1. 88/9/171دکتر باقری مقدم

2. Exercise Prescription for Osteoarthritis دکتر احمد باقری مقدم متخصص پزشکی ورزشی

3. Osteoarthritis is a form of arthritis that features the breakdown and eventual loss of the cartilage of one or more joints. Cartilage is a protein substance that serves as a "cushion" between the bones of the jointsarthritis It called degenerative joint disease. the most common form of arthritis. What is osteoarthritis?

4. pathology In healthy joints cartilage acts as a shock absorber when you put weight on the joint. The slippery surface of the cartilage allows the bones to move smoothly. joint osteoarthritis the cartilage gradually becomes rough and thin, and the bone underneath thickens. Over time the cartilage may wear away entirely, and the bones will rub together.

6. Primary osteoarthritis osteoarthritis not resulting from injury or disease, is mostly a result of natural aging of the joint. With aging, the water content of the cartilage increases, and the protein makeup of cartilage degenerates..

7. Secondary osteoarthritis is a form of osteoarthritis that is caused by another disease or condition obesity,obesity repeated trauma surgery to the joint structures abnormal joints at birth (congenital abnormalities) gout, gout diabetes,diabetes hormone disorders.

8. The symptoms of osteoarthritis tend to develop slowly pain or soreness when you move certain joints or when you've been inactive for a prolonged period The affected joints may also be stiff or creaky Typically, osteoarthritis leads to morning stiffness that resolves in 30 minutes When osteoarthritis affects the hands, some people develop bony enlargements in the fingers, which may or may not cause pain. Symptoms

10. In most cases, osteoarthritis develops in the weight- bearing joints of the knees, hips, or spine It's also common in the fingers, thumb, neck, and big toe. Other joints are usually not affected, unless an injury is involved. Where Does It Hurt?

12. Every joint comes with a natural shock absorber in the form of cartilage. This firm, rubbery material cushions the ends of the bones and reduces friction in healthy joints. As we age, joints become stiffer and cartilage is more vulnerable to wear and tear. At the same time, repetitive use of the joints over the years irritates the cartilage. If it deteriorates enough, bone rubs against bone, causing pain and reducing range of motion. Causes

13. 1-unknown 2-heredity 3-excess weight (obesity) :puts extra stress on the weight- bearing joints, especially the knees and hips. 4-joint injury: a- sport (wear and tear in joint). b- occupation (squat position over many years. 5-other disease RA. 6-high heel shoes.

14. Osteoarthritis usually starts in the late 40s, 50s or 60s and is uncommon before the age of 40. It is probably due to several factors that accompany growing older – muscles become weaker we put on weight our body is less able to heal itself. Age

15. Sex For most joints, especially the knees and hands, osteoarthritis is more common and severe in women.

16. Obesity For many people, this is an important factor in causing osteoarthritis, especially at the knee. Being overweight also increases the chances of osteoarthritis worsening once it has developed.

17. Joint injury A major injury or operation on a joint may lead to osteoarthritis at that site in later life. There are some abnormalities of the joint that you can be born with or which develop when you are a child, such as Perthes' disease of the hips, which also lead to osteoarthritis in later life.

18. Joint injury Normal activity and exercise is good rather than bad for joints and does not cause osteoarthritis. very hard repetitive activity may injure joints. This explains why osteoarthritis is more common in people in some physically demanding jobs, such as farmers (osteoarthritis of the hip) and professional footballers (osteoarthritis of the knee)

19. Heredity There is one common form of osteoarthritis (nodal osteoarthritis) that strongly runs in families. This particularly affects the hands of middle- aged women. In knee and hip osteoarthritis, heredity plays a smaller, though still significant, role. We know these are linked with single genes that affect collagen – an essential component of cartilage.

20. People with diabetes may be prone to osteoarthritis. Other endocrine problems also may promote development, including acromegaly, hypothyroidism, hyperparathyroidism, and obesity. Endocrine Al.yami2008

21. Posttraumatic Traumatic causes can be further divided into macro or micro trauma. An example of macrotrauma is an injury to the joint such as a bone break causing the bones to line up improperly (malalignment), lose stability, or damage cartilage.

22. This category would include infected joints, chronic gouty arthritis, and rheumatoid disease. Inflammatory joint diseases: Al.yami2008

23. Metabolic Diseases causing errors of metabolism may cause osteoarthritis. Examples include Paget disease and Wilson disease.

24. Congenital or developmental Abnormal anatomy such as unequal leg length may be a cause of osteoarthritis. Al.yami2008

26. Genetic A genetic defect may promote breakdown of the protective architecture of cartilage. Examples include collagen disturbances such as Ehlers- Danlos syndrome.

27. Neuropathic nerve problems. The loss of sensation may affect how the body knows the position and condition of the joints or limbs. In other words, the body can't tell when it is injured. Al.yami2008

29. One of the major risk factors for osteoarthritis is something none of us can control – getting older. Gender also plays a role. Over age 50, more women than men develop osteoarthritis. In most cases, the condition results from normal wear and tear over the years. But some people have a genetic defect or joint abnormality that makes them more vulnerable. Risk Factors

30. Because injured joints are more vulnerable to osteoarthritis, doing anything that damages the joints can raise your risk. This includes sports that have a high rate of injury and jobs that require repetitive motion, such as bending the knees to install flooring. Obesity is another risk factor – it has been linked specifically to osteoarthritis of the knees and hips.

32. Sign and symptoms 1-pain, especially when moving a joint. 2-swelling or bumps. 3-sore and stiff (fingers and foot). 4-hear grating sound when the roughened cartilage on the surface of the bones rubs together. 5- hard movement (walk and up stair).

33. Decreased Physical Activity Changes in Joint Pain Muscle Weakness Loss of Normal Function

34. Joint affected OA commonly affects weight-bearing joints such as hips, knees, feet and spine. However, non-weight bearing joints such as finger joints.

35. Diagnosis 1-history of symptoms 2-physical exam.. 3-blood test to detect (OA or RA). 4- x-ray

36. Factor to distinguish OA and other disease. 1-Osteoarthritis usually occurs in older people after the age 45 years, but occur at any age. 2-It is usually located in only one or a few joints. 3-The joints are less inflamed than in other arthritic conditions. 4-Progression of pain is almost always gradual. 5-It affects men and women in equal numbers but after the 50 age the women is more.

37. Complication of OA 1-The muscles that hold the joint in place weaken because they are not being used. 2-Over time, the joint looses its shape and does not work at all.

38. it can lead to deformities that take a toll on mobility Severe loss of cartilage in the knee joints can cause the knees to curve out, creating a bow-legged appearance (shown on the left). Bony spurs along the spine (shown on the right) can irritate nerves, leading to pain, numbness, or tingling in some parts of the body. Long-Term Complications

40. Treatment Individualized treatment Comorbid conditions Patient's needs and expectations Types of treatment Non-pharmacological Patient education Exercise Therapy Assistive devices PT & OT Weight management Supplements Pharmacological Simple analgesics NSAID COX-2 inhibitor Local analgesics Intra-articular corticosteroid Intra-articular hyaluronic acid ­ like product Surgery Arthroscopic debridement or joint lavage Osteotomy for mal-alignment of the knee or hip Arthroplasty

41. Medical 1-Analgesics drugs: A) Acetaminophen :to relieve mild to moderate arthritis pain. Side effect: liver damage. B) Codeine preparation: to relive severe arthritis pain. Side effect: may cause constipation 2-Cream and gels: to temporary pain relive.

42. 3-Nonsteroidal anti-inflammatory drugs (NSAIDs): To reduce pain and swelling of the joint and decrease stiffness. a) Non-selective NSAIDs: e.g. aspirin -Low dose use to relive pain. - Higher dose and regular use to suppress inflammation Side effect: Stomach upset, diarrhea and abdominal pain B) Selective NSAIDs (Cox-2 inhibitor): are as effective as non-selective NSAIDs and less cause gastrointestinal injury and side effect.

43. Joint irrigation: the joint space is flushed with fluid to remove cartilage debris, irritating crystals and other substance. *use to reduce pain, stiffness and tenderness and allow for increased physical activity. Corticosteroid: May be injected into the joint to relive severe inflammation. Cortisone as asteroid that reduce inflammation and swelling.

44. Surgical 1-Arthroscopy: use to 1-invistigation of joint. 2-treatment: a) To remove damage (debridement) b) To flush the joint to remove any loose part (lavage or irrigation) *Advantage: 1-delay the need fore more serious surgery e.g. joint replacement. 2-the incision is small size. 3-the pain that result of surgery is minimal 4-restore function and decrease pain. *Disadvantage: 1-Risk of anesthesia. 2-infection 3-damage to nerve or blood vessels 4-DVT

45. 2-osteotomy: Is procedure change the position or alignment of knee so your weight shift away from the damage area. This procedure only be done when only one area or side of knee damage. *Advantage: Decrease pain and restore function. *Disadvantage: May need knee replacement surgery in future.

46. 3-arthroplasty:(joint replacement) Procedure done by artificial joint replace all joint (total replacement) or part of knee damage (Unicompartmental knee arthroplasty). Artificial joint made from metal and plastic. Advantage: 1- the result of the joint replacement are generally excellent (there are significant pain relief and improve function). Disadvantages: 1-rehabilitation may take 3to6 month. 2-the artificial joint may loosen or wear out so that second surgery is needed. * The life span or artificial is about 10 years in 9%of the people.

47. Physical Therapy Physical therapy and exercise improve flexibility and strengthen the muscles surrounding the joints. People who exercise regularly their arthritis will typically have less pain and better function than those who are inactive. physiotherapy treatment program will help: Reduce pain Improve movement and posture Strengthen muscles Improve independent function Assess and treat biomechanical problems that may exacerbate the pain and loss of function

48. Exercises prevent the disability that result from inactivity. promotes the health and normal function of muscles and bones. keeps the muscles toned increases bone mineral density, which reduces the risk of osteoporosis and fractures. It promotes cardiovascular health, which decreases the risk of heart disease. psychosocial benefits including an improved sense of well-being and the relief of depression.

49. Benefit of exercise in osteoathritic conditions Alleviate pain, improve physical fitness, improves quality of life Better ambulatory status Less dependent Self confidence Social integration Avoid unnecessary medications Defer surgical need

50. فواید ورزش در مبتلايان به آرتروز افزایش قدرت عضلانی بهبود حرکت مفصلی کاهش درد بهبود بیومکانیک بهبود توان عملکردی

51. ورزش ملایم ورزش با شدت پایین تاکید بر قدرت و انعطاف پذیری ورزش آبی ورزش با ماشین ورزش بدون درد

52. Classic teaching - recommended activities Swimming, cycling Mild calisthenics exercise which promote joint movements, limited pressure and impact in joints Other low impact weight-bearing exercise such as walking and hydro-exercise would help to improve bone density and structure Older adults- Combination of aerobic exercise, strength-training exercise, balance and flexibility exercise Start low and progress according to tolerance and preference

53. Initial Evaluation & Assess Pain severity Physical impairments Physical disabilities Check Medically stable Without joint laxity Willing to exercise Exercise prescription Re-evaluate at 4 wks Monitor at 4-6 months, Encourage increasing physical activities

54. Exercise dose - Start Golden rules Effectiveness Accessibility Safety Individualised Enjoyment Regular evaluation Assess motivation Family & Community PAR-Q/med-X Problem orientated Enjoyment Achievements & reinforcement

55. Components Warm-up Gentle flexibility Conditioning Aerobic activity Strength-training Static muscle stretching Cool-down Progression Initial, improvement, maintenance

56. Exercise prescription plan Flexibility Initialhold 5-15 seconds Ultimate 3-5 stretches, hold 20-30 sec Aerobic exercise 20-30 minutes/day, 3-4 /wk Strength-training exercise Isometric hold <6 sec, 20sec rest period, daily Useful in acute phase Isotonic 6-15 repetitions, 2-3 / wk

58. Programme For Osteoarthritis

60. Safe Play Low back conditions Avoid or minimise exercise that precipitates or exasperates forced extreme flexion, extension, and violent twisting, correct posture, proper back exercise Osteoporosis Avoid exercise with high risks for fracture Push-ups, curls-ups, vertical jump and trunk forward flexion, Engage in low-impact weight-bearing activities and resistance training

61. Safe Play Arthritis – acute ( infective, rheumatoid, gout) Treatment, plus judicious blend of rest, splinting and gentle movement Arthritis – subacute Progressive increase of active exercise therapy Arthritis – chronic ( osteoarthritis ) Maintenance of mobility and strength, non-weight bearing exercises to minimise joint trauma ( e.g. cycling, aquatic activity etc.)

62. My practice Find out the obstacles Support Companion Family Skills Set the goal (phase approach) Enjoyment Achievable The rose garden Caution about the fluctuations Occasional attack of inflammations Ways to deal with it

63. Upper limbs Stress Shoulder Range of Motion Active Active assisted passive Balance muscle training Multiple directions Static dynamic

64. Knees Stress Full Range of motion, especially full extension Mild pain Active ROM, 10 rep Flexibility and static exercise, 10 rep x 6 sec Dynamic exercise, Quads & Hamstring 10 rep Low-impact activities 20 min, 3x/wk

65. Backs Stretching Pectorals, back extensors, hamstrings, psoas Active ROM ex 10 x /day Dynamic ex Trunk & hip muscle 5-8 rep Aerobic ex 20 min 3 x /wk

66. Issues of different exercise Brisk walk, Jogging Swimming Aerobic dance TaiChi

67. Brisk walk, jogging, hiking Preparation Park, podium, gym Surface, terrain Shoe wear, clothing Warm up Pacing Warm-down Issues of knee brace Advise on control of flare up Caution about the yellow flag Increase swelling, morning stiffness

68. Swimming Swimmer vs. Non-swimmer Community resources Hydro exercise vs. lap-swimming Style Breast stroke – Knee ROM required Free style – Shoulder Rom required

69. Taichi Proved to be good in aerobic ability, muscle strength & Balance Community resource Demanding on Knees Co-ordination Stress on the need of warm up Stress enjoyment

70. Range-of-motion exercises are gentle stretching exercises which move each joint as far as possible in all directions. These exercises need to be done daily to help keep joints fully mobile and prevent stiffness and deformities. ROM (range-of-motion) exercises are especially important for arthritis patients, who because of intense inflammatory pain tend not to want to move painful joints. Range of Motion Exercises

72. Strengthening Exercises Strengthening exercises help increase muscle strength. Strong muscles help to support the joints, making the joints more stable, and helping a person move more easily and with less pain. The two types of strengthening exercises are isometric and isotonic: Isometric exercises involve tightening the muscles, without moving the joints. These exercises are especially useful when joint motion is impaired. Isotonic exercises involve strengthening the muscles by moving the joints.

76. Stretching Exercises Stretching the muscles that support the knee is important in preventing injury. Flexible muscles are not as easily injured as tight muscles. Tightness of muscles connected to the knee can also pull the knee out of alignment. When doing stretching knee exercises, be careful to go slowly and not to overstretch.

78. Aerobic Exercise Aerobic exercise benefits those with knee problems by toning the muscles of the leg that support the knee joint to absorb shock before it reaches the knee joint. Aerobic exercises also help in weight reduction. Losing weight reduces stress on the knee joint - the impact placed upon on the knees is three times the body weight while walking. Aerobics also stimulate your the body to release endorphins - natural painkillers produced by one's own body.

79. Aerobic exercise is important for the health of the heart, lungs, and overall function of the body. Warm up before aerobic exercise to slowly increase your heart rate and breathing rate. Five minutes of slow paced walking, and a few minutes of stretching are sufficient. Cooling down in the same manner is also important be sure to stretch your quadriceps and hamstrings.

80. Walking: Start with about 5 minutes of slower paced walking to warm up. Walk at a medium pace for about another 10 minutes per day and gradually build up to 30 - 60 minutes by adding a few minutes each time you walk. End your walk with 5 minutes of slower paced walking. After you get into better shape you can start walking at a faster pace to increase the intensity of your walks.

81. Swimming and Water Exercises swimming is an excellent no-impact exercise. Regular 'land' exercises can also be done underwater. The buoyancy of the water supports most of the body's weight while the resistance of the water make your muscles work harder to perform movements. You can use dumbbells and weights strapped to the ankles to intensify the workout without stressing the knees and other weight-bearing joints.

82. Stationary bikes: Make sure your seat is high enough so that your knees are not bent beyond a 90-degree angle. Your knee should be slightly bent when your pedal is furthest away. An upright stationary bike (looks like a regular bike) gives you a higher intensity work out than a recumbent bike.

83. Heat and cold therapies Applying heat and cold to arthritic joints can help to control symptoms such as pain and stiffness. Heat therapy : Heat relieves pain and stiffness in arthritic joints. Heat can be applied to the joints with hot packs, hot water bottles, heating pads, or electrically heated mittens. Heating pads should be set on a timer and used for no more than 20 minutes at a time. The heating pad can be reapplied after 20 minutes of no use.

84. Cold therapy : Cold relieves pain in arthritic joints and reduces muscle spasms. Cold can be applied for short periods using ice packs or topical coolant sprays. People with certain medical conditions, such as the Raynaud phenomenon, should not use cold therapy.

85. Orthoses & Assistive devices Orthoses : Orthoses are devices that promote normal alignment and function of the joints. There are many different types of orthoses that can reduce symptoms and help maintain function in people with osteoarthritis. Well-cushioned shoes and shoe inserts may reduce stress on the joints of the spine and leg. Splints that immobilize the joints can reduce pain and inflammation, and many splints can be worn throughout the day and night. Braces can help stabilize unstable joints.

86. Assistive devices : Canes, walkers, electric powered seat lifts, raised toilet seats, and tub and shower bars can reduce the stress on joints and make it easier to perform daily tasks.

87. Activity limitations The following positions and activities place excessive pressure on the knee joint and must be limited until knee pain and swelling resolve: Squatting,Kneeling,Twisting and pivoting, repetitive bending and Bicycling. The preferred exercise equipment for the knee should provide smooth motion of the knee, maximal toning of the front and back thigh muscles (quadriceps and hamstring muscles).

88. آرتریت در مرحله حاد ورزش نکنند سپس: 1. دامنه حرکتی 2. قدرتی(ایزومتریک)

90. Osteoarthritis and Weight If you're overweight, one of the most effective ways to relieve pain in the knee or hip joints is to shed a few pounds. Even modest weight loss has been shown to reduce symptoms of osteoarthritis by easing the strain on weight-bearing joints. Losing weight not only cuts down on pain, but may also reduce long- term joint damage.

92. چاقی فشار خون بالا دیابت سنگ کیسه صفرا سرطان آرتروز بیماری قلبی

93. ورزش مناسب استقامتی :پیاده روی شنا دوچرخه سواری(کالری سوزی) قدرتی :تقویت عضلات شکم

94. توصیه افت فشارارتوستاتیک به خاطر دارو دیابت کفش مناسب خودداری از دراز و نشست زیاد(تنفسی)

95. گرم کردن و سرد کردن تعريف انواع :1-عمومي 2- اختصاصي مد ت:15تا30 دقيقه شدت :در حد تعريق ملايم ميزان ماندگاري اثر: سي دقيقه

97. تمرینات آبی فواید: 1. انتقال بهتر دما(25 برابر) 2. تقویت عضلات(مقاومت آب) 3. تناسب قلبی تنفسی 4. کاهش خستگی عضلات تنفسی بالای آب

100. نوار پیچی

101. Supportive Devices Supportive devices, such as finger splints or knee braces, can reduce stress on the joints and ease pain. If walking is difficult, canes, crutches, or walkers may be helpful. People with osteoarthritis of the spine may benefit from switching to a firmer mattress and wearing a back brace or neck collar.

103. تزریقات اگر دارو و سایر درمان های غیرجراحی برای تسکین دردِ دردهای مزمن زانو موثر واقع نشوند بعضی از پزشکان ممکن است از تزریقات مختلف استفاده کنند..

104. طب سوزنی

105. ماساژ

106. تعويض مفصل زانو

107. زانو پرانتزی

110. زانو ضربدری

112. براي مراقبت از زانوها چه بايد کرد ؟ ١- وزن مناسب داشته باشيد. اضافه وزن مهمترين عامل آسيب زانواست و علت آن فشار بيش از حدي است ک به زانوها وارد مي کند. پس اگر اضافه وزن داريد وزن خود را مناسب کيد و گرنه بايد منتظر شروع درد زانو باشيد

113. ٢- اجسام سنگين را جابجا نكنيد. حمل جسم سنگين موجب آسيب گردن، کمر و زانو مي شود. پس تا جايي که امكان دارد از جابجايي اجسام سنگين خودداري کنيد. به ياد داشته باشيد وقتي جسمي را حمل مي کنيد، فشاري که به زانوها وارد مي شود، چندين برابر وزن آن جسم است.

114. ٣- عضلات ران خود را تقويت کنيد. عضلات ران از مفصل زانو محافظت مي کنند، بنابراين تقويت عضلات ران، از ساييدگي مفصل زانو جلوگيري مي کند و در زانو را کاهش مي دهد. حرکات ورزشي ساده اي براي اين کار وجود دارد که ميتوانيد آنها را به راحتي در منزل و يا در محل کار، در حالت نشسته بر روي زمين و يا روي صندلي انجام دهيد.

115. رعايت نكات زير توصيه مي گردد. -1 از نشستن دو زانو و چهار زانو اجتناب كنيد. -2 درموقع درد از ايستادن و راه رفتن طولاني اجتناب كنيد. -3 از توالت فرنگي استفاده كنيد. -4 در زير نور آفتاب زانوهاي خود را به آرامي ماساژ دهيد. -5 از بلند كردن بار سنگين اجتناب كنيد. -6 روزانه به ميزان كافي آب بياشاميد. -7 در بالا رفتن از پله ابتدا پاي سالم را بالا گذاشته وپاي ناسالم را كنار آن بگذاريد و در پايين آمدن,ابتدا پاي ناسالم را پايين گذاشته و سپس پاي سالم را در كنار آن قرار دهيد.

116. Preventing Osteoarthritis The most important thing you can do to ward off osteoarthritis is keep your weight in check. Over the years, extra weight puts stress on the joints and may even alter the normal joint structure. Preventing injuries is also important. Take precautions to avoid repetitive motion injuries on the job. If you play a sport, use proper equipment and observe safety guidelines.

117. Hamstring Stretch Warm up with a five-minute walk. Then, stretch. Lie down. Loop a bed sheet around your right foot. Use sheet to help pull and stretch leg up. Hold for 20 seconds. Repeat twice, then switch legs. Stretching is one of three important types of exercises for knee OA. Range of motion or stretching exercises keep you limber. Strengthening exercises build muscle strength to stabilize weak joints. Aerobic exercises, like walking, help lung and heart fitness.

119. Calf Stretch Stretching exercises loosen muscles, improve flexibility, and help prevent pain and injury. Use a chair for balance. Bend your right leg. Step back with left leg, slowly straightening it behind you. Press left heel towards the floor. Feel the stretch in your back leg. For more of a stretch: Lean forward, bending the right knee deeper. Don't let the right knee go past your toes. Hold for 20 seconds. Do twice, then switch legs.

121. Straight Leg Raise To try this leg strengthening move, lie on the floor. Prop your back up on your elbows. Bend your left knee, keeping foot on floor. Keep the right leg straight, toes pointed up. Tighten thigh muscles of your right leg. Slowly and smoothly use your thigh muscles -- not your back -- to raise your leg. Pause, as seen above, for five seconds. With thigh still tight, slowly lower leg to ground. Relax. Repeat 10 times. Rest. Do another 10; then switch legs.

123. Quad Set Is the straight leg raise too tough? Do quad sets instead. With these you don't raise your leg. Simply tighten the thigh muscles, also called the quadriceps, of one leg at a time. Start by lying on the floor. Keep both legs on ground, relaxed. Flex and hold left leg tense for five seconds, as seen in right- hand photo. Relax. Do two sets of 10. Then, switch to other leg.

125. Seated Hip March This move can strengthen hips and thigh muscles to help with daily activities, such as walking or rising from a chair. Sit up straight in chair. Slightly kick back your left foot but keep toes on the floor. Lift your right foot off the floor, keeping knee bent. Hold right leg in the air five seconds. Slowly lower your foot to the ground. Repeat 10 times. Rest and do another 10, then switch legs. Too hard? Use your hands to help raise your leg.

127. Pillow Squeeze This move helps strengthen the inside of your legs to help support your knee. Lie on your back, both knees bent. Place a pillow between knees. Squeeze knees together, squishing pillow between them. Hold for five seconds. Relax. Repeat 10 times. Rest, then do another set of 10.

129. Heel Raise Hold back of chair for support. Stand straight and tall. Lift heels off ground and rise up on toes of both feet. Hold for five seconds. Slowly lower both heels to ground. Repeat 10 times. Rest. Do another 10. Too hard? Do the same exercise, only sitting in a chair.

131. Side Leg Raise Hold back of chair for balance. Place your weight on left leg. Lift right leg out to the side. Keep right leg straight and outer leg muscles tensed. Don't slouch. Lower right leg and relax. Repeat 10 times. Rest. Do another 10, then repeat with left leg. Too hard? Increase leg height over time. After a few workouts, you'll be able to raise your leg higher

133. Sit to Stand Practice this move to make standing easier. Place two pillows on chair. Sit on top, with your back straight, feet flat on floor (see left). Use your leg muscles to slowly and smoothly stand up tall. Then, slowly lower yourself back down to sitting. Be sure your bent knees don't move forward of your toes. Try with arms crossed (see left) or loose to your side. Too hard? Add pillows or use a chair with armrests and help push up with your arms.

135. One Leg Balance Your goal is to do this hands-free. Steady yourself on a chair, if needed. First, shift your body weight to one leg but do not lock your knee straight. Slowly raise the other foot off the ground, balancing on your standing leg. Hold for 20 seconds. Lower raised foot to the ground. Do twice, then switch legs. This move helps when getting out of cars or bending. Too easy? Balance for a longer time. Or try with your eyes closed.

137. Step Ups This move helps strengthen your legs for climbing stairs. Face a stable step, both feet on the ground. Step up with your left foot. Follow with your right foot. Stand on top, tall and with both feet flat. Climb down in reverse: right foot down first, then left. Do 10 times. Rest, then repeat another 10 times. Then repeat, starting with right leg first. Too hard? Use a railing, wall, or lamppost for balance. Or try a lower step.

139. Walking With stiff or sore knees, walking may not seem like a great idea. But it's one of the best exercises for knee arthritis. It can reduce joint pain, strengthen leg muscles, and improve flexibility -- and it's good for your heart. The best part -- no gym membership needed. Good form is key: Look forward, walk tall. Keep arms and legs moving, relaxed. Always ask your doctor before starting exercise when you have osteoarthritis.

141. Low-Impact Activities Being active may also help you lose weight, which takes pressure off joints. Other exercises that are easy on the knees: biking, swimming, and water aerobics. Water exercise takes weight off painful joints. Many community and hospital wellness centers, YMCAs, and pools offer classes for people with arthritis. Don't give up favorite activities, like golf. Talk to your doctor or physical therapist about modifying painful moves.

142. Thank you for your attention دکتر باقری مقدم www.bagherimoghaddam.ir Ahmad_bagheri2001@yahoo.com 09132073251 تلفن همراه