Rheumatologic Conditions

1. Rheumatologic Conditions • Over 100 forms of arthritis • 3 major and common conditions • Osteoarthritis (OA) • Rheumatoid arthritis (RA) • Fibromyalgia syndrome (FMS) • Each condition has no known cure • Treatments • Surgical procedures for OA and RA • Pharmacological approach (All three) • Patient education • Exercise programming, nutritional counseling, behavior modification • All three conditions usually lead to long-term disability!

2. Osteoarthritis • Degenerative joint disease or osteoarthrosis • Most common form of arthritis • One of the most common chronic diseases in the US • 40 million Americans • 2nd most common cause of long-term disability in the adult pop. • This is not a normal characteristic of aging as many claim it to be!

3. Epidemiology & Pathophysiology • Characterized by: • Localized degeneration of the articular cartilage • This is the major pathology! • Synthesis of new bone at the joint surfaces/margins • Typically effects: • Hips • Knees • Feet • Spine • Hands

4. Primary Risk Factors • Age • Gender • Race • Occupation (related to chronic overuse) • Obesity • History of joint trauma • Bone or joint disorders • Genetic mutations of collagen • History of inflammatory arthritis

5. Who Does OA Affect? • Symptoms are not always present in OA • 90% of population show degenerative effects in weight bearing joints (hips, knees, feet) by age 40! • After age 50, its more prevalent in women than men • Associated  in severity & the # of joints affected • Hip, knee, and hand in women • Older men more susceptible to hip OA • Knee OA is more prevalent in AA women than: • Caucasian females • Obese females • Non-smokers • Physically active females

6. Two Major Types of OA • Primary or Idiopathic • Most common type • Diagnosed when there is no known cause for the symptoms • Secondary • Diagnosed when there is an identifiable cause • Trauma or Underlying joint disorder • Each of these major types has subtypes

7. Common Major Criterion for OA • Presence of pain • No nerve supply to the articular cartilage • Pain may be associated with the following: • Inflammation of the synovium • Medullary hypertension • Microfractures in the subchondral bone • Stretching of periostal nerve endings by osteophytes (spurs) • Stretching of ligaments • Spasming of muscles around the inflamed joint capsule

8. Common Symptoms & Features of OA • Localized pain and stiffness in and around the joint • Osteophytes (bony hypertrophy/spurs) • Cartilage destruction • Joint malalignment • Movement/gait problems • Muscle weakness • Activity limitations • Morning stiffness lasting less than 30 minutes • Pain is worse with activity and better with rest

9. Specific Joint Symptoms • Knee OA • Instability and buckling of the knees • Hip OA • Groin pain and radiating leg pain • Hand OA • Decreased manual hand dexterity • Neck and Low Back OA • Radiating pain, weakness, and numbness (nerve root compression)

10. Common Outcomes • As pain  upon joint loading and weight bearing, physical activity and joint mobility decrease! • Joint contractures especially in the weight bearing joints • Decrease in joint mobility decreases effectiveness of movements • Increase risk of comorbidities due to a lack of activity • Heart disease • Hypertension • Obesity • Diabetes • Depression • Some Cancers

11. Exercise Testing Considerations • Tests should be done in the most pain-free manner • Address patient positioning and biomechanics of tests • Testing sequence • Adequate recovery between different testing components • Does the risk of testing outweigh the benefits? • If it does, don’t test them!!

12. Testing Components • Assessment of pain (qualitative/quantitative) • Arthritis Impact Measurement Scales 2 • WOMAC Osteoarthritis Index • Physical limitations assessment • Physical function assessment • 6 minute walk plus HR response and RPE • Rising from a chair for 1 minute • Flexibility • Sit and Reach, Individual joint ROM • Muscle function • Isometric,istonic, or isokinetic • Cardiovascular function • Submaximal test (Cycle may be better than treadmill)

13. Exercise Prescription & Programming • Address characteristic symptoms and limitations • Focus on functional capability to start • Flexibility is vital due to their restricted ROM • Increase muscular endurance first then strength • Select non-weight bearing resistance training first • Progress to aerobic activities • Minimize pain associated with impact • Add in alternatives to enhance compliance • Kinesthetic awareness and balance • Yoga, Tai Chi, etc. • Table 10.1

14. Flexibility Guidelines • Pain-free ROM • 3-5 times per day • 10-15 minutes per session • Dynamic ROM instead of a passive ROM • Very low intensity • Gentle movements • Modified Yoga would be great!

15. Resistance Training • Isometric training • Pain-free due to lack of movement • Increase muscular strength through maximal voluntary isometric contractions • 3-5 maximal contractions per muscle group once a day • Hold each contraction for 5-10 seconds • 2-3 sessions per week • Start at 10% of maximal values • Progress no more than 10% per week • Start with slow controlled movement velocity • Focus on excellent technique • Gradually increase speed of movement in order to recruit all fiber types

16. Resistance Training • Isotonic and/or isokinetic • Pain-free due to lack of movement • Focus on excellent technique • 2-3 sessions per week • Start with slow controlled movement velocity but progress to moderate velocity as quickly as possible

17. Cardiovascular function • Low impact options • Swimming, etc. • Accumulate 30-60 minutes per day • 3-4 sessions per week • 60-80% of peak HR or 50-70% of HRR or VO2res • Progress slowly with intensity • Be aggressive with duration!

18. DLA/ADL Routine • Design home routine for the individual • Perform daily • Provide specific progressions • Individual should keep diary of ADL activities and how they feel they are progressing!