Arthritis primarily consists of two types: rheumatoid and osteoarthritis.  Osteoarthritis is a degenerative condition that results from wear and tear on joints and breakdown of cartilage that covers the ends of bones.  Typical symptoms of osteoarthritis include pain and stiffness that can be relieved by movement. Movement releases synovial fluid which helps to lubricate the stiff joints.

In contrast, rheumatoid arthritis is a systemic disease that affects the entire body.  Symptoms of rheumatoid arthritis include joint pain and inflammation, especially in the hands and feet, and leads to joint deformity over time.  The challenge for people with rheumatoid arthritis is that inflammation prevents normal use of joints and limits activities.  This reduced activity leads to loss of strength, endurance and mobility.  Over time, muscles and ligaments become so weak that people experience further loss of function. 

Exercise provides a safe, effective and much needed intervention to prevent a continuous cycle of functional loss.  Through age alone, the average individual loses muscle mass (50% between the ages of 20 and 90) and gains fat even as the bones weaken.  Add arthritis to this and the potential for a rapid downhill spiral is certainly there. 

The exercise goal for people with arthritis is to increase range of motion (ROM), muscular strength, flexibility, and balance, and to develop and maintain endurance.  Since arthritis is a joint disease, people with arthritis need to try to move through each joint’s active range of motion on a daily basis.  This regular movement helps prevent stiffness and loss of mobility.  Remember that range of motion is unique to each person and is specific to each joint.  Encourage full ROM, while reminding people to tune into their own body cues.

Since people with arthritis may move less during pain episodes, it’s important for them to perform higher intensity strength exercises when they are not in an inflamed condition. Strength training supports the ability to maintain function.   Strong muscles also assist movement and enable activity with less stress on joints. Therefore mobility should be encouraged as much possible during every program.

For example: 

• Start the participants moving as soon as they get into the water. Walking to engage the large leg muscles is the easiest and safest way to warm up the body and immediately begin strength training for both core and the lower limbs.
• Add some rocking movement to provide active stretching using balanced and coordinated movement for the arms and legs.
• Use the Modified Rebound position for walking when strengthening the upper body. This movement will submerged the shoulders for protection during the power phase of muscle targeting and promote superior leg and core strength with each forward step.

Even when inflamed, joints can still be moved gently through as full a ROM as possible.  In other words, joint inflammation should not be an excuse to skip exercising.

Encourage participants to take responsibility for their own bodies, to recognize their own limits, to respect pain, and to adjust the level of physical activity to the level of disease activity.  However, emphasize that exercise will not always be pain free and that to maintain (and hopefully increase their ROM) individuals will have to explore and challenge their personal pain zone. This is not another way of saying “no pain, no gain”, but rather that arthritis has to be approached much like rehab where you have to push a little past the point of pain and then back off.  If you consistently stop short of the point of pain, your ROM will decrease.  Very much in play here is the SAID principle: Specific Adaptations to Imposed Demands.  Nevertheless, each participant must set limits to avoid overstressing a joint.

Basic Training Guidelines

• Include balance and upper/lower body coordination challenges. These components of fitness are absolutely essential to functional daily living.
• Stress postural components and cue recruitment of transverse abs and other deep core muscles
• Do strength training before cardiovascular training, especially if there are gait disorders.
• Provide an extended warm up of gentle range of motion exercises to fully warm up joints before performing more vigorous strengthening or conditioning exercises
• Change activities and body positions frequently to avoid excessive joint strain from too many repetitions
• Submerge working joints in the water but do not allow those participants with high body fat to simply float around in deeper water. This will not benefit their cardio, muscular strength, or endurance.  Also, these individuals need to lose weight and change their body compositions.  Moving to shallower water for reduced buoyancy assistance will help meet this goal.
• Encourage participants to work at their own pace and reduce intensity throughout exercise as needed. It’s far more likely that you will have to encourage them to pick up the pace.  You absolutely don’t want an infirmity
• Avoid excessive impact or excessive momentum
• Be sure to progressively challenge the clients capacity. As with any other individual, strength training must be incrementally progressive in terms of intensity.  There is no evidence that those with arthritis or even the frail elderly cannot handle high intensity exercise.
• Cue frequently (if using hand held equipment) to maintain a relaxed grip and provide breaks for hand and wrist relief. All isometric exercise increases blood pressure, so a tight grip kicks up the BP unnecessarily.

• Thermo-regulate! Warmer body temperatures encourage greater muscle elasticity and enhance ROM.  Ideal water temperatures for arthritis classes range from 83-88 degrees Fahrenheit  or 28 – 31 degrees Celsius.  For more warmth and comfort, participants can wear thermal pool attire to cover arms, legs and the neck area and exercise mitts.  Remind participants to move continuously in the water to improve thermal regulation.