How Personal Trainers Should Train Clients with Arthritis Today

Introduction

Personal trainers play a vital role in working with clients who have arthritis. They can safely work with clients by ensuring clients have sought advice and clearance from a medical professional and that most movement is not painful. This responsibility, when executed within their scope of practice and following the objectives of this article, can make a significant difference in their clients’ lives.

1. Arthritis pathophysiology
2. Effects of exercise
3. Exercise response
4. Effects of exercise testing
5. Recommendations for exercise programming
6. Considerations for exercise

 

“Arthritis” is an umbrella term for a large family of musculoskeletal disorders involving the degradation of the joints and tissue around the joints from chronic inflammation, swelling, and damage. Common symptoms include pain, decreased range of motion, and joint deformities (14). Arthritis affects 1 out of 5 U.S. and is a leading cause of work disability in adults (1). Arthritis is most common in women but affects people of all races, sexes, and ages (5,18)). Often, those with arthritis have other comorbidities such as diabetes, obesity, and heart disease (1).

 

Arthritis appears to be a normal part of aging because it occurs in most people by age 65 and is found in about 80% of those over age 75 (Aboulenain). However, there is a difference between the rapid onset and progression of arthritis in those under 65 and the slow onset due to aging. 

 

The two most common forms of arthritis are osteoarthritis and rheumatoid arthritis, which will be covered in this article. Other types of arthritis can also be caused by aging, injury, bacterial infection, disease, and other chronic conditions.

Osteoarthritis

Osteoarthritis is caused by the degeneration of joint structures, including cartilage, ligaments, joint lining, and bone. It is most common in the spine, knees, hips, and hands and leads to potential joint replacements, increased sedentary lifestyles, and mortality. Osteoarthritis is the most common form of arthritis in the United States, affecting 13.9% of the population or 26 million adults over 25 (2). 

 

Rheumatoid Arthritis

Rheumatoid arthritis is an autoimmune disease characterized by chronic joint lining inflammation. Muscular atrophy is another consequence of Rheumatoid arthritis, which also contributes to disability, depression, and mortality (2). 

 

Women over the age of 40 are the most likely to have Rheumatoid arthritis, with less than 1% of the population experiencing it. The small joints of the hands and feet are most commonly affected (14), with symmetrical or bilateral pathology. 

 

Understand Arthritis Pathophysiology

 

The basic pathophysiology of arthritis is characterized by the progressive deterioration of the joint’s synovial membrane, leading to joint cartilage degradation. The synovial membrane contains synovial cells that create lubrication between the cartilage ends of the articulating bones. Both acute trauma and chronic wear and tear can be responsible for the deterioration of the synovial membrane and, eventually, the articular cartilage. 

 

The synovial fluid’s lubricant effect creates an extremely low coefficient of friction between the two articulating surfaces. As arthritis progresses, this coefficient of friction increases, leading to a rougher surface for the articulating surfaces to act upon, which in turn causes mechanical wear and tear (Skinner, ACE). 

 

Rheumatoid arthritis is a systemic and chronic inflammatory state that begins with the body’s cells attacking the synovial membrane and articular cartilage (14). This accelerates the wear and tear on the joint as its smooth and lubricated surface is destroyed. The rest of the disease progression is similar to osteoarthritis with the deterioration of the joint cartilage.

 

Arthritis symptoms begin as the articular cartilage thins, allowing the subchondral bone to experience more of the forces transmitted across the joint (7). The subchondral bone has a high concentration of pain receptors, whereas the articular cartilage has none. 

Symptoms

Arthritis looks different from person to person. The three main symptoms of arthritis are joint pain, stiffness, and difficulty performing movements in the affected joints. Other primary symptoms related to the above include muscle weakness and balance issues.

 

Pain is typically related to specific physical activity and resolves with rest. As arthritis develops, pain is more progressive and affects activities of daily living, eventually causing disability. Patients may also experience bony swelling, joint deformity, and instability (patients complain that the joint is “giving way” or “buckling,” a sign of muscle weakness) (13).

 

Cascade of Cartilage Loss that Leads to Bone Loss

1. Trauma, overuse, or autoimmune damage to the cartilage or synovial membrane
2. The collagen matrix is damaged, causing chondrocytes to proliferate and form clusters (13)
3. Inflammation, swelling, and pain
4. Loss of smooth articular surface
5. Chemicals from articular cartilage escape and irritate synovial fluid 
6. Thinning of the articular cartilage
7. Higher forces experienced in subchondral bone
8. Subchondral plate thickening
9. Calcification of the articular cartilage
10. Deformation and stiffening of the joint

 

Explain the Effects of Exercise

Evidence strongly indicates that many forms of exercise improve pain, quality of life, and range of motion (2,3,4,11,18). This includes:

1. Strength training 
2. Aerobic training 
3. Mobility training

 

It is important to note that while movement may cause pain, structured exercise is focused on strengthening the muscles around the joint. Moving the joint through a full range of motion differs from some daily activities that may be attempted with compensatory patterns, which do not effectively build strength and range of motion.

 

The wrong kind of activity can worsen symptoms, but a sedentary lifestyle can worsen symptoms and advance the disease even more severely. This is unfortunate for people with arthritis, as they often fear moving. As a result, they become physically inactive, leading to weight gain and a decline in physical fitness. This can then lead to a cycle of depression and increase the risk of other health issues associated with being overweight and leading a sedentary lifestyle (Moore).”

 

Weight loss is especially vital in overweight and obese people, as each pound of weight loss can decrease the load across the knee 3 to 6 times (13). Essentially, exercise has the following effects on improving arthritis outcomes that all contribute to lowering pain:

1. Weight loss, which reduces the load on the joints
2. Increase in strength and stability of the muscles around the joint
3. Improved range of motion, which reduces tone in the soft tissue 
4. Improved cardiovascular risk
5. Improve the quality of life, which reduces depression and the downward spiral of other comorbidities 

 

Exercise may cause mild flare-ups in pain and swelling but will not lead to further joint destruction (Moore). Individuals in the early stages of arthritis or with good preservation of the articular cartilage tend to respond better to exercise than those with advanced arthritis (Moore). 

 

Effect of Exercise- Research Summary

The following list of conclusions is from research reviews, meta-analyses, or systematic reviews from peer-reviewed journals on topics related to the effects of exercise on arthritis from 2020 to the date of this article’s publication:

1. There is no benefit of adding manual therapy to an exercise program on arthritis outcomes (12).
2. Any exercise is better than no exercise. (8).
3. Exercise has similar effects on pain and function as NSAIDs (16).
4. Many forms of exercise can reduce arthritis symptoms (10).
5. There is little evidence that therapies such as electrophysical agents, manual therapies, acupuncture, taping, dietary interventions, whole-body vibration, or spa have a positive effect compared to exercise-only interventions (6).
6. Unsupervised home-based exercise is safe and effective at improving arthritis outcomes (15).

 

Exercise Response

Discomfort or mild pain is normal during exercise and does not mean the joints were damaged (3). If the discomfort remains the next day, the intensity or duration should be reduced. Identifying the client’s symptom threshold response to exercise will take time and practice. 

 

The symptom threshold is the exposure limit of exercise the body can tolerate before moderate pain is experienced. Modifying exercise variables such as intensity, speed, volume, and range of motion can help clients stay at or below their symptom threshold. Understand which specific movements or conditions cause pain and avoid them.

 

The pain associated with arthritis tends to cause individuals to reduce the size and intensity of their movements to avoid further pain. Personal trainers will likely run into two scenarios with how clients respond to exercise (Moore). The individual responds to the exercise with the following:

1. Neuromotor inhibition to decrease muscular force and range of motion to minimize acute pain.
2. Weakness and deconditioning (not due to neuromotor inhibition) result from chronic fear avoidance and inactivity.

Scenario one will require modifications, trust, and communication to exercise to build confidence in the individual’s ability to increase muscular force and activity. Progress may be made quickly since the reduced force and activity are neuromotor inhibition with less deconditioning. 

 

Scenario two will require more training time to build strength and endurance due to the chronic onset of deconditioning. Modifications, trust, and communication will also be necessary to combat the fear avoidance of movement. 

 

Exercise Recommendations

 

All forms of exercise can be safe and effective as long as each individual’s preferences and situation are considered (5,18). Strength, aerobic, and flexibility training should be included. Adequate warm-ups and cool-downs should facilitate joint lubrication and tissue elasticity (ACE). Regardless of the exercise mode, perform the movement in a pain-free range of motion with large, full-body movements. Communication with clients regarding exercise timing is vital because each client’s symptoms may yield better training results at a specific time when symptoms are lowest.

 

Low-intensity aerobic exercise is better for people with severe arthritis, and high-intensity aerobic exercise is more suitable for people with mild arthritis (20). Strength training’s primary functions are relieving pain, alleviating stiffness, enhancing muscle strength, improving physical function, and increasing the shock absorption ability of the lower extremity muscles during walking (20).

 

Strength Training

Free weights, machines, body weight, etc., are all appropriate modes of strength training. Two or three weekly sessions at light to moderate intensity (Jacobs) are recommended. Moderate intensity is up to 80%, one repetition max.

• Begin with shorter session lengths to determine tolerance
• Multiple short bouts a day are feasible
• 1-3 sets of 6-15 reps
• 2-3 minutes of rest in between sets
• Utilize progressive overload
• Focus on exercises that can improve activities of daily living and counteract the effects of prolonged sitting

Aerobic Training

Walking, swimming, elliptical, etc., are all appropriate modes of strength training. It can be done three to five days a week at a moderate to vigorous intensity, or 60% VO2 max, or heart rate reserve (3). Activities should be low-impact and use large, full-body movements. 

• Multiple shorter bouts of exercise can be appropriate if a more extended session is too much
• Gradually progress session length when able to exercise without pain
• Build up to 150 minutes a week

Flexibility Training

Range-of-motion exercises take joints through their full range in the planes of motion that apply. Exercises should be done in and around the affected joints. A combination of mobility drills and static and dynamic stretches can be done daily. Stretches can be taken to the point of mild discomfort.

 

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9110817/

 

Exercise Contraindications

High-speed or intensity transverse plane moments can contribute to high shear forces in the joint, which can lead to degenerative processes in osteoarthritis cartilage (Zeng). Take this into consideration with exercises that involve twisting the affected joints.

 

Acute flare-ups may occur, necessitating omitting vigorous exercises. However, slower mobility exercises or low-intensity aerobic training can still be done. Other comorbidities are associated with arthritis, making it crucial to identify risk factors that may interact with safely exercising, such as cardiovascular disease, medications, or joint instability (18).

 

High-intensity or impact repetitive exercises (running, jumping, etc.) can significantly harm the affected joint in the long run if the joint damage is advanced (9). Poor adherence and lack of enjoyment are other issues that will reduce the beneficial impact of exercise on arthritis (9).

 

Conclusion

Personal trainers play a vital role in encouraging those with arthritis to move their bodies meaningfully, regardless of the type of exercise. They lead clients to individualize specific exercises to meet their needs and gain the well-established benefits of exercise on arthritis. 

Sources

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