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Exercise in osteoarthritis: Moving from prescription to adherence

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Abstract

Exercise is recommended for the management of osteoarthritis (OA) in all clinical guidelines irrespective of disease severity, pain levels, and functional status. For knee OA, evidence supports the benefits of various types of exercise for improving pain and function in the short term. However, there is much less research investigating the effects of exercise in patients with OA at other joints such as the hip and hand. It is important to note that while the magnitude of exercise benefits may be considered small to moderate, these effects are comparable to reported estimates for simple analgesics and oral nonsteroidal anti-inflammatory drugs for OA pain but exercise has much fewer side effects. Exercise prescription should be individualized based on assessment findings and be patient centered involving shared decision making between the patient and clinician. Given that patient adherence to exercise declines over time, appropriate attention should be pain as reduced adherence attenuates the benefits of exercise. Given this, barriers and facilitators to exercise should be identified and strategies to maximize long-term adherence to exercise implemented.

Introduction

Osteoarthritis (OA) is a chronic joint disease commonly affecting the joints of the knee, hip, and hand. People with OA report pain, difficulty performing activities of daily living, sleep problems, and fatigue. They present with a range of physical impairments including joint stiffness, muscle weakness, altered proprioception, reduced balance, and gait abnormalities. In addition to these, psychological impairments such as depression and anxiety are common.

Exercise is an integral component of conservative management for OA and is universally recommended by clinical guidelines [1], [2], [3], [4], [5], irrespective of patient age, joint involved, radiographic disease severity, pain intensity, functional levels, and comorbidities. Exercise prescription should be individualized based on assessment findings and be patient centered involving shared decision making between the patient and clinician. This chapter reviews the role of exercise in the management of OA. OA in general is covered, but knee OA is a primary focus given that this is the most common lower limb joint affected and that the majority of OA exercise research involves the knee joint.

The first section of the chapter highlights the evidence supporting the effectiveness of exercise in managing symptoms of OA. Following this, practical recommendations are made regarding specific exercise prescription in terms of type, dosage, and delivery methods as well as ways to assess and monitor the outcomes of exercise in individual patients. The subsequent sections cover issues related to implementation of exercise by clinicians and patients. While there is evidence to support the use of exercise, clinicians are not routinely recommending exercise to patients and potential reasons for this are explored. Given that patient adherence to exercise declines over time, appropriate attention should be pain as reduced adherence attenuates the benefits of exercise. Facilitators and barriers to exercise adherence are discussed and practical strategies to improve patient adherence to exercise are provided.

Section snippets

Is exercise effective in reducing symptoms of OA?

While considerable research has investigated the effects of exercise for knee OA, 2002 While considerable research has investigated the effects of exercise for knee OA, there is much less research at other joints such as the hip and hand. For knee OA, systematic reviews and meta-analyses consistently support the benefit of exercise for improving pain and physical function in the short term [6], ∗[7], [8]. One recent review incorporating trial sequential analysis and network meta-analysis

What type of exercise should be recommended?

Many types of exercise have been described in the literature for people with OA, Many types of exercise have been described in the literature for people with OA, including muscle strengthening/resistance training, stretching/range of motion, cardiovascular/aerobic conditioning (such as cycling and walking), neuromuscular exercise, balance training, and Tai Chi. Few studies have directly compared the effects of different types of exercise but systematic reviews suggest clinical benefits from a

How should exercise be delivered?

Global economic austerity along with rising health-care costs necessitates the delivery of exercise in efficacious but cost-effective ways. Exercise can be broadly categorized into three different delivery modes including individual (one-on-one) treatments, class-based (group) programs, and home-based programs. Other common mixed-mode alternatives include combining individual treatment sessions with home-based exercise and augmenting home exercise with either a class-based program or supervised

What exercise dosage should be prescribed?

Exercise programs can differ greatly in terms of their dosage. Exercise dosage encompasses the total number of sessions within a program, the frequency (number of sessions per week), duration (time length of session) or volume (the amount such as number of repetitions/sets), and the intensity (amount of muscular effort or exertion, typically expressed as a percentage of the individual's maximal capacity), all which may affect the outcome [45]. From a clinical perspective, the optimal dosage of

How can clinicians monitor the effects of exercise?

Clinicians should use validated outcome measures to assess the effectiveness of an exercise program. These can include patient self-report measures of pain via a 10-cm visual analog scale or a 0–10-numeric rating scale (Fig. 4). In general, changes of at least 2 cm or 2 units on these scales are needed to represent a clinically relevant amount of change with treatment. A variety of other self-report measures of pain and physical function are available including the Western Ontario and McMaster

Why is exercise not being prescribed by clinicians for patients with OA?

Despite convincing research evidence demonstrating the beneficial effects of exercise for people with OA and the numerous clinical guidelines advocating exercise for OA [1], [2], [3], [5], ∗[20], [54], [55], [56], [57], [58], [59], exercise prescription for people with OA continues to be underutilized by medical practitioners and allied health professionals. Underlying differences in a clinician's knowledge, beliefs, attitudes, and behavior towards exercise, as well as external influences of

Why don't patients adhere to exercise recommendations?

In order to achieve optimal clinical outcomes with exercise, long-term patient adherence to a regular exercise program is critical. For example, Ettinger and colleagues [66] demonstrated a dose–response relationship between adherence and exercise effects in a large 18-month trial involving 439 people with knee OA. With increasing adherence, improvements in pain, walking ability, and disability significantly increased. A study by van Baar et al. [67] clearly showed that the beneficial effects of

How can patient adherence to exercise be improved?

Given that the barriers to exercise adherence are complex and vary across individuals, and may change over time within a given individual, a flexible individualized and proactive approach to exercise prescription by health professionals is required. No single strategy to promoting exercise adherence will suffice across all people with OA. Health professionals should consider and identify the barriers to exercise adherence that exist in individual patients when recommending or prescribing

Summary

Exercise is an integral component of conservative management for OA and is universally recommended by OA clinical guidelines. While considerable research has investigated the effects of exercise for knee OA, there is much less research at other joints such as the hip and hand and the optimal dosage of exercise for people with OA remains unclear. Treatment benefits of exercise of all types may be considered small to moderate; however, the effects are comparable to those of conservative drug

Conflict of interest

All authors state that there are no conflicts of interest.

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