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Physical activity and exercise therapy benefit.pdf




Osteoarthritis (OA) of the hip and knee is among the leading causes of global disability, highlighting the need for early, targeted, and effective treatment. The benefits of exercise therapy in people with hip and knee OA are substantial and supported by high-quality evidence, underlining that it should be part of first-line treatment in clinical practice. Furthermore, unlike other treatments for OA, such as analgesia and surgery, exercise therapy is not associated with risk of serious harm. Helping people with OA become more physically active, along with structured exercise therapy targeting symptoms and impairments, is crucial, considering that the majority of people with hip and knee OA do not meet physical activity recommendations. Osteoarthritis is associated with a range of chronic comorbidities, including type 2 diabetes, cardiovascular disease, and dementia, all of which are associated with chronic low-grade inflammation. Physical activity and exercise therapy not only improve symptoms and impairments of OA, but are also effective in preventing at least 35 chronic conditions and treating at least 26 chronic conditions, with one of the potential working mechanisms being exercise-induced anti-inflammatory effects. Patient education may be crucial to ensure long-term adherence and sustained positive effects on symptoms, impairments, physical activity levels, and comorbidities. J Orthop Sports Phys Ther 2018;48(6):439–447. Epub 18 Apr 2018. doi:10.2519/jospt.2018.7877


Osteoarthritis (OA) is among the leading causes of global disability, with the hip and knee contributing most to the burden. Knee OA alone is estimated to affect approximately 250 million people worldwide. Importantly, most people with OA are of working age, with more than half being younger than 65 years of age, and the prevalence of OA is expected to continue its dramatic increase in the future. Furthermore, OA is a significant barrier to physical activity, due to activity-related pain associated with the disease. Physical inactivity is an underappreciated causal factor of most chronic diseases, including OA, type 2 diabetes, cardiovascular disease (CVD), some types of cancer, and dementia. Therefore, an evidence-based approach is greatly needed to address the future burden and associated costs of not only symptoms and impairments in OA, but also physical inactivity.

We Have a Solution: It's Not a Tablet, Injection, or Surgery

Exercise therapy is a safe and effective solution for managing both OA and a range of other chronic conditions that does not require potentially harmful and costly pharmacotherapy, injections, or surgery. Substantial evidence supports the effects of exercise therapy in the treatment of at least 26 chronic conditions including hip and knee OA


This clinical commentary presents the evidence for exercise therapy as an effective treatment for OA and suggests broad guidance on how to apply this evidence in clinical practice. Subsequently, it highlights the importance of promoting physical activity alongside structured exercise therapy and presents other health benefits that individuals with OA may experience from adequately designed and implemented exercise therapy programs. Finally, it discusses the importance of patient education to long-term adherence and benefits.


Exercise Therapy in OA


Exercise therapy is a specific type of physical activity designed and prescribed for specific therapeutic goals. Compelling evidence from more than 50 randomized controlled trials (RCTs) in knee OA and 10 RCTs in hip OA supports the efficacy of land-based exercise therapy in reducing symptoms and impairments. Compared to the 2 most common pharmacological pain relievers, exercise therapy seems to be at least as effective as nonsteroidal anti-inflammatory drugs and 2 to 3 times more effective than acetaminophen (paracetamol) in reducing pain in knee OA. Like analgesic medication, exercise therapy needs to be taken at a sufficient dose and duration to be effective and ensure optimal and clinically relevant effects on symptoms and impairments (see the TABLE for key exercise therapy recommendations). Importantly, the pain-relieving effect of exercise therapy and other nonsurgical treatments is similar, regardless of knee OA severity, as evaluated by radiography, and pain intensity at baseline However, exercise therapy is not associated with the same risk of adverse events as nonsteroidal anti-inflammatory drugs and acetaminophen.


TABLE Seven Exercise Therapy Recommendations for Hip and Knee Osteoarthritis

1 Provide aerobic, resistance, performance, or neuromuscular exercises tailored and targeted to individual patient needs and preferences

2 Consider aquatic exercise in patients who are unable to adequately complete land-based exercise due to pain

3 Provide a minimum of 12 supervised exercise sessions of 30 to 60 minutes per session over a 6-week period (ie, 2 sessions per week)

4 Encourage an additional 1 to 2 sessions per week to optimize outcomes, particularly related to strength

5 Consider extending initial exercise therapy programs to 12 weeks or longer to optimize outcomes, particularly related to strength

6 Include patient education and consider booster sessions in the long term to enhance adherence and progression

7 Provide education and reassurance about managing potential pain flares and inflammation, and how to modify exercises and physical activity to ensure continued participation

See attached pdf for more detail


Physical Activity and Inactivity in OA

Current physical activity guidelines recommend at least 150 minutes of moderate or 75 minutes of vigorous physical activity, in bouts of at least 10 minutes' duration, per week. Helping people with OA become more physically active, along with participating in structured exercise therapy, is crucial, as the majority of people with hip and knee OA do not meet physical activity guidelines, and are less active than their age-matched counterparts. Importantly, physical inactivity in people with OA also increases their risk of a number of comorbidities and functional decline, leading to higher health care costs. As walking 150 minutes per week might not be tolerable for individuals with end-stage knee OA, other types of physical activity, such as biking and walking with Nordic poles (walking poles specifically designed to be used to support a total-body version of walking), might be preferable for this subgroup. Notably, fewer steps than the recommended 10 000 steps per day might be sufficient, as a recent study found that walking more than 6 000 steps per day protected against developing functional impairments in people with or at risk of knee OA.


Reduced physical activity levels in people with knee OA may be a key factor driving greater body mass index (BMI) in this group of people. Highlighting a likely vicious cycle, risk of knee OA is also reported to increase exponentially with increasing BMI. Importantly for people with knee OA, a 5% reduction in weight leads to moderate to large improvements in functional impairments, and there is a dose-response relationship between percentage of weight loss and symptomatic improvement. Although addressing dietary factors is a key component to achieving weight reduction, increasing physical activity levels will also assist. The relationship of hip OA with greater BMI is less clear, but may still be important in some individuals.


Choice of intervention to improve symptoms and impairments may be the key to improving physical activity levels. Patient education and exercise therapy, including aerobic exercise, can have moderate positive effects on both symptoms and impairments, even in people on a surgical wait list for joint replacement. Physical activity, including exercise therapy, can also improve gait speed and lower-limb function, factors thought to be important to increasing physical activity levels. However, while evidence suggests that there are small long-term improvements in physical activity levels following physical activity interventions in OA, a lack of consensus on methodology and outcome reporting severely hampers the conclusions that can be drawn on the effects on physical activity levels. In severe hip and knee OA, total joint replacement is considered a cost-effective intervention to reduce symptoms and impairments. However, some studies have reported only small increases in physical activity levels post surgery, despite large improvements in symptoms and impairments. These findings highlight a possible need to promote and guide increases to physical activity levels following joint replacement surgery. Clearly, implementing exercise therapy and promoting physical activity in the management of people with hip and knee OA are vital to improving their physical activity levels and the broader health benefits this will lead to; however, more work is needed to support this notion.


The Importance of Physical Activity and Exercise Therapy to Overall Health

Physical activity represents a cornerstone in the primary prevention of at least 35 chronic conditions, and exercise therapy is considered first-line treatment in many chronic conditions. Physical inactivity is regarded both as a cause and a consequence of OA and is associated with a number of diseases, such as CVD, type 2 diabetes, and dementia. Two out of 3 people with OA have comorbidities, including CVD, type 2 diabetes, and mental health conditions,and people with hip and knee OA are at higher risk of all-cause mortality compared with the general population. The association of OA with CVD and dementia is particularly pronounced. The benefits of physical activity and exercise therapy to people with hip and knee OA are, therefore, not limited to addressing symptoms and impairments, but can also decrease the risk and impact of comorbidities.


Recommendations for the implementation of exercise therapy are hard to dispute in light of strong supporting evidence, reduced potential harms compared with other common OA treatments such as analgesia and surgery, and its beneficial effects on overall health. With the growing international burden of OA, embracing exercise therapy and promoting physical activity as first-line treatments offered to all people with hip and knee OA are essential. This clinical commentary provides a clear “call to action” for exercise therapy in hip and knee OA, along with key exercise therapy recommendations based on current evidence to help reduce future burden and costs.

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