Tricks of the Trade
The term arthritis describes two distinctly separate medical conditions: rheumatoid arthritis (RA) and osteoarthritis (OA). RA is an autoimmune disease that results in swollen, painful joints, which are a contraindication to exercise. If a client has this symptom, ask him or her to wait until it has diminished before exercising.
OA is the more common condition and is caused by degeneration of the articular cartilage of a joint. The result is very painful, as it leads to bone-on-bone contact. Subchondral (below the cartilage) bone is full of free nerve endings and sends pain signals with each contact. During exercise, this condition can give a person sharp pains and restrict range of motion.
I am currently working with a client with OA issues in her hip. The goal is to remain pain free throughout as much of the ROM as possible. I begin with isometrics within the pain-free ROM. Because of the overload principle, she is able to increase strength at the angle of the isometric hold, and the strengthening effects carry over 10 degrees on each side. She works at various angles as long as she is pain free. She trains to the point of pain (in a given ROM), holds the isometric contraction just prior to the bone-on-bone contact and then returns to the start.
Note that by adjusting the angle of the client’s body or the affected limb, you can find an angle where there is no longer bone-on-bone contact, and you can train in a fuller ROM. For instance, my client with hip issues is restricted in her ROM when doing a clamshell on her side, but by changing her position to supine and using a band around her knees, she can move through a greater ROM—pain free.
Although working with clients with arthritis may seem daunting, you can use these strategies not only as a starting point but also as a way to progress your clients without causing further injury.
Remember, we are not going to cure arthritis with exercise. Our job is to make clients stronger and more functional and to improve their overall quality of life.
Medical Exercise Specialist
Owner, Fit 4 Life DC
A swimming pool that is 84–88 degrees Fahrenheit provides a soothing exercise environment for clients who have arthritis. A simple water-walking program is the most some clients can stand until they become stronger. If they have the physical ability, you can incorporate noodles and buoys into their aqua programs.
If I am working with clients in the fitness center, I have them use the NuStep®. This seated elliptical machine accommodates arthritic hand, knee, back and foot issues. For example, it has a glove that fits around the handles, enabling the user to move the arms without having to grip them.
For strength training, wrist and ankle weights and an adjustable cable machine are all excellent for clients who have arthritis. The Nautilus One® selectorized equipment is perfect for these clients. It has a low rise, and most of the pieces have only one seat adjustment. The weight stack is a cam system that allows users to adjust the weights with the center of a palm, so that those who cannot grip a small pin on a weight stack can still work out, using their palm to make the adjustments. In addition, this equipment has levels ranging from 1 to 50 pounds.
Which types of exercise I train clients to do depends on the range of a client’s arthritic challenges and whether the arthritis is flaring up on a particular day. I utilize aqua, tai chi and other exercise programming from the Arthritis Foundation, which has studied and approved the exercises for all forms of arthritis. I also refer to the exercise protocol devised by Miriam Nelson, PhD, for people who have osteoporosis.
I always ask a client at the beginning of a session, “How are you feeling today? Are you experiencing any pain issues?” If a shoulder, wrist, finger or knee, for example, is flaring up, we either do not exercise that area that day or we adjust the exercise to accommodate the flares. You never know how a client may be feeling before a session. Yesterday, a client arrived with swollen ankles, and it would have been detrimental for her to use ankle weights. Instead, I put weights around her thighs and worked her legs in a safer ROM.
It’s hard for some clients to realize that exercise and nutrition are keys to breaking the circle of pain that all people with arthritis experience. Once clients regularly do gentle exercise and gradually build themselves up through more aggressive exercising, they can learn to control their arthritis.
ACE-Certified Personal Trainer
Get Fit In 5
Sun City West, Arizona
For my clients who have arthritis, I make sure I maintain an open line of communication throughout our sessions. I always ask if certain exercises are bothersome or painful, and I make adjustments if necessary. Even though I choose exercises that won’t irritate the joints, I still ask about comfort levels.
Continued learning is key: When I get a new client with arthritis, I research the best exercises for that person; which exercises to avoid (often twisting movements); times of day to exercise (mornings are better for many people, but whatever time of day the client is in the least amount of pain or discomfort is best); and the effects of arthritis medication on body composition and exercise tolerance.
With arthritic clients, I start their strength training on machines, to make sure their bodies have good support—especially if clients have back problems. As people get stronger, I incorporate more strength exercises away from the machines.
I also focus on low-impact exercise: no jumping, running, etc. Clients use recumbent bicycles (if they have back problems and a weak core), elliptical machines and stationary bikes; and they engage in water walking (we have a lazy river in our facility).
I encourage my clients to watch their diet and avoid inflammatory foods (e.g., sugar and refined and processed foods) to help manage their arthritis pain.
Sarah Jane Parker
Certified Personal Trainer
I train many people with arthritis, and they are often referred to me by doctors.
With any of these clients, I ask for a medical clearance. I like to have an accurate diagnosis so I know exactly what medical issues I am working with. I also encourage clients to bring me the list of exercises recommended for them by their physical therapist, and we incorporate these exercises into the regular program they are doing for joints and muscles not affected by their arthritis.
I always begin the session with joint preparation, which involves slow movements such as arm circles or back-and-forth leg movements. Very little stretching should be done in the beginning. After joint preparation, the next step is a cardio routine at an intensity appropriate for the client. For example, if clients have arthritis in their knees, I have them walk on a treadmill or pedal a stationary bike that does not elicit any pain. I demonstrate the proper form on the bike and adjust the seat height. This is very important for joint integrity. I start arthritis clients at 60% of maximum heart rate or less, depending on their abilities.
Cardio is followed by stretching. Then we begin their physical therapy exercises.
The types of exercises I teach clients who have arthritis are specific to the areas of the body where the arthritis occurs. If arthritis is in the shoulder, for example, we do tubing exercises. We start with a high tube row. Then we do internal and external rotation with tubes. If arthritis is in the knee, we do straight-leg raises and then progress and overload with ankle weights as they improve. If arthritis is in the spine, we do over-the-ball exercises and press-ups and other back exercises. The idea is progression and overload.
Note: Knowing about a client’s pain is always important. I ask clients to please let me know when they feel any joint pain so I can adjust the exercise.
Del Mar, California