At some point in their careers, every personal trainer will work with a client who has arthritis. Trainers who are not aware of how to work with these types of clients may try to "out exercise" arthritis, which runs the risk of further damaging the clients' joints.
If you have worked in the fitness industry for more than five minutes, you have worked with an arthritis client or two. According to the Centers for Disease Control, 30.8 million people were diagnosed with osteoarthritis (OA) from 2008-2011. An eye-opening related statistic is that 62 percent of arthritis patients are younger than 65 years old.
OA is common and can be quite problematic when working with a client affected with joint inflammation. You cannot "out-rep" arthritis, meaning when a client complains or is diagnosed with arthritic knee pain, you can't just coach them through the exercise by having them practice more. Their joints are damaged. No matter how well you are cueing a client through an exercise, the fact is that their body may literally not be able to perform that exercise. If you keep trying to "out exercise" arthritis, you will lose and run the risk of further damaging your client's joints.
If you desire to work with arthritis clients (and at some point you will work with them whether or not you plan to), you must get specialized education on how to train arthritic clients. Be aware that typical personal trainer certifications and even many of the corrective exercise specializations out there don't provide enough depth in their content to truly equip you to address the needs of an arthritic client. (Check out The Medical Fitness Network for courses specific to osteoarthritis.)
As a Medical Exercise Specialist, I have invested in my education so I could understand the pathology of OA, how to program design for OA and what specific challenges the OA client faces when exercising.
Below is my brief Arthritis 101 "course" you can use to work with current OA clients as you look for continuing education.
Osteoarthritis is characterized by thinning and destruction of the articular cartilage of the joints, followed by remodeling of the underlying bony surfaces. Articular cartilage is a multi-layered tissue that draws its strength from collagen fibers and its resiliency from proteoglycans that attract water to the connective tissue matrix that acts as the structural support of cartilage. Cartilage is 60-80 percent water by weight. The strongest of the three layers is the superficial layer due to the high density of collagen fibers. The deep layer is the weakest due to low collagen density. Articular cartilage also acts as a shock absorber and reducer of friction. Normal human cartilage without injury should last for 80 years and be able to absorb forces greater than eight times a person's body weight without injury. The factors that seem to destroy and wear down the cartilage in an arthritic joint are:
- Excessive body weight
- Lack of joint surface alignment, lubrication and disease
- Reduced integrity of ligaments and strength of surrounding muscles
The earliest biomechanical change in the arthritic joint is increased water content within the cartilage. The early failure and destruction of the collagen fibers in the joint trigger proteoglycans to attract more water and cause swelling. As the changes in the joint progress, there is loss of proteogylcans, which in turn causes loss of water in cartilage. The cartilage loses its elasticity, becomes less resistant to repeated stress and the process of disintegration of cartilage begins. Progressive thinning of the cartilage occurs, and the final stage of joint degradation is the loss of articular cartilage. At this point, the joint surface is made up of subchondral bone that is eroded from the bone-on-bone grinding. This phase is severely painful. Along with the loss of articular cartilage is a remodeling of subchondral bone, which gradually leads to thickened bone. The shape of the end of bone often changes during this remodeling. A characteristic component is the formation of new bone at the joint margin (osteophyte or bony spur).
The goals and objectives of exercise are:
- Increase or maintain functional strength, endurance, functional capacity and joint stability
- Increase cardiovascular capacity
- Increase or maintain range of motion
- Develop independent home stretching and strengthening program
- Improve or maintain joint strength and stability
In order to best manage OA, your first priority is to rebalance the muscles surrounding the joints. This means determining which muscles are overactive and which are underactive and then creating a sequential progression of restoring balance, strength and mobility throughout the arthritic joint and possibly the joint above or below the affected joint.
Rebalancing should then be followed by improving the way the affected joint works in combination with the rest of the body during functional movement patterns. While it is important to restore balance to certain muscle partnerships, it really means nothing if your client is a rock star on the table and then aggravates their knee stepping off the curb to go to their car after your session. You must train your client to move better through their activities of daily living.
Once your client is moving with significantly less pain throughout their day, consistently performing prescribed at-home exercises and completing sessions with you with minimal pain, you can begin adding strengthening and endurance circuits. Please remember that in order to teach your client's nervous system a new pattern, you must build up the strength and endurance of that pattern before you load it up with resistance and duration. If you prematurely add weight, intensity or time to a neuromuscular system learning a new pattern, the body will revert back to its arthritis-producing movement patterns and aggravate your client's joints. Square one is frustrating for you and the client. Be disciplined and structured in your approach.
Here are the fundamental guidelines to training OA clients:
- Avoid high-impact activities (jumping, running, agility drills, burpees, dynamic lunging)
- Avoid stretching into the extremes of range of motion (go to their comfort level, slow and steady progression)
- Do not exercise painful or swollen joints (again, squatting through knee pain will not reduce pain)
- Measure painful response two hours after exercise and the next day (Check in with your client.)
Sample OA Fitness Program
Here is a sample program for OA in the knee that I have used to successfully manage hundreds of clients. I hope this helps you set more clients free from their pain.
Pathology of Knee OA:
- Poor ankle dorsiflexion
- Internal rotation of femur
- External rotation of tibia
- Poor hip extension
The key objective to training OA is to help the client learn how to move without producing pain. This means teaching their nervous system to move away from the faulty OA patterns. You can do this through manual guidance, re-adjustment through movement phases, shortening the pattern range of motion or using counter resistance during the movement (i.e. bands around knees during squats or banded tibial IR during a step up).
Here are what you should focus on in an eight-week program:
Release (myofascial release or dynamic stretch): ankle plantarflexors, biceps femoris, TFL, rectus femoris
Activate: tibialis posterior, vastus medialis, glute medius, medial hamstrings, adductor magnus
Functional Movements: Knee banded kettlebell deadlift, tibial banded (lateral anchor) step ups
Strengthening (one to three sets, 10-15 reps, stop when form degrades for two reps):
Split squat, multi-planar step ups, hex bar deadlifts
Functional circuit (one to three sets, 10 reps per exercise, rest 30-60 seconds. Lower reps if form degrades): exercise ball knee flexion, lateral band walks, side to side kettlebell squats, kettlebell squats
Trevor Wicken has been serving his clients as a Medical Exercise Specialist for 15 years. He is passionate about coaching his clients how to exercise to reduce chronic pain, prevent recurring injuries and manage medical conditions. He has a broad background in the fitness industry including training and management in medical, private, commercial and specialty based fitness centers. He is on the advisory board of the Medical Fitness Network. Wicken holds a bachelor’s degree in sports medicine from Colorado State University and a master’s degree from California University of Pennsylvania in exercise science and biomechanics. You can find out more about him on his website: www.RiseAndMove.com or email him at Trevor@RiseAndMove.com.