Clinical Exercise Prescription

Although not an area I wish to pursue as a career, clinical exercise prescription enables me to draw on a lot of the knowledge that I have gained during the last 3 years of my studying. During my last term at University I undertook a clinical module, of which assessment was based on a comprehensive coursework, theory and practical examination. This was by far one of the most enjoyable modules I took whist studying for my degree and consequently when arriving back home I was faced with a great opportunity to use the knowledge in a meaningful way. My granddad, who is in his late 70's now, sadly suffers from several medical conditions; crumbling vertebrae, nerve end damage and arthritis of the spine. He approached me, asking for my advice on this matter, and after discussing his illness and daily lifestyle routine, I have given him a simple programme to complete for the next 2-4 weeks. After this I will assess how he is doing and review his progress. Below I have put together some information regarding exercise, arthritis and what I have recommended to my Grampy!

Exercise as a treatment for Arthritis

- An emerging body of research highlights that light to moderate intensity exercise can play a restorative role in combating the declines in health and functional capacity caused by Arthritis (Strasser et al., 2010).

- Although pain and functional limitations present challenges to physical activity amongst individuals with Arthritis, regular exercise can help manage and minimise typical symptoms (Klippel, 2001).


- In Stenstrom & Minor’s (2003) systematic review of 15 Arthritis health studies, it was found that general health and functional ability improved (by an average of 30% and 18%, respectively) when patients were engaged in dynamic physical activity patterns (Stenstrom & Minor, 2003). 

Process of Arthritis: Bone starts to be worn down. Bone moves against bone increasing erosion and pain. Spurs develop to compensate = deformation = joint moves incorrectly = pain 

Improved Cartilage Health

- As cartilage is avascular, nutrition occurs through diffusion of synovial fluid (O’Hara, Urban, & Maroudas, 1990).

- Diffusion aided by “pumping” effect that mechanical loading produces (Van Den Hoogen et al., 1998).

- Regular exercise in animals may increase proteoglycan content through increased synthesis and retention, particularly in dynamic loading (Van Den Hoogen et al., 1998).

- Dynamic exercise can increase circulating insulin-like growth factor (IGF) by 25% (Melikoglu, Karatay, Senel, & Akcay, 2006).

- Suggestion that IGF’s can stimulate synthesis and reduce degradation of proteoglycans, thus enhancing cartilage health (Melikoglu et al., 2006).

- Larger solutes, like IGF’s, rely on intermittent loading to reach cells, due to importance for production of synovial fluid and distribution across joint surface (O’Hara et al., 1990).

- Implications are paramount to cartilage health as proteoglycans are one of the main contributors to durability (Van Den Hoogen et al., 1998).

Recommendations for future exercise

- Exercise during the day when pain has subsided.

- Some discomfort may be present during or shortly after activity, although this does not mean further joint destruction.

- If pain persists longer than 2-hours post-activity and exceeds pre-activity levels, duration and intensity of activities need to be decreased.

- During “flare ups”, performing range of motion exercises so as not to exacerbate condition is encouraged.

- Every session should incorporate a warm-up and cool-down in order to minimise pain. These may both include slow actions of moving joints through a full range of motion.




An example of some of the exercises I have prescribed - all exercises involve the use of simple resistance bands. Note - all exercises were conducted sitting down due to the patient also having arthritis in the hip. Please feel free to leave any comments regarding the above, I feel this is an interesting topic and hope that this can have a big impact on friends and family who have similar conditions.

References

Klippel, J. H. (Eds.). (2001). Primer on the rheumatic diseases (12th ed.). Atlanta, GA: Arthritis Foundation.
Melikoglu, M. A., Karatay, S., Senel, K., & Akcay, F. (2006). Association between dynamic exercise therapy and IGF-1 and IGFBP-3 concentrations in patients with rheumatoid arthritis. Rheumatology International, 26(4) 309-313.

O’Hara, B. P., Urban, J. P. G., & Maroudas, A. (1990). Influence of cyclic loading on the nutrition of articular cartilage. Annals of the Rheumatic Diseases, 49(7), 536-539.

Stenstrom, C. H., & Minor, M. A. (2003). Evidence for the benefit of aerobic and strengthening exercise in rheumatoid arthritis. Arthritis & Rheumatism, 49(3), 428–434.

Strasser, B., Leed, G., Strehblow, C., Schobersberger, W., Haber, P., & Cauza, E. (2011). The effects of strength and endurance training in patients with rheumatoid arthritis. Clinical Rheumatology, 30(5), 623-632.

Van Den Hoogen, B. M., Van De Lest, C. H. A., Van Weeren, P. R., Lafeber, F. P. J. G., Lopes-Cardozo, M., Van Golde, L. M. G., & Barneveld, A. (1998). Loading-induced changes in synovial fluid affect cartilage metabolism. British Journal of Rheumatology, 37(6), 671-676.