Osteoarthritis: To Move or Not To Move?

Osteoarthritis (OA), which is also known as degenerative joint disease, involves a wearing down of the flexible cartilage tissue at the ends of the bones that form joints. It is the most common form of arthritis, and it is estimated that over 32.5 million US adults are affected by it!(1) Prevention strategies of arthritis before it occurs is the most effective way to make sure it will not become an issue in your life. These strategies may include improving movement patterns, staying active, keeping your muscles strong and joints flexible, having good nutrition while avoiding processed and pro-inflammatory foods, staying hydrated, maintaining a healthy weight, and ensuring adequate recovery from exercise with enough sleep and gentle movement.

Once a joint has become arthritic, what are some strategies to keep in mind to optimize functioning, improve joint health, and mitigate the impact that this condition could have on quality of life? 

There is plenty of misinformation out there regarding arthritic joints. Even the terms used to describe OA colloquially can impact the public’s perception in a negative way. Degenerative joint disease. Wear and tear arthritis. Bone on bone! These types of descriptions bring scary images to mind, and imply that movement and exercise is actually unhealthy for joints and can contribute to joints wearing out. Certain doctors may tell their patients with OA that they should not do certain things any more- bend, lift, squat, kneel, run.

Too often, adults with arthritic joints begin to fear movement, or the pain that they may associate with movement, and will begin to exhibit compensations in the way they move. They may begin to become more sedentary, limit participation in various activities, and develop a resentful relationship with the involved body part. These changes contribute to a snowball effect, in which case the changes in mindset and behavior lead to further decline in joint function and tissue weakness, which continues the arthritic process, thereby leading to further pain, fear, and avoidance of movement and activity.

On the other hand, some people may overdo vigorous activity, which can increase inflammation and contribute to additional strain on compromised joints. It can be difficult to find the balance between too much and not enough. Lower impact, moderate activity performed on a consistent basis tends to be the sweet spot in which those with arthritis can keep their joints mobile and strong without contributing to flare ups and potential joint injury. 

Movement is absolutely essential for all of us, and especially for those with OA. If the question is move or don’t move an arthritic joint, the answer is to move intelligently and often.

As arthritic joints tend to become hypersensitized to loading, we must load the joints efficiently without strain, and allow the muscles and other tissues around the joint to get stronger. Stronger, smarter muscles will provide shock absorption and support for the joints, which helps attenuate the forces from daily life, movement, and exercise (like having your own built-in knee brace!) Movement has been shown to limit pain and improve joint motion, as well as prevent the risk of a future injury or fall. (2)
Joints that become arthritic tend to be synovial joints, meaning the joints rely on synovial fluid (the lubricating WD-40 of our joints) to move smoothly. In order for the synovial fluid to stay healthy, slippery, and plentiful, we must move the joint! Movement of joints helps to improve synovial quality and distributes the fluid around the joint so we can move without friction. Additionally, movement helps to distribute blood flow (which contains nutrients and oxygen) around the joint tissues, and can help decrease excessive muscular tension which may be associated with a pain pattern. Exercise has even been shown to activate genes that can help to rebuild cartilage!2 Cartilage has a limited potential to rebuild, but it is possible, and the cartilage that we do have can be strengthened just like other tissues. 

If you have OA, it can be very difficult to get your joint moving and begin the process of regaining strength and mobility. When joints have been painful for a long time, central sensitization may have occurred, which involves central nervous system changes in our perception and response to pain. The pain perceiving pathways may now be embedded deep into our brain circuits, including the prefrontal limbic regions, which is associated with our emotional responses. (3) Combined with structural, tissue-level changes, it is no surprise that many with OA fear movement and require guidance from a physical therapist or other health practitioner to get moving again. Fortunately, physical activity has been shown to have a positive effect on central sensitization, as it can help modulate the pain response by decreasing excitability in the motor cortex as well as stimulating the release of endogenous opioids (endorphins and other substances that are our brain’s natural pain relievers). (3) 

At the Wellness Station, we will be able to guide you intelligently and compassionately towards building strength, improving function, and opening up your life to greater possibilities.

Here is one of my favorite, low-impact exercises for building strength and control in the lower body and core. This can be especially helpful for individuals with knee and/or hip arthritis, in which cases standing exercises like squatting may be inefficient and painful. Many people have done the “bridging” exercise. The Feldenkrais-inspired bridge is known as “spine like a chain”. It involves pressing through the feet to begin to lift one vertebrae at a time from the ground, and lowering down in reverse. This can help to strengthen the glutes and thigh muscles, mobilize the spine, and improve awareness of how we utilize the forces from the ground to move our bodies. Check out this video from Paul McAndrew to get a visual and verbal demonstration of the movement: Spine Like a Chain

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team

References:

1. https://oaaction.unc.edu/oa-module/oa-prevalence-and-burden/ 

2. https://lonepeakpt.com/blog/living-arthritis-move-more-or-move-less#:~:text=Moving%20is%20essential%20if%20you,helps%20your%20joints%20be%20healthier 

3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5074793/ 

Osteoporosis and Osteopenia: A Healthy Movement Practice

Are there any special considerations for a movement practice for someone who may be at risk of osteopenia or osteoporosis, or perhaps is already diagnosed with a condition of impaired bone density? 

Absolutely! One size does not fit all when it comes to movement, especially when it comes to protecting the integrity of our bones. At the Wellness Station with our Feldenkrais-inspired approach, it is our job to address osteoporosis and osteopenia with individually-crafted lessons that are unique for every individual. Factors that are important to consider throughout therapy are how to maintain and increase bone density, improve muscular strength and responsiveness, body awareness, and help prevent the risk of a fall or compression fracture.

Here are some key considerations when engaging in yoga or any movement if you are aware that you have decreased bone mineral density:

1. Communicate effectively with your body: 

When we move, we are engaging in a dialogue with our body. We initiate the movement, and it is our job to listen to how our body responds, and modulate our movement based on that response! In other words, what are the subtle signs that we can pick up when we are putting our body through strain? Do we notice when we are doing a forward fold that we feel uncomfortable pressure in our abdomen? Do we notice that the way we pick up a heavy object from the floor causes us to hold our breath and feel a sense of distress? If so, we have to change the way we are moving.

2. Modify movements that put excessive load on the front of the spine or neck of femur: 

The most common osteoporotic fractures are of the front vertebral bones in the low or mid back. Notice in this image the location of the compression fracture is in the front of the spinal bone towards the middle of the back. There are many types of movements that increase load on these bones, such as bending forward at the waist, as well as twisting and turning the body when bent at the waist. When engaging in movement that involves compression of the front spine, consider the load that is going through these bones, and be careful not to push or strain if any discomfort is felt.

Consider a forward fold. Especially if the hamstrings are tight, the spine may become very rounded in this pose, which can put extra load through the front vertebral bodies, especially if we are straining to try to get the hands to the ground.

When modifying your movement practice, consider the intention of the movement, and modify to match the intention but in a safer and more effective way.

The intention of a forward fold is to experience lengthening and relaxation throughout the back of the body, including the hamstrings, gluteals, and muscles of the low back, and the fascia (connective tissue) that runs down the back of our body.

Notice that in this movement sequence, these same intentions are met, but the spine is fully supported by the ground and we are able to move dynamically without increasing the load on the vertebral bodies.

The neck of the femur just below the hip joint is also a common fracture area. Be cautious about poses such as pigeon, as this position subjects that bone to a high amount of load. Many people practice pigeon in a very passive way, which is not helpful for strengthening the bones and the surrounding hip musculature.

Consider these hands and knees variations of pigeon pose. Notice that by performing this “wagging the tail” movement, we are bringing suppleness into the whole spine, and also challenging the weight-bearing leg (the leg that is down on the ground). Notice that “sitting back” into the weight-bearing leg is very similar to the “pigeon” position, but it is a dynamic rather than a passive movement. This challenge can stimulate bone density as well as improve strength and responsiveness of the supportive hip muscles including the gluteals and piriformis.

After you get the hang of wagging your tail, try to make circles! Notice the engagement of the entire body with this dynamic movement pattern.

3. Prioritize extension postures rather than flexion postures

Flexion-based movements such as forward folds are when the spine is bending forward, which puts more compression on the front of the vertebrae. Extension-based movements do the opposite. Also known as backbends in yoga, extension-based postures are very safe for those with bone density loss. Spinal extension helps to reverse the compression on the front of the body, and helps to strengthen the muscles that promote healthy posturing. 

Notice these extension-based movements performed while lying on the belly. This is an excellent way to build strength and awareness of the back side of the body. Notice the balance and stability that is created by performing these diagonal movement patterns  in which the right upper body moves with the left lower body, and vice versa.

4. Challenge your balance with ease and support 

Yoga can be an excellent tool for improving balance, but it is important to be able to maintain stability and ease throughout your standing practice. There is no point in practicing feeling unbalanced, so modify your practice to meet yourself where you are. If you are feeling too challenged and at risk of falling, then this is not doing you any favors. Maintain stability and ease by modifying and using props. My favorite props for balancing poses are the wall, chairs, and even the kitchen counter. By gently contacting one of these props with a hand, we can maintain groundedness, and correct ourselves more easily if we begin to lose our balance.

Notice the use of the wall as a prop to perform this standing side bending and circular movements. This sequence is the same as what we did on hands and knees, but now in a standing position. As balance is a dynamic process, adding movement is more helpful for improving balance compared to holding a static position such as tree pose. Additionally, the weight-bearing leg is being stimulated in a way that will help improve bone density and strength. This is also a great way to warm up the body before further activity such as going on a jog.  

At The Wellness Station, we will help you become aware of habitual movement patterns, yoga poses, and lifestyle factors that may be affecting your bone density and risk of fractures. We will help you develop or modify your movement practice with considerations of your individual needs, medical history, and goals. Every day is an opportunity to get to know your body on a deeper level in order to stay active, healthy, and strong, even with osteoporosis.

Staying Safe and Strong with Osteoporosis

Osteopenia and osteoporosis are conditions that are characterized by a loss of bone density.

Osteopenia- An earlier stage of the disease in which the body reabsorbs bone quicker than new bone is laid down.

Osteoporosis- The progressed form of the disease in which the bones have thinned significantly, contributing to pain, postural changes, and fractures

This thinning is most likely to occur in the vertebral bones in the front of the spine, the hips bones, and the wrists. These conditions are so common that it is expected that 1 in 3 women and 1 in 5 men will suffer from an osteoporotic fracture some time in their lives. If you are over 50, especially if you are female, it is a great idea to consider your risk of developing osteoporosis, and what you can do to improve your bone density and minimize the risk of a fracture as you age. Other risk factors for osteoporosis include having a small frame, having low estrogen (perhaps related to a surgery or a medication), and prolonged use of corticosteroid medication.

It is important to be aware of your bone mineral density as you age by asking your doctor for a DEXA scan. There are also medications that can be prescribed that help bone density, so discuss this option with your doctor if you are at risk of osteoporosis. Lifestyle factors such as adequate dietary intake of calcium and vitamin D (which we can also get from sunshine), and avoiding smoking and drinking can help prevent loss of bone density.

While people at risk of osteoporosis should be mindful about how they move, it is crucial to participate in regular physical activity to keep muscles and bones strong. Weight-bearing exercise is incredibly important for maintaining bone density, as bones adapt to the forces they are subjected too. It is also important to train your balance, as falls in the elderly are commonly associated with fractures.

A regular yoga practice can be an excellent way to improve strength of the bones and muscles, as well as body awareness, balance, and coordination, all critical factors for avoiding falls and fractures. Discuss with your provider how you might develop or modify your yoga practice to maximize bone density and minimize risk of a fracture.

Written by Jacob Tyson, DPT - Physical Therapist, Yoga Instructor and The Wellness Station Team

Stay tuned for Part II for some key considerations for modifying a yoga practice to address concerns about bone density loss.