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EXERCISE AND
ARTHRITIS
Guidelines for the Fitness Professional
by Cary Wing, Ed.D. and James A. Peterson, Ph.D., FACSM
This article provides an overview of the key factors necessary to
constitutes an appropriate exercise program for
clients with arthritis based on current guidelines.
This article addresses both factors.
understand why and how exercise should be an integral part of the
ARTHRITIS: UNDERSTANDING THE BASICS
treatment plan for individuals with arthritis. After reading this article,
For fitness professionals to train clients with
arthritis effectively, they need to have a working
understanding of this medical condition (Table).
As such, an awareness of key factors involving
arthritis is essential (7).
) What is arthritis? Arthritis is a term that collectively refers to a group of approximately
100 different rheumatic diseases that typically
affect the body_s skin and musculoskeletal
systemVprimarily, the joints. The more common types of arthritis include osteoarthritis
(the most prevalent type), rheumatoid arthritis
(the most crippling form), gout, juvenile arthritis, lupus, and fibromyalgia (3,10,11). See
Figure 1 for a comparison of osteoarthritis (OA)
and rheumatoid arthritis (RA).
Learning Objective
the fitness professional will be able to design a safe and effective
exercise program for clients.
Key words:
Osteoarthritis, Exercise Prescription, Healthy People 2020, Causes
of Arthritis, Rheumatoid Arthritis
I
ndividuals who believe that arthritis is a
major health problem in the United States
have some pretty compelling statistics to validate their concerns. More than 350 million people
worldwide, including 50 million Americans, have
some type of arthritisVa number that translates to
nearly one-in-five adults (8). Furthermore, arthritis
is the leading cause of disability among Americans
older than 15 years and the second (only to heart
disease) most prevalent reason for work disability
(6). In fact, the economic cost of arthritis in just the
United States is $128 billion annually (14).
For many years, the recommendation was that
individuals with arthritis should limit activity, and,
for the most part, confine that activity to the pool.
Now, however, an abundance of research validates
the beneficial effects of a variety of exercise modalities in managing the symptoms of arthritis (7). In
addition, one of the goals of Healthy People 2020
is the prevention of illness and disability related to
arthritis and other rheumatic conditions (9). Fortunately, the fitness professional is in a position to
provide programs to manage the disease safely and
effectively. The key issue for the fitness professional is to understand the role exercise can play in
the treatment plan. It also is important to know what
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TABLE: Frequently Asked Questions About Arthritis
1. If the joints of individuals with arthritis ache, should they avoid exercise? If symptoms are chronic (as opposed to acute) and a person is not
experiencing active inflammation, exercise can improve the situation (1).
2. What happens to the condition of individuals who do not exercise? Without exercising, joints will experience even more stiffness and pain with
decreased function.
3. Do age and gender affect a person’s relative risk for arthritis? Yes. Although all age groups experience arthritis, the condition is more common as
individuals get older. Furthermore, women are approximately 50% more likely to have arthritis than men (7).
4. Should exercise be adapted for individuals with arthritis? The American College of Sports Medicine recommends several exercise modifications for
people with arthritis, including begin slowly and progress gradually, avoid strenuous exercises during acute flare-ups and periods of inflammation,
and adapt the exercise to the specific needs of the individual (2).
5. Should individuals with arthritis exercise under the supervision of a trained professional? If multiple health problems exist or the exercise needs
modification, a health professional trained in arthritis protocols and procedures should monitor an individual (13).
6. Does diet affect the efforts to maintain joint health? Yes. In addition to helping an individual maintain a healthy body weight and thereby reducing the load
forces (stress) on weight-bearing joints, a number of foodstuffs (e.g., omega-3 oils and antioxidants) decrease the symptoms of certain forms of arthritis (5).
) What are the symptoms of arthritis? Depending on the type of
arthritis, there are a number of symptoms that can be associated
with the condition. They include stiffness of the joints; joints
that exhibit redness, swelling, warmth and/or tenderness; fever;
weight loss; lethargy; and an overall sense of being unwell.
) What causes arthritis? Subject to the type of arthritis in
question, a number of factors can lead to arthritis. Osteoarthritis results from wear and tear on the body’s cartilage and
most commonly affects the joints of the hands, hips, spine,
and/or knees (2). Rheumatoid arthritis is a systemic inflammatory disease that results from overactivation of the body’s
immune system affecting joint tissues (2). Other factors that
lead to different forms of arthritis include diet, obesity, a
defect in the body’s chemistry, a disease of the body’s
connective tissue, or an injury to a joint.
) How should arthritis be treated? Treatment options for arthritis depend on the form of arthritis and the individual’s personal
needs and situation. A comprehensive treatment program for
arthritis can include several elements, for example, weight
loss, actions to protect the joint, medications, surgery, dietary
changes, and a properly designed exercise program.
EXERCISE AND ARTHRITIS: THE PROGRAM
Exercise is as essential for individuals with arthritis as for
anyone else. Individuals with arthritis who exercise regularly
have less pain, more energy, and improved function (1).
Specifically, exercise helps keep bones and cartilage tissue
healthy and strong, helps keep joints from becoming unduly
stiff, helps enhance the level of muscular fitness around the
joints, and helps improve the overall level of fitness.
Modes of Exercise Training for Clients With Arthritis
The key to an arthritis exercise program is to identify an exercise
regimen that best meets an individual’s needs and expectations. It
must be safe, effective, and personally enjoyable. As a rule, the
fitness professional should design an exercise program that includes
four major types of exercise (1,2). The recommendations for frequency, intensity, time, and type are similar to those for apparently healthy clients with some additional considerations (2).
Figure 1. Comparison between OA and RA (12).
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Exercise and Arthritis
more traditional form of resistance training is isotonic exercising/
active strengthening, which typically is undertaken using
machines, handheld weights (e.g., dumbbells), or resistance
bands. At all times, emphasis should be placed on proper body
alignment and exercising to the point of pain tolerance.
•
•
Flexibility. Flexibility exercises involve stretching muscles
and connective tissues and moving all the joints of the body
through their normal maximal range of motion. Range-ofmotion exercises help reduce stiffness in affected joints.
These are performed at least daily (1,2).
Resistance or strength training. There are several contributing
factors in the loss of muscle strength in arthritis (Figure 2).
Resistance exercise, however, can increase strength and
enhance the capability of muscles to support the joints of the
body. The client performs exercises with a relatively low amount
of weight to start, about 10% of maximum, and progresses about
10% per week as tolerated. All major muscle groups should be
included. Frequency should be 2 to 3 days per week with one or
more sets of 10 to 15 repetitions per exercise per session. The
•
Aerobic. Aerobic or cardiovascular exercise helps improve the
overall level of fitness. Aerobic exercise involves non- or lowimpact activities (e.g., walking, water aerobics, swimming,
indoor or outdoor cycling, elliptical training) that engage the
major muscles of the body, thereby placing a demand on the
body’s cardiovascular system. Depending on the existing level
of overall fitness, clients should start slowly and progress
gradually. When first starting out, the client should perform
several brief (i.e., a few minutes) bouts of aerobic exercise as
tolerated to reach 20 to 30 minutes daily. At times, pain limits
the intensity level, but 150 minutes of moderate-intensity
activity per week accumulated for 3 to 5 days or 75 minutes of
vigorous-intensity per week is the recommended goal (7). The
fitness professional should keep in mind the guidelines for exercise prescription and modify the use of equipment, as needed,
such as seat height and load, or resistance, in cycling (2).
Figure 2. Loss of muscle strength in arthritis (12).
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•
Notifying the referring physician if the exercise regimen
causes persistent fatigue, a diminished level of range of
motion in joints, swelling in joints, and/or continued pain. If
such circumstances occur, the fitness professional needs to
modify the exercise program, paying special attention to the
duration and/or intensity of exercise (2).
TAKE-HOME POINTS
Arthritis is a serious medical problem because it is the leading
cause of disability in the United States.
• The term Barthritis[ encompasses more than 100 types of
rheumatic diseases.
•
Exercise is beneficial for people with arthritis.
•
Relative to the specific form of arthritis, a number of factors
can cause arthritis.
•
The type of arthritis and an individual’s personal needs and
situation influence the treatment options.
•
Depending on the form of arthritis and a person’s gender, age,
and genetic predisposition, individuals can lower their relative
risk or suffering from arthritis by undertaking certain steps.
•
The general benefits of exercise for individuals with arthritis
are similar to those for healthy individuals.
•
An appropriate exercise program for individuals with arthritis
is one that is safe, effective, and enjoyable.
•
An exercise prescription for arthritis should include flexibility exercises, resistance exercises, aerobic exercise, and
body awareness programs.
•
A regular exercise program provides a viable means for most
individuals with arthritis to control and manage their medical
condition by decreasing symptoms (pain and stiffness) and
improving function.
Figure 3. Tai chi and qui gong tips (12).
•
Body awareness. A joint and its surrounding muscles are
often affected by surgery or the disease itself, resulting in
impaired balance and coordination. Exercises to improve posture, balance, joint position, coordination, and relaxation
should be included in a comprehensive treatment plan (7,13).
Examples of this less recognized group of exercises as a
component of the arthritis exercise program are tai chi, qui
gong, and yoga. The fitness professional should determine the
need for these exercises in improving overall function and
include as tolerated in the exercise plan (Figure 3).
Incorporating Exercise Into a Treatment Plan for Clients
With Arthritis and Special Considerations
Integrating exercise into an arthritis treatment program involves
several key components including:
• Checking with the individual’s physician or health care team
to identify any risk factors that may interact with safely
performing the exercise, that is, cardiovascular disease, medications, or joint instability.
•
Designing an exercise regimen to address a client’s individual level of fitness. Individuals with arthritis generally tolerate
symptom-limited exercise testing to determine fitness levels (2).
•
Incorporating an adequate warm-up and cool down in the
exercise plan to protect joints and decrease the potential of
pain. The warm-up and cool-down periods should be 5 to 10
minutes in length and involve slow movements through a
joint’s range of motion (2).
•
Educating the client to listen to his/her body to reduce the risk of
injury. Clients should avoid strenuous exercise during acute
bouts of inflammation, but it is beneficial to continue to move
joints gently through their full range of motion during this period
(2). Fear of pain often leads clients to avoid exercise (Figure 4).
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Figure 4. Cycle of pain (12).
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Exercise and Arthritis
SUMMARY
The increase in the number of individuals, especially older
adults, with a variety of disease-related symptoms affecting
their exercise regimen, provides fitness professionals with
opportunities to expand their scope of services. As Healthy
People 2020 indicates, exercise remains an underused intervention in the treatment of arthritis. Extend your knowledge
base to position yourself to work with these individuals. You
should be well versed in pain relief methods, proper body
mechanics, and exercises to protect the joints. There are a
number of organizations offering continuing education credits,
certifications, programs, and courses focused on training individuals with arthritis (2,4,12). With the appropriate background and education, you, the fitness professional, can provide
a referral pathway to achieve the goal of Healthy People 2020.
Acknowledgments
The authors thank the Aquatics Department at HealthPlus Fitness
Center, AL, for providing the pictures of its arthritis program.
References
1. American College of Rheumatology Web site [Internet]. Exercise and
arthritis; [cited 2011 Jan 13]. Available from: www.rheumatology.org.
2. American College of Sports Medicine. Exercise Prescription for Other
Clinical Populations: ACSM’s Guidelines for Exercise Testing and
Prescription. 8th ed. Philadelphia (PA): Lippincott, Williams, & Wilkins;
2010;10:225Y8.
3. American College of Sports Medicine. ACSM’s Exercise Management for
Persons With Chronic Diseases and Disabilities. 2nd ed. Champaign
(IL): Human Kinetics; 2003.
4. Arthritis Foundation Exercise Program [Internet]; [cited 2011 Jan 13].
Available from: http://www.arthritis.org/programs.php.
5. Arthritis Today Web site [Internet]. Arthritis foundation: food and inflammation;
[cited 2011 Jan 13]. Available from: http://www.arthritistoday.org.
6. Brault MW, Hootman J, Helmick CG, et al. Prevalence and most
common causes of disability among adults, United States, 2005.
Morb Mortal Wkly Rep. 2009;58(16):421Y6.
7. Centers for Disease Control and Prevention Web site [Internet]. Arthritis;
[cited 2011 Jan 13]. Available from: www.cdc.gov/arthritis.
8. Cheng YJ, Hootman JM, Murphy LB, Langmaid GA, Helmick CG.
Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity
limitation V United States, 2007Y2009. Morb Mortal Wkly Rep.
2010;59(39):1261Y5.
9. Healthy People 2020 Web site [Internet]. Topics and objectives: arthritis,
osteoporosis, and chronic back conditions; [cited 2011 Jan 13]. Available
from: www.healthypeople.gov.
10. Helmick CG, Felson D, Lawrence R, Gabriel S, et al. Estimates of the
prevalence of arthritis and other rheumatic conditions in the United
States: part 1. Arthritis Rheum, 2008;58(1):15Y25.
11. Millar A L. Action Plan for Arthritis. Champaign (IL): Human Kinetics; 2003.
12. Stuhr R, Everix D. The Fitness Professional’s Guide to Training Clients
With Osteoarthritis, American Council on Exercise (ACE). Online course
in partnership with the Association of Rheumatology Health Professionals
and the Arthritis Foundation, 2010.
14. Yelin E, Murphy L, Cisternas MG, et al. Medical care expenditures and
earnings losses among persons with arthritis and other rheumatic
conditions in 2003 and comparisons with 1997. Arthritis Rheum.
2007;56(5):1397Y407.
Additional Resources
American College of Rheumatology. Treatment Guidelines. Available from:
http://www.rheumatology.org/practice/clinical/patients/index.asp.
Arthritis Foundation Web site [Internet]. Available from: www.arthritis.org.
Healthy People 2020 Web site [Internet]. Available from: www.healthypeople.gov.
Mayo Foundation for Medical Education and Research Web site [Internet].
Available from: www.mayoclinic.com/health/arthritis.
Medline Plus Web site [Internet]. Available from: www.nim.nih.gov/medlineplus/
arthritis.html.
National Institute of Arthritis and Musculoskeletal and Skin Diseases
(NIAMS) Web site [Internet]: Information Clearinghouse, National
Institutes of Health. Available from: www.niams.nih.gov.
National Public Health Agenda for Osteoarthritis, Centers for Disease Control
and Prevention, and the Arthritis Foundation [Internet]; [cited 2010
Feb 4]. Available from: http://www.cdc.gov/arthritis/docs/OAagenda.pdf.
The Johns Hopkins Arthritis Center Web site [Internet]. Available from:
www.hopkins-arthritis.som.jhmi.edu/mngment/exercise.html.
Disclosure: The authors declare no conflict of interest and do
not have any financial disclosures.
Cary Wing, Ed.D., has been in the health
and wellness field for more than 25 years,
and she has been directly involved in the
development and management of medically
integrated health/fitness centers. She lectures
and writes, extensively promoting the medical fitness industry, the medical fitness
model, and the benefits of a healthy lifestyle. Dr. Wing served
as an executive director of the Medical Fitness Association for
10 years and is currently the director of Business Development
for Medical Fitness at Fitmarc.
James A. Peterson, Ph.D., FACSM, has been
integrally involved in the development of all
three editions of ACSM’s Standards and
Guidelines for Health/Fitness Facilities and
has served as the editor of the Take 10 column in the ACSM Health & Fitness JournalÒ
since the Journal’s inception.
CONDENSED VERSION AND BOTTOM LINE
Individuals with arthritis should exercise. This article reviews
the epidemiology, the physical symptoms associated with
arthritis, and current exercise guidelines. Fitness professionals can have a positive impact on clients with arthritis by
developing a safe, effective, and relevant exercise regimen.
13. Westby M. Exercise and Arthritis. American College of Rheumatology
Patient Fact Sheet; 2009.
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