Lucy Hicks
It’s no secret that regular exercise is important. But for patients with painful joints, it can be the last thing they want to do. Exercise is one of the cornerstones of managing arthritis, yet nearly one third of patients with arthritis are inactive.
Guidelines recommend that clinicians encourage their patients to engage in physical activity, but it can be difficult to know where to start.
Medscape Medical News recently spoke to experts on what resources are available, how much exercise is ideal, and how to motivate patients to move more.
What Are the Benefits of Exercise in Osteoarthritis?
Nearly all professional societies agree that exercise is one of the hallmarks of managing osteoarthritis (OA). According to two Cochrane reviews, there is high-equality evidence that exercise can help reduce pain as well as improve physical function in both hip and knee OA. In fact, physical activity can decrease pain and improve function by 40% in adults with arthritis, according to the Centers for Disease Control and Prevention.
Exercise also plays a large role in preventing disability by improving joint range of motion as well as maintaining muscle mass that supports joints.
There is also preliminary evidence that exercise could have a structural benefit to osteoarthritic joints. In a study of about 1200 individuals with knee OA, those who walked for exercise not only had reduced frequent knee pain, compared with non-walkers, but also were 20% less likely to have worsening of medial joint space narrowing.
Beyond symptom and impairment improvements, exercise can also play a role in staving off other chronic diseases linked to OA, such as cardiovascular disease and type 2 diabetes. Physical activity and exercise “are 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,” wrote the authors of a commentary in the Journal of Orthopaedic & Sports Physical Therapy.
The known mental health benefits of exercise can also be beneficial for patients, as rates of depression and anxiety can be higher in people with arthritis than in the general population.
What Is the Ideal Amount of Exercise for Patients?
Current guidelines recommend that adults should get 150 minutes of moderate physical activity each week. But for patients with chronic pain, that may seem unachievable, said Kelli Allen, PhD, a professor of medicine and exercise physiologist at the University of North Carolina School of Medicine in Chapel Hill, North Carolina, during a presentation at the American College of Rheumatology 2023 Annual Meeting in San Diego. Promisingly, research has shown that some exercise is better than none.
photo of Kelli AllenKelli Allen, PhD
One study looking at over 1500 adults with lower extremity joint symptoms suggested that approximately 1 hour of physical activity per week increased the likelihood that participants remained disability-free over 4 years. In another analysis looking at 280 studies, researchers concluded that resistance training programs lasting 3-6 months resulted in moderate improvements in pain and physical function, but these benefits did not depend on exercise volume or participant adherence.
“These findings highlight the flexibility available for clinicians in the prescription of resistance exercise for knee and hip OA without compromising improvements in pain and physical function,” the authors wrote.
Step counts can be another way to measure activity, with 10,000 steps being a common target. But fewer steps a day can also yield health benefits. One study found that among nearly 1800 participants with knee OA, each additional 1000 steps per day was associated with a 16%-18% reduced risk of developing functional limitations 2 years later. Walking 6000 steps a day was the threshold that best determined who would develop functional limitations and who would not.
“I think it’s really a helpful message to encourage people with chronic pain that if you can get to 6000, maybe that’s a good goal,” Allen said.
Going for a 20-minute walk three times a week can be a good place to start, said Grace H. Lo, MD, an associate professor in the Division of Immunology, Allergy, and Rheumatology at Baylor College of Medicine in Houston, Texas. For people who currently do not do any activity, Lo recommends starting small, like walking to get the mail every day. “Do something practical that is something they can sustain and keep in their daily activities that will help to increase their function and hopefully lessen some of their symptoms.”
photo of Grace LoGrace H. Lo, MD
Are Certain Types of Exercise More Beneficial?
There is no specific type of exercise that is best for OA, so it comes down to patient preference. The best exercise is “whatever somebody is actually going to do,” Allen noted.
Una Makris, MD, an associate professor of internal medicine in the Division of Rheumatic Disease at the University of Texas Southwestern Medical Center and rheumatologist at the North Texas VA Health Care System in Dallas, Texas, said that her practice focuses on a combination of aerobic activity, functional balance, and strength training, as recommended by the World Health Organization.
photo of Dr Una MakrisUna Makris, MD
“It’s not clear to me that one type of exercise is better than another; it’s more about what does this patient enjoy, and how can we make this a routine, so it is a sustainable behavior,” she told Medscape Medical News in an email.
Generally, lower-impact exercises like biking, walking, or swimming tend to be better for OA, Lo added. Several studies have also shown Tai Chi to be beneficial in patients with OA, she said. More recently, Lo has conducted research on gardening as an exercise intervention for OA.
“It’s a great way to encourage people to exercise,” she said in an interview with Medscape Medical News. “Besides the fact that they’re physically active, they can also be outside. There are a lot of mental health benefits to doing gardening as well.”
Allen added that certain exercises should be considered on the basis of an individual’s goals and physical needs. If someone has balance issues, for example, then yoga or Tai Chi could be useful to add to their exercise program, she said.
What Resources Are Available?
The Osteoarthritis Action Alliance has a list of 23 evidence-based exercise programs that have been shown to improve arthritis symptoms. These arthritis-appropriate, evidence-based interventions vary from instructor-led, in-person sessions to self-directed programs.
Walk with Ease (or Camine Con Gusto in Spanish) is one popular program, noted Allen. The program can be in-person or self-directed, with a required booklet that costs $11.95. However, there are discounted books for community-based organizations. The My Knee Exercise program, created by the University of Melbourne, Melbourne, Australia, provides a free, self-directed, 6-month strengthening program. The availability and cost of other programs are dependent on the format and location, the guide noted.
But understanding what programs are available in certain communities takes time, which can be a barrier to clinician referrals, noted Katie Huffman, the director of education and outreach at OA Action Alliance.
“We would love to see these programs being covered by payers and health plans so that there’s incentive for providers to refer and patients to participate in the programs,” she noted.
While some states do cover a limited number of programs under Medicaid, coverage across states and payers is not yet universal.
In addition to these programs, the alliance has a simple guide to help plan workouts based on current activity level. The guide links to free exercises from CreakyJoints, an online community for people with arthritis, and the Arthritis Foundation.
Lo also noted that the Veterans Affairs program, “VA Whole Health,” has free resources that are available to anyone. The provided videos offer Tai Chi, chair exercises, and guided meditations.
“It’s thoughtful to people who have some limitations in their physical activity,” she said.
Because the program is online, it could be difficult to access for those who are not comfortable with electronics, she said, “but if you can find a way to pass that, I think that this is an amazing resource,” she said.
How Do You Motivate Patients to Move?
“When it comes to motivation, I don’t think there is a one-size-fits-all approach,” said Makris. She tries to identify what matters most for each patient as a starting point. “When they can identify something in their day-to-day life that they value, then I like to link a physical activity-based goal to that,” she said. Setting physical activity goals using the mnemonic SMART (Specific, Measurable, Attainable, Realistic, and Timely) can be useful, she advised.
The OA Action Alliance also provides additional tools for clinicians on how to counsel patients on behavior change.
Understanding the patient’s lifestyle is also crucial when discussing physical activity, Lo added. “You have to give them practical solutions that they can actually incorporate into their lives,” she said.
Discussions around physical activity should be an ongoing part of clinic visits, both Lo and Makris agreed, to celebrate achievements and revise goals.
“I’m kind of notorious for being really slow in clinic because I just let people talk,” Lo said. “I do feel like these extra moments, when you spend time talking about these things, allow your recommendations to be more customized for the patients” and make the biggest impact.
Allen, Lo, and Makris reported no relevant financial relationships.
Leave a Reply