arthritis and exercise exercise referral cpd pure training and development © 2014
TRANSCRIPT
ARTHRITIS AND EXERCISE
EXERCISE REFERRAL CPD
Pure Training and Development © 2014
Tutor – Who am I?
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• 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
• If you would like this training in a different format
please contact us
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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
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Let’s get ready
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AETIOLOGY & PATHOPHYSIOLOGYof Arthritis
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Do you know the key differences between OA and RA?
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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
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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)
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• 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
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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
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Pathophysiology of Osteoarthritis
www.interactive-biology.com
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Pathophysiology of Osteoarthritis
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
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Pathophysiology of Osteoarthritis
Osteoarthritis Image
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Arthritis Research UK
Osteoarthritis Image
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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
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Pathophysiology of Osteoarthritis
Osteoarthritis Image
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• 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)
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Pathophysiology of Osteoarthritis
• Discomfort
• Pain
• Stiffness
• Swelling
• Decreased range of motion
• Physical changes
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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
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Osteoarthritis - Medications
Break TimeTake a 10-15 minute break.
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• 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
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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
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Pathophysiology of Rheumatoid Arthritis
Pathophysiology of Rheumatoid Arthritis
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Arthritis Research UK 2014
Pathophysiology of Rheumatoid Arthritis
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Arthritis Research UK 2014
Pathophysiology of Rheumatoid Arthritis
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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
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Symptoms of Rheumatoid Arthritis
• NSAID/Corticosteroids – aim to reduce swelling and pain
Side effects:• Gastrointestinal problems• Potential asthma attacks for asthmatics• Risk of osteoporosis
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Rheumatoid Arthritis - Medications
• Over 100 types of arthritis • Gout • Ankylosing spondylitis • Cervical spondylosis
Recommended to complete further reading on these conditions.
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Other Forms of Arthritis
Exercise in the Management of the Conditions
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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)
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• 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
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• 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
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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
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• 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
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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)
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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
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Rheumatoid Arthritis & Exercise – Evidence
• People with Arthritis Can Exercise (PACE)• Developed by Arthritis Foundation in America
PHYSICAL ACTIVITYManagement of Condition
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Barriers
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• 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
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• 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.
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Exercise Prescription
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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
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• Exercise should include local muscle strengthening and general aerobic fitness
• Also offer weight loss• Use suitable footwear (arch support and
cushioning) Nice (2008)
Exercise Prescription
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Warm Up• Slow and gradual• Pulse raising and mobility • Seated if balance is affected• Dynamic stretches
Exercise Prescription
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Main Workout• Train unaffected joints for CV • Choose smooth and rhythmic exercises
Cool Down:• Seated or lying for some stretches
Exercise Prescription
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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
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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
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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
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EXERCISE PRESCRIPTIONExercise Ideas
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• Observation • Talk test• RPE
• Be aware of medication affecting their pain sensation levels
EXERCISE PRESCRIPTIONMethods of Monitoring
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• 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
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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
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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
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• Arthritis UK – Keep Moving document
Exercise Advice
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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).
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• 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
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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
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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
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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?
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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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