# Exercise as it relates to Disease/Effects of swimming and cycling for people with osteoarthritis

This page is based on the research article conducted by Mohammed Alkatan, et al, in 2016. The title of the article is; Improved Function and Reduced Pain after Swimming and Cycling Training in Patients with Osteoarthritis

## What is the background to this research?

Arthritis by definition is the swelling/inflammation of one or more joints and has many different categories and the different categories have different symptoms, such as Rheumatoid arthritis, childhood arthritis, fibromyalgia to name a few but the one being looked at in this research is Osteoarthritis. Osteoarthritis symptoms include joint pain, stiffness, decreased range of motion in joints and swelling, it is caused by damage to joint cartilage between the bones. Cycling was used in this research as a comparison group because it has been shown to be effective in alleviating pain for patients with osteoarthritis and is a land-based non-weight bearing exercise.
The primary aim of this study was to determine the effects of a swimming exercise training intervention on the primary symptoms of osteoarthritis this is because the traits of water based exercise, because of the buoyancy of the water creates minimal weight bearing for a participant and has been widely recommended as a treatment option for osteoarthritis. Considering how widely recommended it is this is the first research piece to look at the effects of a swimming exercise program for patients with osteoarthritis and with substantially more studies to be conducted. Another factor about a swimming intervention is that most patients with osteoarthritis are obese and with that comes heat-related problems when exercising outside especially during summer, so swimming decreases the risk of the heat-related problems because they are surrounded by water that cools down the body.
A secondary aim of the effect on quality of like was addressed in this study. The hypothesis for this study was that the swimming intervention would produce reductions in joint pain, stiffness and improvements in functional capacity in patients with osteoarthritis.
It is important to look at studies like this for patients with osteoarthritis because it could potentially decrease the severity of symptoms which then improves how they cope doing everyday activities without pain or limitations. It is also a way for them to do exercise that doesn't put them in a place of discomfort and is easily accessible to a lot of people with the wide variety and access to pools.

## Where is the research from?

This study was approved by the Board at the University of Texas Austin and was conducted through the cardiovascular ageing research laboratory at the university. It included participants with mild to moderate radiographic osteoarthritis. The researchers conducting this research piece were Mohammed Alkatan, Jeffrey R. Baker, Daniel R. Machin, Wonil Park, Amanda S. Akkari, Evan P. Pasha and Hirofumi Tanaka.
On the basis that this study was performed at and through the University of Texas at the Austin campus it implies that all participants would have been around that area restricting the amount of participants being able to participate in the study. Considering Texas is the second largest state by population and size it has a low percentage of people with any kind of arthritis with only 20.2% where as other states such as West Virginia and Kentucky have over 30% of their population living with arthritis. This means the results won't be as accurate because it is based on one area in one country and could possible not be as effective in another state or country.

## What kind of research was this?

The study was randomised clinical trial and the researchers settled on doing it this way to avoid having any possible bias. There were precautions taken when randomly assigning the participants to a group with having a blinded investigator hand out envelopes with the prevention group the participant would be in. A randomised clinical trial was the best possible kind of study to do in this particular research because it would produce reliable evidence and ensure bias would not play a factor in the results.

## What did the research involve?

All participants were recruited from orthopaedic clinics and senior centres through emails, flyers and sharing information. All participants were either middle age or older with osteoarthritis and had to go a careful screening process to make sure they qualified.Baseline measurements were taken before undertaking any exercise. Then using the randomised study design participants were randomly assigned either the swimming or cycling exercise program by a blinded investigator.
For the first few weeks participants exercised in their allocated group for 20-30 minutes a day, 3 days a week at an intensity of 40-50% of their heart rate reserve. As the participants level improved over the weeks the intensity and duration of the exercise was increased with the maximum participants reached being 40-45min a day, 3 days a week at an intensity of 60-70% of their heart rate reserve. The exercise program ran for 12 weeks and while undertaking the exercise programs all participants were instructed to maintain their usual lifestyle and dietary habits.
The swimming exercise group was located at the Gregory gymnasium at the University of Texas at Austin campus in a 25-yard pool (22.86 m) and to ensure the participants felt comfortable the pool was kept at a temperature between 27-28 degrees celsius. The swimming session were overseen by an investigator that was certified as a Red Cross Water Safety and Red Cross Lifeguard instructor. The participants either used the stroke freestyle or breast stroke or a combination of the both for the duration of the program. One participant had no previous experience in swimming so they undertook one on one session containing swimming with a kick board and fins to maintain the prescribe heart rate zone. The heart rate monitors were strapped around the participants chest and were waterproof so they could wear them while swimming.
The cycling program on a stationary bike located in the exercise training intervention core laboratory at the University of Texas at the Austin campus, this exercise program was supervised by an investigator that was a certified personal trainer. The program included the investigator instructing the participants to cycle continuously except for the times when heart rate needed to be measured. The heart rate monitors were strapped around the participants chest.
At the end of the 12 week all participants then went through the testing phase agin maintaining the order of how it was conducted when doing the baseline tests. To test physical performance participants completed a 6 min walk test, to determine the pain and disease severity the researchers used a WOMAC index (self-administered questionnaire). The questionnaire consists of 24 questions and each is rated on a 5-point likert scale with 0= no pain, 4= extreme pain, these deals with the participant's perception of pain, stiffness and physical function all symptoms of osteoarthritis.
Limitations to the study as pointed out by Alkatan and colleagues was that the study was only conducted over a 3 months span only showing what 3 months of a swimming intervention program can do to benefit osteoarthritis symptoms. Another limitation is the lack of participant blinding to treatment allocation and this is shown through the withdrawal of 2 participants because they were unhappy with the intervention group they were placed in. Only using patients who have mild to moderate radiographic osteoarthritis were included in the study, there were no severe cases of osteoarthritis such as patients that require a walker to assist them in walking meaning the results can not be generalised to patients with more severe cases of osteoarthritis. So to improve the study would be getting a larger amount and more variety of participants well as conducting the study for longer to see if the benefits kept increasing or if it was only for a certain amount of time.

## What were the basic results?

Out of the 48 participants that passed the screening process 40 completed the research with 8 withdrawing. Out of the 8 that withdrew 4 were from the swimming intervention group and 4 were from the cycling intervention group. In the swimming intervention group 1 person withdrew due to a chlorine sensitivity, 1 withdrew due to personal reasons, 1 withdrew from a non- related injury and another 1 withdrew because they were unhappy with the randomisation. In the cycling intervention group 1 person withdrew due to an employment conflict, 1 withdrew because they were unhappy with the randomisation and 2 withdrew due to knee pain when cycling.
Between the 2 groups after the baseline testing was conducted there was there was no significant differences between the physical characteristics and body stature. After the completion of the 12-week program body mass, visceral adiposity and hip/waist circumference decreased in both training groups (all p < 0.01) but there was no significant difference between the two intervention groups. There were reductions in joint pain, stiffness and functional limitations that was determined using the WOMAC index between both intervention groups. There was also significant increases in the distance covered in the 6-minute walking test between both the swimming and cycling intervention groups (p < 0.001).
Focusing on the swimming intervention group it produced approximately 40% reduction in joint pain, approximately 30% reduction in the feeling of stiffness and approximately 25% reduction in functional limitation in every day activities. In conjunction with these improvements there were improvements in physical performance, upper and lower body muscle strength and a reduction in in body mass.
Alkatan and colleagues interpreted this data as that a swimming intervention produce the same results as a cycling intervention program meaning the benefits for this population are well established but there will still need to be more studies conducted to determine if there would be continuous benefits and if they would improve the symptoms of osteoarthritis if the swimming program continued for a longer period of time.

## What conclusions can we take from this research?

Based on previous research patients have already benefitted from participation in a cycling as an exercise intervention to help reduce the symptoms of osteoarthritis but there has been numerous studies which has concluded that it is beneficial for patients.
Considering it is the first study looking at the effects of swimming it has shown a positive benefit for the participants. Based on the buoyancy of the water and minimal weight bearing it is a perfect fit for patients with osteoarthritis because there is minimal impact in the joints that are usually affected when doing tasks that are land based. This study has proven to a minimal extent that a swimming exercise intervention has beneficial impacts reducing stiffness and joint pain. More research has to be conducted before it can be considered the best intervention for patients with osteoarthritis.

## Practical advice

When consulting with a doctor about ways to help alleviate joint pain and stiffness and to help improve function in every day life activities mention a swimming exercise program and see what your doctor recommends.
If you participate in a swimming program recommended by a doctor you need to ensure you stay within the guidelines that are set by a doctor to ensure oyu get the proper benefits.
Water aerobics can be an alternative to a swimming program because has been proven to decrease pain by a 5-point lower score. So due to the lack of research based on a swimming program water aerobics can be an alternative based on all the benefits of minimal weight bearing that is produced when being in water.

## Further information/resources

What is arthritis?
Types of arthritis
Osteoarthritis
Prevalence of arthritis in the US
Prevalence of arthritis in Australia

## References

* 1 2 Centers for Disease Control and Prevention, n.d., Arthritis; Arthritis Types
* 1 2 Amanda J. Salacinski, et al (2012), The Effects of Group Cycling on Gait and Pain-Related Disability in Individuals with Mild-to-Moderate Knee Osteoarthritis: A Randomised Controlled Trial. Journal of Orthopaedic & Sports Physical Therapy 42 (12) 985-995
* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Mohammed Alkatan, et al (2016), Improved Function an Reduced Pain after Swimming and Cycling Training in Patients with Osteoarthritis. Journal of Rheumatology, 43 (3) 666-672
* ↑ IPL (2000 & 20010), States - Ranked by Size & Population.
* ↑ Centres for Disease Control and Prevention (2019), Chronic Disease Indicator : Arthritis
* ↑ Akobeng AK (2005), Understanding Randomised Controlled Trials. Archives of Disease in Childhood 90:840-844
* ↑ K.K. Mangione, et al (1999), The Effects of High-Intensity and Low-Intensity Cycle Ergometry in Older Adults with Knee Osteoarthritis. The journals of gerontology; 54 (4); 184-190
* ↑ E.M Bartels, el at (2016), Aquatic exercise for the Treatment of Knee and Hip Osteoarthritis, Cochrane Database of Systematic Reviews (3)