Research, Resource & Education

ARTHRITIS
Definitions, Exercise, Precautions & Diets

Table of Contents

Starting an exercise program with arthritis or pre-arthritis can be different than for an otherwise  healthy adult. Bones can be strengthened with proper nutrition and weight bearing exercises. The decision to start an exercise routine for arthritis can feel overwhelming and intimidating. However, it’s important to keep in mind that proper nutrition and weight-bearing exercises are essential for managing arthritis symptoms and maintaining overall health and well-being.  

It is recommended that if you’re new to exercising or have pre-existing health concerns, you should consult your physician before beginning any exercise program. This will ensure that you receive personalized recommendations tailored to your unique health status, and potentially prevent any complications that may arise.

It is important to remember that the information presented here and in books is of an educational nature and should not be used in lieu of medical advice from your doctor and healthcare team.

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Arthritis Types, Commonly Affected Joints & Definitions

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  • Osteopenia is a condition of bone that is slightly less dense than normal bone, but not to the degree of bone in osteoporosis.
  • Your bones are usually at their densest when you’re about 30.
  • Osteopenia, if it happens at all, usually occurs after age 50.
  • The exact age depends how strong your bones are when you’re young.
  • If they’re hardy, you may never get osteopenia.
  • If your bones aren’t naturally dense, you may get it earlier.
  • Osteoporosis is a condition characterized by a decrease in the density of bone, decreasing its strength and resulting in fragile bones.
  • Osteoporosis literally leads to abnormally porous bone that is compressible, like a sponge.
  • This disorder of the skeleton weakens the bone and results in frequent fractures (breaks) in the bones.
  • Bones that are affected by osteoporosis can break (fracture) with relatively minor injury that normally would not cause a bone to fracture.
  • The fracture can be either in the form of cracking (as in a hip fracture) or collapsing (as in a compression fracture of the vertebrae of the spine).
  • The spine, hips, ribs, and wrists are common areas of bone fractures from osteoporosis although osteoporosis- related fractures can occur in almost any skeletal bone.
  • Osteoarthritis likely begins with the breakdown of articular cartilage, a tough material that cushions and protects the bone ends.
  • Cartilage allows bones to smoothly glide over one another and effectively absorb the shock of physical movement.
  • With OA, cartilage becomes damaged and ineffective, leaving the bones to rub against one another during movement.
  • This process may be stimulated by high circulating levels of pro- inflammatory cytokines and other inflammatory cells.
  • Friction in the joint causes pain, swelling, and decreased range of motion.
  • Sometimes small deposits of bone, known as osteophytes, start to grow at the edge of the joint.
    • If these osteophytes break off and float into the joint space, they can cause more pain and damage
  • Rheumatoid arthritis is an inflammatory disease that causes pain, swelling, stiffness, and loss of function in the joints.
  • The body’s immune system essentially turns against itself.
  • RA typically occurs in a symmetrical pattern. For example, when one knee or hand is involved, the other one is also involved.
  • The disease often affects the wrist and finger joints closest to the hand. Other body parts and systems can also be affected. (National Institute of Arthritis and Musculoskeletal and Skin Diseases (NISM)
  • Inflammation in the synovium causes changes in the joint as well as ligament laxity and loss of strength.

Disease Characteristics

There typically are no symptoms in the early stages of bone loss. But once your bones have been weakened by osteoporosis, you may have signs and symptoms that include:

  • Back pain, caused by a fractured or collapsed vertebra
  • Loss of height over time
  • A stooped posture
  • A bone fracture that occurs much more easily than expected

(Mayo Clinic)

  • Onset older age
  • Joint pain, swelling and stiffness after periods of inactivity or excessive use
  • Morning stiffness lasts less than 30 minutes
  • Cartilage degeneration
  • Grating or ‘catching’ sensation during joint movement
  • Joint instability and buckling (knee)
  • Bony growths at the margins of affected joint (osteophytes / bone spurs)
  • Loss of mechanical integrity of the joint
  • No visible joint changes can be seen in the spine, knee, or hip
  • Spurring and enlargement of finger joints (proximal and distal interphalangeal joints or PIP and DIP) can become visible
  • In OA of the foot, the metatarsal phalangeal (MTP) joints drop down and the fat pad slips, causing hammer toes.
    • This may affect shoe selection and ability to do weight-bearing exercise.
  • Onset younger age
  • Gradual or rapid onset of symptoms/pain
  • Morning stiffness over 30 minutes to several hours
  • Worse pain in the morning and at end of day
  • Primarily affects synovium and may include internal organs
  • Typically, small joints of hands and wrist symmetrically with ulnar deviation
  • “Crippling” arthritis
  • Red, swollen, warm, tender joints
  • Fatigue, fever, loss of energy, malaise
  • May have rheumatoid nodules
  • Acute & chronic inflammation and pain
  • Loss of joint integrity

Risks

  • Women more than men
  • Age. Increases as we age.
  • Race: White or of Asian descent
  • Family History.
  • Small body frames have higher risks
  • Hormones
    • Sex hormones. Reduced estrogen in menopausal women.
    • Men with a gradual reduction in testosterone levels.
    • Thyroid problems –increased.
    • Overactive parathyroid and adrenal glands.
  • Dietary factors
    • Low calcium intake
    • Decreased weight or food intake.
    • Gastrointestinal surgery.
  • Steroids and other medications used to combat or prevent:
    • Seizures
    • Gastric reflux
    • Cancer
    • Transplant rejection
  • Medical Conditions
    • Celiac disease
    • Inflammatory bowel disease
    • Kidney or liver disease
    • Cancer
    • Lupus
    • Multiple myeloma
    • Rheumatoid arthritis
  • Lifestyle choices
    • Sedentary lifestyle.
    • Excessive alcohol consumption
    • Tobacco use.
  • Increasing age
  • Family History
  • Injury or overuse
  • Old joint, injuries/surgeries
  • Aging athletes
  • Muscle weakness
  • Impaired proprioception can lead to the loss of protective muscular reflexes.
    • Reflex inhibition is a response to pain and joint effusion (swelling).
  • High bone mass
  • Disuse– Moderate physical activity decreases OA risk.
  • Overweight/Obesity– increases the mechanical load on weight bearing joints.
  • Family History
  • Smoking. Some studies show it also can make it progress faster and lead to more joint damage.
  • Obesity. You also may be able to lower your chances by losing weight, especially if you’re 55 or younger.
  • Research shows there may be a link between RA and periodontal (gum) disease.
    • Brush / floss and see your dentist for regular checkups.
      (Web MD)

Prevention

  • Protein: Building blocks of bone.
  • Body weight: Being underweight increases the chance of bone loss and fractures.
    • Excess weight is known to increase the risk of fractures in your arm and wrist.
    • Maintaining an appropriate body weight is good for bones.
  • Calcium. Men and women between the ages of 18 and 50 need 1,000 milligrams of calcium a day.
    • This daily amount increases to 1,200 milligrams when women turn 50 and men turn 70.
  • Vitamin D improves your body’s ability to absorb calcium and improves bone health in other ways.
    • People may get adequate amounts of vitamin D from sunlight.
    • Scientists don’t yet know the optimal daily dose of vitamin D for each person.
    • A good starting point for adults is 600 to 800 international units (IU) a day, through food or supplements.
  • Exercise. Combine strength training, weight-bearing, and balance exercises.
    • Strength training helps strengthen muscles and bones in your arms and upper spine.
    • Weight-bearing exercises such as walking, jogging, running, stair climbing, skipping rope, skiing, and impact- producing sports affect mainly the bones in your legs, hips, and lower spine.
    • Balance exercises such as tai chi can reduce your risk of falling.
    • **Swimming, cycling, and exercising on machines such as elliptical trainers can provide a good cardiovascular workout, but they’re not as helpful for improving bone health.

(Mayo clinic: Exercising with osteoporosis: Stay active the safe way)

  • See Osteoporosis
  • Moderate physical activity actually decreases OA risks.
  • Weight loss.
    • For every one pound of weight lost, there is a 4 lb. reduction in the load exerted on the knee for each step taken during daily activities.
    • Losing as few as 11 pounds can cut the risk of developing knee OA by 50% for some women.
    • Weight loss of only 15 lbs. can cut knee pain in half for overweight individuals with arthritis.
  • There’s no known way to prevent RA, but scientists are studying DNA markers that show that someone will develop it.
  • New research has shown that there is a narrow window of opportunity for early treatment that can literally stop the disease in its tracks.
  • Timely diagnosis and treatment can prevent the progression of RA and the associated joint destruction. ACE: Fitness Professionals Guide to Training Clients with Osteoarthritis

*** “Ideally, you should begin treatment within 3 to 6 months of your first symptoms”.
(Web MD)

Exercise Tips

High-impact weight-bearing exercises may not be safe for you if you have a higher chance of breaking a bone.

  • Talk to your doctor about your workout routine.
  • They may recommend that you focus on low- impact exercises that are less likely to cause fractures and still build up your bone density.
  • These include:
    • Elliptical training machines
    • Low-impact aerobics
    • Stair-step machines
    • Walking (either outside or on a treadmill machine)
  • Making exercise for osteoporosis safe to ensure your safety during exercise for osteoporosis, keep these guidelines in mind:
    • If you already have osteoporosis, be careful of exercises that involve bending and twisting at the waist. This motion can put you at risk of fracture.
    • Exercises that involve waist twisting include sit-ups, toe touches, and rowing machines. Golf, tennis, bowling, and some yoga poses also include some twisting at the waist.
    • Talk to your doctor before choosing any of these activities.
  • Acute (symptoms less than 7 days)
    • Focus on maintaining flexibility only.
    • Do exercise daily during this phase to prevent loss of motion and contractures (muscle / tendon tightening that prevents normal movement).
  • Sub-acute (symptoms lasting 1-6 weeks)
    • Work on maintaining/increasing flexibility and strength.
    • Some cardiovascular activity can be done.
  • Chronic (symptoms lasting longer than 6 weeks)
    • Focus on progressive strengthening and increase cardiovascular fitness.
  • Exercise daily when pain and stiffness are the least (when medications have the greatest effect and/or energy is highest).
  • Perform gentle ROM exercises for the affected joint(s) in both the morning (before rising) and evening to reduce stiffness.
  • Include all planes of movement around the affected joint and adjacent joints.
  • Avoid overexertion and extreme ranges of joint flexion or extension.
  • Modify as needed – for example, replace the Long Arc Quad (LAQ) with the Partial Arc Quad (PAQ) to decrease ROM.

Modify or Discontinue Exercise

If you have osteoporosis, don’t do the following types of exercises:

  • High-impact exercises. Activities such as jumping, running or jogging
  • Avoid jerky, rapid movements in general. Choose exercises with slow, controlled movements.
  • Bending and twisting. Exercises in which you bend forward at the waist and twist your waist, such as touching your toes or doing sit-ups, can increase your risk of compression fractures in your spine if you have osteoporosis.
  • Other activities that may require you to bend or twist forcefully at the waist are golf, tennis, bowling, and some yoga poses.
    (Mayo clinic: Exercising with osteoporosis: Stay active the safe way)
  • Joint pain/discomfort during the exercise or continuing pain (pain that lasts more than 2 hours after exercising and/or exceeds pain severity before exercise)
  • Respect pain–use it as a ‘warning’ sign. “No pain, no gain” is not true with arthritis.
  • Increased joint swelling/tightness immediately after or the day following activity
  • Decreased range of motion
  • Increased weakness
  • Altered gait following participation in a weight-bearing activity
  • Unusual or persistent fatigue

Osteoporosis - Exercise Types

  • Fall prevention is especially important for people with osteoporosis.
    • Stability and balance exercises help your muscles work together in a way that keeps you more stable and less likely to fall.
    • Simple exercises such as standing on one leg or movement-based exercises such as tai chi can improve your stability and balance.
  • These moves don’t directly strengthen your bones.
    • They can, though, improve your coordination, flexibility, and muscle strength.
    • That will lower the chance that you’ll fall and break a bone.
    • You can do these every day.
  • Balance exercises such as Tai Chi can strengthen your leg muscles and help you stay steadier on your feet.
  • Posture exercises can help you work against the “sloping” shoulders that can happen with osteoporosis and lower your chances of spine fractures.
  • Routines such as yoga and Pilates can improve strength, balance, and flexibility.

**Some of the moves you do in these programs, including forward-bending exercises, can make you more likely to get a fracture.

  • Weight-bearing aerobic activities involve doing aerobic exercise on you r feet, with your bones supporting your weight.
    • These types of exercise work directly on the bones in your legs, hips and lower spine to slow mineral loss.
    • They also provide cardiovascular benefits, which boost heart and circulatory system health.
  • It’s important that aerobic activities, as beneficial as they are for your overall health, are not the whole of your exercise program.
  • Swimming and cycling have many benefits, but they don’t provide the weight-bearing load your bones need to slow mineral loss.
    • However, if you enjoy these activities, do them.

There are two types of weight-bearing exercise: high-impact and low-impact.

  • High impact includes workouts like:
    • Brisk walking
    • Climbing stairs
    • Dancing
    • Hiking
    • Jogging
    • Jumping rope
    • Step aerobics
    • Tennis or other racquet sports
    • Yard work, like pushing a lawnmower or heavy gardening
    • But be careful.
  • High-impact weight-bearing exercises may not be safe for you if you have a higher chance of breaking a bone. Talk to your doctor about your workout routine. They may recommend that you focus on low-impact exercises that are less likely to cause fractures and still build up your bone density.
  • These include:
    • Elliptical training machines
    • Low-impact aerobics
    • Stair-step machines
    • Walking (either outside or on a treadmill machine)

**If you’re new to exercise or haven’t worked out for a while, you should aim to gradually increase the amount you do until you get to 30 minutes of weight-bearing exercise per day on most days of the week.

  • Moving your joints through their full range of motion helps you keep your muscles working well.
  • Stretches are best performed after your muscles are warmed up at the end of your exercise session, for example, or after a 10-minute warm-up. They should be done gently and slowly, without bouncing.
  • Avoid stretches that flex your spine or cause you to bend at the waist. Ask your doctor which stretching exercises are best for you.
  • Examples of flexibility exercise for osteoporosis include:
    • Stretches
    • Tai chi
    • Yoga
  • Resistance means you’re working against the weight of another object.
  • Resistance helps with osteoporosis because it strengthens muscle and builds bone.
  • Studies have shown that resistance exercise increases bone density and reduces the risk of fractures.
  • Resistance exercise for osteoporosis includes:
    • Free weights or weight machines at home or in the gym
    • Resistance tubing that comes in a variety of strengths
    • Water exercises

Osteoarthritis (OA) & Rheumatoid Arthritis (RA) - Exercise Types

Flexibility:

  • Joint motion may be maintained by performing active range of motion exercises through the entire range, 3-5 times daily.
  • Move slowly and gently through full ROM, but not past the point of usual pain/discomfort.
  • Reduce the number of repetitions with active inflammation and avoid overstretching.
  • Move the affected joint GENTLY.
  • Use a slow, steady rhythm and do not bounce.
  • Adapt by using self-assisted techniques (wand or pulley) to perform gentle ROM or stretching.
  • A warm environment promotes elasticity.

Balance:

  • The pain, stiffness, joint instability, and muscular weakness associated with OA can alter proprioception and prevent efficient, controlled and integrated movement.
  • Stiff and painful movements require more energy and increase fatigue.
  • Include static and dynamic balance by introducing progressive balance challenges:
    • Progression from double limb to single limb stance activities tiptoe walking, retro walking, and lateral walking.
    • Use equipment with unsteady surfaces: rocker boards, balance discs, BOSU balls, foam cushions and rolls
  • Start with isometric or low load exercises.
    • Gradually transition to isotonic/dynamic exercises and functional movements.
  • Resistance level should first be determined by the response of the joint and not muscle fatigue.
  • Although it is ideal to perform an exercise through the complete range of motion, it may be necessary to perform a certain strength exercise in a more limited range of motion to avoid joint pain.
  • If you can handle more challenging exercises in joints not affected by OA, adapt the program accordingly.

Progression guidelines:

  • Ensure that you can easily perform an exercise correctly during at least 2 consecutive workouts.
  • Increase resistance by no more than 10% each week.
  • Don’t change too many things at a time; if you experience joint symptoms, you’ll know what may have caused the problem.
  • Review posture, alignment, and body mechanics.
    • The joint being exercised should be in line with the equipment fulcrum or biomechanical stresses may increase on an unstable/misaligned joint.
  • Watch your neck/spine position, particularly during abdominal work.
    • Keep in neutral.
    • Don’t forget about the hands/grasp and thumb/fingers involvement.

Isometric:

  • Isometric strengthening is appropriate for those deconditioned or with joint pain during isotonic or dynamic movement.
  • Isometric exercise allows you to strengthen the muscle without moving the joint, minimize atrophy, maintain/increase static strength/ endurance, and improve tone to prepare for dynamic and weight-bearing activity.
  • Perform each exercise at multiple angles throughout the range to simulate function.
    • Intensity: Good quality contraction of the muscle (moderate to hard intensity)
    • Frequency: Start with 5-10 reps daily. Proceed to 3 x 15 reps.
    • Duration: Hold isometric contractions 5-10 seconds.

Isotonic (Strengthening / Resistance above):

  • Dynamic or isotonic exercises maintain/increase muscle power and endurance, simulate functional movements, enhance synovial blood flow and promote strength of bone and cartilage.
    • Intensity: Start w/ light resistance (10% 1 RM) and progress to light to moderate resistance (40-60% 1 RM)
      • 1 x 10; 2 x 10; 3 x 10; 3 x 15
    • Frequency: 2 – 3 times per week on alternate days
    • Duration: 15–30 min. Progress by first increasing repetitions (10-15 reps/exercise), then increase weight by 10% week or to pain tolerance.
  • Use lower resistance bands/weights to decrease stress on joint and adjust equipment for good biomechanics
  • Put weights more proximal (closer) to the joint to decrease lever arm.
  • **Typical quad exercises such as full ROM knee extensions may exacerbate symptoms and contribute to further degeneration of the joint.
    • Modify as needed – for example, replace the Long Arc Quad (LAQ) with the Partial Arc Quad (PAQ) to decrease ROM.
  • Aerobic exercise is an integral part of an exercise program for individuals with osteoarthritis and is associated with the following benefits:Improved cardiovascular function
    • Increased muscular strength and flexibility
    • Improved physical and social activity levels
    • Reduced fatigue
    • Decreased depression and anxiety
    • Decreased pain
    • Decreased or unchanged disease activity
  • Modes of aerobic exercise that work particularly well for individuals with OA include:
    • Walking
    • Bicycling
    • Swimming or water exercise
    • Low impact aerobics/chair exercise
  • Intensity
    • For individuals who have not exercised in over 3 months/deconditioned, start at 40-60% Heart Rate Reserve (HRR/Karvonen)
    • For patients at average levels of fitness >60% HRR is appropriate.
    • More fit individuals can tolerate higher intensity levels depending upon joint mode and the presence of joint symptoms.
  • Duration
    • The initial phase should consist of short bouts (5-10 minutes).
    • Progress to 20-30 minutes above daily activity (150 min./week of moderate intensity) to increase fitness level.
    • Individuals may tolerate more daily exercise by breaking it up into multiple bouts.
      • For example, a 30-minute walk may produce knee discomfort or swelling.
      • Two 15-minute walks may be tolerated without symptoms.
    • Focus on duration before intensity.
  • Frequency
    • 3–5 days/week–individualize based on fitness and joint response (provided the person is not in the acute phase).

Arthritis and Nutrition

The Ultimate Arthritis Diet - Arthritis Foundation

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Other Possible Arthritis Diets

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Arthritis Guide

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Arthritis References

  • ACE – Fitness Professionals Guide to Training Clients with Osteoarthritis
  • American College of Sports Medicine (ACSM) https://www.acsm.org/
  • Association of Rheumatology Health Professionals (Now the Rheumatologist) (ARHP) https://www.the-rheumatologist.org/article/association-of-rheumatology-professionals-new-name-but-the-commitment-remains-the-same/
  • Arthritis Foundation The Ultimate
  • Arthritis Diet by Amy Patural – www.arthritis.org/living-with-arthritis/arthritis-diet/anti- inflammatory/the-arthritis-diet.php
  • Arthritis Foundation www.arthritis.org/living-with-arthritis/exercise/
  • CDC.gov cdc.gov/nccdphp/dnpa/physical/growing_stronger/
  • Celiac Disease Foundation celiac.org/live-gluten-free/glutenfreediet/food-options/#B3q0UllhdIeaKFky.99
  • Chewfo www.chewfo.com/diets/the-mediterranean-diet-cookbook-by-rockridge-press-2013-food-list-what-to-eat-and-foods-to- avoid/
  • David Perlmutter www.drperlmutter.com/eat/foods-that-contain-gluten/
  • Dr. Weil www.drweil.com/drw/u/ART02012/anti-inflammatory-diet
  • National Institute of Arthritis and Musculoskeletal and Skin Diseases (NISM) https://www.nih.gov/about-nih/what-we-do/nih-almanac/national-institute-arthritis-musculoskeletal-skin-diseases-niams
  • National Osteoporosis Foundation – (Now the Bone Health and
  • Osteoporosis Foundation (BHOF)) https://www.bonehealthandosteoporosis.org/news/national-osteoporosis-foundation-is-now-bone-health-and-osteoporosis-foundation/
  • NIA Publications www.niapublications.org/exercisebook/chapter4_strength.htm
  • Mayo Clinic www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/gluten-free-diet/art-20048530
  • MedicineNet.com
  • Prevention https://www.prevention.com/health/diet-lowersalzheimers-risk
  • US News https://health.usnews.com/best-diet/mediterranean-diet
  • WebMD.com