Posted on Wednesday, September 10, 2014

Q & A: Exercises Beneficial in Managing Rheumatoid Arthritis

Q. I have rheumatoid arthritis in my hands, wrists, and elbows. What type of exercise can I do to keep my upper body strength? –Gloria

A. Thanks for your question, Gloria, as it presents an opportunity to discuss a very devastating disease, Rheumatoid Arthritis (RA). Your willingness and desire to maintain your upper body strength despite the disease is an encouragement to others who may be suffering as well.

Rheumatoid Arthritis (RA) is one of 171 different types of arthritis. RA is most commonly diagnosed in women, with nearly three out of four cases involving women. Over 46 million people in the United States alone suffer from one form of arthritis or another, and this number is climbing rapidly. The most commonly recognized forms of arthritis are osteoarthritis and RA. Osteoarthritis is most commonly associated with “wear and tear” syndromes (degeneration of the joint from excessive use or injury). RA (known as an inflammatory arthritis) is an autoimmune disease in which the immune system works against normal body cells by attacking the joint surfaces and eventually, even the body organs. As the condition progresses, joint surfaces become severely damaged–leading to deformities and dysfunction.

A person with RA should always be medically managed by a specialist in the disease. Symptoms are typically quite severe and not only cause pain and deformities, but also excessive fatigue and loss of appetite. RA can be found in only one joint or area, but it’s usually associated with many areas in combination, typically in a symmetrical pattern. Eventually, it can affect the entire body including the internal organs.

In addition, it is important that you and your loved ones learn as much about the disease as possible. There must be a multifactorial approach to managing the disease. Consider the following:

Medical/Physician Management – This may include pharmacological management or surgical intervention, including total joint replacement.
Nutritional Management – Eat foods which promote a low inflammatory diet, including a diet high in Omega-3 fatty acids and other natural herbs (like garlic and turmeric) which can naturally lower inflammation.
Weight Management – It is important to manage your weight effectively. Excessive body weight can cause additional “wear and tear” (particularly on the lower extremities joints) and can worsen any damage caused by RA. Also, excessive weight can worsen RA symptoms or even cause osteoarthritis. If possible, you don’t want more than one form of arthritis if it can be avoided.
Activity Modification – As the disease progresses, it is important to understand how your body is functioning and then learn how to adapt to manage the disease. Unfortunately, certain activities and how you perform them will need to be modified or avoided. Learn to pace yourself and take more frequent rest breaks. Adequate night time sleep is also critical. Depending on the joints affected, learning to limit the use and strain on the joint is important. For example, if your knee is affected, then repeatedly going up and down stairs could cause a strain. You may choose to eliminate or minimize the frequency of that particular activity. Repetitive joint motion and in particular, repetitive joint loading and hyper loading, should be avoided and/or minimized. Learning to use adaptive devices to limit the strain placed on the body during activities will also be helpful.
Modalities – This is a broad category, but in general the application of heat, cold, or over-the-counter topical agents, such as Arnica Montana (an herbal rub) or Biofreeze, may help manage pain and stiffness. Gentle massage and TENS (Transcutaneous Electrical Nerve Stimulation, a form of electrical stimulation) may also be beneficial.
Splints – Many times, custom or over-the-counter splints (particularly for the upper extremities) can be utilized to provide support and comfort to joints which are in pain and/or suffering from deformity.

Now that you have a clear understanding of RA and options available to manage the disease, I will specifically address Gloria’s question regarding exercise for the upper extremity and exercise in general. Although the research for exercise for individuals with RA is far from complete, it indicates that a regular exercise and range-of-motion (ROM) program is a critical component to proper management of the disease. (Make sure you are adequately rested before performing any exercise program.) General guidelines for exercise include:

Strength Training – Strength training is encouraged, and the exercise program should be established by a professional who is familiar with managing RA. Excessive shearing forces and rotational forces and/or exercises should be avoided. Joints with severe involvement should be exercised with caution and an emphasis should be placed on ROM versus actual loading of the joint. All exercises should be performed in a slow and controlled environment within the available ROM. Maintaining muscle mass through strength training is critical and should be performed only one to two times per week to minimize any risk of over stressing the joint.
Endurance Training – Endurance training is critical for general health and should be included as part of a comprehensive exercise program for individuals with RA. Avoid cardiovascular exercise (running, jogging, skipping, jump roping, etc.) which produces high impact forces. Instead, focus on less impact activities such as bicycling, rowing, or water aerobics.
Flexibility Training – Flexibility training is important for everyone as part of a healthy lifestyle, but it’s critical for those with RA. A person should take every joint through a full ROM at least once a day. I highly encourage a regular two to three times a week flexibility program in addition to a daily ROM program. Appropriate options include: yoga, Pilates, Tai Chi, water aerobics, or a self-stretching routine. The program should be performed in a slow and very controlled manner by taking care to never overstretch a joint or to move too quickly.
Aquatic Therapy – Many find that performing a regular exercise program in an aquatic environment can satisfy most exercise needs, including flexibility and strength. Water can also be very useful in pain control and help with relaxation. Exercising in a reduced gravity environment like the pool limits the compression forces on the bones. Additional weight training or body weight exercise should still be performed to insure adequate bone density as one ages.

To specifically answer Gloria’s question on the upper extremities, I would encourage her to daily perform an upper extremity stretching routine which takes all of the upper extremity joints through at least one full ROM. Be sure to take several rest breaks during the day to perform stretching and ROM exercises. Strengthening exercises for the shoulders, elbows, wrists, and fingers would also be beneficial. Be sure to work the finger extensors (opening the hand) and not just the flexors (squeezing). Finger Putty is a great product which enables you to perform a variety of hand and finger exercises. I would also encourage an emphasis on posture and upper back stretching as demonstrated in My Top 8 Stretches to Eliminate Neck, Upper Back, and Shoulder Pain. Gloria, I hope you find this information to be helpful as you manage your RA. Please let me know if you have additional questions.

I would love to hear from more of you! What are your experiences dealing with rheumatoid arthritis? Have you or a loved one been dealing with this condition? What has worked or not worked for you? Additional discussion can help others to manage a very difficult disease. Please leave your comments below.

If you have a question that you would like featured in an upcoming blog post, please e-mail contact@thePhysicalTherapyAdvisor.com. Be sure to join our growing community on Facebook by liking The Physical Therapy Advisor!

Disclaimer: The Physical Therapy Advisor blog is for general informational purposes only and does not constitute the practice of medicine or other professional health care services, including the giving of medical advice. No health care provider/patient relationship is formed. The use of information on this blog or materials linked from this blog is at your own risk. The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Do not disregard, or delay in obtaining, medical advice for any medical condition you may have. Please seek the assistance of your health care professionals for any such conditions.

Posted on Wednesday, July 16, 2014

Is Running Safe?

Is physical activity, like running, safe? Most of the time, the answer is YES! The key is to rule out possible issues (especially as you age) which may make physical activity unsafe. More potential issues need to be screened the older you are and based on how healthy of a lifestyle you may have. Being well informed initially allows you to tailor an exercise program which can be safe and effective in maximizing your particular goals and needs.

How to Start?

I recommend that you take a Physical Activity Readiness Questionnaire (PAR-Q). The PAR-Q has been designed to identify the small number of adults for whom physical activity may be inappropriate or those who should have medical advice prior to initiating in physical activity.

The American College of Sports Medicine (ACSM) also offers information and a similar version of the Par-Q with clear guidelines on when a person should or should not see a physician before starting an exercise program. (When To See a Physician Before Exercising)

Assuming that you have been cleared for physical activity, let’s specifically discuss running. Let’s attempt to get one myth off the table first. Running is bad for the knees. This can be true and false. Let’s dive deeper. Running can be “hard” on the knees in certain circumstances:

If you have significant degeneration of your knees, such as severe osteoarthritis (loss of the cushion between the knee bones known as the meniscus).
You are morbidly obese.
You have some sort of bone disease, such as osteochondritis dissecans, where you experience cracking in the articular cartilage of the bone and loss of blood flow (causing the bone to die, which is known as avascular necrosis).
If you have had a prior knee injury such as a meniscus injury or surgical repair of the meniscus; micro fractures repair of the knee cartilage; or a total joint replacement in the lower extremity such as the knee, hip, or ankle.

It is possible that running may not be the best activity choice for you, but with proper training and a strong focus on technique, it is still possible.

Research indicates that running for the typical person will not cause excessive wear and tear or injury to the knee. If injury is already present, then running could possibly worsen it. It is true that running can lead to aches and pains, including conditions such as patellar femoral knee syndrome (runner’s knee). It is also true that sitting like a couch potato can also lead to knee arthritis and cardiovascular disease as well as a list of other medical conditions.

A vast majority of running related injuries can be easily avoided through proper training, proper running form, proper footwear, and proper recovery. Running is an excellent form of exercise and a wonderful stress reliever.

The key to a successful lifelong running program includes:

Proper Training – Find the right balance of volume and intensity for you. Each one of us is capable of some running. The key is to discover the right amount for you to remain healthy and engaged in the activity.
Proper Running Form – There are many different running styles and form. Some focus on a mid-foot strike while others, a heel strike. Some prefer a run/walk protocol or a power walking protocol. You may also be interested learning more about the Chi Running Technique (http://idahoezrunning.com/freedemo/). The key is to find a coach who can help you find the right technique for your particular body style and goals.
Proper Equipment and Footwear – Your feet and knees absorb a bulk of the force as you run. Ensuring that you have adequate footwear is imperative. I highly recommend visiting your local running store for a gait evaluation. These professionals will properly fit you into a real running shoe. (The quality of a shoe from a big box store will be poor in comparison.) Your shoes should be changed every 300-500 miles depending on the style of the shoe and how much wear and tear accumulated.
Cross Train – As big of a fan as I am of running, it shouldn’t be your sole form of exercise. It is an excellent form of cardiovascular exercise, but it doesn’t address strength training. Strength training is an important component to a healthy lifestyle. I cross train by performing CrossFit and through weight training multiple times per week.
Vary Your Running – Don’t run on the same surface each time, and don’t run the same speed every time. Your body loves variety, and you will, too!

Running is well worth the effort and the risk of a potential orthopaedic related issue in order to avoid the risk of cardiovascular disease, diabetes, heart disease, cancer, obesity, and osteoporosis. Seek the advice of a physical therapist or fitness coach to help you train and recover properly. If a problem occurs, you will be armed with tips and strategies to deal with it before it becomes a major issue. Happy running!

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Posted on Wednesday, July 9, 2014

Q & A: How to Prevent My Mom From Falling Out of Bed

QMy mom has fallen out of bed several times recently. She doesn’t know why or what happens, only that she just ends up on the floor. She also has minor dementia, and she needs help when walking. What can I do to help? -Kelly

A. Thanks for your question, Kelly! Falling out of bed may sound like an unusual experience to hear about an older person. It’s often thought of as an issue for young children, but surprisingly and unfortunately, falling out of bed is an issue for older adults as well.

Falling is the number one cause for fracture in the elderly. Many times, a fracture will lead to a cascading decline in mobility and function. Finding methods to limit falling, without restraining or inhibiting important functional mobility, is critical.

The following are reasons why a person may fall out of bed:

Changes in mobility, such as a recent surgery or stroke.
Illness: Many illnesses can cause weakness which makes getting in or out of the bed difficult.
A person has a new bed which is higher or lower than it was previously.
A person has new bed coverings which are slicker than the previous bedding.
New night time clothing which are slicker than the old clothing.
New night time clothing which clings to the bedding and causes increased difficulty with movement on or off the bed.
New Sleeping Environment: Sleeping on a new bed, on the different side of the bed, different lighting, or changes in nearby furniture.
Recent medication changes which have affected how deeply a person is sleeping or causes grogginess upon waking.
Incontinence: If a person has the urge to use the bathroom or needs to rush to the bathroom to prevent an accident, then the risk of falling out of bed increases.
Sundowners: Many older adults with dementia will suffer from a condition known as sundowners in which fatigue causes increasing confusion at the end of the day.
Eyesight Related Issues: New corrective wear which isn’t fitting or working properly, such as a new pair of bifocals when the person didn’t wear them previously. Maybe worsening eyesight from conditions such as glaucoma, macular degeneration, or cataracts.
Benin Paroxysmal Positional Vertigo (BPPV)
Poor environmental lighting.

One simple trick to prevent a person from falling out of bed (without restraining them or using bed rails) is to use a simple water noodle. Just place the water noodle along the inside of the mattress pad or sheet. (For those with young children, this tip may also be particularly useful if you are transitioning a young child into a bed without railings for the first time.)

Sometimes as a person ages or becomes more confused or frail, we want to discourage them from getting in or out of bed without assistance. This may be an appropriate time to utilize the “water noodle technique” (as I call it). The idea is to simply provide a minor barrier (a reminder) of where the edge of the bed is located and that the person shouldn’t be attempting to get out of bed without calling for assistance.

For some, this minor barrier is all that is needed to actually physically limit his/her ability to get in and out of bed without assistance. This serves as a temporary solution while the person is recovering from or modifying the underlying reason why he/she is at elevated risk of falling out of bed.

The water noodle also provides a subtle physiological barrier. When the body is moving, it subconsciously feels the barrier and tends to not proceed any further in that direction. I have witnessed the water noodle technique work repeatedly in homes (with both adults and children) and nursing homes with great success.

Kelly also mentions that her mother is having difficulty with dementia and walking. Unless the mother’s dementia is so severe (like she is actually losing her ability to walk or she can’t follow any time of direction), she may be a good candidate for physical therapy treatment. Depending on the situation, she may benefit by going to an outpatient facility for physical therapy or she may qualify for home health physical therapy. I strongly encourage you to seek a physical therapist who is an expert with gait (walking) and balance physical therapy or who had experience in geriatric related physical therapy care. You can search for specific providers here: American Physical Therapy Association (APTA)

In addition, Kelly, you may be interested in reviewing my prior posts on balance related issues, How Do I Improve Balance? (Part I) and How Do I Improve Balance? Part II. Good luck, and thank you for your question.

Posted on Wednesday, June 18, 2014

Improving Balance by Using a Water Noodle

Balance is an important part of mobility. It is usually overlooked and taken for granted until mobility is significantly affected. Like all exercise, balance exercise should be fun and convenient. So, how do you use a common water noodle to improve balance? Let’s get started!

Integration of lower extremity muscle strength and range of motion (ROM) is important to maintaining good balance and mobility. Your calf muscles play an important role in balance. If your calves are tight, then you are more likely to tip over backward as you age. The strength of the calf muscles is also important for ambulation. Try these two exercises to stretch your calves. Hold each stretch for at least 30 seconds twice each leg.

Your ankles and calves work together to prevent falls which utilizes a reflex known as ankle strategy. It can help you recover from minor losses of balance. It is an essential front to back movement of the ankle. If you are pushed forward slightly, the ankle will bend and the calves will push you backward so you can maintain your upright stance. If you have tightness in your calves, loss of ankle ROM, weakness or poor sensation, then this crucial strategy is affected. The use of a water noodle can help address this issue. (You can purchase one at your local retailer or sometimes, even at the dollar store. I have cut mine down to about one foot in length to be more manageable.)

First, stand on the water noodle. Very slowly and under control, try to keep your balance while you rock your feet back and forth (touching your toes, then your heels). Feel the motion of the feet and the control of the ankles. You can practice this exercise with your shoes on or off. For added difficulty, close your eyes!

A water noodle can also be used to work on proprioception and somatosensory integration for balance. Somatosensory is the integration of the neurological system (the brain and nerves throughout the body) with the musculoskeletal system. This includes all the touch and movement nerve receptors in the muscles, tendons, and joints. This also includes proprioception, which is the brain’s ability to know where the body is located in space. For example, if you close your eyes and lift your arms overhead, you know where yours arm are located. Practicing balance on a softer or unstable surface helps to train the somatosensory system and helps to work the smaller stabilization muscles in the ankle. This is also an excellent way to prevent ankle sprains!

Practice standing on the water noodle. At first, you may need to use your finger (or hand) on a counter top or chair for balance. Practice holding for 30 seconds to start. Then build up to holding the position for a minute. To increase the difficulty level, try standing on the water noodle with one foot, then gently touch the opposite toe on the ground and bring it back. The further the foot reaches out, the harder the exercise. Imagine the numbers on a clock and work your way around the clock and back, each time gently touching a tip toe and then returning the foot back to the standing leg. Repeat on the other side.

For additional information on the five different body systems which affect balance and how they work together to insure proper balance and mobility in our environment, please refer to How Do I Improve Balance? (Part I) and How Do I Improve Balance? (Part II). If you desire specific advice, I highly recommend that you seek assistance from a qualified medical doctor or physical therapist that is well versed in balance related disorders.

One of the best ways to maintain your balance as you age is to remain active and move more! Balance is an integration of many body systems, so movement is an excellent way to work on all of the body systems!

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Also, if you have a question that you would like featured in an upcoming blog post, please e-mail contact@thephysicaltherapyadvisor.com.

Posted on Wednesday, June 11, 2014

7 Reasons Why the Squat is Fundamental to Life

If you were born and raised in an industrialized nation (like the U.S.A.), then squatting was probably something you did as a child. As soon as you became school age, you rarely squatted again. In other countries around the world, squatting is a normal part of daily life. In countries such as India and in many Asian countries, it is common to see very aged individuals who are still perfectly capable and comfortable in a full squatting position. When was the last time you saw a 75 year old man in a full squat? (A full squat will vary from person to person, but typically your hips are well below your knees and your thighs are past a parallel position.)

Here are 7 reasons why we should continue squatting as a lifelong pursuit:

1. Maintain Lower Extremity Strength: The squat activates nearly all of the muscles in the lower leg. It is particularly effective at activating the muscles in the legs referred to as the posterior chain, which includes the hamstrings, the glutes (or buttock muscles), and the hip adductors (or the groin muscles). It also activates the calves, the stabilizing muscles in the ankles, the quadriceps, as well as the core (the abdominals and lumbar extensor muscles). In short, the squat works just about every muscle in the trunk down toward the legs. These muscles are critical for all functional mobility related movements, including walking; getting up from a chair or a toilet; or picking up someone or something.

2. Maintain Lower Extremity Range of Motion (ROM): Moving into a full squat position takes quite a bit of flexibility. Most children have no problem squatting. As we age, we tend to become less flexible which is primarily due to non-use. Physiologically, muscles, tendons, and ligaments lose some elasticity and can become stiff. The squat requires good hip mobility, knee mobility, lumbar and pelvic mobility as well as ankle mobility. It requires adequate muscle length and joint range of motion in all of the major joints of the lower leg and all of the major muscles of the lower limb.

3. Maintain Bone Density: Squatting activates the major muscles of the lower limb and trunk. The pull of the muscle against the bone stimulates the bone to grow and improve its density. Squatting is also a weight-bearing exercise meaning it is against gravity. If you add any type of resistance, then that load to the bone once again stimulates bone growth. Squatting is a fundamental movement to prevent osteoporosis.

4. Maintain Balance: Squatting activates the lower leg muscles. Adequate lower leg and trunk strength is a critical component to balance. It also activates the somatosensory system. This is the integration of the neurological system (including the brain and nerves throughout the body) with the musculoskeletal system. This includes all the touch and movement nerve receptors in the muscles, tendons, and joints. (Please refer to How Do I Improve Balance? (Part I) and How Do I Improve Balance? Part II.)

5. Aids in Digestion: Many people in “civilized nations” might not know this little known fact, but incidences of constipation have increased since the advent of the toilet. This is because people are no longer squatting in the woods, over a hole, or some form of plumbing. The body’s colon has three major parts: the ascending, transvers, and descending colon. When you are in a full squat, the thighs put pressure on the ascending and descending colon, which stimulates the smooth muscles to move (this is known as peristalsis). When in the full squat position, the rectum (which is a short, muscular tube which forms the lowest portion of the large intestine and connects it to the anus) is allowed to straighten and unkink. Feces collects in the rectum until pressure on the rectal walls causes nerve impulses to pass to the brain. The brain sends messages to the voluntary muscles in the anus to relax, which permits expulsion. If you are experiencing constipation, take a walk and then spend time relaxing in a full squat position.

6. Prevents Osteoarthritis: There are many potential causes, like trauma or infection, for osteoarthritis. Trauma can be from a one-time accident or due to accumulated trauma or over-use syndrome. Just as common as over-use causing osteoarthritis is under-use. A joint cannot remain healthy if it does not move through its full available range of motion (ROM) on a regular basis. If you never move into a full squat, then you likely never take your knees or hips through their full ROM. According to osteoarthritis statistics, countries in which people still rest and spend extended time in a full squat have the lowest incidences of osteoarthritis. Squatting does not cause arthritis; it actually protects the body from it.

7. Fundamental to All Mobility: Maintaining your ability to squat, and (more importantly), come up from a squat is vital. Your ability to do so is critical to your ability to function independently. In my experience of working with seniors, there are two main reasons why a person will need additional care and support: 1. The person can no longer safely get from point A to point B (this usually involves walking). 2. The person is no longer able to stand up from a sitting position. This means he/she cannot get up and down from a chair, a toilet, or even the bed. If you cannot perform these activities safely and independently, then you will need additional care. Typically, it is a major sign of failing health when an aged and infirmed person loses the ability to care for him or her due to weakness and other factors. (This statement is not directed at someone who has suffered a spinal cord injury or has some form of paralysis which affects his/her ability to utilize lower extremities.) The squat is a critical exercise to maintain mobility and function as we age.

Squatting is one of the first abilities we develop as a child, and it needs to be one of the last ones we lose as we age. Your ability to perform a squat is fundamental to how you are able to function throughout your life. Keep squatting!

If you have a question that you would like featured in an upcoming blog post, please email contact@thephysicaltherapyadvisor.com.