exercise Views on exercise range from those enthusiasts who point to its importance in managing obesity, diabetes, hypertension, and arthritis and suggest that it can prevent cancer to the "when I feel the urge to exercise I quickly lie down till it passes" brigade. For people with musculoskeletal disorders, exercise becomes more difficult and at the same time more important. It is important for pain relief, maintaining independence, recreation and quality of life, recovering from surgery or severe bouts of arthritis, improving sleep, managing body weight, and feeling better. Specific problems require specific exercises, and exercises need to be done correctly. Many people will require the help of a physical therapist or personal trainer to achieve this. Specific exercises that may be required, for example those to restore normal scapu-lohumeral rhythm in a patient with shoulder pain, are beyond the scope of this book. This section will first address some general principles of rehabilitation exercises and then aspects of exercise in general as they apply to people with arthritis.
Rehabilitation Exercise Rehabilitation is defined as "restoration to a former capacity." In patients with chronic arthritis, restoring or improving functional level may be a more appropriate definition. Rehabilitation may be required in a patient with severe inflammatory arthritis such as rheumatoid arthritis once the inflammation has been controlled, in a patient who has gradually lost functional ability, following an acute injury, and always following surgery. Everybody has different goals and abilities as well as different forms of arthritis at various stages. Rehabilitation programs should be tailored to each individual's needs and abilities. The goals should be realistically achievable and the time frame appropriate. Important aspects of rehabilitation include the following.
• Muscle Conditioning When a joint is painful and swollen, the muscles that normally move it weaken rapidly. This is worsened by inactivity, particularly if the muscles are habitually held in a shortened position. So, for example, when an athlete injures a knee or someone with ankylosing spondylitis develops an inflammatory effusion at the knee, the quadriceps muscles (the large muscles in front of the knee) that extend and stabilize the knee will rapidly decon-dition. Although this is easily seen as a reduction in size, the weakening is always greater than the size change would suggest. This is because there is an increase in fatty tissue in the muscle with deconditioning. Following resolution of such an event it is therefore necessary to condition the muscle again.
Muscle conditioning requires overload and activity-specific exercises. The latter is most relevant to athletes and indicates that different types of exercise will produce different conditioning effects. The individual's goals must be known when devising an exercise program. In order to increase muscle strength, power, and endurance, it is necessary to overload it. This means that if a patient with arthritis just wants to be able to walk reasonably well after a knee replacement, walking by itself is not adequate muscle conditioning for the quadriceps muscles that have become small and weak prior to surgery. There are several ways in which overload training is achieved:
(a) Increasing speed of movement, e.g., for quadriceps doing leg extensions (straightening the knee from a sitting position) or climbing stairs faster
(b) Increasing the number of times the exercise is repeated, e.g., more leg extensions or stairs
(c) Exercising more frequently, e.g., from once a day to twice then three times a day
(d) Exercising against resistance, e.g., attaching a weight to the shoe before doing leg extensions.
(e) Decreasing the rest time between exercises
(f) Altering the range through which the muscle is exercised
This final method is a very specialized area and should be done only under expert guidance. Usually a muscle is best exercised through its full normal range of movement.
The four components of muscle conditioning that need to be considered in planning rehabilitation exercise are strength, power, endurance, and motor reeducation.
1. Strength is the muscle's ability to exert force. This can improve before any noticeable increase in muscle size. This improvement is thought to be due to the improved blood supply and metabolic efficiency that occur with training. Three main types of exercise are used.
(a) Isometric exercises are when a muscle is contracted without moving the joint. These can be started before a joint has completely settled down as they cause very little pain and will not cause an inflamed joint to flare. They can prevent a lot of the wasting that occurs with a painful joint and perhaps some of the loss of proprioception (see below). The muscle is usually contracted for six seconds followed by a 20-second rest. Ten to 20 contractions are performed many times a day at increasing intensity with the joint in various positions.
(b) Isotonic exercises involve moving a joint through its range of movement with a constant resistance, e.g., doing a biceps curl holding a dumbbell. These can be concentric (when the muscle shortens) or eccentric (when the muscle lengthens). Eccentric exercise is particularly important in rehabilitation, especially if there has been a tendon or musculotendinous injury. It should be started very gradually, however, since too rapid an increase can damage a decon-ditioned muscle. The use of free weights is almost always better than using exercise machines. Free weights provide appropriate stress to all the involved tendons and ligaments. They require activation of not only the muscle group being trained but also all the stabilizing and postural muscles and in this way prepares the individual for real-world activity. Exercise machines cut out all postural and supporting muscle action and should be used only to achieve specific, short-term goals. (c) Isokinetic exercises are when the speed of movement is constant throughout the full range. Because the force that a muscle is capable of exerting is different when the muscle is at different lengths, isokinetic exercises are done against a machine that is capable of varying its resistance in response to the force applied. It is possible to perform more muscle work with this form of exercise than isometric or isotonic exercise, but there is maximal loading at the weakest points of the range of movement. Isokinetic exercise is used mainly for testing rather than for rehabilitation itself.
2. Power is the speed at which muscles can perform work or explosive strength. A standing high jump, for example, is a measure of power in the leg muscles. It is important in sports such as sprinting and the jumping and landing of basketball players. Power exercises come later in a rehabilitation program. Plyometric exercises such as hopping and bounding are often used before an athlete attempts actual sport-specific maneuvers.
3. Endurance is the ability of muscle to perform repeated contractions. Most marathon runners will have highly developed endurance, although they may have relatively little power compared with a tennis player. Endurance is improved by performing many repetitions of an exercise with relatively little resistance, e.g., walking, jogging, cycling.
4. Motor reeducation is important because muscles do not act in isolation. Rather, the prime mover works with the help of synergistic or supporting muscles on the background of stabilizing muscle action. In addition, human action usually involves a chain of movements (the kinetic chain) rather than one group of muscles moving a joint. For example, a right-handed baseball pitcher's throw (excluding the windup) begins with pressure being exerted onto the ground by the right foot and is then followed by a chain of movements through the body until the right wrist and fingers apply the final acceleration and curve to the ball. Following a significant injury or flare of arthritis it is not uncommon for these chain movements to become relatively uncoupled or for stabilizing muscles to become inactivated. This is a frequent cause, for example, of shoulder injuries or tendinitis to fail to settle after what appears to be adequate treatment. Muscle reeducation is required to restore the normal patterns of movement, and this is as important in elderly patients with rheumatoid arthritis as it is in elite athletes. The first step toward muscle reeducation is an analysis of faulty movement patterns by a skilled examiner.
• Flexibility The pain of an inflamed arthritic or injured joint causes the person to restrict its movement. The swelling in the joint also reduces the amount of movement possible and there is spasm of the muscles around the joint that cause a variable degree of splinting. The joint capsule, ligaments, and other soft tissues can in a short while start to contract so that once the original inflammation has been successfully treated, the joint may be stiff with a limited range of movement and tight muscles and tendons. Joint mobilization is used to free up the joints and stretching to relax the muscles and lengthen tendons. Mobilization should be started as soon as possible before severe restriction develops. There are many mobilization and stretching techniques taught by physical therapists that are appropriate at different stages of rehabilitation.
• Proprioception Normally our joints, muscles, and tendons are continuously sending nerve impulses to the spinal cord and brain carrying information about the position of our limbs and joints in space. This is called proprioception. Following injury or surgery these nerve pathways are damaged, leading to poor balance, poor coordination, and reduced sense of joint position. This can lead to reinjury. Proprioceptive training involves retraining these nerve pathways. Following an ankle injury, for example, a patient might start by standing on one leg, progress to standing on an unstable surface such as a wobble board, and then progress to one-leg trampoline jumping.
• Functional Exercise Rehabilitation progresses from the conditioning of muscle groups and retraining faulty movement patterns to activities that the individual intends doing for work or recreation. These latter are broadly termed functional exercises. Although basic functional activities such as walking and jogging are started early on in rehabilitation, more advanced activities such as would be required for a soccer player or manual worker to return to sport and work will start only once muscle conditioning, flexibility, and proprioception are progressing well. initially functional exercises that simulate the individual's desired activity are done in a controlled setting. The intensity is gradually increased with careful monitoring before specific sport or work activities are started. Even then it is advisable to return to previous levels of activity in a graduated fashion.
• Biomechanical Abnormalities These may have produced the injury or be the result of either injury or progressive arthritis. They may present as muscle tightness or weakness or actual joint abnormalities. Clearly, successful rehabilitation will depend on identifying them and correcting or ameliorating them. This can be achieved by muscle stretching, conditioning, proprioceptive training, taping, and orthotics and shoe modification.
One of the major advances in treating muscu-loskeletal conditions over the past 25 years has been the realization of the dangers of rest, especially bed rest, and the importance of exercise. Much pain and disability suffered by arthritis patients is due to poor posture and muscle function that results from inactivity and muscle imbalance rather than active arthritis itself, although the arthritis may have initiated these problems. Most people with arthritis who take up exercise find it helpful. Benefits that they report include more flexibility, less pain, and improved general health. People find controlling their weight easier if they exercise regularly. They sleep better, have more energy, and find the exercise helps in dealing with stress. in general, exercise should involve some combination of aerobic activities for endurance, stretching or range of movement exercises, and strengthening exercises for muscle conditioning (see Rehabilitation Exercise section above).
For those with severe arthritis, it is advisable to take advice before starting an exercise program. This may be from the patient's doctor, a physical therapist, or both. The Arthritis Foundation in most areas is likely to have appropriate exercise classes or be able to advise on what is available locally. There are also a number of very good self-help exercise books for patients with arthritis. Exercise should be enjoyable, although this will vary among individuals. Many people enjoy exercising to music (in a gym, at home, or with a Walkman), some like exercising in a group, others alone, some in the morning, and others later in the day. Warming up before vigorous exercise or stretching is important. Gentle exercise is the usual way to warm up, but this can be helped by having a warm environment, using heat rubs, or simply dressing warmly.
Relaxation techniques are a very rewarding way to end an exercise session. Progressive relaxation where each part of the body is first moved (usually contracted) and then relaxed before moving on to the next part is a commonly used technique. There are many others, however, including breathing techniques, imagery, and meditation. Many tapes are available to assist with relaxation. People with muscular pain find this particularly helpful. Walking is the most readily available form of aerobic exercise and can be fun (e.g., with a pet or friend), uplifting (in a beautiful park), educational (listening to a lecture on a Walkman), or incorporated into daily life (walk to a friend's house rather than driving). Cycling is also a good aerobic exercise that avoids much of the impact of walking or jogging, especially when using a stationary bike or modern mountain bike.
Two forms of exercise are particularly useful while joints are inflamed or very painful. Exercising in water, especially warm water, can give pain relief as well as useful exercise even when hips, knees, or ankles are too painful to walk any distance on. Not only is the water and the warmth relaxing but it also unloads the weight-bearing joints while providing good resistance to muscle action. The other useful form of exercise is isometric exercises, as discussed above under Rehabilitation Exercise.
Although recreational exercise is generally more fun, activities such as housework and gardening can be turned into therapeutic exercise. it is important to be aware of doing tasks with a good posture and alternating activities frequently. if weeding for example, weed for 10 minutes and then get up and carry the weeds to the compost heap rather than remaining kneeling for 40 minutes. Consider the use of gardening stools, wheelbarrows, high chairs in the kitchen, and ergonomic tools so as not to cause strain. it is clear, however, that the benefit of housework as exercise is less than enjoyable recreational exercise.
eye problems Several rheumatic illnesses can have associated eye problems. All parts of the eye can be involved, but different illnesses are more likely to affect particular parts of the eye.
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