A Synovial Joint connects two or three bones covered with Articular Cartilage. This joint is bordered by a capsule and ligaments and is lined by an inner layer of tissue known as Synovium. Most joints in the Human body are Synovial such as Hips, Knees and Shoulders.
The posterior Facet Joints of the Spine are Synovial as well.
The basic requirement for healthy function of the joint is the integrity of the Articular Cartilage. Cartilage viability is maintained by Synovial Joint Fluid and by mobility of the of the joint (1,2). Arthritis is a painful inflammatory disease of synovial joints. The articular cartilage is damaged, joint motion is reduced and joint function deteriorates. Care of the diseased joint can be taken by exercises so called ‘Pain Free’, which increase the flexibility of the joint and extend the vitality of the cartilage.
The exercises in this book were specifically planned for the treatment of affected Hip joints. We later applied these principles to benefit other synovial joints (3). Therefore basic examples of exercises for other joints such as Knees, Shoulders and the Spine’s Facet joints were introduced as well.
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People of all ages will benefit from the exercises. Arthritis of a variety of joints affects at any age one of six people, that is about 17% of the population. Degenerative arthritis (osteoarthritis) is more common among adults.
Pain in arthritic joint is due to inflammation of the synovial lining of the joint and erosion of the cartilage. Any activity of the joint bearing weight such as walking, climbing stairs and rising from a sitting position increases the pain. At a late stage of the disease pain increases even at rest and during night. Instinctively to control the pain, motion of the joint is reduced and remains limited, resulting in contractures of ligaments and joint capsule and shortening of muscles. Arthritis is a chronic disease characterized by long and slow process with acute inflammatory attacks that enhance damage to the joint structures and cause deterioration of function.
It is well known that physical activity improves health and body wellness and In healthy joints activity and exercises maintain and improve function as well. However, since conventional active exercises increase pressure within the joint, their influence on the arthritic joint is negative. They evoke painful inflammatory response and loss of function. For that purpose ‘Pain Free Arthritis Exercises’ were designed - to control the cycle of pain of the arthritic joint.
‘Pain Free Exercises’ were initially planned for post operative rehabilitation of people with disease of the Hip joints undergoing surgery. It was soon noted that by practicing the exercises on regular basis most patients had an easier and more consistent post operative course.
Further experience with same exercise regime prior to surgery showed advantage for patient since they maintained wide range of mobility that facilitated the surgical procedure and rehabilitation.
What are ‘Pain Free Exercises’?
The basic concept is to move the joint in painless maximal range. This is accomplished by Gravity Dependent Movements (GDM) and/or Reverse Action Movements (RAM). Either method maintains the joint pressure at minimum, does not provoke pain, and the extent of motion is easily controlled to reach the threshold of pain and not to proceed further.
Gravity Dependent Movement such as abduction of the hip joint is done passively without activation ofmuscles by letting the thighs falling apartwhen lying down (exercise 1).
Reverse Action Movement such as flexion of the Hip joint is done by bending forward over the hips in the sitting position (exercise 4) with the thigh muscles at rest.
The exercises are carried out on a bench in three basic positions - lying down, sitting up and standing on hands and knees.
Standing on Hands and knees
The Importance of Motion to the Natural Joint
A Synovial Joint such as the Hip joint consists of a ball shaped femoral Head moving within a matching Socket in the pelvis. Motion of the joint is smooth, almost with no friction due to the properties of the Articular Cartilage, which covers the contacting surfaces and the Synovial Fluid that efficiently lubricates and nourishes the cartilage.
Articular cartilage consisting of cells,collagen fibers and bonding glyco-protein is of unique structure resembling a sponge with tiny pores. It lacks blood supply and nerves. Nourishment of the cartilage and clearance of waste is carried out by synovial fluid diffusion through the pores. It therefore requires a constant amount of synovial fluid, which is secreted by dedicated cells of the synovial tissue (4,5).
Nourishment of the cartilage by inflow and outflow of synovial fluid through the pores depends on intermittent pressure at the contact areas of the cartilage all over the entire joint surface. Under compression the fluid is squeezed into the joint cavity and re-enter into the cartilage substance when pressure is released.
The articular cartilage is sensitive to injury. It does not heal nor does it regenerate. Therefore any damage is likely to extend to further erosion and lead to Arthritis at some point in time. The significance of motion in full range and in all directions is in having all the remote parts of the joint cartilage lubricated by the synovial fluid. Concurrently the full range stretches the capsule and capsular ligaments, and prevents the creation of adhesions and scarring of the synovial tissue.
The Importance of Motion to Muscles and Tendons
When affected by Arthritis, the inflammatory process within the joint causes thickening and adhesions of the capsule and ligaments that result in loss of motion. Muscles and their tendons that control the joint motion get shorter and lose their normal range. This is a cyclic process: Patients refrain from moving the painful joint, ligaments and muscles further contract, motion decreases and the joint function further deteriorates.
Stretching the muscles and capsular ligaments by the exercises helps regaining motion and prevents further adhesions of tissue. These are achieved by adjusting and increasing the extent of motion repeatedly, though up to the threshold of pain.
If pain interferes with exercising, selective ingestion of anti- inflammatory drugs (NSAID) may be taken to allow prudent and gentle continuation of the regime.
How did the Concept of Passive Exercises start?
Among populations in the Far East and specifically in South East Asia, the incidence of Primary Degenerative Arthritis of the Hips joints is particularly low. The life style of people at home and outside is characterized by resting in a squatting position sitting on their heels. It is done with full range of motion of the hips and knee joints from early childhood to old age. This was speculated in the Orthopedic literature as having a positive effect of keeping the vitality of the joints’ structures and articular cartilage (6,7).
During our studies, we noticed that by keeping range of motion and muscle function the joint function remained protected. Indeed in some cases the need for surgery in early stage of the disease was delayed. When a regime of pre-surgery exercises was initiated and started, recovery following surgery was significantly enhanced.
The concept of Pain Free Arthritis Exercises was implemented by Professor David G. Mendes MD, and the Physical therapists Kobi Schwartz and Danny Kelman at the Center for Implant Surgery, the Bnai Zion (Rothschild) Medical Center in Haifa, Israel. The method was routinely practiced for over twenty years, by patients prior to surgery and following surgery of hip joints implants. Results were rewarding in postponing the need for surgery in some and in having efficient rehabilitation for those who underwent surgery. The system was implemented in other Hospitals in Haifa as well, namely Elisha Hospital and Horev Medical Center.
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