Exercise Prescription for Arthritis and Rheumatological Problems

1. Exercise Prescription for Arthritis and Rheumatological Problems

2. You & Your patient are supported

3. Common Conditions • Degenerative Knees • Degenerative Hips • Shoulder Stiffness • Painful back conditions • Painful neck conditions • Polyarthritis- seropositive / seronegative

4. Associate Problems • Lower limb • Wasting of the thigh and leg • Stiffness • Obesity • Home bound and dependent • Upper limb • Stiffness • Impaired self care and dependent • Spine • Stiffness • Impaired sitting and standing tolerance • Disease related • Neuropathy • medications

5. Worry of exercise in Osteoarthritis Increased physical activity exaggerate joint symptoms ? Rejected by studies

6. Benefit of exercise in osteoathritic conditions • Alleviate pain, improve physical fitness, improves quality of life • Better ambulatory status • Less dependent • Self confidence • Social integration • Avoid unnecessary medications • Defer surgical need

7. Classic teaching - recommended activities • Swimming, cycling • Mild calisthenics exercise which promote joint movements, limited pressure and impact in joints • Other low impact weight-bearing exercise such as walking and hydro-exercise would help to improve bone density and structure • Older adults- • Combination of aerobic exercise, strength-training exercise, balance and flexibility exercise • Start low and progress according to tolerance and preference

8. Am Geriatric Society Panel on Exercise & OA

9. Am Geriatric Society Panel on Exercise & OA • 2001 June Consensus practice recommendations • Initial Evaluation & Assess • Pain severity • Physical impairments • Physical disabilities • Check • Medically stable • Without joint laxity • Willing to exercise • Exercise prescription • Re-evaluate at 4 wks • Monitor at 4-6 months, Encourage increasing physical activities

10. Exercise dose - Start • Assess • motivation • Family & Community • PAR-Q/med-X • Problem orientated • Enjoyment • Achievements & reinforcement • Golden rules • Effectiveness • Accessibility • Safety • Individualised • Enjoyment • Regular evaluation

11. Components • Warm-up • Gentle flexibility • Conditioning • Aerobic activity • Strength-training • Static muscle stretching • Cool-down • Progression • Initial, improvement, maintenance

12. Exercise prescription plan • Flexibility • Initial hold 5-15 seconds • Ultimate 3-5 stretches, hold 20-30 sec • Aerobic exercise • 20-30 minutes/day, 3-4 /wk • Strength-training exercise • Isometric • hold <6 sec, 20sec rest period, daily • Useful in acute phase • Isotonic • 6-15 repetitions, 2-3 / wk

13. Programme For Osteoarthritis

14. Programme For Osteoarthritis

15. Safe Play • Low back conditions • Avoid or minimise exercise that precipitates or exasperates • forced extreme flexion, extension, and violent twisting, correct posture, proper back exercise • Osteoporosis • Avoid exercise with high risks for fracture • Push-ups, curls-ups, vertical jump and trunk forward flexion, • Engage in low-impact weight-bearing activities and resistance training

16. Safe Play • Arthritis – acute ( infective, rheumatoid, gout) • Treatment, plus judicious blend of rest, splinting and gentle movement • Arthritis – subacute • Progressive increase of active exercise therapy • Arthritis – chronic ( osteoarthritis ) • Maintenance of mobility and strength, non-weight bearing exercises to minimise joint trauma ( e.g. cycling, aquatic activity etc.)

17. My practice • Find out the obstacles • Support • Companion • Family • Skills • Set the goal (phase approach) • Enjoyment • Achievable • The rose garden • Caution about the fluctuations • Occasional attack of inflammations • Ways to deal with it

18. Upper limbs • Stress • Shoulder Range of Motion • Active • Active assisted • passive • Balance muscle training • Multiple directions • Static • dynamic

19. Knees • Stress • Full Range of motion, especially full extension • Mild pain • Active ROM, 10 rep • Flexibility and static exercise, 10 rep x 6 sec • Dynamic exercise, Quads & Hamstring 10 rep • Low-impact activities 20 min, 3x/wk

20. Backs • Stretching • Pectorals, back extensors, hamstrings, psoas • Active ROM ex 10 x /day • Dynamic ex • Trunk & hip muscle 5-8 rep • Aerobic ex • 20 min 3 x /wk

21. Issues of different exercise • Brisk walk, Jogging • Swimming • Aerobic dance • TaiChi

22. Brisk walk, jogging, hiking • Preparation • Park, podium, gym • Surface, terrain • Shoe wear, clothing • Warm up • Pacing • Warm-down • Issues of knee brace • Advise on control of flare up • Caution about the yellow flag • Increase swelling, morning stiffness

23. Swimming • Swimmer vs. Non-swimmer • Community resources • Hydro exercise vs. lap-swimming • Style • Breast stroke – Knee ROM required • Free style – Shoulder Rom required

24. Taichi • Proved to be good in aerobic ability, muscle strength & Balance • Community resource • Demanding on • Knees • Co-ordination • Stress on the need of warm up • Stress enjoyment

25. Individualized treatment Comorbid conditions Patient's needs and expectations Types of treatment Non-pharmacological Patient education Exercise Therapy Assistive devices PT & OT Weight management Supplements Pharmacological Simple analgesics NSAID COX-2 inhibitor Local analgesics Intra-articular corticosteroid Intra-articular hyaluronic acid­like product Surgery Arthroscopic debridement or joint lavage Osteotomy for mal-alignment of the knee or hip Arthroplasty Osteoarthritis

26. Important charts “Supplementary Information on Writing an Exercise Prescription”