HYDROTHERAPY AND SWIMMING

Exercise in the water is very beneficial for people with rheumatoid arthritis because you can put the joints through a full range of movements while the water supports your joints. This means that the exercise is safe for you. Swimming will also maintain muscle strength and if you are able to swim at speed this will also benefit the heart and lungs.

Hydrotherapy is therapy in the water – i.e. exercise in the water – and this is also excellent for increasing the range of movements at the joints and reducing pain. Physiotherapy departments sometimes have a hydrotherapy pool and you may be able to have sessions there if your GP refers you. Our local hydrotherapy pool has a weekly session for arthritis patients. You can start with hydrotherapy if your joints are very painful because the water is warmer than in most swimming pools and this is why it is good for pain relief. If you are able to join a health club with a pool the water will normally be warmer than council pools and it will also be less crowded which means that it is much easier to exercise.

Arthritis Care Research published the results of a controlled trial of hydrotherapy for rheumatoid arthritis in 1996.2 In this clinical trial patients showed improvements in both physical and psychological measures after the four-week sessions and at the three month follow up. Women also had improvements in joint tenderness and range of movements at the knee. Here are some exercises that I do in the swimming pool.

Exercises in the water

• 1Lie on your back with your hands at your sides then stretch them up and out so that they touch over your head.
• 2Walk on your toes or do the ankle exercises. Try to run through the water.
• 3Try, if you are able to, to do all the different strokes – i.e. breaststroke, crawl, backstroke, sidestroke, doggy paddle and butterfly – as they all exercise different joints.
• 4Use a float and stretch your arms out in front of you.

In fact you can do any of the standing exercises in the water. Alternatively go to an aqua-aerobics class.

THE BENEFITS OF EXERCISE

I have looked at research to find out what proven benefits exercise has shown for people with rheumatoid arthritis. A working party of the Royal College of Physicians3 convened in 1989 and they examined the evidence for regular exercise. They made several recommendations for their members. Their conclusions were that there is now good evidence of many physical and psychological benefits to the general population in taking regular exercise. They recommended that doctors should check if patients are taking exercise and then advise patients on the extent and type of activity suitable for each individual. They also stated that exercise should start in childhood and continue into old age wherever possible.

In 1994 P.H. Fentem4 wrote ‘The benefits of exercise in health and disease’. He said that people with disabilities were prone to inactivity and this must not be accepted as normal. He mentioned the deleterious effects of inactivity and stated that the benefits of exercise could mean a return to work for people with rheumatoid arthritis who had previously given up their jobs due to ill health.

An article on the ARC website5 contains an interview with Kathleen Turner who has rheumatoid arthritis. In the article Kathleen explains that her doctor told her:

‘Get into the pool no matter how much it hurts, no matter how little you can do, but keep moving.’

She goes on to say that this is the best thing for her, better than any drug. She has to keep moving. I agree with Kathleen Turner: it is very important to keep moving. It prevents the joints feeling stiff and maintains the muscle strength. It is still important to balance activities and it is still necessary to rest when there is an acute flare-up but generally keep moving is a good motto.

A PERSONAL SCENARIO

You need to be able to find a way of exercising which suits you and hopefully that you also enjoy. I have never had a problem with taking exercise as I have always enjoyed sports like badminton, walking, swimming etc. The main problem that I have had to deal with is the deterioration of my joints over many years. Activity and exercise does not stop the disease, it only helps by maintaining muscle strength and keeping a good range of movement at all the joints for as long as possible. If muscles are not used they will waste and strong muscles help to support the joints. This is particularly important where there is joint damage.

The problems that I have had to face in the past include having to play badminton with no wrist movement (and that is certainly not ideal!), having to change my three-mile walks to shorter bird watching rambles, swimming at half my previous speed and strength and not being able to play tennis.

I am not a very competitive person but it can be frustrating at times. Some people prefer not to do things at all if they cannot do them extremely well. In this case they may well find that they need to give up certain pastimes and find a new challenge. I always chose to carry on while I could still enjoy the activity. I do not play badminton any more because I cannot run and in the past I had to give up tennis because the racquet was too heavy for me (although racquets are now much lighter than they used to be.) My yoga abilities have also diminished. I used to be able to do the lotus but now I am lucky if I can do a few stretches. I do enjoy my swimming though. It allows my joints to feel much more mobile and the jacuzzi afterwards is a reward for the exercise before!

I will never know how much the exercise has helped me but I do feel that it is of great value both in maintaining my physical functioning and my mental health, given the severe joint damage that I have suffered over the years.

GOOD POSTURE

As well as doing exercise it is important to ensure that you have good posture. This is particularly important for anyone with rheumatoid arthritis because the pain or discomfort that occurs tends to make you avoid certain positions and movements. This means that if, for instance, your right foot hurts then you will put more weight on the left one, or if your neck hurts you may hold your head in a tilted position without realising it. In either case the body is not working in its natural way and the spine will be compensating to keep the body in balance. This can cause back problems and/or damage to the joint that is working harder, such as the left foot or the neck in the instances above.

Avoidance of any particular movement for prolonged periods means that the ligaments and tendons in the affected area will shorten because they are not being used fully. This means, for instance, that if you were to remain sitting in a wheelchair for months and you never straightened your legs out, the tendons would gradually shorten and the knees would become contracted and then it would become impossible to stand. This is why it is vital to put all joints through their normal range of movements (or as much as you can manage) regularly and to try as far as possible to ensure correct posture at all times. A Physiotherapist or Occupational Therapist will be able to give advice on this.

Alexander Technique

Alternatively it may be worth paying privately for a practitioner who can advise you on the Alexander Technique, particularly if bad habits have already been practised for a long time.

The Alexander Technique teaches you to be aware of your body and to think about the way that you are carrying out physical actions. The practitioner will guide you and make you aware of incorrect postures and in this way you will improve the body’s alignment. This will then prevent bad posture, muscle tension and pain.

GUIDELINES FOR GOOD POSTURE

Here are some general guidelines to follow.

Standing

Figure 13a illustrates good posture and the following text summarises how to achieve this.

• Always ensure that your head is not tilted to the left or to the right, forwards or backwards. Look in the mirror to make sure you are looking straight ahead. If your head is carried correctly then it is more likely that weight will be spread through your body correctly.
• If your weight is not distributed properly this will place a strain on your joints. Stand so that your weight is placed equally through both feet.
• The ankles, knees, hips and shoulders should be in line when standing.
• Do not stand for too long.

Figure 13b is an extreme example of bad posture, demonstrating how not to stand! The head is tilted, the weight is on one side, the body is twisted and the shoulder joint is dropped on one side. The weight is distributed unevenly and the joints are under strain.

Walking

• Wear supportive shoes that give arch support and support to the inside of the foot.
• Push off from the heels and roll onto the toes.
• Try to keep a spring in the step if at all possible.
• Do not walk with the head down. Ensure the head is in a balanced position as in standing.

Sitting

• Sit on a chair of the correct seat height so that your back is supported and your feet are flat on the floor.
• An armrest and headrest are useful.
• You should sit up straight and not slump down, however you should relax the shoulders. See Figures 14a and 14b, showing good and bad sitting posture.
• It is important to choose furniture that is supportive, firm and comfortable.
• If you have short legs you may find that many chairs have too great a distance from the back to the front of the seat, and it is therefore difficult to support your back and reach the floor without curving your back. Shop around and find one that is suitable, it will be well worth it.

Lying down

• Have a mattress that is firm but also feels soft.
• Use a pillow that just cushions the curve at the neck. It should not be too high and you should not use two unless you have some sort of breathing problems.
• Ensure that the bed is of an appropriate height to get in and out of easily. This will prevent strain on the knees and hips when you get out.

Working at a worktop or desk

See Figures 15a and 15b demonstrating correct and incorrect posture when seated at a desk.

• The desk should be of an appropriate height so that you do not have to lean forward. Your arm should be supported when writing.
• A speakerphone is essential if you have to do a lot of phone work.
• Worktops should be of an appropriate height. You need the surface lower for hard work, such as mixing a cake, but higher for chopping and lighter work.

Whatever you are doing remember to change positions frequently. You should not sit at a keyboard for more than 20–30 minutes. Stand up and walk across the office, stretch your fingers etc. This will prevent you getting stiff and will allow you to move more easily.

If you have unsuitable furniture and equipment at your workplace you could give Access to Work a try. This is a scheme that can be used to fund adaptations to your workplace if you have a disability (details in Chapter 8).

The good posture habit

It does seem that there is a lot to remember, but if you remind yourself to think about your posture for a few weeks then you will easily get into the habit of good posture. It will be time well spent if it reduces joint damage and pain.