Arthritis & Exercise - Pure Training and Development 2020 - PTD Hub

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Arthritis & Exercise - Pure Training and Development 2020 - PTD Hub
Arthritis & Exercise
        Part 1

                   Pure Training and Development © 2020
Arthritis & Exercise - Pure Training and Development 2020 - PTD Hub
Tutor – Who am I?

• Emma Haughton

• Creator of workshops and seminars
• 7 years experience in Exercise
  Referral Industry
• Passionate about improving the health and
  wellbeing of your community
Arthritis & Exercise - Pure Training and Development 2020 - PTD Hub
Learner Support
✓ Home study does not mean no support

✓ Supporting materials in ‘Resources’
  section

✓ Contact us for different formats

 Call:        03302231302

 Email:       support@puretraininganddevelopment.co.uk

 Or Facebook Messenger
Arthritis & Exercise - Pure Training and Development 2020 - PTD Hub
Learning     • Explore the aetiology and pathophysiology of
               osteoarthritis and rheumatoid arthritis
Objectives   • Understand the recent prevalence statistics of
               arthritis in the UK
             • Identify the benefits of physical activity and
               exercise in the management of the condition
             • Identify an exercise prescription framework
             • Recognise and apply health and safety
               considerations
Arthritis & Exercise - Pure Training and Development 2020 - PTD Hub
Let’s get
ready to
study…
Arthritis & Exercise - Pure Training and Development 2020 - PTD Hub
Question…
      Do you know the key differences between
                   OA and RA?

On a piece of paper, bullet point the key things you remember
about Osteoarthritis and Rheumatoid Arthritis.

You have 1 minute….
Arthritis & Exercise - Pure Training and Development 2020 - PTD Hub
• An estimated 18.8 million people live with a
Introduction     musculoskeletal condition in the UK (GBD 2017)
& Prevalence
               • There are more than 100 different forms of
                 arthritis
               • Most common two explored during this
                 seminar:
                  • Osteoarthritis and rheumatoid arthritis
               • 8.75 million live with osteoarthritis
               • 430,000 live with rheumatoid arthritis (Arthritis
                 Research UK, 2019)

               • Each person is affected in a unique way
Arthritis & Exercise - Pure Training and Development 2020 - PTD Hub
Introduction   • Estimated to cost the economy £10.2 billion
                 in direct costs to the NHS and wider
& Costs          healthcare system
               • Cumulatively the healthcare cost will reach
                 £118.6 billion over the next decade.

               • The cost of working days lost is £2.58
                 billion in 2017 rising to £3.43 billion by
                 2030.

               Sourced: York Health Economics, “The Cost of Arthritis: Calculation conducted on behalf of
               Arthritis Research UK,” Unpublished, 2017.
Arthritis & Exercise - Pure Training and Development 2020 - PTD Hub
Aetiology &
Pathophysiology
of Osteoarthritis
Arthritis & Exercise - Pure Training and Development 2020 - PTD Hub
Pathophysiology of Osteoarthritis

•   Common in older population
•   Osteoarthritis is a non-inflammatory condition
•   Functional limitations and reduced quality of life
•   No cure but condition can be managed
•   A condition which typically has a gradual onset
Pathophysiology of Osteoarthritis

• Cartilage acts as a shock absorber
• 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
Impact bearing properties are diminished

                    Body compensates by changing shape, thickening
                    (subchondral sclerosis ) and developing bone spurs
                    (osteophytes/osteophytosis)

Pathophysiology     Movement becomes restricted and painful
of Osteoarthritis

                    All contributes to joint crepitus and pain

                    Inflammation of joint membrane in severe arthritis
Osteoarthritis Image

                  Arthritis Research UK/Versus Arthritis
Osteoarthritis Image

                  Arthritis Research UK/Versus Arthritis
Condition can occur with and without
                    symptoms of pain and weakness

                    Can affect any joint in the body

Pathophysiology     Commonly affects hips, knees, spine and
of Osteoarthritis   hands

                    Changes occur to the entire joint, not just the
                    cartilage and bone

                    Observed physical changes occur
Pathophysiology of Osteoarthritis

• Inflammation is a frequent
  symptom
  –   (Sokolve et al, 2013)

• Muscle wastage occurs
• Connective tissues, tendons
  and ligaments become tight
• Results in reduced range of
  movement
• Discomfort

Signs and Symptoms   • Pain (exercise and rest)
                     • Stiffness
                     • Swelling
                     • Decreased range of motion
                     • Muscle weakness
                     • Joint deformity
                     • Joint instability
                     • Depression (Lepine & Briley, 2004)
Causes/Risk Factors

•   Age
•   Gender
•   Obesity
•   Occupation
•   Sedentary lifestyle
•   Physical injury/trauma
•   Genetic factors

                   Georgiev et al, 2019
• Pain relievers such as paracetamol
Medications    • NSAID/Corticosteroids – aim to reduce
                 swelling and pain

Side Effects   •   Gastrointestinal problems
               •   Potential asthma attacks for asthmatics
               •   Addiction
               •   Increased risk of osteoporosis
Aetiology &
Pathophysiology of
Rheumatoid Arthritis
Pathophysiology of Rheumatoid Arthritis

• Approximately 430,000 people in UK (VersusArthritis, 2019)
• Cause is not fully known
• Auto immune disease
• Chronic inflammatory disease
• Systemic condition
• A condition typically with a rapid onset
• Indicated by flare up and remission phases
Pathophysiology of
 Rheumatoid Arthritis
• Tends to affect smaller joints
   • Hands, fingers and toes
• Antibodies attack synovium
• Thick and swollen synovium
• Synovium invades and destroys
• Hot, red and swollen
• Stretched capsule can cause
  instability/ deformation
Pathophysiology of Rheumatoid Arthritis

                            Arthritis Research UK/Versus Arthritis
Pathophysiology of Rheumatoid Arthritis

                             Arthritis Research UK/Versus Arthritis
Flare ups and remissions

               Pain

               Inflammation

 Symptoms      Damage to joint tissues

      of       Fever

Rheumatoid     Joint deformity

   Arthritis   Limited ROM

               Symptoms during a flare up include:
               •   Fatigue
               •   Loss of appetite
               •   Muscle aches
               •   Red, swollen and painful joints
• NSAID/Corticosteroids – aim to reduce
Medications      swelling and pain
               • DMARDS – reduce joint damage and
                 promote remission
               • Goal is to supress the immune system
Side Effects
               •   Gastrointestinal problems
               •   Potential asthma attacks for asthmatics
               •   Risk of osteoporosis
               •   Hypertension
Causes/Risk Factors

• Age

• Genetic factors

• Gender

• Smoking

• Obesity

• Diet
Associated Risks

• Increases the risk of
  •   CV disease and stroke
  •   Lung disease
  •   Osteoporosis
  •   Higher risk of falls
  •   depression
Many more arthritic conditions:

             Gout (1.6 million)
 Other
Forms of     Ankylosing spondylitis (222,00 people)

 Arthritis
             Cervical spondylosis

             Recommended to complete further reading on these
             conditions.
Break Time

Take a 10-15
minute break
End of Part 1
Please continue with Part 2

                      Pure Training and Development © 2020
Arthritis & Exercise
        Part 2

                   Pure Training and Development © 2020
Welcome back
from break…
Exercise
In the management of these conditions

                                Pure Training and Development © 2020
What are the
  benefits of
physical activity
 and exercise?
Decrease Decrease joint pain and stiffness

           Improve
             or     Improve or maintain joint motion
           maintain
Physical            Decrease the risk of cardiovascular
Activity   Decrease disease (higher in those with rheumatoid
                    arthritis)
Benefits             Improve ability to do activities of daily
           Improve   living (i.e. access in and out of car or
                     going up and down stairs)

           Decrease Decrease disease activity
Better pain management

           Increase muscular strength

           Improved bone mineral density protect against osteoporosis

Physical   Maintain control of weight

Activity   Improved balance and co-ordination

Benefits   Reduced stress and depression

           Improved sleep patterns

           Increased energy levels

           Improved self-esteem
Reduces risk of:
            Hip and knee osteoarthritis pain by 6% (Hurley et
            al, 2018)

Regular     Joint and back pain by 25% (Choi et al, 2010)

physical    Depression by up to 30% (DOH, 2011)
activity
            Hip fracture rates by up to 68% (Scottish Government,
            2003)

            Falls by 76% (Foster et al, 2017)

           Source: https://www.versusarthritis.org/media/14594/state-of-musculoskeletal-health-2019.pdf
Highlighted Statement

Advise people with osteoarthritis to exercise as a core
treatment, irrespective of age, comorbidity, pain severity
or disability.

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

                                                     NICE (2008 - 2020)
Osteoarthritis &                         A review suggested that ‘aerobic,
Exercise - Evidence                strengthening, flexibility, aquatic, yoga and
                                    Tai chi improve outcomes related to joint
                                        symptoms, mobility, quality of life,
                                      psychological health, musculoskeletal
                                    properties, body composition, sleep and
                                        fatigue. (Wellsandt et al 2018; Schiphof et al, 2018)
  'the benefits of exercise
   therapy extend beyond
 pain and physical function        ‘there is substantial evidence regarding the
  with moderate effects on             benefits of strengthening exercises to
 depression in people with          reduce pain in knee osteoarthritis patients.
 hip and knee OA’ (Hurley et al,      Based on the included studies analysis,
        2018, Villafane, 2018)     exercises should be performed three times
                                       weekly for a duration of 8-11 or 12-15
                                                 weeks.’ (Imoto et al, 2019)
There is strong evidence to
Rheumatoid Arthritis                                   suggest that increasing
                                                       physical activity
& Exercise –Evidence                                   and/or exercise can
                                                       simultaneously improve
                                                       symptoms and reduce the
                                                       impact of systemic
No studies have found increased disease                manifestations in RA. (Metsios et
                                                       al, 2018)
activity as a result of physical training

                                                        ‘Based on the evidence,
                                                        aerobic capacity training
‘Physical activity and exercise are effective
                                                        combined with muscle
methods to improve arthritis symptoms,
                                                        strength training is
enhance mental health and reduce the risk
                                                        recommended as routine
for CVD; however, the majority of patients
                                                        practice in patients with
with RA lead sedentary lifestyles.’ (Veldhuijzen van
Zanten et al, 2015)                                     RA” (Hurkmans et al, 2009; Verhoeven et
                                                        al, 2016)
Barriers

• External influences/ previous advice
• Pain
• Fatigue
• 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 Time

Take a 10-15
minute break
End of Part 2
Please continue with Part 3

                       Pure Training and Development © 2020
Arthritis & Exercise
        Part 3

                   Pure Training and Development © 2020
Welcome back
from break…
Exercise
Prescription
• Manage pain and discomfort
Key
             • Improve joint range of motion
Objectives
             • Increase muscular strength
             • Improve balance and co-ordination
             • Decrease excess body fat (where applicable)
             • Improve quality of life
             • Change health behaviour with education
               and advice
Slow and gradual

                 Pulse raising and mobility

Warm Up
Considerations
                 Seated if balance is affected

                 Dynamic Stretches
Train unaffected joints for cardiovascular

Main             Choose smooth and rhythmic exercises

Workout
Considerations   Consider the order of exercises

                 Ensure the focus is on functional strength
                 and endurance and cardiovascular fitness
Slow and extended period

Cool Down        Seated or lying for some stretches
Considerations

                 Hold to the point of tension within pain
Exercise Prescription

American College of Sports Medicine Exercise Guidelines for Osteoarthritis and Rheumatoid arthritis

                      Cardiovascular                         Musculoskeletal                                Flexibility

Frequency             3-5 days a week                         2-3 days a week                                  Daily

                Moderate Intensity (40-59%                                                       Move through ROM feeling
                                                  60-80% 1RM. Initial intensity should be
                          HRR)                                                            tightness/stretch without pain. Progress
 Intensity                                            lower (50-60% 1RM) for those
                       RPE 11-16/20                                                       ROM of each exercise only when there
                                                   unaccustomed to resistance training
                 Or vigorous (≥60% HRR)                                                          is very little or no joint pain

                                                    Use healthy adult values and adjust         Up to 10 repetitions for dynamic
              150 mins per week of moderate
   Time                                           accordingly (i.e. 8-12 repetitions for 2-4   movements, hold static stretches for
              intensity or 75 mins of vigorous
                                                   sets); include all major muscle groups                   10-30s

               Activities with low joint stress    Machine or free weights. Body weight
                                                                                               A combination of dynamic and static
   Type          such as walking, cycling,        exercises might also be appropriate for
                                                                                               stretching focused on all major joints
               swimming or aquatic exercise                 select individuals
Exercise Prescription

American College of Sports Medicine Exercise Guidelines for Osteoarthritis and Rheumatoid arthritis

                      Cardiovascular                         Musculoskeletal                                Flexibility

Frequency             3-5 days a week                         2-3 days a week                                  Daily

                Moderate Intensity (40-59%                                                       Move through ROM feeling
                                                  60-80% 1RM. Initial intensity should be
                          HRR)                                                            tightness/stretch without pain. Progress
 Intensity                                            lower (50-60% 1RM) for those
                       RPE 11-16/20                                                       ROM of each exercise only when there
                                                   unaccustomed to resistance training
                 Or vigorous (≥60% HRR)                                                          is very little or no joint pain
                                                                                                          Hold a stretch for 5-10
                                                                                                           secs and repeat 5-10
                                                    Use healthy adult values and adjust         Up to 10 repetitions for dynamic
              150 mins per week of moderate                                                                          times
   Time                                           accordingly (i.e. 8-12 repetitions for 2-4   movements, hold static stretches for
              intensity or 75 mins of vigorous
                                                   sets); include all major muscle groups                     (Versus Arthritis)
                                                                                                            10-30s

               Activities with low joint stress    Machine or free weights. Body weight
                                                                                               A combination of dynamic and static
   Type          such as walking, cycling,        exercises might also be appropriate for
                                                                                               stretching focused on all major joints
               swimming or aquatic exercise                 select individuals
Exercise Prescription - Exercise Ideas
Versus Arthritis UK suggest these exercises are regular
examples to integrate:

Knee Osteoarthritis:
• Sit to stand
• Quadriceps strengthening exercises
• Step ups

Hip Osteoarthritis:
• Hip abduction
• Hip extension
Exercise Prescription - Exercise Ideas
Versus Arthritis UK suggest these exercises are regular
examples to integrate:

Rheumatoid Arthritis:
• Whole body exercises
• Low impact aerobic exercises i.e. swimming, walking
Exercise Prescription - Methods of Monitoring

• Observation
• Talk test
• RPE

• Be aware of medication affecting
  their pain sensation levels
Exercise Prescription -
    Contraindications & Considerations
Do not exercise a joint during acute flare ups

Avoid/reduce high impact exercises (depending on the client)

Avoid excessive repetitions

Avoid over stretching the joints

Do not bounce when stretching

Avoid prolonged exercise in the same position

Avoid kneeling positions (as appropriate)
Exercise Prescription -
   Contraindications & Considerations
Perform an extended warm up and cool down

Be aware of the side effects of medication

Monitor pain levels

Consider shorter durations and build over time

Inform the client about post exercise associated muscle discomfort

Check for suitable footwear
Exercise Advice

• Resources from Arthritis
  Research UK/Versus Arthritis
Two key forms of arthritis: OA and RA

          OA is the degeneration of the joint

          RA is an auto immune condition causing synovial
          membrane swelling

Summary   8.75 million with OA

Points    430,000 with RA

          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 pain
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)

Summary   Aerobic exercise is recommended on 3-5 days per

Points
          week

          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 (2018)
Regularly assess the client to identify safe methods of
          progression

          Do not exercise the area affected during a flare up

Summary   Encourage good posture during exercise and in daily

Points
          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
1. Exercise and osteoarthritis: an update

              2. Exercise as medicine to be prescribed
                 in osteoarthritis

Recommended
   Reading
                    In Your ‘Resources
                         Section’
Useful Websites & Documents
 Information and links can be found within the
             ‘Resources Section’.

     Exercises to manage pain - Versus Arthritis

                        NHS Website
                     Arthritis Foundation

The Arthritis Society Top 10 Exercises for Arthritis PDF
         (type this in to a search engine to directly access PDF)
Other CPD Seminars
References
•   Baillet, A., Vailliant, M., Guinor, M., Juvin, R and Gaudin, P. (2012). 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, 2011.
•   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 (2008,2014). Osteoarthritis: The care and management of osteoarthritis in adults, quick reference guide. NICE. Updated version retrieved in August 2018, from
    https://www.nice.org.uk/guidance/cg177/chapter/1-Recommendations#non-pharmacological-management-2
•   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?
•   State of musculoskeletal health 2017. Arthritis & other musculoskeletal conditions in numbers. Arthritis Research UK.
•   Hunter, D.J & Eckstein, F. (2009). Exercise and Osteoarthritis. Journal of Anatomy, 214 (2), 197-207.
•   Veldhuijzen van Zanten et al. (2015). Perceived Barriers, Facilitators and Benefits for Regular Physical Activity and Exercise in Patients with Rheumatoid Arthritis: A Review of the Literature. Sports Med, 45(10), 1401-
    1412.
•   ACSM Guidelines for Exercise Testing and Prescription. 10 th Edition. Wolters Kluwer Health
•   Osthoff, AK R., Juhl, CB., Knittle, K., Dagfinrud, H., Hurkmans, E., Braun, J., Schoones, J., & Niedermann, K. (2018). Effects of exercise and physical activity promotion: meta-analysis informing the 2018 EULAR recommendations for
    physical activity in people with rheumatoid arthritis, spondyloarthritis and hip/knee osteoarthritis. BMJ, RMD Open 2018;4:e000713. doi: 10.1136/rmdopen-2018-000713
•   Imoto AM, Pardo JP, Brosseau L, Taki J, Desjardins B, Thevenot O, Franco E, & Peccin S. (2019) Evidence synthesis of types and intensity of therapeutic land-based exercises to reduce pain in individuals with knee osteoarthritis.
    Rheumatol Int. 2019 Jul;39(7):1159-1179
•   Wellsandt E, & Golightly Y (2018) Exercise in the management of knee and hip osteoarthritis. Curr Opin Rheumatol. 2018 Mar;30(2):151-159
•   Georgiev T, & Angelov AK (2019). Modifiable risk factors in knee osteoarthritis: treatment implications. Rheumatol Int. 2019 Jul;39(7):1145-1157.
•   Veldhuijzen van Zanten JJ, Rouse PC, Hale ED, Ntoumanis N, Metsios GS, Duda JL, & Kitas GD (2015). Perceived Barriers, Facilitators and Benefits for Regular Physical Activity and Exercise in Patients with Rheumatoid Arthritis: A
    Review of the Literature. Sports Med. 2015 Oct;45(10):1401-12
•   M. Hurley, K. Dickson, R. Hallett, R. Grant, H. Hauari, N. Walsh, C. Stansfield and S. Oliver. (2018). Exercise interventions and patient beliefs for people with hip, knee or hip and knee osteoarthritis: a mixed methods review. Cochrane
    Database of Systematic Reviews, no. 4.
•   B. Choi, J. Verbeek, W. Tam and J. Jiang (2010). Exercises for prevention of recurrences of low-back pain. The Cochrane Database for Systematic Reviews, vol. 1
•   Guidance from the Chief Medical Officers in the UK on the amount and type of physical activity people should be doing to improve their health. 2019. Access via: https://www.gov.uk/government/collections/physical-activity-guidelines
•   Arthritis Research UK. The Musculoskeletal Calculator (prevalence data tool). 2019.
•   Hurkmans E, van der Giesen FJ, Vliet Vlieland TP, Schoones J, & Van den Ende EC. (2009). Dynamic exercise programs (aerobic capacity and/or muscle strength training) in patients with rheumatoid arthritis Cochrane Database Syst
    Rev. 2009 Oct 7;(4).
•   Metsios, GS., &Kitas, GD. (2018). Physical activity, exercise and rheumatoid arthritis: Effectiveness, mechanisms and implementation. Volume 32, Issue 5, October 2018, Pages 669-682.
•   Pedersen, B.K., & Saltin, B. (2015). Exercise as medicine- evidence for prescribing exercise as therapy in 26 different chronic disease. Scandinavian Journal of Medicine & Science in Sports. 3, 25: 1-72 Joint Bone Spine. 2016
    May;83(3):265-70. doi: 10.1016/j.jbspin.2015.10.002. Epub 2015 Nov 28.
•   Verhoeven F, Tordi N, Prati C, Demougeot C, Mougin F, & Wendling D. (2016). Physical activity in patients with rheumatoid arthritis. Joint Bone Spine. 2016 May;83(3):265-70
•   Ravalli S, Castrogiovanni P, Musumeci G. Exercise as medicine to be prescribed in osteoarthritis. World J Orthop. 2019;10(7):262–267. Published 2019 Jul 18. doi:10.5312/wjo.v10.i7.262
•   Goh SL, Persson MSM, Stocks J, et al. Efficacy and potential determinants of exercise therapy in knee and hip osteoarthritis: A systematic review and meta-analysis. Ann Phys Rehabil Med. 2019;62(5):356–365.
    doi:10.1016/j.rehab.2019.04.006
•   Public Health England: Muscle and bone strengthening and balance activities for general health benefits in adults and older adults (2018). Sourced from:
    https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/721874/MBSBA_evidence_review.pdf
•   The state of musculoskeletal health 2019: Versus Arthritis. Sourced from: https://www.versusarthritis.org/media/14594/state-of-musculoskeletal-health-2019.pdf
Thank you
for participating in today’s training

            Any Questions?

        Tutor: Emma Haughton
                 t: 03302231302
   e: support@puretraininganddevelopment.co.uk
     w: www.puretraininganddevelopment.co.uk

/PureTrainingandDevelopment           @PureTraining2
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