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Rheumatology Videos Aug 11, 2022

The Importance of Exercise for People with Arthritis

A UT Health Austin rheumatologist explains the role of exercise in arthritis management

Written by: Lauren Schneider

“As we get older, arthritis shows up at any point,” says rheumatologist Kevin V. Hackshaw, MD, who serves at the Rheumatology Clinic at UT Health Austin. “The most important approach to treatment of arthritis is exercise.”

In this webinar, Dr. Hackshaw defines different arthritic conditions and offers suggestions for how people with arthritis can incorporate exercise into their treatment strategy.

According to Dr. Hackshaw, osteoarthritis is the leading cause of disability in the elderly population. This progressive, degenerative form of the condition is largely thought to be non-inflammatory and typically affects the hand joints, spine, and weight-bearing joints of the upper and lower extremities.

Symptoms associated with osteoarthritis:

  • Dull joint pain made worse by activity
  • Stiffness following periods of immobility (“gelling”)
  • Crepitus, or joint creaking. “As we get older, there is less fluid in the joints that surrounds each of our joints. You are now experiencing the cartilage rubbing against the adjacent cartilage. In the worst scenarios, you can have the bone rubbing against the bone,” says Dr. Hackshaw
  • Bony enlargement
  • Mild swelling
  • Absence of morning stiffness

Arthritis patients with morning stiffness likely suffer from an inflammatory form of arthritis such as rheumatoid arthritis.

Dr. Hackshaw says that with age, joint pain is most commonly experienced in the shoulders, hands, hips, and knees.

Arthritis in the shoulders can often result from damage to the rotator cuff, which Dr. Hackshaw defines as “the muscles that stabilize the joint, hold it in place and allow you to do all the things that you need to do with regard to rotation of the shoulder.”

Causes of rotator cuff damage

According to Dr. Hackshaw, “85% of individuals will have some rotator cuff disease.”

“The blood flow to the rotator cuff is dependent on gravity. When your arm is overhead, you’re actually decreasing blood flow to the rotator cuff,” he explains.

In younger people, rotator cuff damage is caused by overuse through motions like pitching a baseball or swinging a tennis racket. “These are types of activities where you are constantly using your arm overhead.”

The rotator cuff can also be damaged during sleep if your arms are positioned above your shoulders.

“One of the first things you can do [to prevent rotator cuff damage] is make sure that you’re sleeping with your arms below your shoulder level, keeping them at your side,” says Dr. Hackshaw. “You almost have to retrain yourself as you get older because of this type of issue.”

Stages of rotator cuff damage

Dr. Hackshaw describes the three stages of rotator cuff damage, emphasizing that the first two stages are reversible with adequate treatment.

Stage 1: Tendon hemorrhage and edema (Age <25)

During this stage, “there is some bleeding into the tendons [that connect the rotator cuff] and they begin to swell. You might not experience any pain at that time.”

Stage 2: Tendinitis and fibrosis of of subacromial bursa (Age 25-40)

“As you get into ages 25 to 40, you begin to develop some inflammation, some fibrosis (scarring) of the bursa (cushions around joints) and the tendon structures that hold the shoulder in place.”

Stage 3: Tears of the rotator cuff and the bicipital tendon (Age >40)

“Once you get above the age of 40, you begin to experience tears of the rotator cuff and also to [the] bicipital tendon. When those tears become symptomatic enough and large enough, then you experience chronic pain, night pain.”

Rotator cuff disease can lead to impairments in the following shoulder motions.

  • Forward flexion
  • Forward extension
  • Internal rotation
  • External rotation: One way a clinician can test for rotator cuff disease is by having a patient hold their arm at their side and push it outward. “If they can’t push out against your resistance, and particularly if doing that leads to pain in the shoulder girdle area, that is indicative of a rotator cuff tear or rotator cuff disease,” says Dr. Hackshaw.
  • Shoulder abduction: “As the individual tries to hold the arm up [at a 90° angle] and the physician is pushing down on the arm,if that activity leads to pain in the shoulder area, that’s what we call rotator cuff disease.”

Another test used to identify rotator cuff damage is the empty can test, in which an individual holds their arms out and rotated as though they were emptying a can of liquid. The doctor then pushes against their arms downward and the individual is asked to resist this force.

According to Dr. Hackshaw, osteoarthritis is associated with bony enlargements in the hands. When these bony enlargements occur in the distal joints (closer to fingertips), they are known as Heberden’s nodes. Bony enlargement in the proximal joints (closer to the palm) are known as Bouchard’s nodes.

Arthritis in the hips is associated with a decrease in cartilage between the hip joint and the pelvis, as visible on an x-ray. “As a result, individuals don’t have the ability to externally rotate the hip in or out.”

In advanced cases, the cartilage has decreased to the point where the hip and pelvis are “totally bone-on-bone,” preventing the patient from crossing their legs.

“Knees, similarly, can have osteoarthritis,” says Dr. Hackshaw. Cartilage in the knees is often worn down in patients who have been overweight for several years.

Dr. Hackshaw emphasizes that when it comes to arthritis management, “exercise is number one,” noting that while there is no medical consensus about the best form or amount of exercise for individuals with arthritis, “the bottom line is we want patients moving.”

He highlights many additional health benefits associated with exercise, including the following:

  • Reduced risk of dying prematurely
  • Reduced risk of dying from heart disease
  • Reduced risk of stroke
  • Reduced risk of developing diabetes
  • Reduced risk of developing high blood pressure
  • Lower blood pressure in patients with high blood pressure
  • Reduced risk of developing colon cancer
  • Reduced feelings of depression and anxiety
  • Easier weight control
  • Stronger bones, muscles, and joints
  • Improved balance, reducing the risk of falling

Medications

Dr. Hackshaw mentions several classes of medication that can be combined with exercise for arthritis management.

Over-the counter medications
  • Acetaminophen
  • Oral or topical non-steroid anti-inflammatory drugs (NSAIDs)
  • Topical anti-inflammatory compounds such as capsaicin
  • Glucosamine with chondroitin
  • Turmeric
  • Tramadol
  • Duloxetine
Prescription medications

“All of these should be used after consulting with your physician to make sure that there are no contraindications to using any of these agents,” he cautions.

Weight Loss

“Trying to achieve a normal body mass index is one of the key goals that all of us should have no matter what our age,” says Dr. Hackshaw. “You can come up with weight goals in conjunction with your physician to make sure that whatever you’re doing is safe based on other underlying comorbidities that you might experience.”

Dr. Hackshaw names several exercises that may be useful to arthritis patients, listed below with the timestamp of his description.

Detailed illustrations and additional instructions on how to perform the exercises mentioned in this webinar can be found by clicking the exercise name.

Stretches

Back
Calves
Hamstring
Hands/wrists
Hips
Knees
Neck
Quadriceps
Shoulders/rotator cuff

Strength exercises

Arms
Abdominal muscles

“For those who might experience some low back pain, core abdominal strengthening is key,” says Dr. Hackshaw.

Back
Hamstrings
Hips
Quadriceps
Triceps

Balance exercises

Please remember to contact your provider with any questions you have to ensure you receive answers specific to you.

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