DOES PHYSICAL EXERCISE HELP PATIENTS WITH OSTEOARTHRITIS?

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Osteoarthritis (OA) is a disease of the joints and is the most common joint disease in the world. OA is a chronic multifactorial disease that compromises joint components. This impairment generates joint stiffness, deformities, pain, and functional reduction.

Previously, OA was thought to be solely caused by cartilage thinning. Currently, it is known that it is a disease of the entire joint. With the loss of cartilage, the bone grows to repair the damage. However, the usually abnormal bone growth increases the joint’s impairment, with pain and instability of the joint itself.

OA affects both men and women and is one of the biggest causes of disability in people as they age.

Some estimates indicate that, in Brazil, OA affects around 6–12% of adults and more than a third of the elderly. Some international data reveal that knee OA is the main cause of disability for people over 50 years of age.

This joint disease initially presents itself as a result of wear and tear on the articular cartilage and continues with a chronic evolution with degenerative aspects, with pain, morning stiffness, muscle atrophy, and bone crepitation. The radiological aspects of the compromised joint allow confirmation of the diagnosis.

It is worth mentioning that it is a very common condition and is diagnosed in around 44% and 70% of individuals over 50 years of age; and in the age group over 75 years old, 85% of individuals are affected. OA is one of the main causes of medical consultations and is responsible for an exorbitant number of absenteeism and disability retirements.

Typically, the onset of OA development is between 50 and 60 years of age. Some data indicate that around 12% of the population over 65 years of age have symptomatic OA, with complaints of pain, mainly in the morning, in one or more joints of the body.

Given the broad clinical picture of the disease, several forms of intervention have been suggested, such as medication, surgery, physiotherapy, and physical exercise

And how can physical exercise help with OA?

In the past, immobility was the prescription for patients with OA.

Today, it is known that physical exercise improves or maintains muscle strength, physical fitness, and general health. Generally speaking, people exercise for a variety of reasons, either to lose weight or to strengthen muscles, and here we can include relieving the symptoms of osteoarthritis.

Muscle weakness has been associated with functional impairment and loss of strength in the periarticular region can result in instability and abnormal stress on the joint. There is accumulating and suggestive evidence that muscle strengthening can reduce the progression of the disease.

Well, we all know that regular exercise is important for overall health.

But for patients with joint pain, exercise may be the last thing they want to do. Although exercise is a mainstay of arthritis treatment, nearly one-third of arthritis patients are inactive.

What are the benefits of exercise in osteoarthritis?

According to two Cochrane reviews, there is high-quality evidence that exercise can help reduce pain as well as improve physical function in hip and knee OA. Some data indicate that physical activity can reduce pain and improve function by about 40% in adults with arthritis.

Exercise also plays an important role in preventing disability, by improving the range of joint movement and maintaining the muscle mass supporting the joints.

One study, involving approximately 1,200 patients with knee OA, compared two groups of patients, those who walked with those who did not walk. In the group of those who walked, there was a reduction in knee pain and a 20% less likelihood of worsening joint space narrowing.

There is no doubt that patients with OA have other chronic diseases, such as cardiovascular disease and diabetes, and, in these cases, the benefits of physical exercise are already well known.

On the other hand, rates of depression and anxiety are often higher in people with OA than in the general population. The benefits of exercise for this group of diseases are also well known.

So, there are many reasons for OA patients to “move”.

Is there an ideal amount of exercise for OA patients?

First of all, it is worth noting the words of Dr. Kelli Allen, in a presentation at the Annual Meeting of the American College of Rheumatology (San Diego, 2023), when she commented on the research that indicated that “some exercise is better than none”. The researcher added that current guideline recommendations for adults to get 150 minutes of moderate physical activity per week may not be feasible for patients with chronic pain.

It is true, however, that the suggestions of a study, with a large number of adults with lower limb joint complaints, are that around 1 hour of physical activity per week could keep participants free from disability for 4 years.

How many steps can bring health benefits?

A commonly suggested goal is 10,000 steps per day. But fewer steps per day also bring health benefits.

There is a study including approximately 1,800 patients with knee OA that brought very interesting data. Walking 6,000 steps per day was an important milestone in determining the risk of developing functional limitations.

This study made another contribution. An additional 1,000 steps per day was associated with a 16% to 18% reduction in the risk of developing functional limitations over the next 2 years. And yet, there appear to be additional benefits from adding successive and subsequent 1,000 steps.

According to Dr. Allen, the helpful message is to encourage people with chronic pain. “If we can get to 6,000 steps a day, that might be a good goal.”

When interviewed about this topic, Dr. Grace H. Lo (Baylor College of Medicine, Houston, Texas) commented that “taking a 20-minute walk three times a week can be a good starting point.” For those who do not do any activity, she recommends a more cautious start, that is, little by little. She also highlights the importance of maintaining the frequency of daily physical activity.

Many people ask: What types of exercise are most beneficial for those with OA?

No one type of exercise is the best for OA. The patient must choose the one that best suits him. Dr. Allen added that the best exercise is “anything someone is going to do.”

These are also the words of Dr. Una Markis (North Texas VA Health Care System, Dallas, Texas) “It’s not clear to me that one type of exercise is better than another. This has more to do with what the patient likes and how we can make this a routine so that it is a sustainable behavior.” She added that “generally, lower impact exercises like cycling, walking or swimming tend to be better for OA.” This researcher recently conducted studies on gardening as a type of exercise for OA and concluded that “it’s a great way to encourage people to exercise.” Lots of positives to gardening. Dr. Markis commented that “in addition to physical activity, patients can also be outdoors. And gardening also has many benefits for mental health.”

What features are available?

There are many evidence-based exercise programs available that have been shown to improve arthritis symptoms. Talk to your doctor and seek the best advice for you. As the program is online, it may be difficult for those who are not comfortable with these means of access. But if you can enlist the help of a family member or friend you may benefit from these exercise programs.

Dr Markis concluded that there is no one-size-fits-all approach. She commented that she tries to identify what is most important for each patient as a starting point. This researcher tries to identify something in each patient’s daily life, in particular, and link a goal based on physical activity to that.

Dr. Lo commented that understanding a patient’s lifestyle is also crucial when discussing physical activity. “You need to give them practical solutions that they can incorporate into their lives,” she said.

The review by Duarte and colleagues, which involved the evaluation of several studies, confirmed the effectiveness of using exercises in improving symptoms resulting from osteoarthritis, however, it brings information that there is no consensus regarding application parameters, such as intensity and duration of each type of exercise. Verification of the selected and evaluated articles indicated that physical exercise is an effective method of therapeutic intervention in the treatment of osteoarthritis, reducing pain and increasing mobility.

However, the study conducted in four centers in Sweden and Norway (with the inclusion of 189 patients with knee osteoarthritis) deserves special attention.

Participants were randomly selected to practice low-intensity/short-duration or high-intensity/long-duration exercise, three times a week, for 12 weeks, under the supervision of a physiotherapist.

The low-intensity/short-duration program consisted of performing five exercises (ergometric bike, squats, climbs, descents, and knee extensions) for 20 to 30 minutes. Participants in the high-intensity/long-duration group performed 11 exercises in each session for 70 to 90 minutes.

“Patients in both groups improved significantly over time, but high-intensity/long-duration exercise was not superior to low-intensity/short-duration exercise in most comparisons,” according to the Swedish research team.

An important point of this study: is treatment adherence. Adherence was “almost perfect” in the low-intensity/short-duration group and slightly lower in the high-intensity/long-duration group, according to the researchers. Dr. Kim Bennell (University of Melbourne, Australia) also comments that, although all clinical management guidelines for knee osteoarthritis recommend physical exercise, “we don’t know the ideal dose”.

The ideal dose involves the frequency per week, the number of exercises, sets, and repetitions, and the intensity and duration of the exercise sessions.

However the results of this study suggest that a shorter program with fewer exercises may still provide benefits, and it may be easier for patients to start and continue exercising than with a program that requires more time and effort. The researchers concluded that “low-intensity, short-duration exercise is feasible in the treatment of knee osteoarthritis.”

Certainly, patients with OA must receive personalized guidance to obtain better results and their doctors are the professionals who can best recommend the appropriate treatment.

Anyway, move! Seek guidance from your doctor!

References

• DUARTE VS et al — Fisioter Mov. 2013 jan/mar; 26(1):193–202
• SILVA NCOV et al — Acta Fisiatr. 2014; 21(3):141–146
• TORSTENSEN TA et al — Ann Intern Med, February 2023
• REMALY J — Medscape February 3, 2023
• HICKS L — Medscape Medical News, February 14, 2024
• FRANSEN M et al — Cochrane Database of Syst Reviews 2014, Issue 4.
• ANDRADE MAS — Medium.com Jun 2, 2022