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Osteoarthritis Exercise Treatment

Introduction

Osteoarthritis is a common cause of pain and disability in the aging population.   There are multiple approaches that osteoarthritis patients and doctors can use to alleviate pain and maximize functional abilities. One of these methods is exercise.   Patients with osteoarthritis might ask, how can exercise help me?   Won’t exercise make my arthritis worse?   These are valid questions and concerns and in fact at one time it was thought that rest was best.   However, many years of research and evidence-based medicine have increasingly demonstrated many benefits of exercise, including such benefits among patients with osteoarthritis. Accordingly, there has been a positive shift towards routinely including exercise as part of the comprehensive treatment of osteoarthritis.

What is Osteoarthritis and how does it cause pain and disability?

In order to appreciate how exercise can benefit you, it is important to understand a little bit about the disease process. There are multiple different types of arthritis, many of which are listed within this website. The most common type of arthritis is called osteoarthritis (OA, also called degenerative joint disease, or DJD). Osteoarthritis is the type of arthritis that affects us as we age, particularly with involvement of weight bearing joints such as the knees and hips.  Most commonly osteoarthritis is thought to be due to the loss of cartilage within the joint space.  Normally, cartilage acts as a cushion to protect joints from wear and tear, as well as absorb and transmit some of the forces we put through them in our everyday life.   With increased wear on the joints, this cartilage can break or become frayed so much that there are areas where there is little or no cartilage left at all.  When it becomes severe enough, the bones can come into contact with one another.  This process can result in many things including pain, a change in shape of the joint and extra bone formation.   All of these changes can affect the ability to perform normal physical activity.   This can set up a vicious cycle whereby pain leads to decreased activity, which leads to muscle weakness and a decrease in the normal motion of the joint, which further results in joint deformity and loss of function.  This cycle is depicted in figure 1.     Exercise, when done properly and tailored to your individual needs, is an excellent way to break this cycle, or perhaps to prevent or delay this cycle from occurring in the first place.  

Decreased Physical Activity

Changes in Joint

Pain

Muscle WeaknessLoss of Normal Function

Figure 1:  

Goals of Exercise

            Exercise can help to achieve a variety of goals in patients with osteoarthritis. Ultimately we want to reduce pain, improve function, and prevent disability, all with the ultimate goal of improving quality of life.  There are many ways that these goals can be achieved through exercise programs, and there are multiple goals for an appropriate exercise program, as discussed below.   

Muscle Strengthening

One of the ways to help achieve these goals is through muscle strengthening.  In general, appropriately strengthened muscles may help to minimize the adverse effects of weight bearing on the joints by reducing the amount of force that is transmitted across the affected joints. It has been shown that weak quadriceps muscles are common in people experiencing symptoms of osteoarthritis at the knee. In addition, studies have shown that when these patients strengthen their quadriceps muscles significant improvements in pain and function are seen when compared with those who did not strengthen these muscles.

Improving Flexibility and Joint Motion

Another goal of the exercise program is increasing flexibility and range of motion of the affected joints.  Often, when people do not use their muscles, not only do the muscles become weak, but they can also change shape and shorten to the point where they limit normal movement.  This abnormal muscle shape and length can also contribute to the visible joint deformities that result from severe arthritis. Flexibility exercises may begin with simply taking the joint through its normal range of motion on a frequent, regular basis. Additionally, overcoming tightness in muscles/tendons can be accomplished via prolonged, sustained stretching that specifically targets the muscles/tendons that were found to be restricted.

Improve Aerobic Functioning

Often, people with osteoarthritis limit their activities due to pain and range of motion restrictions. This can result in decreased cardiovascular fitness, with associated functional decline and adverse effects on overall health.  Thus, it is important that patients with osteoarthritis find ways to maintain cardiovascular fitness. By improving endurance, you may be able to regain functions that have been lost, and reengage in enjoyable activities that had been discontinued.  In addition to functional improvements, exercise has also been shown to decrease pain in osteoarthritis. For example, participating in aerobic exercises such as walking or cycling has been shown to decrease the pain related to arthritis.  

Weight Loss

In addition to the direct benefits exercise has on local tissues, it also has more far-reaching benefits throughout the patient as a whole. One such benefit is weight loss, which is particularly important in osteoarthritis patients who are overweight. Mechanically, for every 1 pound increase in weight across a joint, the force is increased by 2-3 pounds.  Thus, through weight loss, there is a decrease in forces across the joint. Weight reduction decreases the likelihood of developing osteoarthritis, as well as decreasing symptoms in patients who have osteoarthritis, particularly for those with involvement of weight-bearing joints. Weight-reduction also improves a patients exercise tolerance and aerobic abilities, with associated improvements in functional activities and improved sense of overall well being.  

Types of Exercise

            There are a variety of types of exercises available for patients with osteoarthritis, with no single program being the perfect match for all patients. The most effective programs are those that are designed to meet your individual needs.  Finding the right combination of aerobic exercise, muscle strengthening and flexibility is an important goal for you, your doctor, and your physical therapist.  Recognizing your limitations and any medical conditions that may be affected by an increase in physical activity, is important in arriving at the best exercise plan for you.   Therefore as always, it is best to check with your doctor before beginning any formal exercise program. If, after starting such a program, you find particular activities that significantly worsen your pain, then discontinue those exercises until consulting with your doctor, physical therapist, or trainer, to see if the activities or your technique can be appropriately modified.  

Aerobic

            Aerobic exercise strives to improve cardiovascular function through activities that will increase your heart rate.  Traditionally, this can be achieved via activities such as walking, jogging, biking, swimming and rowing, when these are done for an appropriate amount of time.   With any aerobic activity, one must remember to consider proper breathing techniques, adequate hydration and nutrition, and prior cardiovascular status.   Factors such as frequency of activity, duration of exercise, intensity can all be tailored to your personal needs and abilities.   On the whole, it is recommended that for benefits of aerobic exercise to be achieved, that you should aim to have 30 minutes of moderate activity most days of the week. Within that 30 minute time interval, there should be a warm up, a workout and a cool down.  In people who are sedentary, the first goal should be to minimize time spent sitting throughout the day.  There are simple ways to incorporate this into daily routines such as parking the car a little further away, taking the stairs instead of the elevator or taking many short walks throughout the day.  

Muscle Strengthening

There is more than one way to increase muscle strength and it is not limited to lifting free weights.  The use of weight machines and elastic therapy bands are additional ways to strengthen muscles.   There are a few methods in which a muscle can be strengthened depending on the way in which it is targeted.  

Strengthening exercises can be classified into three categories: isometric, isokinetic, and isotonic exercises.  Isometric exercises are those in which you are strengthening your muscles by contracting them and not moving them through their normal range which might be painful if you have arthritis.  An example of this is simply contracting your leg muscles, without moving your joints.  Isometric exercises are often the best type of exercise to begin with in a strengthening program, particularly in patients who can not tolerate repetitive joint motion. A problem with isometric exercises is that they tend to raise the blood pressure more than others.  Remember to always check with your physician before starting any new exercise regimen.  Isotonic exercises are those in which you contract your muscle throughout the full range of motion, again using constant weight or resistance, such as performing a biceps curl while holding a dumbbell.  Lastly, isokinetic exercises involve constant speed of motion throughout the joint range during muscle contraction, while the amount of resistance may vary throughout the range. Isokinetic exercises are infrequently used, due to equipment requirements and uncertain correlation to functional activities.

When beginning resistance training, it is good to start with just a single set of up to 15 repetitions, done 2 days a week.   It should incorporate exercises that target major muscle groups such as quadriceps, hamstrings, and gluteal muscles.  One possible goal is to complete 2 sets of 10 repetitions before resistance is increased.  For people who have restrictions in their ability to execute full range of motion, it is better to use lighter and easier weights with additional repetitions.  For patients in which putting the joint through repetitive range of motion aggravates their pain, it is best to start with isometric exercises.  A word of caution in patients with a history of heart problems; isometric exercises may not be the best type of strengthening for you and, therefore, it is best to discuss this with your doctor before implementing such an exercise plan.

            Here are some examples of exercises specifically for the legs good for those with osteoarthritis of the knee and or hips.  

Table 1.1:  Strengthening Exercises for Knee and Hip

Quadriceps

1)  Quad sets:   while in a seated position, with legs fully extended in front of you, make a muscle with your thighs trying to push the back of your knee down towards the floor.  Hold for 10 seconds, relax and then repeat.

2)  Wall slide:  place your back up against the wall with your hips and knees bent to a 90 degree angle as if you were sitting in a chair.  Hold this position for 10 seconds, then come up and relax.  Repeat.

3)  Isotonic Quad exercise:  sitting in a chair with your feet planted flat on the floor, raise your right leg straight out in front of you. Relax and bring back to the floor.  Repeat on the left.   As you are able to you can add ankle weights to increase resistance.

Hamstrings

1)       Isometric: while lying on the floor place heels on surface such as a couch or an exercise ball.   Press down using the backs of your thighs and hold contraction for 10 seconds.  Relax and then repeat.

2)       Isotonic:  lying on your belly with a pillow under your abdomen to support your back, bend your knee and bring your foot back towards your buttock.  Bring back down to the floor repeat on the other side.

Gluteal Muscles

1)  Isometric:  Lying down on a flat surface back flat on the floor, bend your knees so that your feet are flat on the floor.  Raise your buttocks up off the ground contracting your butt muscles together.  Hold for 10 seconds then relax.

Calf muscles (gastrocnemius)

1)  Using a wall or chair for balance, go up on your toes using your calf muscles hold yourself.  Contract for 10 seconds, relax and repeat.

Flexibility Training.

            Everyone has probably heard at least once in their life the importance of stretching before physical activity.  In people with osteoarthritis, improving flexibility has an even greater benefit than simply providing a warm up before exercise.  There are a few different types of stretching exercises; static, ballistic and something called proprioceptive neuromuscular facilitation (PNF).  Static stretching is what most people are familiar with and most often recommended by doctors.  It involves stretching the muscle slowly and holding it in that position for 10 to 30 seconds.  The key is that it should be pain free without any abrupt, jerky, or bouncing movements.  (Ballistic, jerky, bouncing approaches to stretching have no position to hold, and are generally not recommended, due to potential for injury and exacerbation of the underlying arthritis.) Lastly proprioceptive neuromuscular facilitation is a technique used by physical therapists in which muscle contractions are utilized in order to achieve a reflexive relaxation.

            There are other methods of improving flexibility that involve whole body training and working with breathing exercises.  Activities such as tai chi and yoga are excellent ways to improve your flexibility with the added benefit of a total body workout and relaxation.  Here are a few examples of stretching exercises.

Table 2.1:  Stretching Exercises for the Knee and Hip

Hamstring Stretch:  while seated with legs straight out in front of you, drop your chin to your chest and reach your hands towards your toes.   Start by reaching for your knees, then shin bones, ankles and if you can to your toes.  Go slow and try to incorporate your breathing to reach a little further.    Never stretch to the point of pain, only to when you feel a tug or tightness in your muscles.  Hold for 10 seconds, relax and repeat.  If this is too difficult, it can be modified by doing one leg at a time.

Quadriceps Stretch:  using a chair or a wall to steady yourself, bend your knee to bring your foot to your buttocks and hold with your hand.  You should feel the stretch in the front of your thigh.  Try and keep your knee close to your other knee and try to stand up straight without leaning forward or backward.  Hold for 10 seconds, relax and repeat on other side.

Calf stretch: using a wall, place both hands on the wall in front of you.  Step backwards on your right foot and push your heel down towards the floor.   You should feel this in the back of your calf and into your heel.  Hold for 10 seconds relax and then repeat on the other side.

Hip Stretch: Modified lunge.  Use a pillow under your knee to protect it.  Kneeling on the floor, place one foot out in front of you, foot planted on the floor.  Lean forward to feel a stretch in your other hip.  Do not allow your knee to go over your ankle.   Hold for 10 seconds, relax and repeat on other side.

Gluteal Stretch:  Sitting on a flat surface with feet stretched out in front of you, cross one leg over the other while bending at the knee.  Wrap your arms around that leg and hug your leg in towards your chest.  You should feel this one in your buttock area. Hold for 10 seconds, relax, and repeat on other side.

Physical Therapy

            Your doctor might decide that a formal physical therapy program would be most beneficial in the treatment of your arthritis.  Physical therapy is a branch of rehabilitative health that uses specially designed exercises and equipment to help patients regain or improve their physical abilities.  Therapists can design an individualized program that emphasizes active and passive range of motion exercise, muscle strengthening, and joint protection principles.  In addition, modalities such as ultrasound, massage, heat/ice, and electrical stimulation are available for use if needed.

General Considerations

            There are a few things to consider when coming up with an exercise plan.   You can alter your workout by changing the intensity, such that you can have either a high intensity or a low intensity workout.  If you normally exercise on land, you can try doing your workouts in the water, where the buoyancy effect of the water results in decreased weight bearing onto joints.  There are even special pools that are a higher temperature than normal specifically for the treatment of arthritis to aid in movement. Remember that there is a balance between the benefits of weight-bearing activities and nonweight-bearing activities. Weightbearing is beneficial for preventing osteoporosis and helping joint cartilage to acquire nutrition from joint fluid. The potential disadvantages of weight-bearing exercises include additional stress over the effected joint, which might increase pain and/or inflammation.  There are a variety of exercises available, including weightbearing and those which are just minimally weight bearing.  Weight-bearing activities would include walking, jogging, etc. Examples of minimal weight bearing exercises include the stationary bike, swimming and rowing.  

The following is a table summarizing the guidelines for the role of exercise in the treatment of osteoarthritis of the knee and hip.  These guidelines were formulated after careful evaluation of the many research studies published regarding exercise and arthritis.

Table 3.1: Summary of Guidelines for the Use of Exercise to treat arthritis of the knee and hip.

Both strengthening and aerobic exercise can reduce pain and improve function as well as health status.

There are few contraindications to participating in strengthening or aerobic exercise.

Participating in both general (aerobic fitness training) and local (strengthening) exercises is an essential, core aspect to treatment of all patients.

Exercise therapy should be individualized and patient centered taking into account factors such as your age, your medical conditions and overall impairment.

Exercise programs should include advice and education from your doctor or therapist to promote a positive lifestyle change with an increase in physical activity.

Group exercise and home exercise are equally effective and your preference should be considered.

Adherence is the main predictor of long term outcome from exercise

Strategies to improve and maintain adherence should be adopted, such as involving your spouse or friends in exercise

The effectiveness of exercise is not related to the presence or severity of findings on X-ray

Improvements in muscle strength and position sense gained from exercise programs may decrease the progression of your arthritis.

Adapted from Roddy E, Zhang W, Doherty, M, Arden NK, Barlow J, Birrell F, Carr A, Et. Al. Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee- the MOVE consensus. Rheumatology 2005;  44 67-73.

Conclusions

            Exercise therapy is an important component within the comprehensive treatment of patients with osteoarthritis. When properly prescribed, exercise can be a safe and effective method of relieving pain, enhancing function and ultimately improving the patient's overall sense of well-being and quality of life.  The exercise program should be tailored for the specific patient, since there is not a single exercise plan that is recommended for all patients with arthritis.   An exercise plan should focus on strength training, improving flexibility and recovering range of motion.   By working closely with your doctor you can determine which exercise plan will work for you, based on your individual needs and preferences.   It is imperative to stress the importance of seeing your doctor before starting or substantially modifying a formal exercise program, since creating a safe and effective exercise program requires considering factors such as general medical conditions, your current level of functioning, as well as the type and severity of arthritis in a given patient.

Special thanks to Dr. Patrick Foye and Dr. Todd Stitik for their time, guidance and the contribution of their knowledge and expertise to this article.

Author:   Janel Solano, BA, New York College of Osteopathic Medicine of the New York Institute of Technology, Old Westbury, NY

    Patrick M. Foye, M.D., Assistant Professor of Physical Medicine and
Rehabilitation, UMDNJ: New Jersey Medical School, Newark.  Co-Director, Osteoarthritis clinic, University Hospital, Newark, NJ

             Todd P. Stitik, M.D., Associate Professor of Physical Medicine and
Rehabilitation, UMDNJ: New Jersey Medical School, Newark.  Co-Director, Osteoarthritis clinic, University Hospital, Newark, NJ

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