Training Clients With Joint Health Challenges
By Jason Theodosakis, M.D., M.S., M.P.H., FACPM “Dr. Theo”
In the personal training and fitness field, it’s extremely common to have clients who are affected by arthritis or other problems related to their joints. Many do not adhere to their training regimen because of the discomfort they experience with exercise.
With a little knowledge, exercise professionals can be viewed as allies for those who battle with chronic joint problems and not as one woman proclaimed, “the people who exacerbate my symptoms.”
It’s no surprise that certain sports and activities increase the chance of developing osteoarthritis. Weightlifters tend to get osteoarthritis in the knees and low back at an increased frequency compared to other athletes. Soccer players develop OA in the neck at a rate of three times that of neck arthritis in other athletes; and swimmers and volleyball players are more likely to develop OA of the shoulders. Sports that lead to ankle sprains commonly, such as basketball and volleyball also cause a higher incidence of ankle osteoarthritis - a condition that is actually rare in those without a history of trauma to the ankle. Of course, we’ve all seen hockey players or football players who appear to be crippled in their 30s from osteoarthritis.
What IS a surprise to many is that OA often starts in the 20s or 30s — it’s not just an old person’s disease. Since cartilage has no nerve endings, damage to the joint and subsequent osteoarthritis can take years or even decades to become symptomatic. If a girl tears her ACL at age 18, she has a high likelihood of developing x-ray confirmed osteoarthritis by age 30. We now know that the osteoarthritic process can start immediately after the injury — it just takes 10 years or more for it to show up on x-ray.
Despite the fact that there are many causes of joint pain, the most common cause of chronic joint pain is the result of arthritis.
The Arthritis Foundation recommends that people who are experiencing intermittent or continuous joint pain for two weeks or longer should have a high index of suspicion that they may be suffering from one of the forms of arthritis. Arthritis affects about one in three adults and is now the number one cause of disability in America, according to the CDC.
About half of the cases of symptomatic arthritis are due to osteoarthritis (OA), a disease that causes synovial joints to degenerate over time, leading to pain, stiffness and functional limitations. OA has major public health impact, not only from the pain and disability but because of the tens of billions of dollars spent on direct and indirect health care costs.
Due to its wide reaching impact, finding a treatment for OA that is both cost-effective and has a low incidence of morbidity and mortality is of prime importance. The first step in helping someone with joint pain is to make sure they have received an accurate diagnosis. As many as four in five people with chronic symptoms in a joint haven’t ever actually visited a health-care professional for an accurate diagnosis and treat ¬ment.
Refer clients who experience joint pain (for more than a couple of days) to a qualified health practitioner. This is a good practice — not only for the client’s health, but also as a valuable tool to keep injury lawyers at bay. Just because a client is experiencing joint problems, does not necessarily mean they have arthritis. In fact, there are dozens of causes of back pain and knee pain. Failure to recognize the proper diagnosis, and institute prompt treatment can result in severe consequences, such as in those who have joint pain due to infection or cancer. Fortunately, these two life-threatening conditions are relatively rare causes of joint pain in the general population.
As with most chronic conditions, there’s no simple fix. The best approach is an integrative strategy utilizing many steps. Here’s a brief summary of six key steps taken from my book, The Arthritis Cure — Revised Edition (St. Martin’s Press 2004.)
STEP 1 Have a Thorough Consultation with a Physician
For the most accurate diagnosis, get an evaluation from a specialist physician. In general, rheumatologists, sports medicine physicians and physical medicine and rehabilita ¬tion doctors spend more time studying osteoarthritis and have more experience seeing patients with osteoarthritis than other types of physicians. Orthopedic surgeons, as the name implies, spend a great deal of time and effort learning the latest in surgical care. Despite specializing in the muscu ¬loskeletal system, a surgeon may not be the best first choice for evaluating your osteoarthritis and recommending the proper non-surgical care.
STEP 2 Take Glucosamine/Chondroitin
These supplements are the heart of The Arthritis Cure treatment program. Glucosamine and chondroitin have been shown to help stimulate cartilage repair but are even more effective at slowing down the disease process in osteoarthritis. They are available in the United States without a prescription as dietary supplements.
The general dose for an adult is 1,500 mg of glucosamine; 800-1,200 mg of chondroitin, once daily, with or without food.
Some practitioners are now recognizing that increasing the dose can offer additional relief to those resistant to the starting dose.
It’s not uncommon for people to use up to double the dose for each of these supplements.
None of these supplements have known in ¬teractions with other medications, so they appear to be safe when taken together. In fact, many physicians are prescribing fast acting medicines such as acetaminophen or an over-the-counter anti-inflammatory drug at the same time they start their patients on the supplements. Then, over the next couple of weeks, they wean the patients off of the drugs and keep the patients on the (safer) supplements.
Utilizing the supplements long-term is shown to be a great advantage from a cost/benefit/risk ratio. In many countries, glucosamine/chondroitin are actually subsidized by national health care agencies since they can obviate the need for drugs, physical therapy, hospitalizations and surgery. Some of the new research on the supplements has shown us that patients should continue taking the supplements for at least six months to get an accurate assessment of their value in controlling symptoms.
Supplement Quality Remains An Issue
So many glucosamine/chondroitin products are on the market today that it’s often difficult to choose which one might be the best for you. Unfortunately, there are great number of products out on the market that don’t deliver what they say on the label, and many that don’t even include the amounts or types of ingredients that have been shown to be effective in research. For instance, chondroitin should not be used if the dose below 800 mg — there’s no evidence of effect below this dose, and the form of chondroitin may be important. We know that chondroitin obtained from avian (bird) cartilage, for instance, appeared to be ineffective in one major clinical study.
STEP 3 Improve Biomechanics to Counteract Stress to Joints
Improving your client’s biomechanics is where trainers can shine the most. Biomechanics is the study of the mechanical forces exerted on the body by movement. Improper alignment or incorrect use of muscles, bones, tendons, ligaments, and joints can cause excessive force on a limited area of the body, leading to injury. A great example of this would be improper lifting.
Everyone knows that picking up something heavy incorrectly can quickly lead to low back problems, or bad form while swinging a tennis racket can cause tears in the tendons around the elbow.
One of the general principles about mechanics is to focus more attention to the areas that are most deficient. For instance, people have their favorite stretching exercises mostly because they’re good at them but they failed to devote enough attention to those areas in which they are most inflexible, same goes for strength. By focusing on the weakest or most inflexible areas, there will be a greater balance to the overall mechanics, which will eventually help decrease the chance of a joint breaking down.
STEP 4 Regular, Low Impact Exercise
Regular, lifelong exercise fends off a host of health problems. It’s also a great way to burn calories and lose weight.
Although we used to think that exercise caused arthritis by causing excessive wear and tear (that appears to be true with the hip and high-impact exercise), we now know that regular, low-impact exercise is an excellent means of helping to keep joints healthy.
In fact, when evaluating women with knee osteoarthritis, it’s interesting to note that weakness in the quadriceps muscles often precedes the symptoms of knee pain. How could this be? When the supporting structures around the joint are weak, there is a greater force applied to the bone and cartilage within the joint. Furthermore, when you bear down on a joint, as you do when exercising, the nutrient-rich fluid in the cartilage is squeezed out, just as if the cartilage were a soggy sponge.
Then, when you release the pres ¬sure this fluid rushes back into the cartilage, both nourishing it and keeping it moist.
The continual rushing in and out of fluid is critical to the health of the cartilage, not only to the matrix, but to the cartilage cells themselves. Without exercise, the cartilage becomes thinner, less stiff and more susceptible to damage. In addition to keeping the “cartilage sponge” in action, the proper exercises strengthen the structures around a joint, which helps to reduce the pressure to which the joint is subjected.
STEP 5 Eat a Healthful, Joint-Preserving Diet
What you eat (or don’t eat) can affect your joints. Certain foods can encourage or discourage the joint-busting free radicals, help to increase or decrease inflammation, and stimulate cartilage repair. Perhaps the most healthy diet is based on the Mediterranean diet with additional highly purified, Omega-3 fish oil concentrate, and vitamin D supplements. Not only will this diet help counteract the effects of osteoarthritis, but appears to be the best overall diet for general health.
Antioxidant supplements are crucial for helping glucosamine/chondroitin work more effectively, as well for countering joint-damaging free radicals in your body. In particular, vitamins C and E, and the mineral manganese increase the effectiveness of both glucosamine and chondroitin and have beneficial effects on joint functions. Make sure these are either included in the supplements that you buy or take them separately.
Manganese, which is important for the synthesis of cartilage components, is also an antioxidant. A deficiency of this mineral, which you need in only trace amounts, can often go unnoticed and can lead to osteoarthritis. Found in many whole foods such as nuts, beans, oatmeal, oranges, spinach, blueberries, and raisins, manganese is usually lacking in processed foods.
Vitamin C serves as an antioxidant that “recharges” other antioxi ¬dants. Because it is water-soluble, vitamin C is eliminated from the body in just a few hours (even the “time-released” kind), so taking several smaller doses throughout the day is much more effective than taking one large dose. I generally recommend taking between 60 and 250 milligrams of vitamin C per day in one to two divided doses. Even if you just take it once a day, you’ll still get the benefit of vitamin C, because that’s enough for your body to make the collagen you need for healthy joints and connective tissue.
STEP 6 Maintain Your Ideal Body Weight
Excess pounds are bad news for weight-bearing joints such as the hips and knees. Researchers have conclusively linked weight gain and obe ¬sity to osteoarthritis, specifically of the knee. In a study done at Chicago’s Cook County Hospital, doctors noticed that obesity was common in osteoarthritis patients, and that a large percentage of them had gained weight just before the disease hit. Fifty percent of those with osteoarthritis had been overweight for three to 10 years prior to the onset of the disease.
Keeping your weight under control is a crucial part of The Arthritis Cure, for some joints must bear dozens of times the impact of your body weight during normal, everyday activities. If you gain just 10 pounds, you may be increasing the force certain joints must bear from 25 pounds up to 100 pounds! That’s why staying slim is one of the most important things you can do for the life of your joints.
A recent survey of those trying to lose weight revealed that only 25% were combining dieting with regular exercise to lose weight. We know that both are required for long-term weight control. Trainers and other exercise professionals are well equipped to advise their clients about the best forms of exercise for controlling weight.
Working with clients who have joint health problems is often not easy. Clearly there’s no, one simple answer and a multitude of interventions is often necessary for successful outcome. When instituting any type of intervention, consider what the risk/cost/benefit ratios are to determine the usefulness.
With proper education and commitment, you can be a valuable partner toward improving the health of your client. Not only will you improve your job satisfaction, but you will probably make a friend for life.
About the Author
Jason Theodosakis, MD, MS, MPH, FACPM is board certified in Preventive Medicine and Sports Medicine. He is on the medical staff at Canyon Ranch resort in Tucson, AZ, and served as the director of the University of Arizona College of Medicine’s preventive medicine residency training program. He was proclaimed to be one of the world’s 14 greatest doctors by Rodale press. His book, The Arthritis Cure (revised 2004), a New York Times # 1 Bestseller now in 13 languages, greatly influenced broader acceptance of glucosamine and chondroitin as an arthritis therapy in the US. Most recently, he served on the oversight steering committee for the NIH-sponsored GAIT trial. More information on Dr. Theodosakis and his treatment program are available at his web site at www.drtheo.com.