ARTHRITIS AND EXERCISE EXERCISE REFERRAL CPD Pure Training and Development © 2014

ARTHRITIS AND EXERCISE

EXERCISE REFERRAL CPD

Pure Training and Development © 2014

Tutor – Who am I?

COPYRIGHT © PURE TRAINING AND DEVELOPMENT

• Emma Howard• Creator of these workshops and seminars • 5 years experience in Exercise Referral Industry

• Passionate about improving the health and wellbeing of your community

Learner Support

• Home study does not mean no support

• Please call us on 03302231302

• Email us on

[email protected]

• If you would like this training in a different format

please contact us


mailto:[email protected]

Learning Objectives

• Explore the aetiology and pathophysiology of osteoarthritis and rheumatoid arthritis

• Understand the recent prevalence statistics of arthritis in the UK

• Identify the benefits of physical activity and exercise in management of the condition

• Identify an exercise prescription framework• Recognise and apply health and safety considerations


Let’s get ready

Pure Training and Development © 2014

AETIOLOGY & PATHOPHYSIOLOGYof Arthritis


Do you know the key differences between OA and RA?


On a piece of paper bullet point the key things you remember about OA and RA.

You have 1 minute….

Aetiology & Pathophysiology

• There are over 200 conditions which fall under the ‘arthritis’ category (Buckley, 2008; Arthritis Care, 2014)

• Most common two explored during this workshop:• Osteoarthritis and rheumatoid arthritis • Each person is affected in a unique way• Around 10 million people suffering in the UK (Arthritis

Care, 2014)

• 8.75 million suffer with osteoarthritis • 400,000 people suffer with rheumatoid arthritis


Aetiology & Pathophysiology

• The cost of musculoskeletal conditions on NHS is £5 billion (Right Care, 2011 & DoH, 2011)

• Fourth largest budget spend for NHS• Projected to be a 50% increase in arthritis by

2030 (HL Select Committee, 2013)


• Common in older population• Injury, inactivity or genetic predisposition can

also have a role• Functional limitations and reduced quality of

life• Osteoarthritis is a non-inflammatory condition• No cure but condition can be managed


Pathophysiology of Osteoarthritis

• Cartilage acts as a shock absorber and mould• Enables smooth movement of bones • Starts with progressive loss of articular cartilage• Degenerative condition of the joints• Bone becomes exposed • Surfaces become rough and thin



www.interactive-biology.com



www.interactive-biology.comImages taken from for illustration purposes: www.hightimes.com

• Movement becomes restricted and painful• Impact bearing properties are diminished• Body compensates by changing shape, thickening

and growth spurs (osteophytes)• New bone remodelling causes osteophytosis,

subchondral sclerosis (thickening) and synovitis (inflammation of synovium) and thickening of capsule

• All contributes to joint crepitus and pain • Inflammation of joint membrane



Osteoarthritis Image


Arthritis Research UK



Arthritis Research UK

• Condition can occur with and without symptoms of pain and weakness

• Can affect any joint in the body• Commonly affects hips, knees, spine and

hands• Changes occur to the entire joint, not just the

cartilage and bone• Observed physical changes occur





• Inflammation not traditionally associated with OA but is a frequent symptom – could suggest local inflammation (Wenham & Conagham, 2010; Pelletier et al, 2001)

• Muscle wastage occurs• Connective tissues, tendons and ligaments

become tight • Results in reduced range of movement

Buckley (2008)



• Discomfort

• Pain

• Stiffness

• Swelling

• Decreased range of motion

• Physical changes


Symptoms of Osteoarthritis

• Pain relievers such as paracetamol • NSAID/Corticosteroids – aim to reduce swelling

and pain

Side effects:• Gastrointestinal problems• Potential asthma attacks for asthmatics• Addiction


Osteoarthritis - Medications

Break TimeTake a 10-15 minute break.


• Approximately 400,000 people in UK with rheumatoid arthritis (RA) (NICE, 2008)

• Cause is not fully known• Auto immune disease • Causes chronic inflammation of synovial

membrane • Antibodies from immune system attack bodily

tissues• Systemic condition as it also affects organs


Pathophysiology of Rheumatoid Arthritis

• Tends to affect smaller joints• Hands, fingers and toes

• Chronic inflammation can attack ligaments, cartilage, tendons, bones

• Swelling, pain, stiffness and can be deformed • Synovial membrane thickens to heal itself • Joint swells as synovial fluid accumulates





Arthritis Research UK 2014







• Flare ups and remissions• Pain• Inflammation• Damage to joint tissues• Fever • Joint deformity • Limited ROM • Symptoms during a flare up include:

• Fatigue• Loss of appetite • Muscle aches fever• Red, swollen and painful joints


Symptoms of Rheumatoid Arthritis

• NSAID/Corticosteroids – aim to reduce swelling and pain

Side effects:• Gastrointestinal problems• Potential asthma attacks for asthmatics• Risk of osteoporosis


Rheumatoid Arthritis - Medications

• Over 100 types of arthritis • Gout • Ankylosing spondylitis • Cervical spondylosis

Recommended to complete further reading on these conditions.


Other Forms of Arthritis

Exercise in the Management of the Conditions


Highlighted Statement

Exercise* should be a core treatment for people with osteoarthritis, irrespective of

age, comorbidity, pain severity and disability.

Exercise should include:• Local muscle strengthening• General aerobic fitness

NICE (2008)


• Decrease joint pain and stiffness.• Improve or maintain joint motion.• Decrease the risk of cardiovascular disease

(higher in those with rheumatoid arthritis).• Improve ability to do activities of daily living

(i.e. access in and out of car or going up and down stairs)

• Decrease disease activity ACSM (2008)

Physical Activity Benefits


• Better pain management• Increase muscular strength• Develop stronger bones – which can help protect

against osteoporosis• Maintain control of weight• Improved balance and co-ordination• Reduced stress• Improved sleep patterns• Increased energy levels• Better breathing• Improved self-esteem. Arthritis Care (2014)

Physical Activity Benefits


Physical Activity for Arthritis

• Low activity levels consistently identified as key parameter associated with musculoskeletal disorders (Minor & Kay, 2003).

• NICE (2008) state exercise should be a core treatment irrespective of age, comorbidity, pain severity and disability

• Also offer weight loss (NICE, 2008)

• Use suitable footwear


• According to NICE (2008) exercise and PA should be targeted at the affected joints.

• Exercise should include local muscle strengthening and aerobic fitness

• Exercise should be individualised for the client based on their needs, circumstances and motivations.

• Also need to change health behaviour


Osteoarthritis & Exercise

• 12 weeks of progressive resistance training exercise reduced pain, improved strength and function for females for OA of knee (Jorge et al, 2014).

• A review suggested ‘aerobic, strengthening, aquatic and Tai chi exercise are beneficial for improving pain and function in people with OA with benefits seen across the range of disease severities’ (Bennell et al, 2011)

• A review suggested that muscle strengthening and aerobic exercises are effective in reducing pain and improving physical function in patients with mild to moderate OA of the knee (Iwamoto et al, 2011)


Osteoarthritis & Exercise - Evidence

• Exercise improves overall function for those with RA without detrimental effects to disease activity (Cooney et al, 2011).

• Resistance training RA is safe according to a meta analysis (Baillet et al, 2011)

• Be aware of the degree of joint deformity • Start with low intensity exercises and progress

slowly


Rheumatoid Arthritis & Exercise – Evidence

• People with Arthritis Can Exercise (PACE)• Developed by Arthritis Foundation in America

PHYSICAL ACTIVITYManagement of Condition


Barriers


• External influences/ previous advice• Pain • Speed joint breakdown/wears joint down• Psychological concerns• Excess weight • Experienced exacerbating symptoms and

stopped/been put off• Understanding the benefits

Psychological Aspect


• Fear largely contributes to lack of exercise• Misunderstanding about further damage• Motivation is key – use SMART goals• Find an enjoyable form of exercise

• RA can be disabling and impact life and work• Depression, anxiety and lack of motivation

Break TimeTake a 10-15 minute break.


Exercise Prescription


Exercise PrescriptionKey Objectives

• Improve joint range of motion • Improve quality of life • Increase muscular strength • Increase balance and co-ordination• Decrease excess body fat (where applicable) • Change health behaviour with education and

advice


• Exercise should include local muscle strengthening and general aerobic fitness

• Also offer weight loss• Use suitable footwear (arch support and

cushioning) Nice (2008)



Warm Up• Slow and gradual• Pulse raising and mobility • Seated if balance is affected• Dynamic stretches



Main Workout• Train unaffected joints for CV • Choose smooth and rhythmic exercises

Cool Down:• Seated or lying for some stretches




Exercise PrescriptionAmerican College of Sports Medicine Exercise Guidelines – osteoarthritis and rheumatoid arthritis

Cardiovascular Musculoskeletal Flexibility

Frequency 3-5 days a week 2-3 days a week Before aerobic or strength training

Intensity 60-80% MHRRPE 11-16/20

Not specified Within pain threshold

Time 5-10 mins each session building to 30 mins each session

1 or more sets of 2-3 reps building to 10 reps

Not specified

Type Large muscle activities, walking, cycling, swimming, water aerobics, dance

Circuit training, free weights, machines, bands, Pilates mat and equipment based sessions

Increase/maintain ROM

• Cardiovascular• Cycling, walking, swimming, CV machines

(NICE, 2008)

• Resistance • Machines and progress to free weights• Resistance bands

• Flexibility exercises• Hold a stretch for 5-10 secs and repeat 5-10 times

(Arthritis UK)

Exercise PrescriptionModes of Exercise


Arthritis Research UK suggest these exercises are regular examples to integrate:Knee Osteoarthritis: • Sit to stand• Quadriceps strengthening exercises• Step upsHip Osteoarthritis:• Hip abduction• Hip extension

Exercise PrescriptionExercise Ideas


Arthritis Research UK suggest these exercises are regular examples to integrate:Rheumatoid Arthritis:• Whole body exercises• Low impact aerobic exercises i.e. swimming,

walking

EXERCISE PRESCRIPTIONExercise Ideas


EXERCISE PRESCRIPTIONExercise Ideas


• Observation • Talk test• RPE

• Be aware of medication affecting their pain sensation levels

EXERCISE PRESCRIPTIONMethods of Monitoring


• Do not exercise a joint during acute flare ups• Avoid high impact exercises• Avoid over stretching the joints• Do not bounce when stretching

EXERCISE PRESCRIPTIONContraindications & Considerations


Osteoarthritis Considerations

Considerations

Programming Considerations Cautions/risks

Promote mobility - ↑ROM pain free

Side effects of medication Avoid high impacts

Promote flexibility Level of pain experienced Avoid excessive repetitions

Strengthen muscles that support affected joints

Some exercise positions may be uncomfortable (kneeling)

Avoid prolonged exercise in same position

Consider specific muscle before increasing

resistance

Ensure good supportive footwear


Rheumatoid Arthritis Considerations

Considerations

Programming Considerations Cautions/risks

Promote mobility - ↑ROM pain free

Consider previous joint damage Avoid exercise in periods of flare up

Ensure smaller joints are mobilised

Exercise later in the day to avoid morning stiffness

Avoid impact

Strengthen muscles that support affected joints

Careful selection of exercise positions

Avoid excessive repetitions

Promote flexibility Be sensitive to emotional effects of the condition

Avoid contact sports

Careful considerations of equipment if grip is affected

Avoid fast paced movements


• Arthritis UK – Keep Moving document

Exercise Advice


Summary Points• Two key forms of arthritis: OA and RA• OA is the degeneration of the joint • RA is an auto immune attack causing synovial

membrane swelling• Approximately 10 million people in UK (Arthritis Care)

• 8.75 million with OA• Programmes won’t necessarily be the same each

session • Every individual diagnosed with arthritis will be

unique and requires an individualised programme• Regular participation in exercise can improve function

and reduce painCOPYRIGHT © PURE TRAINING AND DEVELOPMENT

Summary Points• Evidence supports exercise as a form of

management for both OA and RA• Evidence supports that exercise does not cause

damage to the joints (as long as it’s safe and appropriate)

• Aerobic exercise is 3-5 days per week, building from 5 minutes to 30 minute sessions

• Gentle, low impact exercise for shorter durations should be performed at the start

• Include resistance and flexibility components into the training programme using ACSM guidelines (2009).


• Regularly assess the client to identify safe methods of progression

• Do not exercise the area affected during a flare up

• Encourage good posture during exercise and in daily life

• Exercise has psychological benefits for the condition

• Build a rapport with your client and you will be able to work more effectively with them.

Summary Points


RECOMMENDED READING

1. Exercise and Arthritis Review – Journal of Anatomy

2. Effectiveness of exercise for osteoarthritis of the knee: A review of the literature – World Journal of orthopedics


Helpful Websites

People with Arthritis Can Exercise (PACE)• http://www.arthritis.ca/page.aspx?pid=1286

Exercises to manage pain for client• http://www.arthritisresearchuk.org/arthritis-information/exercises-to-manage-pain.aspx

Factsheets for different areas affected by arthritis• http://www.arthritiscare.org.uk/PublicationsandResources/Listedbytype/Factsheets


http://www.arthritis.ca/page.aspx?pid=1286



http://www.arthritisresearchuk.org/arthritis-information/exercises-to-manage-pain.aspx

http://www.arthritisresearchuk.org/arthritis-information/exercises-to-manage-pain.aspx

http://www.arthritiscare.org.uk/PublicationsandResources/Listedbytype/Factsheets



References• B,A., V, M., G, M., J, R and G,P. (2011). Efficacy of resistance exercises in rheumatoid arthritis:

meta analysis of randomized controlled trials. Rheumatology, 51(2), 519-527.

• Cooney, J.K., Law, RJ., Matschke, V., Lemmey, A.B., Moore, J.P., Yasmeen, A., Jones, J.G., Maddison, P and Thom, J.M. (2011). Benefits of Exercise in Rheumatoid arthritis. Journal of Aging Research.

• Wenham, C. Y. J. & Conagham, P.G. (2010). The Role of synovitis in osteoarthritis. Therapeutic Advances in Musculoskeletal Disease, 2(6), 349-359.

• Pelletier, J-P., Martel-Pelletier, J., & Abramson, S.B. (2001). Osteoarthritis, an Inflammatory Disease: Potential Implication for the Selection of New Therapeutic Targets. Arthritis & Rheumatism, 44(6), 1237-1247.

• Jorge, R.T.B., De Souza, M.C., Chiari, A., Jones, A., Fernandes, A.DR.C., Junior, I.L., Natour, J. (2014). Clinical Rehabilitation. [ahead of print].

• NICE (2008). Osteoarthritis: The care and management of osteoarthritis in adults, quick reference guide. NICE. Retrieved on January 24, 2014, from http://www.nice.org.uk/nicemedia/pdf/CG59quickrefguide.pdf

• National Collaborating Centre for Chronic Conditions. Osteoarthritis: national clinical guideline for care and management in adults. London: Royal College of Physicians, 2008.

• Right Care (2011), The NHS Atlas of Variation in Healthcare. • 4 Department of Health (2011), England level data by programme budget: 2010-11. • HL Select Committee (2013), Ready for Ageing?


http://www.nice.org.uk/nicemedia/pdf/CG59quickrefguide.pdf

http://www.nice.org.uk/nicemedia/pdf/CG59quickrefguide.pdf

Thank youfor participating in today’s training

Any Questions?

Tutor: Emma Howardt: 03302231302

e: [email protected] w: www.puretraininganddevelopment.co.uk

/PureTrainingandDevelopment @PureTraining2


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ARTHRITIS AND EXERCISE EXERCISE REFERRAL CPD Pure Training and Development © 2014