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CHAPTER ESSAY QUESTIONS: ARTHRITIS INSTRUCTIONS
1. Explain the pathophysiology of arthritis.
“Arthritis is a generic term for conditions that involve inflammation of one or more joints…
Although the etiologies, presentation, and clinical manifestations of the various forms of arthritis
are generally distinct, they share common features that impair the following: exercise tolerance,
muscle strength, muscular endurance, aerobic capacity, range of movement (ROM),
biomechanical efficiency, and proprioception” (Ehrman, Gordon, Visich, & Keteyian, 2019).
There are three stages of arthritis. The first stage is acute which has reversible signs and
symptoms in the joint related to synovitis. The second stage is chronic, which is stable but
irreversible structural damage brought on by the disease process. The third stage is chronic with
acute exacerbation of joint symptoms, which has increased pain and decreased range of motion
and physical function. (Ehrman et. al., 2019).
There are five primary types of arthritis which include osteoarthritis, chronic radiographic
join tdisease, rheumatoid arthritis, ankylosing spondylitis, and chronic spinal ankyloses
predominant with decreased spinal and thoracic mobility. “Osteroarthritis (OA) is a complex
disease whose pathogenesis includes the contribution of biomechanical and metabolic factors
which, altering the tissue homeostasis of articular cartilage and subchondral bone, determine the
predominance of destructive over productive processes” (Iannone & Lapadula, 2003). While
with rheumatoid arthritis it is “a chronic autoimmune disorder, characterized by systemic
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inflammation and symmetrical polyarthritis, that affects various tissues and organs but
principally targets synovial joints” (Ehrman et. al., 2019). Ankylosing spondylitis is also an
autoimmune disease, as well as a chronic inflammatory arthritis. This condition will primarily
affect the spine and sacroiliac joint.
The American College of Rheumatology (ACR) has different criteria for each type of
arthritis. “Joint pain can arise from pathological changes in joint capsule and periartuclar
ligaments, intraosseous hypertension, muscle weakness, subchondral microfractures,
enthesopathy, and bursitis, and it may be exacerbated by psychosocial factors including
depression” (Ehrman et. al., 2019). Although, there are no definitive tests or markers for athritis
diagnosis. There are some serum and synovial fluid tests that can assist in arthritis type
differentiation. “The signs and symptoms of arthritis are as follows: pain, stiffness, effusion,
synovitis, deformity, and crepitus” (Ehrman et. al., 2019).
2. Explain the special considerations when prescribing exercise to an arthritic client.
When prescribing exercise to an individual with arthritis there will be similar goals. These
goals would include “maintain or improve physical function by maintaining or improving muscle
strength, cardiorespiratory fitness, and range of motion, improve body composition (i.e., restore
muscle mass and reduce fat mass) and, when appropriate reduce body weight, reduce the risk of
comorbidities such as CVD, type II diabetes, metabolic syndrome, and osteoporosis, reduce
inflammation and pain, and prevent contractures and deformities” (Ehrman et. al., 2019). When
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they are beginning an exercise program the individual requires education, skill acquisition,
reinformancement, and monitoring. Supervision allows the individual to participate in the
activities safely, and ensure there are no injuries occurring. In addition, while they are
performing an exercise they will have someone there to correct technique, or make modifications
if something feels uncomfortable on the joints. “The exercise professional should consider the
success of various treatment modalities for particular joint impairments, as well as the
individual’s affected areas, level of fitness, surgical history, comorbities, medications, age,
personal goals, and lifestyle…If pain occurs, it can become difficult to motivate a person to
maintain adherence to an exercise program” (Ehrman et. al., 2019).
Other considerations must be taken into account such as their age and possible sedentary
lifestyle, arthritis location, patients balance and fatigue levels. It is necessary to consider the best
mode of physical activity for the patient. For example, arthritis in the knees or legs, it may be
easier to perform physical activity in an aquatic setting, versus a land program. For individuals
with arthritis within their hand, it will be challenging to grip “heavy” weights, therefore free
weights are not going to be a safe form of training for them. Other considersations include
“preventing musculoskeletal injury, fatigue, previous joint replacement, time of day, water
therapy, footwear, CV and pulmonary issues with RA, ankylosing spondylitis, corticosteroids,
and body composition” (Ehrman et. al., 2019).
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3. What are the ACSM guidelines for exercise prescription for those who have arthritis?
While the incorporation of physical activity is beneficial for individuals who have arthritis, it
is vital to consider a patient’s personal intensity preference to allow for activity to occur without
pain and fatigue. Aerobic, resistance, and flexibility are all recommended for an individual with
arthritis. Aerobic exercise is recommended to occur 3 to 5 days per week for a total of 150
minutes per week for moderate intensity or 75 minutes per week for vigorous intensity. Moderate
intensity is referred to as 40%-59% VO2R or HRR or vigorous intensity is referred to as >60%
VO2R or HRR. Aerobic exercises include low joint stress activities such as walking, cycling,
swimming, or aquatic exercise. Resistance training should occur 2 to 3 days per week at 60%-
80% of a patients one repetition maximum. Initial intensity should be lower for those
unaccuomsted to resistance training, therefore occurring at 50%-60% of a patients one repetition
maximum. The goal is to hit all major muscle groups with 8-12 repetitions for 2-4 sets total.
Resistance training can be done with machine or free weights, or body weight exercises.
Considerations to what form of arthritis the patient has is vital. Lastly, flexibility should be
performed daily with a combination of dynamic and static stretching focused on all major joints.
This can be conducted up to 10 repetitions for dynmic stretching, and 10-30 seconds for static
stretching. The goal is to increase range of motion, stretch with some tightness but avoiding pain.
(Reibe et. al., 2018).
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4. Read the case study on p. 443 of the Ehrman et al. text and answer the 4 questions.
What exercise advice should the rheumatologist have given Mrs. PJ when she was initially
diagnosed with RA?
When Mrs.PJ was diagnosed with RA, there are a few different things the rheumatologist could
of disclosed to her. “The joints mostly affected by RA are the small joints of the hands and feet,
followed in order of prevalence by the larger joints of the wrists, elbows, shoulders, and knees,
although any joint with synovial lining is susceptible. In addition to joint pain, stiffness, and
damage, RA also has extracellular effects. Some are specific to RA, such as rheumatoid nodules,
while nonspecific effects include muscle loss, increased adiposity, fatigue, and exacerbated
cardiovascular disease (CVD), metabolic syndrome, type II diabetes, and osteoposis risk”
(Ehrman et. al., 20119). In addition, stiffness will be worse in the morning, therefore it would be
better to participate in activities later in the day. “A drop in barometric pressure along with an
increase in humidity can increase pain, as can cold conditions” (Ehrman et. al., 2019). In the
form of exercise training, aerobic and resistance training should be incorporated. “Whole-body
dynamic exercise is preferable to static or isometric exercise, as the former elicits greater
improvements in body composition, strength, aerobic capacity, and function and is more relevant
to the performance of ADLs. Additionally, higher-intensity exercise consistently produces
significantly better gains than low-intensity ROM exercises” (Ehrman et. al., 2019).
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Which comorbid conditions are elevated in an individual with RA such as Mrs. PJ? What
are the contributory factors to this increased comorbidity risk?
With RA there are a few different comorbid conditions that can occur. The first is the elevated
risk for cardiovascular disease (CVD) and osteoporosis. With the risk of osteoporosis this can
also decrease the bone mineral density, to put the individual at risk of fractures and injuries. In
addition, it can exacerbate metabolic syndrome, type II diabetes, and increase adiposity. There is
also a risk for Raynaud’s syndrome. “RA is associated with interstitial lung disease, and those
with AS often have restrictive lung disease because of impaired chest expansion and upper lobe
bilateral pulmonary fibrosis” (Ehrman et. al., 2019). Contributing factors to this are due to the
stiffness of the joints, and decreasing muscular strength. This increases the risk for osteoporosis.
The increase in adiposity and possible decrease in physical activity can contribute to an increased
risk of cardiovascular disease. A decreased VO2 could also negatively harm an individual to
increase their risk for lung related complications.
What plans could be put in place to help this patient achieve good long-term compliance to
exercise?
A plan that could be put in place to help this patient achieve good long-term compliance with
exercise is to have her get a personal trainer, or participate in group exercise programs. In
addition, having a friend or family member participate in exercise with her may assist with
compliance. This will allow having someone to hold her accountable to participate in physical
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activity daily. Keeping a daily/weekly log can also allow show the improvements that are
occurring over time, which can act as a motivation factor. Short term and long term goals are
also necessary for the best results.
What are the anticipated benefits of exercise training for Mrs. PJ?
Anticipated benefits of exercise training for Mrs. PJ would be decreasing her pain and stiffness
in her hands, feet, and left knee. In addition, it would be increase her muscular strength and
endurance as well. This can lead to can increase in her VO2max. Incorporation of physical activity
will also allow her to perform her activities of daily living easier, and possible continue her
recreational activities down the road. Another benefit is “improve body composition (i.e. restore
muscle mass and reduce fat mass) and when appropriate, decrease body weight” (Ehrman et. al.,
2019). Participation in physical activity can also see positive results on her blood work.
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SOURCES
Ehrman, J. K., Gordon, P. M., Visich, P. S., & Keteyian, S. J. (2019).IClinical exercise
physiology. Champaign, IL: Human Kinetics.
Iannone, F., & Lapadula, G. (2003). The pathophysiology of osteoarthritis. Aging Clinical and
Experimental Research, 15(5), 364-372. doi:10.1007/bf03327357
Riebe, D., Ehrman, J. K., Liguori, G., & Magel, M. (2018) ACSMs guidelines for exercise testing
and prescription. Philadelphia: Wolters Kluwer.
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