Skeeter Buck has had 4 years of joint pain with some very severe occasions. He complains of stiffness in his wrists, hands, knees, and feet. The stiffness seems to last anywhere from 30 minutes to 2 hours in the morning. When his joints are sore he is very unstable and feels as though he has no balance. The joint pain does not occur on a regular basis but when it does, he tends to lose his appetite. Medication: Cortisone shot (every 3 months), Aleve, Tylenol Medical History: 4 years of joint pain. Recently symptoms worsened. Family History: Grandmother and mother have rheumatoid arthritis and have had surgery.
Grandma had a hip replacement and his mother had a knee replacement. Most of his family is overweight but there is no history of diabetes or heart disease. Social Lifestyle: Married with 2 children and wife is pregnant with their third. Lives in North Bay where he is the manager at a bank. He walks with a cane when his ‘flare ups’ are bad. Lifestyle History: Enjoys playing with the kids. He is as active as he can be without being in pain. He helps coach the hockey team his oldest son plays on. Wife is a dietician and so he eats healthy meals on a regular basis.
Risk Factors: He is a non-smoker, regular cholesterol levels, and normal blood glucose levels. Physical Examination General Appearance: Looks healthy, comfortable and has great colour in face. Vital Signs: Blood Pressure = 123/82 mmHg in both arms, Pulse = 72 beats per minute, Respiration= 17 breaths per minute, Mass= 82 kg, Height = 70 in. (175 cm), BMI= 27, Waist Circumference = 34in. Cardiovascular: No carotid bruits, no jugular venous distension, clear lungs, normal point of impulse, regular rate and rhythm, no extra heart sounds, no edema, normal peripheral vascular exam.
Skin: no rashes, a bit red, swollen and warm around knuckles on hands and feet. Musculoskeletal: walks slow due to pain, joints on the hands and feet are a bit swollen, does not have a full range of motion in his joints. Neurologic: Normal cranial nerves, loss of fine motor skills in hand, normal sensory exam. Resting Electrocardiogram before Exercise Test: Sinus rhythm, rate= 72 beats per minute, no Q waves, ST or T wave abnormalities. Computer interpretation is normal electrocardiogram. Diagnosis:
Rheumatoid arthritis in wrists, hands, knees, and feet causing stiffness in the morning and pain throughout the day especially after more than normal use of the joints. This causes exercise intolerance and fatigue. Plan Complete a standard cycle ergometer test and initiate a training program focussing on increasing exercise tolerance, muscle strength, and range of motion. ** Please refer to following pages for pre-screen and informed consent forms! ** PATHOPHYSIOLOGY Rheumatoid Arthritis Rheumatoid arthritis is a type of inflammatory arthritis and an autoimmune disease.
An autoimmune disease is one where the body’s immune system becomes confused and begins to attack its own body. In rheumatoid arthritis the target of the immune attack is the lining of the joints (synovial) and sometimes other internal organs. This causes swelling, pain, inflammation, and joint destruction. Inflammatory cells release enzymes that can digest bone and cartilage causing limited bone motion. This inflammation of joints usually occurs in a symmetrical and bilateral pattern (what happens on one side of the body, happens on the other).
Rheumatoid arthritis is also characterized by aggravations and remissions (periods of time with intensified symptoms followed by period of time with reduced symptoms). Rheumatoid arthritis usually begins slowly, starting with only a few joints and spreading to others over a period of a few weeks to a few months. People with rheumatoid arthritis have impaired exercise tolerance. The disease affects flexibility, biomechanical efficiency, muscle strength, endurance, and speed, which contributes to functional limitations.
There are three levels of classifying rheumatoid arthritis disease stages: 1. Acute: reversible signs and symptoms in the joint related to synovitis 2. Chronic: stable but irreversible structural damage brought on by the disease process 3. Chronic with acute exacerbation of joint symptoms: increased pain and decreased range of motion and function often related to overuse or superimposed injury. (3) Figure:(12) Signs and Symptoms of Concern (13)You should see your doctor if you experience any of the following symptoms for more than two weeks: Feel unusual pain and stiffness in your joints
Pain and stiffness in the morning lasting more than 30-60 minutes before you feel any relief Feel more fatigued than normal Lack of hunger leading to weight loss Importance of Exercise for Rheumatoid Arthritis Patients Although people with rheumatoid arthritis may be hesitant to exercise due to pain they experience within their joints, current evidence suggests that a significant amount of disability related to the condition occurs from lack of fitness. By not exercising, muscle strength and endurance begins to deteriorate.
This weakens the joint and contributes to accelerating the speed or arthritis. By not exercising you are also putting yourself at risk for other chronic diseases such as coronary heart disease, diabetes mellitus, and osteoporosis. The American College of Sport Medicine outlines three goals for exercise and arthritis. The goals are: 1) preserve or restore range of motion and flexibility around the affected joints; 2) increase muscle strength and endurance to build joint stability; 3) increase aerobic capacity in order to enhance psychological state and decrease the risk of cardiovascular disease.
(8) Although long term effects of dynamic weight bearing exercise on those with rheumatoid arthritis remains unclear, current data suggests that vigorous exercise may be used to improve joint mobility, muscle strength, and aerobic capacity without causing joint damage (except when there is an acute joint inflammation or uncontrolled systemic disease)(8). Those with rheumatoid arthritis should remember that post exercise discomfort should be expected, but activities causing increased joint pain enduring for greater than two hours post-exercise should be discontinued.
As previously mentioned, people with rheumatoid arthritis often have little aerobic capacity due to inactivity, but it has been shown to be a safe and beneficial form of treatment for those who are not experiencing acute symptoms. The American College of Sports Medicine suggests that people with rheumatoid arthritis should participate in large muscle activities such as walking, cycling, rowing, swimming, and dance at 60-80% of their peak heart rate or 40-60% VO2max, a rate of perceived exertion (RPE) rating of 11-16, 3-5 days per week for five minute sessions building up to thirty minutes.
When working with people with rheumatoid arthritis, it is important to emphasis duration is more important than intensity with goals of increasing VO2max, peak work, and endurance within 4-6 months. It is also important to have at least fifteen minutes of warm-up and cool-down. (8) MEDICATION Although there is no specific cure for rheumatoid arthritis at the present, there are a range of medications available to manage the symptoms to improve the condition. Rheumatoid medications can be classified into different classes such as NSAIDs, Corticosteroids, DMARDs, Biological Agents, Salicylates, and Pain Relief Medications.
Your doctor will most likely use a combination of these drugs to alleviate pain and prevent further damage to the joints. NSAIDs NSAIDs or Non-steroidal Anti-inflammatory Drugs are effective in pain relief and inflammation reduction, but do not serve to protect the joints from further damage. NSAIDs prevent your body from producing a substance called prostaglandins, which is primarily responsible for inflammation and pain. When taken in extreme dosages for a long time, these drugs can produce severe side effects, such as stomach bleeding, gastric ulcers, as well as potential damage to the kidneys and liver.
Corticosteroids Corticosteroids suppress the immune system, thus managing inflammation. Although these may be very effective in treating rheumatoid arthritis, they have been said to trigger adverse side effects if used in prolonged periods. Examples of these side effects include easy bruising, glaucoma, cataracts, diabetes, excessive weight gain, and thinning of the bones. DMARDs DMARDS or Disease Modifying Anti-Rheumatic Drugs are groups of medications that serve to inhibit the immune system from damaging the joints, thus slowing further joint damage.
Rheumatoid arthritis causes permanent joint damage in the early stages and so it is very important to start these medications right away. The risks for severe side effects are high with these medications. Taking DMARDs for a long time may result in bone marrow and liver toxicity, vulnerability to infections, skin allergies, and autoimmunity. Biological Agents Biological agents or biological drugs function to alleviate inflammation via various methods. An example of how they work is by inhibiting tumour necrosis factors.
They also can treat inflammation through eradicating Beta cells. Salicylates Salicylates reduce the body’s production of prostaglandins. The use of salicylates has been replaced with NSAIDs, mainly due to the fact that they caused adverse side effects. Pain Relief Medications While anti-pain drugs neither decrease inflammation nor suppress further joint damage, these medications allow the individual become more comfortable and eventually function better. (2) PHYSICAL ASSESSMENT PROTOCOL
To determine baseline levels and the areas exercise is in need of improvement, exercise testing can be used to evaluate the different exercise parameters. Those with rheumatoid arthritis tolerate sub-maximal and subjective symptom-limited treadmill tests that require less than 3 miles per hour walking speed. Early-onset muscle fatigue may limit receiving accurate information. Since people with rheumatoid arthritis may have troubles performing maximal treadmill test, sub-maximal bicycle tests may provide more accurate information without over-stressing joints.