Stop popping pills, sitting in warm baths, and resting on the couch to treat your aching body. Doctors and scientists are now preaching the benefits of exercise to treat arthritis. The creaking joints, pain with bending, squatting, or stairclimbing, and difficulty buttoning clothes are all symptoms of one of the most debilitating diseases today. Either you, a family member, or a friend has some form of arthritis. Osteoarthritis (OA) affects more than 21 million Americans, according to the American College of Rheumatology. Learn how you can decrease pain, stop the progression of the disease, and improve your functional capacity by adding moderate aerobic, resistance, and flexibility exercises to your daily routine.

What is Osteoarthritis?
There are over 100 different forms of arthritis, but OA, which used to be called degenerative joint disease, is the most common. It can affect children, but most often affects middle-aged and older people. Women are generally affected at a younger age and are more likely to have painful symptoms than men [1, 2]. OA involves degeneration of cartilage on the ends of bones that form joints like in the neck, lower back, knees, hips, and fingers, but the joint most commonly reported with symptoms and disability is the knee [2]. Cartilage is a protective spongy material that acts as a shock absorber to keep bones from rubbing together. The joint is enclosed in a capsule of tissue called the synovium. The synovium's lining releases a slippery fluid that nourishes the joint and helps it move smoothly. Ligaments, muscles, and tendons support the joint for movement and balance. As the cartilage is damaged, the bone and surrounding structures break down as well. This causes the typical OA symptoms of inflammation, pain, stiffness, crepitus (creaking), and deformity. It is these symptoms that lead to inactivity and decreased functional capacity in those with OA.

Risk Factors
Some of the risk factors associated with OA can be avoided. Much literature supports a definite link between obesity and knee OA. The Framingham Osteoarthitis Study showed that weight loss reduced the risk for symptomatic knee OA in women [2]. In fact, this study showed that just a 10 pound decrease resulted in a 50% reduction in the odds of developing knee OA. In subjects that already had OA, weight loss reduced their joint pain. Repetitive trauma, like that experienced in elite and professional athletes, has also been shown to be a preventable risk factor. Previous injury to a joint, a joint that has been subjected to prolonged heavy use, or a joint damaged by prior infection or inflammatory arthritis is at risk for OA. Unfortunately, age is an OA risk factor that is not preventable [2]. The good news is that habitual physical activity like household, job, and leisure activities in the middle-age years do not increase the risk for OA [3].

How OA Affects Your Body
The symptoms of OA such as pain, decreased range of motion (ROM), and instability all lead to a decrease in functional capacity. Functional capacity is the body’s ability to perform at its optimum level and a decrease is seen in decreased VO2 max (oxygen consumption per minute), decreased muscular strength, decreased flexibility, and decreased ability to perform activities of daily living. When OA sufferers are in pain, they typically rest. This leads to less compressive forces on bones and muscles. It is these compressive forces that move the synovial fluid in the joints around for lubrication and distribution of nutrients. Also, inactivity results in weak and atrophied muscles. A study that involved strengthening the quadriceps muscle of knee OA patients found that reduced functional capacity is due to reduced muscle function [4].

OA Management
The goals of managing OA are to control pain, minimize disability, and educate the patient and family [5]. Pain management can be handled pharmacologically with aspirin-free pain relievers like acetaminophen and non-steroidal anti-inflammatory drugs like ibruprofen. Corticosteroids are sometimes prescribed by doctors to reduce severe pain and swelling. Surgery is an option for severe cases when all other methods have failed.
Non-pharmacological management includes the use of modalities like heat or cold, joint protection techniques like avoiding prolonged standing, kneeling and squatting, assistive devices like canes and walkers, proper shoes and orthotics, and exercise. The American College of Rheumatology published guidelines for the treatment of knee OA that suggest that exercise be one of the mainstays of OA treatment [5].

Exercise and OA
It has been said “exercise may be the most effective, malleable, and inexpensive modality available to achieve optimal outcomes for people with OA” [6]. A study on a group of 120 patients with rheumatoid arthritis (RA) and OA showed that a 12-week program of aquatics and land walking improved aerobic capacity, 50-foot walking time, depression, anxiety, and overall physical activity more than in a control group that only performed ROM exercises [7]. A surprising finding to this study at a nine-month follow-up showed that the control group also had a significant increase in aerobic capacity. Researchers concluded that this was due to approximately 70% of the control group continuing to exercise and performing more conditioning-type exercises than just ROM. It turns out that the ROM control group got “hooked” on exercise and wanted to continue reaping the benefits. Still, many OA patients are afraid that exercise will increase their symptoms. But, supervised fitness walking and patient education can improve functional status without worsening pain or exacerbating arthritis-related symptoms in patients with osteoarthritis of the knee [8]. A study that divided subjects into a strength training group, an endurance training group, and a combination group, found that joint symptoms varied over time in all groups, but were unrelated to exercise [9]. Additionally, no major injuries occurred in this study. Still another study demonstrated that moderate intensity aerobic and resistance exercise reduced pain and disability, improved physical fitness, and did not exacerbate symptoms in people with knee OA [10].

Types of Appropriate Exercise
Now that we know exercise is beneficial for OA sufferers, what kind of exercise is recommended? Ideally, every exercise program should be individualized and approved by your doctor. Some common treatment goals are to increase strength, joint ROM, muscular flexibility, endurance, and function, and to decrease pain and protect joints from further damage [6]. This can be accomplished by resistance and aerobic exercise and stretching.
Resistance exercises increase or maintain muscle strength and tone. Strong muscles stabilize your joint, allow easier movement, and improve balance. You can start resistance exercises by performing simple isometrics and then progress to isotonics. Isometrics are exercises where the joint does not move, but the muscles surrounding the joint are tightened, held for about 10 seconds, then relaxed. An example is quadsetting, where the straight leg is supported on a flat surface and the quadriceps muscle, the muscle on the top of the thigh, is contracted. Eventually, full ROM isotonic exercises can be added.
Aerobic exercise, or endurance exercise, is as simple as walking. Start slowly and build your endurance up for a goal of 20 to 30 minutes, three times a week.
Flexibility exercises are types of stretching exercises that can increase joint ROM. You can also perform ROM exercises just by flexing and extending the joint and moving them in a circular motion.

How to exercise
Plan your exercises sessions when you have less stiffness or pain, for example, in the afternoon, rather than the morning. It is important to start slowly and build up the amount of time you exercise and the number of repetitions you do. Let pain be your guide. If you are experiencing pain with exercise, then the exercise isn’t appropriate for you. If you have pain after exercising, remember to decrease the intensity or length for the next session. Stop exercising immediately if you have chest pains, severe dizziness or shortness of breath. Incorporate water and land exercises to receive the unloading benefits of water, as well as the weightbearing benefits of land.
A total body warm-up should be performed first to increase the blood flow to all of your muscles and prepare your body for exercise. This can be as simple as walking in place with high knees and simultaneously swinging the arms. A period of flexibility and ROM activities should follow with every muscle stretched 2-3 times and held for 30 seconds to 1 minute, unless contraindicated because the muscle surrounds an unstable joint. Aerobic exercise can follow next and then a resistance or weight training component can be added or performed on another day. A 3-to-5 minute cool-down period can include slow walking and focus on additional flexibility and breathing and relaxation techniques. Although one side of your body may be weaker or have a more significant amount of arthritis, you should exercise the entire body to achieve the maximum benefits of exercise [4]. To improve or maintain fitness, exercise must be performed regularly and appropriate exercise habits must be maintained [7].

Summing Up the Benefits of Exercise for OA
All forms of exercise will assist you with your weight loss goals and anytime a joint is moved the synovial fluid will lubricate and feed the joint. Research studies have shown that exercise does not increase OA symptoms and can even decrease the risk of further OA development. A program of flexibility and strengthening improves muscle function, exercise capacity, and functional performance [11]. Exercise helps reduce pain and keeps you active, so get off the couch and get to work!
For more information, exercise programs, support groups and other help, visit the American College of Rheumatology website at www.rheumatology.org or The Arthritis Foundation website at www.arthritis.org.

References
1. Davis, M., et al., Knee osteoarthritis and physical functioning: evidence from the NHANES 1 epidemiologic followup study. J Rheumatol, 1991. 18(4): p. 591-8.
2. Felson, D., et al., The prevalence of knee osteoarthritis in the elderly: The Framingham Study. Arthritis and Rheumatism, 1987. 30(8): p. 914-18.
3. Hannan, M.T., David T. Felson, Jennifer J. Anderson and Allan Naimark, Habitual Physical Activity is Not Associated with Knee Osteoarthritis: The Framingham Study. Journal of Rheumatology, 1993. 20(4): p. 704-709.
4. Fisher, N., et al., Muscle rehabilitation: its effect on muscular and functional performance of patients with knee osteoarthritis. Arch Phys Med Rehabil, 1991. 72: p. 367-74.
5. Hochberg, M.C., et al., Guidelines for the medical management of osteoarthritis. Part II. Osteoarthritis of the knee.American College of Rheumatology [see comments]. Arthritis Rheum, 1995. 38(11): p. 1541-6.
6. Minor, M.A., Exercise in the treatment of osteoarthritis. Rheum Dis Clin North Am, 1999. 25(2): p. 397-415, viii.
7. Minor, M.A., et al., Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis. Arthritis Rheum, 1989. 32(11): p. 1396-405.
8. Kovar, P., et al., Supervised fitness walking in patients with osteoarthritis of the knee. Annals of Internal Medicine, 1992. 116(7): p. 529-34.
9. Coleman, E.A., et al., The relationship of joint symptoms with exercise performance in older adults. J Am Geriatr Soc, 1996. 44(1): p. 14-21.
10. Ettinger, W.H., Jr., et al., A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. The Fitness Arthritis and Seniors Trial (FAST) [see comments]. Jama, 1997. 277(1): p. 25-31.
11. Fisher, N. and D. Pendergast, Effects of a muscle exercise program on exercise capacity in subjects with osteoarthritis. Arch Phys Med Rehabil, 1994. 75: p. 792-7.