Exercise for Osteoarthritis

**Topic in Geriatrics:** Exercise for Knee Osteoarthritis

**Objectives:**

1. What is osteoarthritis?
2. How is osteoarthritis diagnosed?
3. What is the evidence for strength training with osteoarthritis?
4. What is the benefits of aquatic therapy for osteoarthritis?
5. What are concerns to look out for with regards to osteoarthritis?

**Defining Osteoarthritis and Diagnosis:**

 Osteoarthritis is defined by the Arthritis Foundation as a degenerative joint disease and is the most common chronic condition of the joints, affecting approximately 27 million Americans. Cartilage begins to break down, causing pain, swelling and problems moving the joint. Over time bones may break down and develop growths called spurs. The most common joint that is affected is the knee, however it can affect any other joint in the body. While osteoarthritis can occur in any population, it is most common in the geriatric population.1

Diagnosis is made using x-ray to determine breakdown of cartilage, narrowing of joint space, and formation of bone spurs. It can also be determined with certain criteria as defined by the American College of Rheumatism.2

Pain in the knee and 3 of the following:2

* 50 years of age
* 30 minutes of morning stiffness
* Crepitus with active motion
* Bony tenderness
* Bony enlargement
* No palpable warmth of synovium

**Evidence for Land Based Exercises:**

 Much research has been done for the effectiveness of land-based exercises in the treatment of osteoarthritis. A Cochrane review from 2015 that looked at exercise for knee osteoarthritis showed that those who exercised reported less pain, higher physical function, and better quality of life than those who were in the non-exercise groups The evidence indicated that land-based therapeutic exercise was more beneficial in the short-term which was defined as at least two to six months after cessation of formal treatment.3

Another study that showed benefits for land-based exercises utilized the following types of exercises:4

* Range of motion exercises
* Squats
* Lunges
* General strengthening
* Muscle strengthening

In addition to resistance training being effective in treating pain and function in those with osteoarthritis, Kabiri et al showed significant improvement in the VAS, KOOS and functional tests when resistance training was combined with aerobic exercise. Three modes of aerobic exercise were combined with lower and upper extremity non-weightbearing strengthening and then compared for effectiveness.5

* Treadmill – showed greater improvement in timed up and go (TUG) scores5
* Cycle ergometer
* Arm ergometer – showed greater pain relief and sport performance5

**Evidence for Aquatic Therapy**

Due to the fact osteoarthritis primarily affects weight bearing joints, making use of buoyancy has shown to reduce the load placed on those joints allowing movement much less painful. In addition to less stress being placed on the joints aquatic exercise can be a great place to start patients out at if they are less confident about being able to move without pain. As is with land based exercises, aquatic therapy has been shown to provide short term benefits, however more research is needed to determine the effectiveness over longer time frames.6 Below is an example of an aquatic therapy program that was designed specifically for individuals with osteoarthritis of the knee.7

* Motor coordination and agility – 4 x 30 seconds with 30 second rest7
	+ Gait training in anteroposterior, lateral-lateral, and diagonal in the shallow end of the pool (1 m deep).
	+ Then they will go up and down the inside of the pool ladder, alternating legs (two steps).

* Flexibility – 6 x 10 seconds with 10 second rest7
	+ Unilateral and alternating stretches of the following muscle groups will be done:
		- Triceps
		- Pectoral
		- Quadriceps
		- Hamstrings
		- Gastrocnemius
		- Thigh adductors
* Space perception, time and speed of reaction – 3 x 1 minute with 30 second rest7
	+ Ball toss in the shallow end of the pool.

* Balance7
	+ 4 x 1 minute with 30 seconds rest
		- Standing position with feet on boards for balance training. Support may be bipedal or single-leg.
		- To increase the degree of difficulty, the eyes may remain closed.
	+ 10 x 10 seconds with 10 seconds rest
		- Triceps
			* Aquatubes will be used to perform the exercises. Individuals remain standing in the middle of the pool with raised shoulders and elbows close to the body, conduct extension and flexion, keeping the forearms pronated.
		- Pectoral
			* Individuals standing, holding shoulder flexion at 90 degrees, holding the plank of exercises and perform flexion and elbow extension.

* Muscle training7
	+ 6 x 40 repetitions with 10 seconds rest
		- Quadriceps
			* While standing in the shallow end of the pool, exercise will be conducted in closed kinetic chain (squat).
	+ 10 x 10 seconds with 10 seconds rest
		- Rectus abdominals
			* For performing abdominal exercises, individuals will support their hands on the horizontal bar of the pool and hold the “kicking” movement, putting bilaterally foot on the wall of the pool and then returning to the ground.

**Caution/Precautions**

* Avoid performing high impact activities or exercises.
* Be aware of any increased joint swelling and consult you physician or physical therapist is this occurs.
* Unusual or persistent fatigue or pain may warrant a change in exercise mode or frequency.

**References**

1. What is Osteoarthritis? (n.d.). Retrieved July 10, 2018, from https://www.arthritis.org/about-arthritis/types/osteoarthritis/what-is-osteoarthritis.php
2. Altman, R., Asch, E., Bloch, D., Bole, G., Borenstein, D., Brandt, K., . . . Wolfe, F.

(1986). Development of criteria for the classification and reporting of osteoarthritis: Classification of osteoarthritis of the knee. *Arthritis & Rheumatism,* *29*(8), 1039-1049.

1. Fransen, M., & Mcconnell, S. (2008). Exercise for osteoarthritis of the knee. *Cochrane Database of Systematic Reviews*.
2. Deyle, G. D., Allison, S. C., Matekel, R. L., Ryder, M. G., Stang, J. M., Gohdes, D. D., ...Garber, M. B. (2005, December). Physical therapy treatment effectiveness for osteoarthritis of the knee: a randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program.
3. Kabiri, S., Halabchi, F., Angoorani, H., & Yekaninejad, S. (2016). Comparison of three modes of aerobic exercise combined with resistance training on the pain and function of patients with knee osteoarthritis: A randomised controlled trial. *British Journal of Sports Medicine,* *50*(Suppl 1), 22-28.
4. Silva, L. E., Valim, V., Pessanha, A. P., Oliveira, L. M., Myamoto, S., Jones, A., & Natour, J. (2008). Hydrotherapy Versus Conventional Land-Based Exercise for the Management of Patients With Osteoarthritis of the Knee: A Randomized Clinical Trial. *Physical Therapy,* *88*(1), 12-21.
5. Alcalde, G. E., Fonseca, A. C., Bôscoa, T. F., Gonçalves, M. R., Bernardo, G. C., Pianna, B., … Arca, E. A. (2017). Effect of aquatic physical therapy on pain perception, functional capacity and quality of life in older

people with knee osteoarthritis: study protocol for a randomized controlled trial.