexibility exercises and a cool down period. By beginning each session with a warm up and ending with a cool down you may reduce muscle soreness and prevent injury.

A good initial area of interest when starting an exercise program is agility and balance. Having good balance is important in performing activities of daily living and maintaining a mobile and independent lifestyle. Agility and balance can be improved at home by jumping in place.  Simply find a suitable place in your home where you can jump in place with both feet together alternating between touching the right and left heel in-between jumps with both feet. You will only need to jump high enough to make a comfortable transition between movements. Begin with 30 seconds and repeat, as your agility and balance improve you may increase each session. Next, practice balancing on one leg and switching legs after 10 to 15 seconds; repeat for three to five sets.

Another area of concern for many arthritis sufferers is the upper extremity. For individuals with Rheumatoid arthritis or Osteoarthritis painful hands and deformity are major concerns, a finger stretch may improve arthritis symptoms. Start by making a tight fist and holding it for 5 seconds, then open your fist and stretch your fingers as far as possible [3]. You may repeat the procedure three to five times. Finger strength may be improved by holding a rubber ball in the hand to be treated; alternately squeezing the ball between your thumb and little finger, and thumb and ring finger, thumb and middle finger, thumb and index finger [3]. Finally squeeze the ball with all of your fingers holding for 3 to 5 seconds; repeat the sequence three to five times [3].  Next, a wrist stretch may improve flexibility and strengthen both the muscles that flex the wrist and extend the wrist. Wrist extension is done by positioning the stretching hand, palm up and fingers pointing away from you. With your other hand, overlap fingers and wrap your thumb behind fingers of the stretching hand. Gently apply pressure so that the wrist and fingers are extended. Perform 3-5 repetitions for 10-15 seconds on each wrist. To perform wrist flexion the stretching hand should be in a flexed position (fingers pointing down). Next, place your other hand against the knuckles and gently apply pressure so the wrist is flexed further. Perform 3-5 repetitions for 10-15 seconds on each wrist. Upper extremity strength may be improved using mechanical aids such as tension bands and dumbbells. Proper use of exercise equipment is important to prevent injury, be certain to read all instructions prior to using tension bands and dumbbells.

Other nonpharmacologic arthritis management techniques include back and chest strengthening. A fun exercise that can be performed with a partner is the seated row, this exercise targets the rhomboids, latissimus dorsi, teres major, trapezius and pectoralis -- all major back and chest muscles that assist in maintaining good posture. Begin with the individuals facing each other in a seated position and with knees slightly bent and feet pressing against one another. Next, with each person holding one end of the towel, perform the exercise by pulling the towel as if you where rowing a boat, leading with the elbow. Remember the line of resistance is anterior just below chest level. 

The shoulder shrug is another technique that may improve posture and reduce back pain. Begin by standing erect with dumbbells or water bottles held at the sides of the body. Lift the shoulders toward the head by elevating the shoulder girdle, and slightly retract the scapulae to rotate the shoulders back. Pause, and then return to the starting position. Avoid rocking or using the legs to initiate the exercise by slightly bending your knees. Repeat the exercise three to five times.

A home exercise program would not be complete without discussing the lower extremity. A good starting point is the squat which targets the gluteals, hamstrings, and quadriceps. Start by standing erect with a neutral spine and feet shoulder-width apart. Slowly lower the body, with the hips moving back as if sitting in a chair. Maintain the weight directly over the heels or mid-foot. Lower to approximately 90 degrees of knee flexion. Pause, and then slowly return to the starting position. Remember to keep the weight over the back portion of the foot rather than the toes; raise the arms to shoulder height to counterbalance. Repeat the exercise three to five times.  If you have trouble lowering your body until 90 degrees of knee flexion, consider placing a chair behind you with some pillows in the chair.  This way, you can lower your body until about 70 degrees of knee flexion (or until you feel the pillows on the chair), pause at that amount of knee flexion, and then return to starting position.  Always perform every exercise in a smooth, controlled motion.  With this exercise, concentrate on keeping your trunk stable.  Your feet should remain firmly planted on the ground, and your knees should not bend past your toes. 

The heel raise is another good exercise that targets the gastrocnemius and soleus, which are muscles that assist in flexing the ankle and raising the heel during walking. Start with feet shoulder-width apart, knees slightly bent, and engage the abdominals to help support the lower back. Plantarflex up (stand on the toes) pause, then slowly lower to the starting position.

Lastly the knee to chest technique is a great maneuver to help stretch the lower extremity and prevent cramping. Lie on your back and pull one knee to your chest. Perform 1-2 sets of 3-5 repetitions per side. Each repetition should last 15-30 seconds.

A few key points to remember, first make sure that you are adequately hydrated. This can be accomplished by consuming fluids before, during, and after exercising. Also do not forget the warm-up and cool-down phases and most importantly, if you experience chest pain, seek immediate medical assistance.  Also be sure to wear proper foot wear.  A lot of knee pain and back pain as well as foot and ankle pain could probably be avoided if people exercised with foot wear that supported their feet and ankles.  If you have arthritis, or are at risk for developing arthritis, the importance of  proper foot wear, often with orthotics, is that much more important.  Finally, remember to check with your physician before starting any exercise regimen.

Authors:  Ashley Simela, B.A., New York College of Osteopathic Medicine, Old Westbury, NY

                Ernest Simela, M.D., Long Island Jewish Medical Center, New Hyde Park, NY

References

JM Hootman, PhD, G Langmaid, CG Helmick, MD, J Bolen, PhD, I Kim, PhD, M Shih, MD, TJ Brady, PhD, J Sniezek, MD, Monitoring Progress in Arthritis Management United States and 25 States. JAMA 2003; 294(7):789-790

Bennell K, Hinman R Exercise as a treatment for osteoarthritis. Current Opinion in Rheumatorlogy 2005;17(5):634-40.

DiGiovanna E, Schiowitz S 1997. An Osteopathic Approach to Diagnosis and Treatment, 2^nd ed. Philadelphia, PA: Lippincott-Raven Publishers.

Ettinger WH, Burns R, Messier SP, Applegate W, Rejeski WR, Morgan T, et al. A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. JAMA 1997; 277:25-31.

Special thanks to Bob Cristofaro MD, and Ernest Simela, MD for their contribution to this article.