Fitness professionals in non-clinical environments will encounter a broad spectrum of prospective clients, each with his or her own needs, issues and abilities. While it is possible to specialize in young, healthy adolescents and adults, it would be foolhardy to discount the middle-aged and older market out of fear or ignorance. There are many issues and concerns the latter bring to the gym, but don’t think you won’t run into at least one of those in the young and healthy: arthritis.
According to the Arthritis Foundation (www.arthritis.org), there are more than 50 million adults and 300,000 children with this joint disease. Arthritis can be categorized by four basic criteria: infectious (e.g. STD, Lyme’s disease), metabolic (e.g. gout), inflammatory (e.g. rheumatoid, psoriatic) and the most common, degenerative [e.g. osteoarthritis (OA). The first two are treatable and oftentimes curable; the latter two are manageable but not yet curable.
A common feature of any type of arthritis is that the movable joints, which are enclosed in a synovial pouch and cushioned by articular cartilage, get inflamed, they ache, hurt to move, and reduce their pain-free ranges of motion. The cartilage deteriorates in the presence of chronically-inflamed synovia, eventually exposing the underlying subchondral bone to greater and more asynchronous forces. These cause both softening of the bone as well as bony growths - i.e. osteophytes and spurs and sometimes cysts.
One consequence of inflammation, pertinent to fitness professionals, is that it impairs neural input to the muscles around the joint(s) which has short- and long-term consequences. The short-term consequence is the muscles are not as capable of providing support and attenuating impact forces to the articulating surfaces. With continued force production and shock absorption, from daily living or recreational pursuits, this leads to further deterioration of the joint.
The long-term consequences are further weakening of the muscles as well as compensatory or decompensatory firing of the muscles that can impact function at the joint or create dysfunctions elsewhere along the kinetic chain. Thus, not only will the stability of the affected joint be compromised, but now neighboring joints or even the entire musculoskeletal system may be compromised.
Compensatory muscle actions may alter primary functions at the affected joint, imposing greater demands on other structures. An arthritic neck, for example, may flex forward more than usual, creating greater loads along the posterior thoracic and lumbar spines. A ready example of decompensation is the limp produced by weakness of the muscles around an arthritic lower extremity joint - ankle, knee or hip. We can observe how turning the foot out, or keeping the knee locked, or externally rotating the hip can torque the lumbo-pelvic region, eventually creating low back issues.
Risk factors for arthritis
With more than 100 types of arthritis, there are innumerable risk factors for fitness professionals to consider. For simplicity sake, we will address the two most common types of arthritis – inflammatory/auto-immune and OA. Metabolic arthritis is caused by disruptions in physiological processes sometimes related to diet or genetic predisposition. Infectious arthritis obviously depends on the source of infection and one’s ability to avoid it. But autoimmune arthritis, most prevalent of which are rheumatoid arthritis (RA) and juvenile arthritis (JA), is mostly a function of a genetic and environmental factors. OA is a wear-and-tear condition, with increasing prevalence with aging, prior use or disuse or abuse, injury, family history and more commonly, even in younger people, being overweight or obese. In this light, OA may be both the least and the most preventable form of arthritis.
Treating and managing arthritis
First, treatment for any form of arthritis depends on its proximate causes. While it may not be possible to cure many types, a medical provider will initially attempt to reduce the inflammation. This may reduce pain and restore some function. If the former cannot be controlled by reducing inflammation, pain management techniques (usually pharmaceutical) can also include acupuncture, mind-body techniques, ice, heat and other modalities. For the latter - restoring function - therapeutic exercises are implemented. Depending on the extent of joint damage, the success of the medically-managed inflammation and pain, and the nature and degree of joint dysfunction, a fitness professional may have a role to play here.
The fitness professional’s guide to helping clients with arthritis
Since we are not directly a part of the medical paradigm, we must recognize our limitations. First, we cannot properly diagnose an arthritic condition even if we can visually, palpably and otherwise observe through movement analysis that a joint is not working properly. Staying within our professional bounds requires that we refer to a medical provider before undertaking any exercises that will engage the affected joint(s).
Second, we cannot prescribe specific treatments. That is, even though it is intuitive to suggest the client take an over-the-counter non-steroidal anti-inflammatory (NSAID), without a comprehensive and thorough medical education and license, the fitness professional would be putting him/herself at risk for liability issues, not to mention putting the client at risk for adverse effects.
Third, we cannot undertake therapeutic exercises unless we are operating within the medical paradigm, such as under the auspices of licensed practitioner, e.g. chiropractor, physical therapist, doctor, etc. The therapist will, after efforts are made to reduce inflammation and pain, attempt to restore range of motion, generate nerve signals to keep muscles “alive” for that time when either remission occurs or inflammation is well-managed, and eventually work to restore function. Function may take many forms, and will be individualized to what the patient requires, e.g. activities of daily living, work, recreation, etc.
But the knowledgeable fitness professional can resort to implementing an exercise program specifically designed for a client, or specific class, that has arthritis by resorting to the fundamentals of any exercise program: cardiovascular, strength, flexibility and balance training. Modifying each according to the abilities of the client(s).
First, the fitness professional should modify either the frequency, intensity, duration or most importantly the type of cardio exercise the client performs. Instead of walking on an arthritic lower extremity, try cycling or the elliptical.
Second, the fitness professional should modify the strength training routine to use lesser resistances (elastic tubes vs free weights) or even the type of contraction: isometric versus isotonic. Isometric exercises can be performed at a client-self-regulated tension within a range of motion that does not cause pain. Furthermore, the fitness professional could strengthen unaffected joints or peripherally-affected muscles to support continued functionality overall. Thus, core work is still valuable for those with OA of the knee or hip.
Third, educating and reinforcing proper stretching for all the joints, especially the affected ones, is within the purview of the fitness professional. In some states, manual stretching is legitimate within reason so long as it is not under the pretense of therapeutic. Thus, assisted stretches such as proprioceptive neuromuscular facilitation (PNF) stretching or long-duration manually-assisted hamstring stretches are worthy of a fitness professional’s talents.
Finally, balance and stability work, where “safety first” is the motto, is within the fitness professional paradigm. Avoiding positions or movements that aggravate or exacerbate pain is foremost; performing simple, static balance movements can only help facilitate function once the pain and swelling abate. And, should a joint replacement be in the client’s future, this kind of work will pay off dearly.
Arthritis comes in many forms, with many causes and a large variety of treatment and management protocols available to the medical professional. But fitness professionals are not relegated to the sideline if the client with arthritis seeks to create a more active lifestyle or prepare for the eventual surgical intervention. Knowing our limits and our obligations to the client should not be a source of fear so long as we educate ourselves on the nature and consequences of the disease. In that case, we enhance our career potential as we enhance the lives of our clients.
Irv Rubenstein, Ph.D. in exercise science (Vanderbilt-Peabody University, Nashville, TN), is the founder and president of STEPS Fitness, Nashville’s first personal fitness training center (1989). He is certified through ACSM-EP, NSCA-CSCS, NSCA-CPT, NSCA-CSPS, and ACE-CPT. Learn more about him and read his fitness and exercise blogs and newsletters at www.stepsfitness.com.
3. Hotting K and Roder B. Beneficial effects of physical exercise on neuroplasticity and cognition. Neuroscience and Biobehavioral Reviews 37 (2013); 2243-2257.
4.Szuhany KL, Bugatti M and Otto MW. A meta-analytic review of the effects of exercise on brain-derived neurotrophic factor. J Psychiatr Res (2015) January; 60:56-64.