Arthritis can have a significant impact on quality of life, and in addition to prescribed medications, exercise is an integral part of disease treatment and prevention of disease progression. To understand the importance of exercise for arthritis, it is helpful to clarify what exactly the disease does to the body.
When paired with other forms of treatment, exercise can be extremely effective in managing and reducing arthritic symptoms. Regular physical activity can result in weight loss or maintenance of weight, which is important for controlling and/or reducing impact forces through the joints. It can also reduce pain due to its analgesic effect on the nervous system. Exercise improves joint health by moving fluid through intra-articular spaces and between layers of surrounding soft tissue. This allows for greater pain free joint range of motion. Individuals with arthritis often develop muscular tightness/stiffness due to the body protecting against pain and dysfunction around a joint. Exercise is important for the health of these muscles as it improves muscular flexibility, hydration, and strength. Cardiovascular endurance is an additional benefit of regular physical activity for individuals with arthritis.
Overall benefits of exercising in arthritis:
- By training the heart and lungs through exercises that challenge the aerobic energy system,
- Increases blood supply and hydration to muscles and joints
- Improved energy endurance with daily activities, household chores, and work duties
- Improved quality of sleep
- Elevated mood
- Higher levels of perceived level of function.
Exercises undertaken by arthritis patients must improve:
- Range of motion or mobility
- Aerobic respiration
- Body balance or body awareness.
Exercise can be incorporated as part of daily living activities such as commuting to/from work or school, and/or it can performed in separate episodes throughout the day. Depending on the type and severity of arthritis, an individual may have much more difficulty exercising at a certain time of day. For instance, they may experience significant fatigue and pain towards the end of the day, making morning exercise a better option. Others may find it challenging to complete one hour of continuous exercise, so it might be helpful to break up their program into two or even three shorter bouts spread throughout the day. Choosing to ride a bike or walk to/from work or while running errands, climbing the stairs instead of taking the elevator, and parking farther away from where one has to go are all examples of ways to add exercise into daily living activities.
Exercising with family members, friends, or coworkers is also a great way to stay active. In fact, studies show that people who exercise with others are much more likely to stick to a program consistently.
Range of motion or mobility exercises are essential for individuals with arthritis because they directly impact a joint’s quality of movement. With every motion that the body performs, our joints move through a complex combination of movements within three planes of motion.
The three planes of motion are the sagittal plane (forward and backward), the frontal plane (laterally to right side and laterally to left side), and the transverse plane (rotationally to right side and rotationally to left side). Joints from head to toe react to other joints above and below them via chain reactions along myofascial connective tissue lines, allowing our body to complete a given motion smoothly.
As part of a comprehensive exercise program, the recommendation for mobility exercise is at least 10 minutes per day.
When a joint is injured or painful and cannot move correctly, or the soft tissue around the joint is restricted, aberrant motion occurs at that joint and/or at joints above and below. This can perpetuate damage and injury along the entire chain, as joints and soft tissue are being tensed or compressed beyond a range that they can tolerate. Range of motion or mobility exercises target this aspect of joint and muscle movement by hydrating joints and soft tissue with blood and fluid, and preparing them proprioceptively to go through a necessary range of motion.
Importance of Stretching
Stretching is perhaps the most well known form of mobility exercise and it can be targeted towards any tissue in the body. Dynamic or moving stretches are always more beneficial than static stretches because dynamic stretching has a dual effect on soft tissue flexibility and joint mobility. Muscles and connective tissues are moved through their desired ranges of motion during dynamic stretching, which reduces built up scar tissue stiffness and activates proprioceptive sensory cells to tell the brain where the body is in space. For a person with arthritis, this stiffness is accentuated by pain and inflammation, so dynamic stretching becomes even more important. Dynamic stretching also pumps nutrients and blood into joints and between soft tissue layers, thus lubricating joint surfaces and allowing for movement to occur more smoothly.
Depending on how a stretch is performed, multiple muscle groups can be affected simultaneously. Stretching should be incorporated into an exercise program based on where a person feels tightness or stiffness and where abnormal tension is assessed by a movement professional. Another form of mobility exercise is myofascial release, a form of deep tissue massage in which external pressure is used to move fluid steadily through tissue layers to decrease adhesions and improve flexibility. Myofascial release can be performed on a person with arthritis by a physical therapist or massage therapist. It can also be practiced by the person on themselves with a foam roller or trigger point device. Foam rollers come in various shapes and sizes to target different areas of the body. Trigger point balls also can be found in different sizes and are used to release local areas of tension and smaller muscles. For maximum effectiveness, myofascial release should be performed slowly with as much pressure as is tolerated by the individual.
Working on soft tissues above and below a target area can provide additional relief due to the connectivity of myofascial lines through the body. If possible, myofascial release should be performed prior to dynamic stretching. Thus, the muscle and soft tissue will be well hydrated before it is asked to move through its full range. For an individual with arthritis, range of motion or mobility exercises such as myofascial release and dynamic stretching can be performed before and/or after or exercise. They are an effective way to warm up before a bout of exercise or at the beginning of the day when morning stiffness is often present.
These exercises can also be helpful to perform in the evening to relax the body before sleep. Important muscle groups to target include: quadriceps, hip flexors, hamstrings, glutes/hip rotators, calves, biceps, triceps, pectoralis, and latissimus dorsi muscles. Each exercise program should be tailored to the individual based on where their mobility is most restricted.
Strength exercises are another important part of a program for a person with arthritis. By increasing muscle fiber recruitment, muscle mass, and force capabilities, strength exercises improve stability around joints and therefore protect against the degenerative effects of arthritis.
Additionally, strength exercises stimulate bone growth, thus having a positive effect on bone density and prolonging joint health. There are two primary components of strength – neuromuscular recruitment, or the ability of the nervous system to activate the right combination of muscles for a given movement, and muscle force capacity, or the ability of a muscle to generate force against a particular resistance. Strengthening exercises must therefore be performed with proper technique and against some kind of resistance.
Resistance could be the weight of a limb against gravity (body weight strengthening), a dumbbell, a kettlebell, a resistance band, a medicine ball, a Vipr (loaded movement device), or water resistance. A strengthening exercise can be local and isolated to one particular muscle group (for example, a single arm bicep curl), or global and functional affecting several muscle groups and joints at the same time (for example, a squat with an overhead press).
A person with arthritis will usually find bigger functional movements to be more tolerable and effective during strength training since they spread stressful forces across multiple muscle groups and joints. Global, functional strengthening exercises will also look and feel like movements performed in everyday life. For instance, a squat is similar to bending down to pick up a child from the floor and a lunge or step up is similar to climbing a flight of stairs.
To strengthen upper body muscles, a comprehensive exercise program should incorporate lifting, pressing, pulling, pushing, carrying, and reaching motions. To strengthen lower body muscles, the program should include bending/squatting, stepping, lunging, balancing, and stepping motions. Jumping or plyometrics are beneficial to add if tolerated by the individual.
Aquatic strength exercises can be a great way for individuals with arthritis to increase volume and intensity of exercise because of the unweighting effect of water. Similar movements can be performed in water as over regular ground – squatting, lunging, balancing, pulling, pushing, etc. Strength exercises should be performed 2-3x per week and a strength program should cover all major muscle groups of the body. In general, 6-10 repetitions and 2-3 sets of each exercise should be performed. For older individuals or whilst someone is experiencing increased arthritic symptoms, 10-15 repetitions per set with lower resistance may be better tolerated.
If performed on the same day as aerobic exercise, strengthening exercise should be performed first. Aerobic exercise is the third form of exercise that should be included regularly in a program for individuals with arthritis. Aerobic means “requiring free oxygen” and refers to exercise that builds the cardiovascular system’s ability to absorb and transport oxygen. This type of exercise has multiple beneficial effects on overall health and fitness, particularly for individuals with arthritis. As a result of aerobic exercise, tiny blood vessels called capillaries increase in size and number within working muscles, therefore improving blood flow and waste removal throughout the body. The heart beats faster to maintain oxygen supply to working muscles and its ability to transport blood improves.
Aerobic exercise also has a significant impact on the nervous system, causing endorphins (aka “feel-good” chemicals) to be released by the brain and circulated through the body. Those who engage in regular aerobic exercise report greater endurance while performing everyday tasks and other types of exercise. Of the many types of aerobic activities, people with arthritis generally find lower impact exercises to be more tolerable. These include walking, swimming, cycling, elliptical, rowing, and stair climber. If impact is not a problem, a treadmill or group exercise class such as zumba, dance, or step may be enjoyed as part of aerobic training.
For any bout of aerobic exercise, a minimum of 20 minutes at a heart rate elevated and sustained above resting levels is required to produce a positive cardiovascular training effect. Weekly recommendations are for at least 150 minutes of moderate intensity exercise, 75 minutes per week of vigorous intensity exercise, or a combination of the two. Of all the categories of exercise, aerobic exercise can be most easily added into the daily routine in short episodes (i.e. commuting on a bike, having a walking meeting, etc.).
Body Balance Exercises:
Exercises that train balance and body awareness make up the final category of exercises that are important for individuals with arthritis. Because the arthritic process affects the articular surfaces of joints and surrounding soft tissues, individuals often have difficulty stabilizing properly during movement due to pain, swelling, and joint stiffness. This can become particularly debilitating with increased age and/or disease progression. Within every joint, there are numerous types of sensory cells that detect parameters such as pain, pressure, vibration, tendon tension, and direction and speed of movement. Together, these complex sensory mechanisms give the brain a proprioceptive picture of where the body is in space and how each part of the body is moving in relation to other parts and to the external environment.
Degenerative conditions of the joint like arthritis can damage these essential pathways and make it more difficult to move smoothly and maintain stability on uneven surfaces. The movement patterns in exercise disciplines such as tai chi, yoga, pilates, and certain group exercise classes can significantly improve balance and body awareness because they focus on alignment and body position, precise activation and inhibition of small muscles, core engagement, using the breath and diaphragm, and holding postures with awareness and control. These movements are often performed more slowly and deliberately than in other types of exercise, thus training the neuromuscular system and the musculoskeletal system to work in synergy.
Balance and body awareness exercises can be performed at any time of day, however, they can be especially helpful early on. In the morning joint stiffness and muscle tightness are often problems for people with arthritis. Balance and body awareness exercises are great tools to combat these restrictions and to awaken the nervous system for proper movement patterns through the rest of the day. When performed in the evening in a restorative manner, these exercises can have a calming effect on the nervous system.
Balance and body awareness exercise should be performed at least 3 times per week for a minimum of 20 minutes per episode. In addressing the magnitude of disability caused by arthritis, regular exercise plays an essential role in effective treatment plans. The human body wants to move and is healthier when it moves often. Although arthritis can make it painful and difficult to do so, there are countless ways to modify exercises so that they are manageable and beneficial for an individual with arthritis.
The four core categories of exercise; range of motion/mobility, strength, aerobic, and balance/body awareness provide a variable framework for planning exercise programs that can be tailored to the individual’s needs and schedule. Ideally, some movement is built into each day of the week. Even on a rest day where no strengthening or aerobic training is planned, ten minutes of mobility work can accelerate the recovery process between workouts (active recovery) and keep the person moving and motivated.
It is also important to always begin or modify an exercise program gradually and with intention. Especially for a person with arthritis, starting a new exercise program or changing one that they already know can be stressful and is often a barrier to healthy activity. In these cases, starting small is always the best way to ease into a new routine; for example, just committing to twenty minutes of aerobic exercise on two days the first week may be enough. Once a person is comfortable with a certain type of exercise, the volume can be changed or an additional type of exercise can be added.
The most important principles to remember in designing exercise for an individual with arthritis are:
1) Movement is medicine for the joints and soft tissues of the body
2) The exercise program must be manageable for the individual
3) The more variety of movement in an exercise program the better it will be. There may not currently be a cure for arthritis, but exercise is certainly a prime tool to fight it!