Chapter 12
Therapeutic Exercise for Arthritis
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Goals of Exercise Intervention
 Slow or reverse body’s response to joint
pathology by increasing strength, flexibility,
endurance & by decreasing pain.
 Improve impairments, functional limitations, and
disabilities resulting from arthritis.
 Lead to overall improved health status as an
effect of cardiovascular, strengthening, ROM,
and stretching exercises.
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Review of Anatomy and Kinesiology
Ligaments, muscles, tendons, capsule, cartilage,
subchondral/trabecular bone.
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Joint Structures – Knee
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Osteoarthritic Knee
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Inflammatory Response to Rheumatoid
Arthritis
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Pathology
Osteoarthritis (OA)
Rheumatoid Arthritis (RA)
Nonsystemic, mostly
noninflammatory,
localized pathology.
Systemic, inflammatory
disease that usually
involves multiple joints
and often affects organ
systems.
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Articular Cartilage
Function
Shock absorption, joint
congruence
Effects of osteoarthritis
Thickening to softening, to
thinning to loss
Effects of rheumatoid
arthritis
Erosion of cartilage
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Synovium
Function
Secretes synovial fluid for
nutrition of cartilage,
lubrication, and stability
Effects of osteoarthritis
Abnormal joint alignment
stresses
Effects of rheumatoid
arthritis
Microvascular lining cells
activated by inflammatory
process, pannus formation
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Ligaments
Function
Stability, reinforce capsule
and limit movement, guide
movement
Effects of osteoarthritis
Abnormal joint alignment
stresses
Effects of rheumatoid
arthritis
Erosion weakens
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Muscles
Function
Reinforce joint capsule,
reflex joint protection, move
joints
Effects of osteoarthritis
Immobility shortens pain,
causes guarding and reflex
inhibition, leading to
weakness
Effects of rheumatoid
arthritis
Joint deformity interferes w/
peak torque, immobility
shortens; myositis weakens;
pain & effusion cause
guarding & reflex inhibition
leads to weakness
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Bone
Function
Structural support
Effects of osteoarthritis
Subchondral bone
remodeling changes shockabsorbing properties, jointmargin spurring leads to
bony blockade and pain
Effects of rheumatoid
arthritis
Erosion leads to joint
deformity, bony blockade,
pain
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Extra-articular System
Function
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Effects of osteoarthritis
Increased energy
expenditure from abnormal
movement patterns
Effects of rheumatoid
arthritis
Myositis, anemia, sleep
disruption, fatigue, increased
energy expenditure from
abnormal movement
patterns
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Classification of Functional Status of
Patients with RA
Class I: Completely able to perform usual activities
of daily living.
Class II: Able to perform usual self-care and
vocational activities, but limited in
avocational activities.
Class III: Able to perform usual self-care activities,
but limited in vocational and avocational
activities.
Class IV: Limited in ability to perform usual selfcare, vocational, and avocational
activities.
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Classification of Progression of RA
Stage I (Early)
No destructive changes on roentgenographic
examination.
Roentgenologic evidence of osteoporosis may
be present.
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Classification of Progression of RA
Stage II (Moderate)
 Roentgenologic evidence of osteoporosis, with or without
slight subchondral bone destruction; slight cartilage
destruction may be present.
 No joint deformities, although limitation of joint mobility
may be present.
 Adjacent muscle atrophy.
 Extra-articular soft tissue lesions, such as nodules and
tenosynovitis.
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Classification of Progression of RA
Stage III (Severe)
 Roentgenologic evidence of cartilage and bone
destruction in addition to osteoporosis.
 Joint deformity, such as subluxation, ulnar
deviation, or hyperextension, without fibrosis or
bony ankylosis.
 Extensive muscle atrophy.
 Extra-articular soft tissue lesions, such as nodules
and tenosynovitis, may be present.
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Classification of Progression of RA
Stage IV (Terminal)
Fibrous or bony ankylosis.
Criteria of stage III.
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Exercise Recommendations for
Prevention and Wellness
Appropriate exercise regimen
should emphasize:
Maintaining appropriate body weight.
Sustaining good postural alignment.
Developing good muscular strength and
length.
Correct movements during functional
activities.
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Therapeutic Exercise Intervention for
Common Impairments
Osteoarthritis
Decrease pain and any inflammation.
Re-establish muscle length and strength
around the joint.
Address adaptive changes in proximal
and distal joints.
Performance of basic functional tasks.
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Therapeutic Exercise Intervention for
Common Impairments
Rheumatoid Arthritis
Considerations are similar to osteoarthritis
Patients must be taught how to recognize
symptoms, to modify activity according to
symptom development and stage of
illness
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Pain
Pain, swelling, and splinting
Disuse atrophy
Reduce protective reflexes
Further cartilage breakdown
Activity reduced further
Decrease in cardiovascular activity
Inefficient movement/muscle patterns
Disruption of soft tissue
balance
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Pain
Exercise is used to restore muscle
balance, joint ROM, CV conditioning.
Thermal modalities and electrical
stimulation (TENS, etc.) for management.
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Impaired Mobility and Range of Motion
Can be diminished by:
Stiffening and shortening of muscles or
tendons from spasm, guarding, or
habitual postures.
Capsular stiffness or contracture.
Loss of joint congruity because of bony
deformity.
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Impaired Muscle Performance
Rheumatoid Arthritis
1-2 daily applications of PROM (large
joints) and AROM (small joints).
Single submaximal isometric contractions
(2/3 of MVC) 6 sec work/20 sec rest (acute
and subacute phases).
Caution should be used during MVC efforts.
Repetitions at various angles.
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Osteoarthritis
Isometric contractions in acute phase.
As pain and swelling decreases,
graduating into a routine containing
dynamic contractions is appropriate.
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Impaired Aerobic Capacity
CV training should be a major part of
therapy programs with osteoarthritis or
Class I, II rheumatoid arthritis.
Aquatic Therapy is an excellent tool –
benefits include:
 Allowing performance of movement patterns that may not be
possible on land because of balance or strength deficits.
 Providing muscle relaxation.
 Modifying pain perception through sensory stimulation.
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Special Considerations in Exercise
Prescription and Modification
Protect joints during strengthening
when ligament or capsular laxity exists.
Restore muscle balance when
splinting, postural habit, pain inhibition
has weakened muscle groups around
one or more joints.
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Special Considerations in Exercise
Prescription and Modification (cont.)
Normalize specific joint movement patterns.
Restore functional activities.
Treat pain during and after exercise.
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Summary
 Exercise can mitigate impairments that lead to functional
deficits in patients with arthritis and has positive effect on
quality of life.
 Disease process of OA and RA attack joint parts and affect
joint integrity.
 Pathology of one joint affects joints proximal and distal in
chain and contralateral joints.
 Management of pain (common impairment) using
therapeutic modalities, safe alignment, bracing, and pacing
are necessary components of exercise prescription.
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Summary (cont.)
 Joint movement is necessary for joint health.
PROM and AROM are chosen depending on the
severity of involvement of joint(s).
 Isometric exercises can be useful in maintaining
strength around the joint.
 Cautious dynamic training offers the advantage of
strengthening periarticular musculature through full
range and increasing cartilage nutrition.
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Summary (cont.)
 CV training is frequently necessary for patients
with RA or OA and has a positive impact on life.
 Because of inflammation, precautions must be
taken when considering exercise prescription.
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