JOINT STRUCTURE

Although RA in particular can affect various areas of the body, arthritis in general is associated with
inflammation of the joints.

SYNOVIAL FLUID
Synovial fluid is a diluted solution of blood plasma plus mucin, and its function is to lubricate the
articulated surfaces and nourish the articular cartilage. However, the status of the synovial fluid may
be affected by its nutrient quality and ability to lubricate. Therefore, any joint inflammation,
bleeding, infection or trauma can potentially affect the quality of the synovial fluid.

CARTILAGE
Cartilage is an essential component of the cartilaginous and synovial joints. Cartilage contains no
blood vessels, lymphatics or nerves, and is therefore limited in its capacity to repair and regenerate.
Thus, any damage or degeneration to the cartilage is generally permanent. Irregularities in or
damage to the articular surface lead to progressive degenerative alterations in the surrounding
cartilage, and ultimately to pain and limitation of movement. Even the normal stresses and strains of
living cause wear and tear on the cartilage, causing it to be less resilient and increasing
susceptibility to damage by enzymes released by certain types of infecting organisms.

OSTEOARTHRITIS
Both in the aged population and in obesity play an important role in the increased prevalence of
OA, and whilst exercise practitioners cannot alter the age of their clients, with appropriate
PA/exercise prescription they may be able to assist them in reducing their body fat levels.

PATHOPHYSIOLOGY AND SYMPTOMS

Osteoarthritis, or degenerative joint disease, is characterized by degenerative alterations of the
hyaline cartilage and hypertrophic changes in the articular bone ends. The affected bone becomes
thickened and spreads outwards forming spurs round the joint margins. Synovial fluid may enter
the bone giving a cystic appearance. The joints that are affected become hypertrophied and there is
a decreased flexibility, which leads to stiffness, pain and limitation in movement.

AETIOLOGY
Although the exact aetiology of OA is unknown, primary or idiopathic OA is viewed as the
inevitable effect of the ageing process, or a lifetime of wear and tear on the joints. Inflammatory
changes do not appear to be significant in OA, but OA can be found in conjunction with RA, where
inflammation plays a considerable part.

Physical activity/exercise
Considering that wear and tear and incorrect loading have been associated with OA, many have
questioned whether regular participation in certain sports may actually increase the risk of
developing OA. Several researchers have reviewed the literature, and taking into account animal
experiments and occupational studies, there is a slight increase in risk of OA in weight-bearing
joints, due to very frequent and heavy exercise over many years. However, for the less active
exercisers and those participating in recreational physical activity, the risk of developing OA in
normal joints does not appear to be increased. Several studies have compared the risk of developing
OA between different sporting activities, and found certain sporting activities to produce a greater
risk of OA than others. The risk of OA of the knee was increased in those with previous knee injury,
high body mass index at the age of 20 years, previous participation in heavy work, kneeling or
squatting work and participation in soccer.

TREATMENT
Treatment is aimed at dealing with the symptoms and retarding the inevitable effects of articular
degeneration. Non-steroidal anti-inflammatory drugs (NSAIDs) are generally prescribed for pain
relief, and depending on the extent of the incapacity, ambulatory aids such as walking supports,
splints or braces may also be used. Other interventions involve physical therapies, such as manual
therapy techniques, balance, coordination and functional retraining techniques.

Physical activity/exercise
Regular PA/exercise is an important therapeutic intervention for all types of arthritis, as it can
prevent deconditioning of the muscles, keep joints stable, improve joint function and flexibility,
decrease pain, enhance aerobic fitness, improve balance and decrease risk of falls. Overweight and
obesity are contributors toward OA, and since weight reduction is commonly an outcome of
PA/exercise programmes, this may, in part, be one of the mechanisms by which PA/exercise
intervention can be effective in treating OA. Regardless of the fact that knowledge concerning the
effect of PA/exercise on cartilage is still limited, it does appear that cartilage adapts to loading in a
similar manner to other biological tissues, such as bone and muscle. Although high-impact exercise
may aggravate OA, most exercise interventions do not appear to produce adverse effects. In fact,
dynamic PA/exercise, such as cycling and walking, have been shown to increase the rate of synovial
blood flow in joints, which may be beneficial in inflamed joints that are chronically hypoxi.

RHEUMATOID ARTHRITIS
It is characterized by inflammation and destructive joint changes and inflammation to the tendon
sheath. The bones of affected individuals with RA also appear to have some erosion of the bone,
joint deformity and a narrowed joint space, due primarily to inflammatory tissue forming over and
destroying the articular hyaline cartilage (a type of connective tissue that thinly covers the
articulating ends of bones), causing the joint to swell and limiting its degree of movement.
However, due to the inflammatory characteristic of RA many body tissues or organs may be
affected, and people with RA often have a propensity toward respiratory and heart problems.

Synovial fluid
The synovial fluid of RA joints is also affected, and often infiltrated by lymphocytes (type of white
blood cell) and plasma cells. It also demonstrates a sterile inflammation, with high neutrophil
counts (white blood cells that remove and destroy bacteria, cellular debris and solid particles) and
increased concentrations of proinflammatory cytokines. The plasma also shows a proinflammatory
shift in T-cell populations (which stimulate other immune cells to proliferate and secrete). These
cells, as well as the synovial membrane cells of the joint capsule, then release lysosomal enzymes
(that cause self-digestion of the cell), which themselves act to perpetuate a chronic synovitis
(inflammation of the synovial membrane of the joint), leading to eventual destruction of the
articular cartilage, and the typical pain, stiffness and loss of function.

TREATMENT
There are three main categories of drug therapies for those with RA, and generally sufferers are
initially prescribed NSAIDs, which are used to reduce pain and joint stiffness but do not influence
the underlying disease process. However, these types of medication may increase risk of ulcers or
kidney damage in those with a history of stomach ulcers or kidney problems respectively. The third
line of drug treatment involves the use of glucocorticoid steroids. These are very effective in
relieving joint pain and stiffness. However, due to their adverse side effects, such as diabetes and
osteoporosis, they are commonly reserved for when the condition is severe and incapacitating.
Rest
Rest is frequently suggested as one of the most effective methods for reducing joint swelling and
pain. During flare-ups of RA symptoms, bed rest of around 2 to 3 weeks may settle acute
inflammation. However, once these acute symptoms have settled, gentle mobilization may be
introduced.

Physical activity/exercise
In the healthy individual the synovial cavity has a negative pressure, and when the joint is exercised
vascular patency is maintained. This allows for nutrition of the articular cartilage, which does not
possess any blood vessels of its own. In RA the cavity pressure is higher than normal, and upon
movement this pressure exceeds the capillary perfusion pressure, resulting in collapse of the blood
vessels. It might therefore be thought that any PA/exercise would be harmful or cause a progression
in the disease. However, research into the effect of PA/exercise on RA has failed to show that
appropriate PA/exercise accelerates the disease. Indeed, in most cases PA/exercise programmes
have been shown to be of benefit to the RA sufferer. For instance, research has shown that dynamic
PA/exercise can increase the rate of synovial blood flow in joints with effusions, possibly benefiting
inflamed joints that are chronically hypoxic due to the elevated intra-articular pressure and chronic
synovial ischaemia.

Immune response to physical activity/exercise

Healthy individuals who regularly perform moderate PA/ exercise tend to show little change in their
pre-PA/exercise immune parameters. A study carried out on 18 RA patients found that after 8 weeks
of cycle training, although aerobic capacity was significantly improved, resting levels of immune
parameters did not significantly change. It therefore appears that whilst the immune system seems
to respond during a bout of PA/exercise, these changes appear to return to pre-PA/exercise once the
PA/exercise has ceased.

Types of physical activity/exercise

Researchers found that although there was no change in the need for RA medication, training of the
muscles acting over the swollen joint led to more than a 35% decrease in the number of swollen
joints. It also appears that dynamic PA/exercise may be more effective in increasing joint mobility
and muscle strength.

PRE-PHYSICAL ACTIVITY/EXERCISE PRESCRIPTION FOR BOTH OA AND RA

Since the large majority of OA sufferers are likely to be elderly, they are also likely to have age-
related co-morbidities, which need to be identified and accounted for within the PA/exercise
programme.

PHYSICAL ACTIVITY/EXERCISE PRESCRIPTION

It is clear that with appropriate PA/exercise prescription, those suffering from OA and RA can
safely participate in PA/exercise programmes and it has been recommended that a comprehensive
PA/exercise programme should include stretching exercises followed by a range-of-motion
programme for joints, muscle strength and aerobic exercise.

FREQUENCY
It is important to maintain joint mobility. Therefore, all joints should be put through a full range of
motion on a daily basis. Additionally, PA/exercise sessions should be frequent. However, if there is
pain and inflammation a few days rest may be required.

INTENSITY
The intensity of PA/exercise prescribed should be based on an individuals pain tolerance and
physical capacity, with low- to moderate-intensity PA/exercise being preferred. High-impact loads
or activities that have a high risk of injury and quick and excessive movements should be avoided.

DURATION
The duration of a PA/exercise will depend upon the needs and physical status of the client/patient.
However, initial sessions may start at around 10 to 15 minutes and gradually increase in duration.

TYPES OF PHYSICAL ACTIVITY/EXERCISE

In order to reduce joint stress, non-weight-bearing activities such as swimming and cycling are
preferred. Dynamic PA/exercise such as cycling and walking has also been shown to increase the
rate of synovial blood flow in joints, which may be beneficial to inflamed joints.

Resistance training
For those with OA of the knee, progressive resistance exercises have been shown to be as effective
as dynamic PA/exercise in producing improvements to the severity of disease, pain and walking
time.

Water-based activities
Water-based PA/exercise is recommended not only because it avoids quick movement, which is not
recommended for those with arthritis, but also because it supports body weight and in warm water
may help reduce pain. Additionally, it has been shown to be a good form of therapy for improving
the strength of those with RA.

WARMING UP AND COOLING DOWN

Warming up before the PA/exercise session is an important part of most individuals PA/exercise
programme; and for those with arthritis there are other pre-PA/exercise interventions that may assist
the arthritic individual during the PA/exercise session. For example, the Arthritis Foundation
recommends that before structured exercise, heat or ice treatments should be applied to the area
being exercised. The rationale behind this is that heat relaxes the joints and muscles and helps to
relieve pain. Cold on the other hand can, for some individuals, reduce pain and swelling. Those with
arthritis also require an extended warm-up lasting at least 10 to 15 minutes. The warm-up should
include gentle range-of-motion and strength exercises before the aerobic/dynamic type activities.
The cool-down should last around 10 minutes, and should incorporate gentle stretching.

CONSIDERATIONS AND CONTRAINDICATIONS

Although it is clear that PA/exercise can be of great benefit to those with OA and RA, PA/exercise
programmes should not include high-impact loads or activities that carry a high risk of injury, or
quick and excessive movements. It is also important to balance rest with activity and passive
PA/exercise, and during acute arthritic flare-ups PA/exercise should be avoided altogether. In some
individuals with OA of the knee, the quadriceps appears to have some impaired proprioception,
particularly when the knee is in more extended positions. This results in a reduction in ability to
accurately and steadily control submaximal force, and eccentric strength.