Physical Activity and Exercise Therapy Benefit More Than Just Symptoms and Impairments in People With Hip and Knee Osteoarthritis
AUTHORS Søren T. Skou, PT, PhD, Bente Klarlund Pedersen, MD, DMSc, J. Haxby Abbott, DPT, PhD, FNZCP, Brooke Patterson, PT, Christian Barton, PT, PhD
Synopsis 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.20 Knee OA alone is estimated to affect approximately 250 million people worldwide.88 Importantly, most people with OA are of working age, with more than half being younger than 65 years of age,24 and the prevalence of OA is expected to continue its dramatic increase in the future.20 Furthermore, OA is a significant barrier to physical activity, due to activity-related pain associated with the disease.25 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.17 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,64 including hip and knee OA.33,34 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.59 Compelling evidence from more than 50 randomized controlled trials (RCTs) in knee OA33 and 10 RCTs in hip OA34 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 drugs8,33 and 2 to 3 times more effective than acetaminophen (paracetamol) in reducing pain in knee OA.8 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 radiography48,75 and pain intensity at baseline.48 However, exercise therapy66 is not associated with the same risk of adverse events as nonsteroidal anti-inflammatory drugs and acetaminophen.8