Exercise and osteoarthritis

There is evidence that aerobic exercise and resistance improved measures of self-reported disability, pain, and physical performance compared with health education in older adults with knee osteoarthritis. This evidence was derived from a randomized, single-blind, controlled trial with 18-month follow-up of 439 patients with confirmed knee OA (Fitness Arthritis and Seniors Trial (FAST)).

A systematic review revealed that both aerobic walking and home based quadriceps strengthening exercise reduce pain and disability from knee osteoarthritis but no difference between them was found on indirect comparison (2).

A systematic review concerning strength training for the knee revealed:

• resistance training improved muscle strength and self-reported measures of pain and physical function in over 50-75% of patients

Both high- and low-resistance strength training significantly improved clinical effects in this study. The effects of high-resistance (HR) strength training appear to be larger than those of low-resistance (LR) strength training for people with mild to moderate knee OA, although the differences between the HR and LR groups were not statistically significant in this study (4).

With respect to hip osteoarthritis, there is also evidence of the benefit of exercise in management of this condition (5).

Comparing high-dose exercise therapy versus low-dose exercise therapy in knee osteoarthritis (9):

• study results do not support the superiority of high-dose exercise over low-dose exercise for most outcomes. However, small benefits with high-dose exercise were found for knee function in sports and recreation and for quality of life

A retrospective cross-sectional study (n=2,607) found (10):

• lower odds of knee pain (OR 0.82, 95% CI 0.68-0.97), radiographic osteoarthritis (0.83, 0.70-0.99) and symptomatic osteoarthritis (0.77, 0.63-0.94) in those who participated in strength training at any time in their lives

Notes:

• NICE suggest that (6) exercise and manual therapy are core treatments for patients with osteoarthritis:
  • exercise should be a core treatment for people with osteoarthritis, irrespective of age, comorbidity, pain severity or disability. Exercise should include:
    • local muscle strengthening, and
    • general aerobic fitness
  • exercise has been found to be beneficial but the clinician needs to make a judgement in each case on how to effectively ensure patient participation. This will depend upon the patient's individual needs, circumstances, self-motivation and the availability of local facilities.
  • manipulation and stretching should be considered as an adjunct to core treatment, particularly for osteoarthritis of the hip
    
    
  • NICE advises general practitioners to (7):
    • aim for 30 minutes moderate activity on 5 days or more per week
    • general practitioners should use a validated scoring system to assess patient activity, they suggest the Department of Health General Practice Physical Activity Questionaire (GPPAQ score) (8)
    • tailor the needs to the individual patient (taking note of age, co-morbidity, pain severity and disability)
    • agree goals
    • follow up a patient's progress at 3 months and 6 months An exercise plan will be dependent on different factors including but not exclusively local facilities available, time, money, co-morbidities, age, social support and chronic disease impact on daily life

Contributors:

• Dr Alethea Beck, General Practitioner, Scottish Borders
• Dr Andrew Murray, General Practitioner, Sports and Exercise Medicine Registrar, Scotland

Reference:

• 1.Evidence-based Medicine 1997; 2(4): 108.
• 2. Roddy E et al. Aerobic walking or strengthening exercise for osteoarthritis of the knee? A systematic review. Ann Rheum Dis 2005;64: 544-8
• 3.Lange AK et al. Strength training for treatment of osteoarthritis of the knee: a systematic review. Arthritis Rheum. 2008 Oct 15;59(10):1488-94.
• 4. Jan MH et al. Investigation of clinical effects of high- and low-resistance training for patients with knee osteoarthritis: a randomized controlled trial. Phys Ther. 2008 Apr;88(4):427-36.
• 5. Tak E et al. The effects of an exercise program for older adults with osteoarthritis of the hip. J Rheumatol 2005;32:1106-13.
• 6. NICE (February 2014).Osteoarthritis The care and management of osteoarthritis in adults
• 7. NICE Pathway 2011, Encouraging people to be physically active, Brief Advice for Adults
• 8. General Practice Physical Activity Questionaire, Department of Health, 2006. (http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_063813.pdf)
• 9. Torstensen TA et al. High- Versus Low-Dose Exercise Therapy for Knee Osteoarthritis: A Randomized Controlled Multicenter Trial. Ann Intern Med. [Epub 24 January 2023]. doi:10.7326/M22-2348
• 10. Lo, G.H et al (2024), Strength Training Is Associated With Less Knee Osteoarthritis: Data From the Osteoarthritis Initiative. Arthritis Rheumatol.