Exercises in Osteoarthritis

Author- Pankaj N, CSCS and INFS Faculty

Introduction to Osteoarthritis

Osteoarthritis (O.A.) is a common joint condition affecting older people, approximately 10% to 20% of people ≥60 years old worldwide. It is a painful and debilitating joint disease and is a leading cause of disability. As the pain becomes chronic, it may occur at rest and during the night. In addition, the joint feels 'stiff,' resulting in typical pain and difficulty when an individual initiates movement after a period of rest.

Individuals with advanced disease may experience crepitus or deep 'creaking' sounds on movement and often a limited range of joint motion. Further, patients experience other impairments like a decreased range of motion, muscle atrophy, loss of muscle strength, loss of joint stability, difficulty performing activities of daily living, and diminished quality of life.

Ultimately, chronic O.A. involving lower limb joints leads to reduced physical fitness with resultant increased risk of cardiometabolic co-morbidity and early mortality. At present, the cure for O.A. is unknown. However, physical exercise effectively manages disease-related problems, such as impaired muscle function and reduced fitness.

International guidelines recommend exercise as a core non-pharmacological therapy since it improves the general well-being while being relatively safe compared with pharmacological treatments.

In addition, recent systematic reviews show that combinations of strength, flexibility, and aerobic exercises, are more beneficial for pain management and disability than general activity (e.g., walking). Thus, exercise for osteoarthritis should aim to improve muscle strength, joint range of motion, and aerobic fitness. Among people with knee O.A., improving muscle strength is one of the main aims of exercise, given that weakness is common. Strength training of sufficient stimulus can address muscle weakness by improving muscle mass and recruitment.

A systematic review conducted by Cochrane wanted to determine whether land-based exercise benefits people with knee osteoarthritis, reduces joint pain, or improves physical function and quality of life. The review included 54 randomized or quasi-randomized controlled trial studies. The studies compared groups given some form of land-based therapeutic exercise versus a non-exercise group. The participants included both male and female adults with an established diagnosis of knee O.A. according to accepted criteria or self-reported knee O.A. based on chronic joint pain (with or without radiographic confirmation). The intervention group received some land-based exercise regimens to relieve the symptoms, regardless of content, duration, frequency, or intensity. The control group was either given any non-exercise intervention or no intervention at all. The outcome measures of all the studies involved assessing knee pain, self-reported physical function, and quality of life (QOL). The study evaluated these outcomes at three-time points:

1. Immediately at the end of treatment (post-treatment.)
2. Two to six months after cessation of monitored study treatment.
3. Longer than six months after ending the monitored study treatment.

The delivery mode of the exercise therapy varied between one-on-one programs, class programs, and home programs. Many home programs incorporate home visits by a trained nurse or a community physiotherapist. Exercises ranged from a simple seated knee extension using leg weight only to straightforward exercises (e.g., straightening knee over a rolled towel). Later, they progressed to functional movements after several months. One of the studies used squat exercises alone to strengthen multiple lower limb muscles. Another study used numerous sitting and standing exercises with bodyweight only. Other studies, although often used a combination of exercise equipment, mainly elastic resistance bands, free weights, or resistance machines.

Finally, several studies employed complex programs, including manual therapy, upper limb, and truncal muscle strengthening, and balance coordination, in addition to lower limb muscle strengthening. Aerobic walking or cycling programs were the focus of some studies. In addition, five studies evaluated Tai Chi classes, and one study used Baduanjin exercises.

Treatment 'dosage' (duration, frequency, intensity) varied widely between studies, along with delivery mode and content. Monitored treatment sessions, presented in individual or class-based format, ranged from 20 to 60ls minutes. In most studies, exercise frequency for monitored classes or individual clinic sessions was two to three times per week; however, frequency varied between once per week and five times per week. The total number of monitored exercise sessions provided ranged from none to 72. The entire treatment duration for monitored classes or individual clinic sessions ranged from one month to six months—two studies prescribed home programs for up to two years.

Intensity achieved during strength training using free or limb weights or Theraband was commonly a 10-repetition maximum (10RM) with varying sets or at least moderate. One study conducted strength exercises at least 60% maximum heart rate (HRmax); this progressed to the highest tolerable intensity. Muscle strength training using a variety of resistance machines was generally very well quantified and ranged from 50% 1RM through 60% to 80% 1RM to maximum effort at various isokinetic speeds. Aerobic exercise intensity, achieved via walking programs, ranged from low to moderate (50% to 70% heart rate reserve (HRR) or 60% to 80% HRmax). One study used moderate-intensity (70% HRmax) stationary cycling. Another few studies used moderate-intensity walking (40% to 60% HRmax or 50% to 85% HRR) or cycling (50% to 60% HRmax) and resistance training in the same session.

Conclusion

High-quality evidence shows that among people with knee osteoarthritis, exercise moderately reduced pain immediately after cessation of treatment and improved quality of life only slightly, without an increase in dropouts. The magnitude of the treatment effect would be considered moderate (immediate) to small (two to six months) but comparable with estimates reported for non-steroidal anti-inflammatory drugs. Moderate-quality evidence indicates that exercise moderately improved physical function immediately after cessation of treatment.

References

1. Pereira, D., Peleteiro, B., Araujo, J., Branco, J., Santos, R.A. and Ramos, E., 2011. The effect of osteoarthritis definition on prevalence and incidence estimates: a systematic review. Osteoarthritis and cartilage, 19 (11), pp.1270-1285.
2. Villafane, J.H., Valdes, K., Berjano, P. and Wajon, A., 2015. Clinical update: conservative management of carpometacarpal joint osteoarthritis. The Journal of Rheumatology, 42 (9), pp.1728-1729.
3. Fransen, M., McConnell, S., Harmer, A.R., Van der Esch, M., Simic, M. and Bennell, K.L., 2015. Exercise for osteoarthritis of the knee: a Cochrane systematic review. British journal of sports medicine, 49 (24), pp.1554-1557.
4. Nielen, M.M., van Sijl, A.M., Peters, M.J., Verheij, R.A., Schellevis, F.G. and Nurmohamed, M.T., 2012. Cardiovascular disease prevalence in patients with inflammatory arthritis, diabetes mellitus and osteoarthritis: a cross-sectional study in primary care. BMC musculoskeletal disorders, 13 (1), pp.1-5.
5. Nelson, A.E., Allen, K.D., Golightly, Y.M., Goode, A.P. and Jordan, J.M., 2014, June. A systematic review of recommendations and guidelines for the management of osteoarthritis: the chronic osteoarthritis management initiative of the US bone and joint initiative. In Seminars in arthritis and rheumatism (Vol. 43, No. 6, pp. 701-712). WB Saunders.
6. Dekker, J. ed., 2013. Exercise and physical functioning in osteoarthritis: medical, neuromuscular and behavioral perspectives. Springer Science & Business Media. ****