Rheumatoid Arthritis

Rheumatoid Arthritis

Article by Shane Armfield

What is Rheumatoid Arthritis?

Rheumatoid Arthritis is an autoimmune disease that causes inflammation in your joints. The main symptoms are joint pain and swelling. Rheumatoid Arthritis can also be referred to colloquially as Rheumatism and is best treated by a physiotherapist with a special interest in Rheumatoid Physiotherapy.

Rheumatoid Arthritis causes inflammation in the synovium (covering of the joint, which produces a small amount of synovial fluid that nourishes the cartilage and lubricates the joint). A build-up of fluid and cells causes inflammation in the synovium. This results in red and swollen joints that produce extra fluid and pain.

Your joint hurts for two reasons:

  • Your nerve endings are irritated by the chemicals produced by the inflammation.
  • The swelling stretches the capsule in your joint.

When the inflammation goes down, the capsule remains stretched and can’t hold your joint in its proper position. This can make your joint unstable, and it can move into unusual or deformed positions over time.

What are the Symptoms of Rheumatoid Arthritis?

Rheumatoid Arthritis varies from one person to another, but it usually starts quite slowly. Symptoms tend to come and go. You may also have flare-ups when your symptoms become worse than normal.

Common symptoms of Rheumatoid Arthritis include:

  • joint pain and swelling (fingers, wrists or the balls of your feet)
  • stiffness (morning stiffness lasting over 30 minutes)
  • tiredness (fatigue), depression, irritability
  • anaemia
  • flu-like symptoms, such as feeling generally ill, feeling hot and sweating.
  • rheumatoid nodules (fleshy lumps below the elbows or on hands and feet)

How is Rheumatoid Arthritis Diagnosed?

Due to the variety of symptoms experienced by patients, diagnosing Rheumatoid Arthritis can be complex. Doctors will confirm the diagnosis based on your symptoms, a physical examination and the results of x-rays, scans and blood tests. Your doctor may also refer you to a specialist (Rheumatologist) to confirm the diagnosis and receive treatment.

Blood tests, in this case, are used to measure inflammation. You may have one of these tests:

  • Erythrocyte Sedimentation Rate (ESR)
  • C-Reactive Protein (CRP).

Both of these may show a high value when inflammation is present. These tests may be repeated from time to time to help monitor your arthritis.

Please seek the professional advice of your doctor or physiotherapist.

What’s the Treatment of Rheumatoid Arthritis?

There is currently no cure for Rheumatoid Arthritis, but various treatments can slow down the condition and keep joint damage to a minimum.

The three main aspects to the treatment of rheumatoid arthritis are:

Physical Therapies for Rheumatoid Arthritis

Looking after your joints and managing your symptoms is very important in the treatment of Rheumatoid Arthritis. Your physiotherapist can suggest several different treatments that may help ease your symptoms and reduce the impact Rheumatoid Arthritis can have on your life.

The following treatments have been shown to help patients with Rheumatoid Arthritis.

  • Therapeutic Exercise
  • Heat/Cold Therapy
  • Education
  • Pain Management
  • Acupuncture
  • Splinting Joints
  • Fatigue management
  • Manual techniques
  • Hydrotherapy

Drugs for Rheumatoid Arthritis

Four main groups of drugs are used to treat Rheumatoid Arthritis:

  • painkillers (analgesics)
  • non-steroidal anti-inflammatory drugs (NSAIDs)
  • disease-modifying anti-rheumatic drugs (DMARDs)
  • steroids.

Your doctor or rheumatologist is the best clinician to discuss these drugs with and will manage the use of these medications carefully.

Surgery

Surgery is occasionally needed for rheumatoid arthritis. These may include injections, tendon surgery or, in extreme cases, joint replacement. Outcomes for these procedures are successful.

Professional healthcare advice is highly recommended.

What Can You Do For Yourself?

Understand your condition and how it affects you

  • “Knowledge is power”. Educating yourself on the condition will help you manage your symptoms better and empower you when you talk to others (Rheumatologist, GP, family etc.) about your condition.
  • Self-management courses – can help you build skills and confidence in becoming more actively involved in your healthcare and managing rheumatoid arthritis day today.
  • Knowing about your medications can help you and your medical provider manage your symptoms more effectively.
  • Understanding how your behaviour and activities influence your symptoms can help you reduce the pain and suffering caused by RA. Speaking to a health professional can help you identify aspects of your life that may be aggravating your RA and help address them.

Keep Moving – But Respect Your Pain & Swelling

  • Exercise helps to lessen your pain in the long run by maintaining muscle strength and optimising joint health.
  • Well-designed activity programs can increase your range of movement, reduce fatigue and help you feel better overall.
  • Appropriate low-impact aerobic activities like hydrotherapy, cycling, Tai chi, pilates and walking can help improve your general health and manage your symptoms.
  • A strength-training program called progressive resistance training (PRT) has been proven to improve physical function in people with Rheumatoid arthritis.
  • Your physiotherapist will assess and prescribe rheumatoid arthritis exercises. Ask them what is best for you.

Relaxation techniques

  • Managing stress and anxiety with muscle relaxation techniques, distraction, guided imagery, and other techniques can help improve your general health and control painful symptoms.
  • Activities such as Tai Chi, Pilates and Yoga are a great way to relax and de-stress while conditioning the muscles and joints in the body.

Aids and equipment

  • Supports such as walking aids and specialised cooking utensils reduce joint strain and help you manage pain and fatigue. Your therapist can give you advice on aids.

Heat and Ice Therapy

  • Heat – heat works to reduce muscle tension and stimulate blood circulation. You may find that applying something warm before getting up in the morning or during the day helps reduce discomfort and stiffness in your joints.
  • Ice – Ice helps reduce inflammation in muscles and joints by constricting blood vessels and preventing fluids from leaking into surrounding tissues. It would help if you tried icing your joints after any significant activity or at the end of the day. This can minimize the inflammation resulting from daily activities.

Activity Pacing

  • Being aware of how your daily habits and activities influence your symptoms is very important. Overexertion can increase your pain and symptoms, while under activity can have similar effects. Learning about activity pacing through diaries and activity management strategies can help you achieve what you want, but with less pain or discomfort.

Sleep Health

  • Poor sleep patterns, sleeping environment, and sleeping position can significantly impact your pain and symptoms. Most people are unaware of the factors that can influence sleep health, so addressing these factors can help you manage your symptoms. A good therapist can assess your sleep health and provide you with aids and education to improve this aspect of your life.

Treat Your Muscles

  • A quality remedial massage may be just the relief your muscles need. Treat yourself to a good rub down with someone you trust. The benefits vary from person to person but may include decreased pain and muscle stiffness associated with your arthritis, increased circulation, and an improvement in your sleep and immune functions. Mentally, massage can also decrease stress and depression. Besides all that, massage feels good!

For more advice, please ask your Rheumatology Physiotherapist, Doctor or Rheumatologist.

General Arthritis Information

What is Arthritis?

Rheumatology Conditions

Rheumatoid Conditions – Overview

Osteoarthritis Conditions

Osteoarthritis – Overview

Spine
Peripheral Joints

What is the PhysioWorks Difference?

You'll be impressed with the experienced physiotherapists, massage therapists, allied health team and reception staff who represent PhysioWorks.

To ensure that we remain highly qualified, PhysioWorks is committed to participating in continuing education to provide optimal care.

If you've been searching for health practitioners with a serious interest in your rehabilitation or injury prevention program, our staff have either participated or are still participating in competitive sports at a representative level.

We also currently provide physiotherapy and massage services for numerous sports clubs. Our experience helps us understand what you need to do to safely and quickly return to your sporting field, home duties, or employment.

How You'll Benefit from the PhysioWorks Difference?

At PhysioWorks physiotherapy and massage clinics, we strive to offer our clients quickeffective and long-lasting results by providing high-quality treatment.

We aim to get you better quicker in a friendly and caring environment conducive to successful healing.

With many years of clinical experience, our friendly service and quality treatment is a benchmark not only in Brisbane but Australia-wide.

What are Some of the BIG Differences?

Our therapists pride themselves on keeping up to date with the latest research and treatment skills to ensure that they provide you with the most advantageous treatment methods. They are continually updating their knowledge via seminars, conferences, workshops, scientific journals etc.

Not only will you receive a detailed consultation, but we offer long-term solutions, not just quick fixes that, in reality, only last for a short time.

We attempt to treat the cause, not just the symptoms.

PhysioWorks clinics are modern thinking. Not only in their appearance but in the equipment we use and in our therapists' knowledge.

Our staff care about you!  We are always willing to go that 'extra mile' to guarantee that we cater to our client's unique needs.

All in all, we feel that your chances of the correct diagnosis, the most effective treatment and the best outcomes are all the better at PhysioWorks.

What is Physiotherapy Treatment?

Physiotherapists help people affected by illness, injury or disability through exercise, manual joint therapy, soft tissue techniques education and advice.  Physiotherapists maintain physical health, allow patients to manage pain and prevent disease for people of all ages. Physiotherapists help encourage pain-relief, injury recovery, enabling people to stay playing a sport, working or performing daily living activities while assisting them to remain functionally independent.

There is a multitude of different physiotherapy treatment approaches.

Acute & Sub-Acute Injury Management

Hands-On Physiotherapy Techniques

physiotherapy treatment

Your physiotherapist's training includes hands-on physiotherapy techniques such as:

Your physiotherapist has skilled training. Physiotherapy techniques have expanded over the past few decades. They have researched, upskilled and educated themselves in a spectrum of allied health skills. These skills include techniques shared with other healthcare practitioners. Professions include exercise physiologists, remedial massage therapists, osteopaths, acupuncturists, kinesiologists, chiropractors and occupational therapists, to name a few.

Physiotherapy Taping

Your physiotherapist is a highly skilled professional who utilises strapping and taping techniques to prevent and assist injuries or pain relief and function.

Alternatively, your physiotherapist may recommend a supportive brace.

Acupuncture and Dry Needling

Many physiotherapists have acquired additional training in acupuncture and dry needling to assist pain relief and muscle function.

Physiotherapy Exercises

Physiotherapists have been trained in the use of exercise therapy to strengthen your muscles and improve your function. Physiotherapy exercises use evidence-based protocols where possible as an effective way that you can solve or prevent pain and injury. Your physiotherapist is highly-skilled in the prescription of the "best exercises" for you and the most appropriate "exercise dose" for you, depending on your rehabilitation status. Your physiotherapist will incorporate essential components of pilates, yoga and exercise physiology to provide you with the best result. They may even use Real-Time Ultrasound Physiotherapy so that you can watch your muscles contract on a screen as you correctly retrain them.

Biomechanical Analysis

Biomechanical assessment, observation and diagnostic skills are paramount to the best treatment. Your physiotherapist is a highly skilled health professional. They possess superb diagnostic skills to detect and ultimately avoid musculoskeletal and sports injuries. Poor technique or posture is one of the most common sources of a repeat injury.

Hydrotherapy

Aquatic water exercises are an effective method to provide low bodyweight exercises.

Sports Physiotherapy

Sports physio requires an extra level of knowledge and physiotherapy to assist injury recovery, prevent injury and improve performance. For the best advice, consult a Sports Physiotherapist.

Vestibular Physiotherapy

Women's Health

Women's Health Physiotherapy is a particular interest group of therapies.

Workplace Physiotherapy

Not only can your physiotherapist assist you in sport, but they can also help you at work. Ergonomics looks at the best postures and workstation set up for your body at work or home. Whether it be lifting technique improvement, education programs or workstation setups, your physiotherapist can help you.

Electrotherapy

Plus Much More

Your physiotherapist is a highly skilled body mechanic. A physiotherapist has particular interests in certain injuries or specific conditions. For advice regarding your problem, please contact your PhysioWorks team.

Arthritis-Related Conditions

General Arthritis Information

What is Arthritis?

Rheumatology Conditions

Rheumatoid Conditions - Overview

Osteoarthritis Conditions

Osteoarthritis - Overview
Spine
Peripheral Joints

Article by John Miller

What is Therapeutic Ultrasound?

Therapeutic ultrasound is an electrotherapy modality that has been used by physiotherapists since the 1940s. Via an ultrasound probe through a transmission coupling gel in direct contact with your skin, ultrasound waves are applied. ultrasound Therapeutic ultrasound may increase:
  • healing rates
  • tissue heating
  • local blood flow
  • tissue relaxation
  • scar tissue breakdown.

How Could Ultrasound Help?

Ultrasound increases local blood flow. This increase may help to reduce local swelling and promote soft tissue healing rates. A higher power density may soften scar tissue.

Specific Ultrasound Uses

Mastitis or blocked milk ducts successfully respond to therapeutic ultrasound. The effect is quite dramatic, with improvement within 24 to 72 hours. The most common conditions treated with ultrasound include soft tissue injuries such as muscle, ligament injuries or some tendinopathies. Phonophoresis uses ultrasound in a non-invasive way of administering medications to tissues below the skin. This method may assist patients who are uncomfortable with injections. With phonophoresis, the ultrasonic energy forces the drug through the skin.

What is an Ultrasound Dose?

A typical ultrasound treatment will take from 3-10 minutes. Where scar tissue breakdown is the goal, this treatment time could be much longer. During the procedure, the head of the ultrasound probe is in constant motion. If kept in continuous motion, the patient should feel no discomfort at all. Some conditions treated with ultrasound include soft tissues injuries such as muscles or ligament injuries, tendinopathy, non-acute joint swelling and muscle spasm.

How Does an Ultrasound Work?

A piezoelectric effect, caused by the vibration of crystals within the ultrasound head of the probe creates the sound waves. The ultrasound waves generated then pass through the skin cause a vibration of the local soft tissues. This repeated cavitation can cause deep heating locally though usually no sensation of heat will be felt by the patient. In situations where a heating effect is not desirable, an athermal application occurs. Athermal doses are typical during acute fresh injury and the associated acute inflammation.

When Should Ultrasound be Avoided?

Contraindications of ultrasound include:
  • local malignancy,
  • over metal implants,
  • local acute infection,
  • vascular abnormalities,
  • active epiphyseal regions (growth plates) in children,
  • over the spinal cord in the area of a laminectomy,
  • over the eyes, skull, or testes
  • and, directly on the abdomen of pregnant women. Treatment ultrasound differs from diagnostic ultrasound!
Like all medical equipment, when used by highly trained professionals, such as your physiotherapist, therapeutic ultrasound is very unlikely to cause any adverse effects. Please consult your physiotherapist for their opinion on whether therapeutic ultrasound could assist your injury. Therapeutic Ultrasound differs from Real-Time Ultrasound Treatment.

What is Osteoarthritis?

Osteoarthritis is one of the most common forms of arthritis, often referred to as degenerative arthritis. The joints show signs of wear: joint cartilage becomes thin, extra bony spurs grow in response to stress, and joint motion lessens. In advanced stages, osteoarthritis can be painful, functionally limiting and depressing.

What is the Osteoarthritis Cure?

Unfortunately, there is no cure for osteoarthritis. But the good news is that there are some better ways to manage your osteoarthritis and slow the degeneration process. This improvement will result in making your life easier and more comfortable. Physiotherapy is a significant part of making your life living with osteoarthritis less painful, comfier and keeping you active. Research supports physiotherapy. Physio can reduce the pain and disability associated with arthritis, especially knee osteoarthritis. http://dx.doi.org/10.1136/bjsports-2016-096458 Seek the professional and helpful advice of your physiotherapist to start enjoying life again today!

Your Osteoarthritis Diagnosis

X-rays are the most straightforward test to confirm osteoarthritis. An experienced practitioner will have an excellent idea of whether you have osteoarthritis when they examine you.

How Does Osteoarthritis Affect Older People?

As you age, most people develop some degree of osteoarthritis. Our joints' wear and tear may occur due to ageing, injury, prolonged microtrauma, overuse of joints, or excess weight. Permanent bony changes occur and will exist even when there are no painful symptoms. Your degree of suffering varies. Whereas some people may be symptom-free others may suffer continuous disabling pain. The most common is mild or intermittent pain provoked by episodes of increased use or minor trauma. The joints most commonly affected are the weight-bearing joints: hip, knee, ankles, feet and spine. However, osteoarthritis can affect any joint in the body and is quite common in the hands and shoulders. Severe cases may require surgical treatment, but most will respond very well to your doctor's physiotherapy and medication.

Osteoarthritis Symptoms

You can suspect osteoarthritis if you experience one or more of the following symptoms:
  • joint pain or tenderness that intermittently returns
  • stiffness, particularly early morning stiffness
  • joint swelling or deformity
  • noticeable joint heat and redness
  • joint movement is strenuous.

Osteoarthritis Treatment

For advice on your osteoarthritis diagnosis, self-help tips or the best treatment of your osteoarthritis, please contact your physiotherapist or trusted health care professional.

calf-exercises Arthritis Treatment

If you think that there’s nothing you can do about arthritis? Great news! You can act right now. Some of the ideas here are simple, one-time actions. Others are the first steps toward longer-term goals. All can directly or indirectly improve your health, outlook or pain levels and generally make life with arthritis a little easier.

Get an Accurate Diagnosis

If you have pain, stiffness or swelling in or around a joint for more than two weeks, it's time to see your doctor, physiotherapist or health professional. These symptoms can develop suddenly or slowly. Only a well-trained health professional doctor can tell if it's arthritis. But "you have arthritis" is not a diagnosis. Ask for a specific diagnosis of the type of arthritis you have. There are more than 100 types – including osteoarthritis (the most common type of arthritis) and rheumatoid arthritis – each of which has different treatments. Getting the right treatment requires getting the right diagnosis.

Protect Your Joints

Avoid excess stress on your joints. Use larger or stronger joints to carry things. Assistive devices can make tasks at home and work easier. Look for them in the kitchen (rubber jar openers, reachers), bedroom (zipper pulls, buttoning aids), bathroom (tub bars, handrails) and for other areas of your life. Look for products with the Arthritis Foundation’s Ease-of-Use Commendation. These are items that are comfortable, easy-to-use or have user-friendly packaging. Also, staying close to your recommended weight helps relieve damaging pressure on hips and knees.

Get Moving

Exercise helps lessen pain, increases range of movement, reduces fatigue and helps you feel better overall. A well-rounded workout routine for people with arthritis includes flexibility exercises to increase motion, aerobic exercises to improve endurance, decreased fatigue, and strengthening exercises to improve muscle fitness. Your physiotherapist can show you range-of-motion exercises and strengthening exercises that are good for arthritis. The Arthritis Foundation also offers general exercise, aquatic, Tai Chi and walking programs. The key is to have a regular exercise program. We commonly recommend that adults do a minimum of 2 hours and 30 minutes of moderate-intensity aerobic activity (brisk walking, gardening) a week or 1 hour and 15 minutes each week of vigorous aerobic physical activity (jogging, aerobic dancing). Whether your activity is moderate or vigorous, the goal is to keep moving.

Lose Weight

Lose weight. You won’t just look better. You’ll feel better, too. Why? Every extra kilogram you carry around translates to added stress to your knees and hips. Excess weight can mean more pain, no matter which form of arthritis you have. It can also contribute to and aggravate osteoarthritis while increasing your risk of gout.

Bone Up

Stock up on your favourite source of calcium. A diet rich in this important mineral can help decrease your risk of osteoporosis. Besides, inflammatory arthritis conditions accelerate bone loss, so getting the optimum calcium intake is critical. Recommended daily doses of calcium are 1,000 mg for adults 50 and younger and 1,200 mg for adults over 50. If you don’t like drinking milk – or want some variety – try consuming more milk products, such as yogurt, cheese and ice cream. Or add powdered milk to puddings, gravies, shakes and other recipes. Other good sources of calcium: broccoli, salmon (with the bones) and kale.

Do Drugs – the Right Way

Take your medication just as your doctor prescribes. If you’re tempted to stop because you feel it’s not working or believe it’s causing side effects, call your doctor first. It can take weeks – or even months – for a medication's full benefits to become apparent, and some side effects ease over time. Stopping medication abruptly may not only cause you to miss out on its benefits – in some cases, but it can also be downright dangerous.

Begin with Breakfast

Grab some fruit, fibre (like oatmeal) and a tall glass of water instead of coffee. Like you’ve always heard, a healthy breakfast is a great way to start the day. Without it, the bad results can range from higher cholesterol, lower energy and overeating throughout the day.

Walk

Please choose your favourite spots (indoors and out) and make plans to walk them at least once a week. Walking is the ideal exercise for most people with arthritis. It burns calories, strengthens muscles and builds denser bones – all without jarring fragile joints.

Sit, Soak and Soothe

A warm bath before bed can relieve muscle tension, ease aching joints and help you get a good night’s sleep.

Treat Your Muscles

Find a remedial massage therapist and treat yourself to a good rub down. The benefits vary from person to person but may include decreased pain and stiffness associated with arthritis, increased circulation, energy and flexibility, eased muscle spasms, and improved body’s sleep and immune functions. Mentally, massage can also decrease stress and depression. Besides, it just feels good. Be sure to find a skilled massage therapist working with people with arthritis, as some massage elements may not be appropriate for you.

Stretch Your Legs

Stretching is a simple way to keep joints and muscles flexible. It relieves stress and can help enable you to maintain your daily activities. Try this to keep your calf muscles strong and flexible: Stand two feet from a wall, with your toes pointed inward, palms against the wall. Keeping your knees straight and feet flat, lean forward onto your hands without bending at the waist. Feel your calf muscles pull and extend. Hold this position for 10 seconds, then gently push away from the wall. Repeat.

Take the Plunge

Exercising in the water can build strength and increase motion range, while the water’s buoyancy reduces wear and tear on sore joints. Some many aquatic programs and exercises are great for people with arthritis. Try water walking, for example. Water provides 12 times with the air resistance, so you’re getting a great workout without the wear and tear on your joints.

Ice it!

When joints are hot and inflamed, applying something cold can decrease pain and swelling by constricting blood vessels and preventing fluids from leaking into surrounding tissues. Our favourite ice pack: a bag of frozen peas or corn that can be moulded to the shape of your body.

Quit Smoking

If only for a day, and then another … and another. Smoking can increase your risk of complications from lupus and rheumatoid arthritis. It can increase your risk of developing psoriasis and can predispose you to osteoporosis. Also, if you have to undergo joint surgery, smoking can prolong your recovery. Arthritis drugs can also be less effective for smokers and smoking can contribute to sleep problems.

Enjoy Your Exercise

Take the work out of working out. Sign up for a class that makes exercise fun – country line dancing, ballroom dancing, swimming, yoga or tai chi. Some have specific benefits for people with arthritis. Tai chi, for example, specifically reduces the pain and impairment for people with severe knee osteoarthritis. The slow, graceful exercise – originally a Chinese martial art – also reduces stress and can improve balance. Yoga strengthens and relaxes muscles stiff from arthritis, as well as helps with weight loss programs. For individual advice, we urge you to seek the opinion of your physiotherapist or trusted health professional.

Why Do Physiotherapists Prescribe You Exercises?

The prescription of exercise appropriate to you and your injury or fitness level is one of the many professional skills of a physiotherapist. Whether you have suffered an acute injury, chronic deconditioning or are recovering from surgery, the correct exercise prescription is essential. That's why your physiotherapist's knowledge and skills will personalise your exercise dose. Your physiotherapist not only is educated in injury diagnosis but also exercise physiology or the science of exercise. This training enables your physiotherapist to assess and diagnose your injury, plus also to prescribe injury, fitness or age-appropriate activities targeted to you now.

What Exercises Should You Do?

Your exercises shouldn't be painful. Please take caution with some overzealous exercise prescribers who believe that the more painful the activity, the better. Thus simply isn't true—notably, the frail, immunosuppressed, deconditioned or post-operative person. You'll find that your physiotherapist will thoroughly examine you and prescribe a series of exercises suitable for you in quantities that will not injure you further. Please seek an exercise expert, such as your physiotherapist, when you are planning your rehabilitation.

What Happens When You Stop Exercises?

Without some simple exercises, we know that specific muscles can become weak. When these supporting muscles are weak, your injured structures are inadequately supported and predispose you to linger symptoms or further injury. You can also over-activate adjacent muscles that may lead to further damage. It is also essential to understand that even if you are "in good shape", you may have crucial but weak localised or stability muscles. When you have an injury, you should perform specific exercises that specifically strengthen the muscles around your injury and the adjacent joints. Your physiotherapist will assess your muscle function and prescribe the right exercises specific to your needs. The exercises prescribed will usually be relatively simple, and do not require any special weights equipment, and can be performed safely at home.

Would You Stop Your Daily Prescription Drugs?

Your physiotherapist will prescribe your individualised dose or exercises. They are using their professional expertise to optimise your exercise dose. Would you just stop taking your regular blood pressure medication because you were too busy or didn't think it was working? We would hope not! Exercise, when prescribed by an expert such as your physiotherapist, should be treated as your recommended dose. Just like when you don't take your blood pressure medication, you can't expect the drugs to work if you don't take them as prescribed by your health professional. So, next time you skip your "exercise dose" just remember that you are not putting your health first. If you have any questions, please contact your Physio Works physiotherapist for your best care.