Alternative Arthritis Exercise Programs
by A. Lynn Miller
Many people do not like to exercise alone, and exercising with a group can be an excellent support mechanism. When a friend of my mother was diagnosed with rheumatoid arthritis, she joined an aquatic ex-class for people with arthritis. The class is like a support group for her, and with regular exercise and medications, she has been able to resume some of the activities that she had given up before her diagnosis. Others have told me that they enjoy classes because they are surrounded by peers and because the classes are designed with the specific problems of arthritis patients in mind.
Exercise classes can have several pros and cons, depending on the specific class that you are considering. The benefit of exercising with people who have problems similar to yours is substantial. A class designed for people with arthritis uses movements and activities that are more suited to stiff joints and limited ranges of motion. Most such classes use low-impact activities with lessened intensity and include more warm-up and cool-down activities in the session. Psychologically, it can build up your self-esteem to feel you are part of a group.
On the other hand, if you decide to join an exercise class that is designed for a younger, fitter clientele, you may find it does not fit your needs. Al-though being around young, vibrant people can be invigorating, it can also be discouraging if you cannot keep up with the pace of a class or if you are a person who compares yourself to those around you. Such frustration can lead to discontinuing exercise altogether rather than modifying the activity. Furthermore, some exercise classes include activities that put arthritic joints under excessive stress, potentially increasing pain and stiffness.
If you prefer to exercise in a group, look for classes designed for people with arthritis or classes with low-impact activities. Many hospitals and facilities offer health and fitness classes for specific groups, such as arthritis patients. Qualified instructors who are educated about special needs related to arthritis usually teach their classes. The Arthritis Foundation has developed community-based programs offered nationwide through the YMCA and other facilities.
Determine whether the facility is easily accessible to you and whether the class hours suit your schedule. I suggest going in and observing a session before joining a class; in this way you can evaluate the level of intensity, the types of movements related to your needs, and even the kind of music used in the class. Pay close attention to how the instructor interacts with the participants; keep away from a class in which the instructor comes across like a drill sergeant. A good instructor should check on individuals occasionally, slowing some down and speeding others up. I like instructors who include some education at the beginning of a course-it shows they are interested in meeting your needs.
You can consider several types of group classes, each with potential benefits. Most classes try to include each component of fitness in the activities. The cardiovascular conditioning benefits may not be as substantial as an equally long session of pure aerobic exercise, but you get the advantage of a well-rounded program. The most common types of classes are aerobics (both on land and in water), tai chi, and yoga classes. Other group classes can be beneficial, but these are the most common. Evaluate the one you are considering using the general guidelines provided here.
Questions to Consider When Choosing an Exercise Class
- How many people are in the class?
- Is the location convenient and comfortable?
- Is the class designed for people with arthritis? If not, can I alter the activities to meet my needs?
- Does the class include a warm-up and a cool-down?
- What is the average fitness level of the participants, and does it match mine?
- Is the instructor well qualified, and how does he or she interact with the class?
- Is the atmosphere one that I would enjoy? For example, if there is music, does it sound like something I would like, or is it too loud?
- Are there other classes at other times that I can attend, if I want to make up missed classes?
- Is the staff prepared to deal with minor and major emergencies? Are they certified in CPR or first aid?
Aerobics classes were given their name many years ago, when the concept of a class conducted with music was first introduced. I have divided such classes into land and aquatic classes, although one could also divide them according to the emphasis, intensity, or purpose of the class. For example, "spinning" is a new type of class that has developed within the last few years. Spinning classes are basically group aerobic classes that use stationary cycles as the workout mode. Each of the various types of land and aquatic classes also emphasize particular elements.
Land Classes: The benefits of participating in aerobics derive from the focus of the class and the frequency of your participation. A class that meets only once a week has limited health benefits, although it might be fun as a change of pace from a more traditional exercise regimen. Look for a class that meets at least three days per week in order to reap any fitness gains. Studies have shown that aerobics participation reduces pain and improves lower-extremity function, strength, walking speed or distance, and aerobic power, which is an estimate of aerobic endurance from a short activity (Perlman et al. 1990; Noreau et al. 1995). Most of these studies also found decreased depression after completion of a class. They have identified cardiovascular benefits only when the frequency is at least three times per week and the intensity is appropriate (50 to 85 percent of HRR).
What to Look For in a Class: As stated earlier, look for an aerobics class that either is intended for individuals with arthritis or uses only low-impact activities. A low-impact class means that there is not a lot of bouncing and jumping, both of which can be very stressful to your joints. Low-impact classes also have fewer injuries associated with them than do high-impact classes (Janis 1990).
The general fitness benefits of a well-designed aerobics class are deter-mined by its components, although the strengthening benefits are limited. The class should have a warm-up period during which the activity is slowly increased, a period devoted to cardiovascular activity (rhythmic activity using larger muscle groups), and a cool-down period. In addition, most will have some calisthenic activity that is designed to tone the muscles. The resistance is usually your limb or body weight, so the focus is on building muscular endurance.
A good instructor is essential. Find out the instructor's qualifications and experience. This is not to say that a new instructor cannot be good, but make sure that he understands the principles of exercise and knows how to help people with activity adjustments. Several groups offer certification, which ensures at least a basic level of knowledge on the instructor's part. The Arthritis Foundation programs provide instructor training that covers not only exercise principles but also information specific to arthritis.
In the 1980s the Arthritis Foundation introduced a program called PACE (People with Arthritis Can Exercise), which is offered nationwide. If you have one of these programs in your community, I highly recommend it. The classes are designed for people with arthritis, and they have a proven record of accomplishment. They provide education on body mechanics, joint protection, and the basic principles of exercise. The program offers two levels of instruction, a basic and an advanced level, which should meet the needs of most participants. When in doubt, start with the basic class to lower the risk of an overuse injury from starting at too high a level.
Basic Requirements : Look for a class that includes the normal components of exercise identified earlier-warm-up, cardiovascular exercise, strength and flexibility activi-ties, and a cool-down. The length of a class is usually 45 to 60 minutes. A good 60-minute class contains at least 10 minutes of warm-up activity, 15 to 20 minutes of large movement aerobics, and 10 minutes of cool-down. The warm-up and cool-down may incorporate range of motion and stretching activities. The rest of the time is usually devoted to muscular conditioning exercises.
Estimate your own target heart rate, as shown in chapter 3. Use this rate to monitor your exercise intensity. I often see people working at too high a level, because they are trying to keep up with the instructor and others around them. Remember, the instructor has been doing this routine for a while and is probably at a different fitness level than you are. If your limbs feel extremely heavy or experience a burning sensation, then you are working more anaerobically than aerobically. In other words, you are producing lactic acid because you are working at too high an intensity, and you need to decrease it. Use the talk test-you should not be breathing so heavily that you cannot respond to a simple question with a short phrase. On the other hand, if you are able to chat with someone, then you are not working hard enough. Again, refer to your target heart rate to assess your intensity.
You may need to modify some of the activities based on your limitations. For example, if you have arthritis in your shoulders, perform only the upper body activities that do not cause increased pain. If the instructor tells the class to do a rapid arm movement overhead, slow down the movement and do it at shoulder level. With lower-extremity arthritis, you may find that you cannot do some of the activities that require lots of rotation at the hip or extreme hip and knee flexion. Usually you can do such motions through a shorter range.
I recommend that you participate in an aerobics class no more than three days per week. The rate of overuse injuries increases with increased frequency of participation in traditional aerobics classes, so limiting the frequency to three days per week should also limit the potential for injury (Rothenberger, Chang, and Cable 1988; Janis 1990). On the alternate days, you can carry out a more traditional cardiovascular program, such as walking, or perhaps a different kind of activity. Not only will your chance of injury decrease, but the varied routine may also help you stick with your program.
As with walking or jogging, you need to make sure that you have good shoes. The types of shoes that are appropriate for jogging are not the same as the ones you need for an aerobics class. Your shoes should have more support in the forefoot as well as adequate cushioning. These shoes may be called Òcross-trainersÓ or something similar. Usually you do not need special clothing as long as what you wear is comfortable and absorbent.
Water Aerobics: Exercise in the water has some unique benefits compared to other pro-grams. The buoyancy of the water reduces the amount of body weight placing stress on joints, and the warmth of the water can lessen muscle stiffness. Movements tend to be less vigorous in a water class, a quality that also contributes to decreased joint stress. Participating in water aerobics classes with appropriate frequency, duration, and intensity can improve your aerobic and functional capacity and decrease pain (Minor et al. 1989; Sanford-Smith, MacKay-Lyons, and Nunes-Clement 1998). Many people tell me that they enjoy and stick with an aquatic class because Òit feels great in the water.Ó One woman reports that she likes aquatic classes in the winter when she cannot get outside as easily. Incorporating an aquatic class into your regimen may be especially beneficial if you have multiple joint involvements, rheumatoid arthritis, or more advanced arthritis.
What to Look For in a Class: As with the land aerobics classes, look for classes specifically designed for people with arthritis. The Arthritis Foundation and the YMCA have developed an aquatic program for people with arthritis that is available nationwide. These classes have been proven effective; they are currently offered at two levels. The focus of the aquatic program is range of motion improvement and muscle strengthening, with an optional segment for building endurance (classes with the endurance segment are longer). If you are considering an aquatic class not designed for persons with arthritis, go in and watch a class. Look for a class that is not too large so that participants can move freely without bumping into one another. An aquatic class, like a land class, should begin with a warm-up period, include both upper- and lower-extremity activities, and end with a cool-down segment. The pace should be brisk and the activities varied.
As with land classes, the Arthritis Foundation/YMCA program provides training to their instructors. Therefore, you know that your teacher has the necessary education about the exercise requirements and special needs of arthritic people. If you check out other programs, look for an instructor who has experience in aquatic exercise and who knows how to adapt movements to individual needs. Any instructor should have basic Red Cross or YMCA lifesaving certification as well as instructor certification. A good teacher includes an education segment, usually before anyone gets into the water, and helps you individualize movements for your capabilities.
Two environmental factors to consider are the temperature and depth of the water. Usually classes designed for people with arthritis have ad-dressed these issues, but it helps to know what to look for. Water temperature should be between 84 and 92 degrees Fahrenheit, slightly warmer than pools that are used primarily for lap swimming. Exercises should take place in water that ranges from mid-chest to shoulder level in depth. The deeper the water, the lower the stress (from gravity) placed on joints in your lower extremities. If you are standing in water that reaches the lower end of your sternum, your body is unloaded by approximately 75 percent.
Basic Requirements: The basic requirements of a program in the water are the same as for a land program-warm-up segment, all three fitness components, and a cool-down period-combined in a class of 45 to 60 minutes. Special water exercise equipment is available to provide an effective resistance component to your program. These devices increase resistance either by enlarging the surface area that pushes against the water, as a hand paddle does, or by increasing the buoyancy of a limb. When you try to push a buoyant object under the water, there is greater resistance to your motion. Although there is some resistance to any motion through the water, such devices can greatly enhance an aquatic exercise class. A good aquatics instructor should explain and demonstrate each new activity before you execute the movement, especially when using equipment such as I have described.
You can safely participate in a water aerobics class five days per week, although you might find that three days per week is enough. Again, try alternating the type of program you do on different days, to give variety to your routine. An important difference between the basic requirements of aquatic programs and land programs is the estimation of work intensity. Your heart rate decreases simply by getting into the water; thus, heart rate may not accurately reflect the true intensity at which you are working. You can try using the same target heart rate you use for land, but you may find that you do not feel as if you are working at as high a level. If necessary, use rating of perceived exertion to evaluate and modify your intensity.
One piece of clothing that you might not think about for an aquatic class is shoes. Because you exercise while standing on the bottom of the pool, your feet can become sore. Get a pair of water shoes-padded slippers with nonskid soles that reduce foot discomfort and lower the chance of slipping.
You may have heard of tai chi but have thought that it is not appropriate for you, especially with your arthritis. Although it originated in the mar-tial arts, several forms of tai chi have been modified to emphasize health benefits. Tai chi focuses on slow, controlled movements throughout a complete range of motion, with minimal impact on the lower extremities. The benefits of tai chi include improved balance and flexibility, some cardiovascular enhancement, and the psychological benefits typically reported with exercise (Matsuda 2003; Young et al. 1999; Lan et al. 1998). Both people who have osteoarthritis and those who have rheumatoid arthritis have used tai chi effectively (Kirstein, Dietz, and Hwang 1991; Lumsden, Baccala, and Martire 1998). Arthritis patients report that the activity does not aggravate their arthritis and helps decrease their stiff-ness and fatigue.
A few years ago some of my students worked with a local senior center, comparing the benefits of different types of group activities. Those that did tai chi demonstrated the best adherence to their programs. They reported that they enjoyed the classes immensely, because the movements were easy to follow and because they were not afraid of hurting themselves (in contrast to some participants in the other activities). Numerous articles cite this type of anecdotal evidence, demonstrating that new activities such as tai chi are worth a try.
What to Look For in a Class: Some information about the history of tai chi, as well as its forms and principles, helps one know what to look for in a class. Tai chi chuan originated in China as a martial art. As with many Eastern practices, it strives to balance the mind and the body by using a blend of focused movement and meditation. The word "chuan" is not used with some of the newer forms, since the emphasis on the combative aspects of the discipline has been removed. Different forms (styles) of tai chi use different numbers of moves, ranging from 9 to 108; the most common form uses 24 moves. Five principles serve as the guide for the forms. These principles include the separation of yin and yang (opposing energy), keeping the body up-right, the waist is the commander, the body is relaxed and movement is flowing and yielding, and attention to present (focus on the movement) (Matsuda 2002).
For a specialized class such as tai chi, one of the first things I look at is the instructor's qualifications. A good instructor has several years of experience in this martial art. I investigated taking a class a few years ago, but decided not to when I found that the "instructor" had only taken one class before deciding to teach it. I would have gotten a more professional training by renting a videotape! A good instructor incorporates education into the class and circulates among class members to correct body postures or refine movements. A smaller class is preferable at the beginning levels, since it allows more individualized attention from the instructor. The class should identify its level so that a beginner is not struggling to keep up with those who have been practicing tai chi for years. Many beginning classes focus on shorter routines that use basic movements or techniques.
Basic Requirements: The benefits of tai chi are greatest in the areas of flexibility and lower-extremity strength. Although you can derive some cardiovascular benefits from tai chi, it does not stimulate the cardiovascular system optimally. To develop a well-balanced exercise program, I suggest doing a cardiovascular exercise program on alternating days with a tai chi class. A well-designed class starts with posture and breathing activities, along with some simple weight shifts and waist turns. After a warm-up period of 15 or more minutes, it progresses to whole body techniques combined with arm and hand movements. A good introductory class introduces only a few forms each session and adds one or two new moves each week. The movements are slow and controlled, flowing from one position to another.
As in other classes, you may need to modify movements because of your arthritis. A videotape on tai chi that I viewed demonstrates movements, such as deep knee bends, that could easily aggravate knee and hip pain. From what I have observed, the primary modifications you may need to make are in the ranges of the movements, but not in speed or repetitions. Other modifications that you may need to make include limiting single stance time and decreasing internal rotation at the hip. As with any exercise, adjust the move based on your pain and your joint limitations. Some classes are designed for people of limited ability and use grab bars or other methods of support to promote safety.
The recommended attire for a tai chi class includes loose, comfortable clothing and soft-soled shoes. If your class is indoors (in warmer climates these classes may be offered outdoors), you can wear a nonskid shoe with thinner soles. For outdoor classes, a walking or tennis shoe gives you better support on uneven ground.
Tai Chi Variations: Several groups have taken the traditional practice of tai chi and modified it to use for health purposes. A range of motion dance program was developed using the principles of tai chi, which has been further adapted for people with various disabilities (Harlowe and Yu 1997). Elderly persons have used a modification that employs nine movements to help reduce falls. Such programs are not traditional tai chi, but you may find that one of them meets your needs for a group class with low-impact activity.
Yoga is another nontraditional exercise that has potential benefits for people with arthritis. As with tai chi, its original purpose is not exercise, but in this case, a means of achieving self-understanding. The National Coalition for Complimentary and Alternative Medicine has classified yoga as a Òmind-bodyÓ therapy because of its emphasis on physical and mental integration. The most common form in the United States is hatha yoga, which focuses on postures and breathing control. Yoga may be helpful in developing and maintaining flexibility, coordination, muscle tone, and balance. Participation in yoga appears to yield specific physical benefits (such as lower blood pressure and cholesterol) as well as improved exercise tolerance (Austin and Laeng 2003). The research demonstrates that benefits for people with arthritis are limited, but promising. These benefits include decreased pain and improved range of motion (Garfinkel et al. 1994). Some people swear by yoga for its effect on improving and maintaining flexibility, as well as for its meditative properties.
What to Look For in a Class: As with tai chi, some information about the history and types of yoga may be helpful in evaluating a class. Yoga started in India more than 2000 years ago, and numerous styles have evolved through the years. The practice of yoga is a meditative one, intended to bring one to a deeper understanding of the universe and of truth, although it has developed a greater focus on physical aspects (Austin and Laeng 2003).
Hatha yoga, as already noted, is one of the most common forms practiced on the North American continent. Even within this form, there are many styles with slightly different focuses. In general, there are eight philosophical principles, called ashtangas, which guide yoga practice. Two of these, asana and pranayama, serve as the basis of hatha yoga; they guide physical postures and breathing patterns, although the other principles are also used. Techniques and principles are supposed to have specific benefits related to different physiological systems. For example, some of the pranayama techniques are supposed to help the respiratory system through back extension coordinated with breathing patterns. A few yoga styles have been developed for therapeutic purposes and use modified positions and some equipment.
As when considering any other class, you should ask a few questions:
1. What is the focus of this particular class and for whom is it designed?
2. What are the instructor's credentials?
3. Does the instructor individualize physical postures?
4. Are equipment adaptations available if necessary?
You may find that a class designed for older or arthritic people is prefer-able, at least to start with. The postures are less likely to be extreme and some adaptations using equipment are usually included. Two modifications that I think are vital are mats and some sort of railing or stable sup-port device. Doing some of the postures on a hard floor can aggravate stiffness and pain. A grab bar can increase safety when performing challenging one-legged standing postures.
The better instructors have a few years of experience, both with yoga and with various physical limitations. Each style of yoga has its own set of teacher certification standards, which can be frustrating if you are trying to find out about your instructor's credentials. One effort to address this problem has been the creation of the Yoga Alliance Registry, which identifies minimum standards and includes all styles.
Basic Requirements: Because yoga is not primarily focused on exercise, it is difficult to deter-mine what basic requirements a class should meet. The primary benefits, as already noted, are flexibility, balance, and some muscle tone. Therefore, you can practice yoga on a daily basis to meet the flexibility component of your training. If you are looking for a well-balanced exercise program, include another type of activity to meet your cardiovascular and strength-training needs.
The duration of yoga classes varies, but the most common community-based programs seem to last between 40 and 60 minutes. Classes usually begin with a basic posture, focusing on breathing, alignment, and body awareness. Postures progress from simple to more difficult and attempt to use a variety of motions. The most common postures involve standing on one leg or both legs, bending forward and backward, sitting, and twisting. Most yoga sessions finish with relaxation postures (Austin and Laeng 2003).
You may need to modify or eliminate some of the more than one hundred postures, for safety reasons. Although no formal contraindications exist for yoga, I believe that you should avoid some postures or at least approach them with caution. I put these postures into two broad classes: those that put unusual stresses on a joint and those that may put stress on a system, such as the cardiovascular system. Some postures may do both. The chapter on flexibility includes an illustration of a posture that could potentially do both. The plough position requires you to lie on the ground and bring your feet over your head, with your legs straight, until your feet touch the ground behind your head. If you have arthritis in your neck, this pose could injure those joints. If you have cardiovascular disease, such as high blood pressure or atherosclerosis (narrowing of the arteries), this position might also stress your system; you may want to limit inverted poses because of the potential effect on blood flow.
Clothing for yoga should be comfortable and nonrestricting. It can be loose and somewhat baggy, such as shorts and a T-shirt or stretchy exercise wear. Whatever you wear, you need to be able to move freely without getting caught in excess folds. One yoga teacher I talked to likes to have everyone barefoot. Being barefoot may not be comfortable if you have arthritis in your feet; a lightweight athletic shoe may be more appropriate. Your shoe should have a nonskid sole and give you adequate support and comfort.
Personalizing Your Program
For each type of class, I have identified ways in which you may need to adjust the activity to accommodate your joint restrictions or personal needs. These methods include slowing down to decrease the cardiovascular intensity; eliminating activities that you cannot do because of joint limitations or pain; and decreasing extreme motions, especially knee and hip flexion. Beyond such adjustments in motion or intensity, classes are not set up for personalization. These types of classes can be used, however, to personalize your entire exercise regimen.
Most classes work best when done two to three days per week, a schedule that allows you to put a different emphasis into your daily program on the remaining days. None of these classes offers optimal cardiovascular or strength conditioning, so I suggest setting up a program that emphasizes these elements at least two days of the week, alternating with the group classes. Another option is to view a group class as an adjunct to your normal program. For example, the university recreation center near me offers tai chi each semester, one day per week. Once a week is not enough to gain any significant benefits, but I can do it as a way to add a group activity into my program. My base exercise regimen can take place five days a week, with the typical components; on the sixth day, I can do tai chi.
Group classes are a pleasant way to incorporate a social aspect into your program, and the variety may help improve adherence to your program. Repeatedly I hear how people like the support they get from being with a group, especially when the group has similar health concerns, such as arthritis. If you are an outgoing person, consider joining a class as an adjunct to your program-it may greatly increase your enjoyment of your exercise routine.
In this article I have discussed various types of exercise classes, including aerobics on land and in the water, tai chi, and yoga. You may come across other types of classes that you wish to consider. Always observe the class and the types of movements it employs first. I have discussed the requirements for each component of fitness, so you can analyze the activities and determine whether the class meets any of these requirements and whether it uses movements that you might find stressful to an arthritic joint.
Excerpted from Action Plan for Arthritis by A. Lynn Millar. Copyright © 2003 by American College of Sports Medicine, Inc. All rights reserved. Excerpted by arrangement with Human Kinetics. $17.95. Available in local bookstores or call 800.747.4457 or click here.