Chapter 36Arthritis

1
Chapter 36-Arthritis Exercise

• Most common forms of arthritis-Osteoarthritis
  (OA), fibromyalgia (FM), rheumatoid arthritis
  (RA).
• OA-degenerative disease that affects articular
  cartilage and underlying subchondral bone.
  Cartilage surfaces are roughened, causing
  hypertrophic changes leading to joint space
  narrowing. Loss of cartilage, bone spur growth
  stiffness of subchondral bone (Fig. 36.2)

2
Etiology

• Usually some biomechanical structural
  abnormalities, obesity alter joint dynamics,
  causing improper loading on joints causing
  microcracks in the subchondral tissue, thins
  articular cartilages. Secondary center of
  ossification causes greater bone deposition,
  decreasing shock absorption of trabecular bone
  further degrading cartilage.

3
Causes of OA

• Inflammation within joint- OA patients have high
  levels of inflammatory cytokine (Interleukin-1
  beta (IL-1Beta) in joint fluid, plus elevated
  levels of IL-6, TNF-alpha, C-reactive protein in
  blood. 5-year prediction of OA progression made
  from CRP and TNF-alpha levels.
• Downward spiral predicted in Fig. 36-4

4
Treatments

• Pain relief best offer to patients.
• Exercise combining endurance exercise
  resistance training can improve function,
  decrease level of disability and pain, faster
  walking paces.
• For overweight individuals, magnitude of weight
  loss contributed to greater self-reported
  improvement in functional status (Table 36-1).
  Measured declines in levels of CRP, IL-6,
  TNF-alpha with subjects who lost 5 body weight.

5
Exercise Prescription

• Based on degree of pain, exercise duration may
  have to be short at first, with planned rest
  breaks. Adding resistance exercise helps improve
  joint force performance. Select low impact
  exercises, non-weight bearing especially for
  those who are overweight. Water exercise is
  perfect environment.
• Exercise should be focused on promoting weight
  loss and improving range of motion.
• Avoid exercise if joint is swollen or inflammed.

6
Pharmacological Treatments

• Acetominophen first choice.
• NSAIDs very popular including aspirin,
  ibuprofen, and naproxen. Block both
  Cyclo-oxygenase 1 2 enzyme, which affect
  stomach, kidney and prostaglandin production,
  respectively. Recent publicity of Vioxxx,
  Celebrex have IDd risk of the COX-2 inhibitors.
• Topical pain med (Capsaicin) best alternative.

7
Dietary Supplements

• Glucosamine-thought to promote synthesis of
  preteoglycan glycosaminoglycan, which are
  components of cartilage, by inhibiting IL-1beta.
  Results of clinical trials are promising but not
  great-reduced pain, inproved self-reporting of
  activity and less joint space narrowing.
• Chondrotin- inhibits degradative enzymes in
  synovial fluid. Again, early results suggest less
  use of NSAIDs, less pain, and better function.
• Combined use- also effective, but used with other
  supplements (Manganese ascorbate, vitamin C).

8
Surgical Treatments

• Debridement-trim torn damaged cartilage
• Lavage-flushing out joint
• Results are mixed, not a big difference in pain
  perception between treatments and placebo
  surgeries found similar relief of pain and
  function as actual treatments.
• Total joint replacements-used for older, advanced
  cases of OA-90 success rate in improving pain,
  quality of life, functional status.
• Partial knee replacement (Osteotomy)-helps with
  joint alignment and best solution for younger,
  less involved condition.

9
Fibromyalgia

• Rheumatologic syndrome-widespread pain for at
  least 3 months, pain at many tender points (11 of
  18) Table 36-2. Diagnosed after other conditions
  eliminated.
• Traced to hypothalamic-pituitary-adrenal (HPA)
  axis, which could lead to reduced levels of
  cortisol, growth hormone.
• Substance P-peptide related to pain-2-3x greater
  concentration with fibromyalgia patients
• Collagen abnormalities related to IL-1beta, IL-6
  TNF-alpha in some patients who experience
  relief with NSAIDs

10
Treatments

• Pain management- cognitive interventions,
  behavioral strategies dealing with chronic
  condition.
• Exercise- Aerobic training improves pain levels,
  global well-being, adherence big issue with these
  folks due to pain
• Most aerobic studies show significant
  improvements. Recent work suggests that
  resistance training can be added safely to
  augment gains made by endurance exercise
  training. Treat each person on a case-by-case
  basis, as pain levels differ greatly.

11
Pharmacologic Treatment

• Antidepressants to improve mood, sleep quality,
  pain fatigue.
• NSAIDs-very limited effectiveness

12
Rheumatoid Arthritis (RA)

• Inflammatory Disease-autoimmune disorder,
  abnormal increase of cells within synovial fluid
  Thicjening of membrane, causing further swelling
• Gradual degradation of cartilage and joint
  articulations
• RF antibody attaches to IgG, causing inflammatory
  cascade.

13
Etilogy

• Genetics may account for up to 60 of cases
• Leukocyte antigen system problem
• Smoking, obese, infections, age and hormonal
  swings other independent risk factors

14
Treatments

• Exercise may be best as long as immune system is
  not aggravated. Very good results with resistance
  training combined with aerobic exercise
• Normal exercise training doesnt seem to
  aggravate inflammatory markers such as IL-1beta,
  TNF-alpha
• 30 60 min/day, 3x per week, 2x resistance
  training at 50-85 MVC doesnt increase pain
  levels.

15
Medications

• NSAIDs, glucocorticoids (steroids), antirheumatic
  drugs (DMARDs)