Again a study published in the New England Journal of Medicine1 reports that there are 16,500 nonsteroidal related deaths occur every year in the United States, which is similar to the number of deaths from AIDS. The prescription of anti-inflammatory medications for persons with osteoarthritis is common practice in medicine. Articles like this one scream to the health care community to find alternative methods for providing relief from the devastation of osteoarthritis. Other articles account the importance of understanding that muscle is the major shock absorbing mechanism of joints and with osteoarthritis as with age this mechanism declines. An article by Serca2 in the Journal of Neurological Sciences determined that there is selective type II atrophy in patients with osteoarthritis. In addition, Nadine Fisher3 in the Scandinavian Journal of Rehabilitative Medicine talked about reduced muscle function in patients with osteoarthritis. She found that osteoarthritic subjects had increased difficulty and pain with ADLs as well as significantly lower strength with knee extension by 72% and knee flexion a 56% decrease. Their decrease in endurance was even more dramatic with the quadriceps having a 203% decrease while the hamstrings showed a 214% decrease.

One notion many people have is that exercise is dangerous for individuals with osteoarthritis and may even complicate symptoms. This is in fact not true. An article by Coleman4 entitled “Relationship of joint symptoms with exercise performance with older adults” showed that moderate stationary cycling in combination with vigorous intensity strengthening did not appear to induce or exacerbate joint symptoms in older adults. Recently in the Journal of the American Geriatric Society5, an article entitled “Exercise Prescription for Older Adults with Osteoarthritis Pain: Consensus, Practice Recommendations - A supplement to American Geriatric Society Clinical Practice Guidelines for the Management of Chronic Pain in Older Adults” extols the virtues of exercise and encourages physicians to send patients for exercise. An even stronger point was made by Slemenda6 in the Annals of Internal Medicine.  In an article entitled “Quadriceps Weakness and Osteoarthritis of the Knee”, quadriceps weakness was found to be a primary risk factor for knee pain, disability, and progression of joint damage in persons with osteoarthritis of the knee. In a follow-up article, Miller7 found that knee strength is more highly associated with self-reports of disability and ambulatory status than is radiographic evidence of osteoarthritis.

In terms of treatment the following studies provide helpful clinical methodology. Marks8,9 found that angle specific strengthening in mid-range was sufficient to strengthen the extensors surrounding an osteoarthritic joint. The carryover went through the full range of motion. This research supports a program that is good for patients who may be unable to do a full range program if it’s too painful but are able to do an angle specific program. In an article entitled “Effects of High Intensity Cycle Ergometry in Older Adults with Knee Osteoarthritis”, Katie Mangione10 found that a program consisting of training for 25 minutes three time a week for 10-weeks at 40-70% maximum heart rate improved gait, pain and aerobic capacity. Another study published in the Annals of Internal Medicine11 found that exercise reduces pain and improves function in patients with osteoarthritis. “Exercise and Weight Loss in Obese Adults with Knee Osteoarthritis”12 showed that a 3-time a week program with one-hour sessions consisting of walking and weight training for 6 months not only helped improve gait as compared to a control group but also impacted weight reduction. Rogind13 designed a 3-month program with twice-weekly sessions consisting of fitness activities, progressive resistive exercises, stretching exercises, balance and coordination activities, which showed improvements in pain, gait speed and crepitus. This program was particularly good for patients with severe osteoarthritis of the knee. Maurur14 looked at isokinetic quadriceps exercise versus educational intervention and showed that the isokinetic group did significantly better with a three times a week program when compared to an educational intervention at eight weeks. The article entitled “Cost effectiveness of aerobic and resistive exercises with seniors with knee osteoarthritis”15 showed that resistance training was more efficacious and cost effective than an aerobic exercise or health education programs in improving function and pain. The program was performed three times a week for three months.

Articles on other areas such as manual therapy and t’ai chi are available but are not as abundant. One good study published by the Annals of Internal Medicine “Effectiveness of Manual Physical Therapy and Exercise on Osteoarthritis of the Knee”16 found that the group who received manual therapy did much better than the group who just did exercise. The protocol is shown below and provides information on progression. Hartman17 in an article entitled “Effects of T’ai Chi Training on Function and Quality of Life Indicators in Older Adults with Osteoarthritis” demonstrated with randomized trials improvements in quality of life. The twice-weekly program which last for 12 weeks consisted of a 10-15 minute warm-up followed by 35-45 minutes of t’ai chi practice and a 5 minute cool- down.

Another area that is extremely important to address when working with arthritic patients is swelling. If a joint is swollen, it is almost impossible to get a strong contraction due to reflex inhibition caused by joint distention. Ways of trying to reduce swelling in a joint that may be particularly effective are electrical stimulation and ice, however; McNair18 found that sub maximal exercise for 3-4 minutes on a swollen joint does decrease the inhibition and helps improve strength. So the key is to have patients warm-up before beginning an exercise program.

Finally, one group that may need special attention is the frail elderly. Therapists may be concerned as to whether or not a progressive resistive exercise program can be effective with this patient population. An article in the American Journal of Physical Medicine and Rehabilitation19 entitled “Progressive Resistive Muscle Strength Training for Hospitalized Frail Elderly” showed that a carefully monitored program of progressive resistive exercise is safe and effective for frail elderly recuperating from an acute illness. The program was 10 weeks, the first 2 weeks were low intensity, and weeks 3-10 were done at 80% of the person’s 1-repetition maximum while monitoring heart rate and blood pressure. The studies and protocols mentioned provide a vast array of effective treatment options, which can truly help the older patient with osteoarthritis achieve excellent outcomes without the deleterious effects of anti-inflammatory medication. Physical therapy is a safe and effective alternative.

 

References

  1. Wolfe MM et al. “Gastrointestinal Toxicity of Nonsteroidal Anti-inflammatory Drugs.” The New England Journal of Medicine, June 17, 1999; 340(24): 1888-1899.
  2. Serca  Journal of Neurologcial Sciences 2000
  3. Fisher NM, Pendergast DR. “Reduced Muscle Function in Patients with Osteoarthritis.” Scandinavian Journal of Rehabilitative Medicine, 1997;29:213-221.
  4. Coleman EA.  “The Relationship of Joint Symptoms with Exercise Performance in Older Adults.”  JAGS 1996;44:14-21.
  5. “Exercise Prescription for older adults with osteoarthritis pain: Consensus, Practice, Recommendations. A Supplement to the AGS Clinical Practice Guidelines on the management of chronic pain in older adults.” JAGS, 2001;49(6):808-823.
  6. Slemenda C, et al.  “Quadriceps Weakness and Osteoarthritis of the Knee.”  Annals of Internal Medicine, 1997; 127(2): 97-104.
  7. Miller ME, Rejeski WJ, Messier SP, Loeser RF. “Modifiers of Change in Physical Functioning in Older Adults with Knee Pain: The Observational Arthritis Study in Seniors (OASIS).” Arthritis Care and Research, 2001; 45:331-339.
  8. Marks R.  “The Effects of 16 Months of Angle-Specific Isometric Strengthening Exercises in Midrange on Torque of the Knee Extensor Muscles in Osteoarthritis of the Knee:  A Case Study.”  JOSPT 1994; 20(2):103-109.
  9. Marks R.  “The Effect of Isometric Quadriceps Strength Training in Mid-Range for Osteoarthritis of the Knee.”  Arthritis Care and Research, 1993;6(1):52-56.
  10. Mangione KK, McCully K, Gloviak A et al.  “The Effects of High-Intensity and Low-Intensity Cycle Ergometry in Older Adults With Knee Osteoarthritis.” Journal of Gerontology, 1999; 54A(4): M184-M190
  11. Puett DW, Griffin MR.  “Published Trials of Nonmedicinal and Noninvasive Therapies for Hip and Knee Osteoarthritis.”  Annals of Internal Medicine, 1994;121(2):133-140.
  12. Messier SP, Loeser RF, Mitchell MN, Valle G, Morgan TP, Rejeski WJ, Ettinger WH.“Exercise and weight loss in obese adults with knee osteoarthritis.” JAGS, 2000;48(9):1062-1072.
  13. Rogind, Henrick et al.  “The Effects of a Physical Training Program on Patients With Osteoarthritis of the Knees.” Arch Phys Med Rehabil, 1998; 79: 1421-1427.
  14. Maurer B, Stern A, Kinossian B, et.  al.  "Osteoarthritis of the Knee: Isokinetic Quadriceps Exercise Versus and Educational Intervention."  Arch Phys Med Rehabil, 1999; 80:1293-1299.
  15. Sevick MA, Bradham DD, Muender M, Chen GJ, Enarson C, Dailey M, Ettinger WH. “Cost-effectiveness of aerobic and resistance exercise in seniors with knee osteoarthritis.” Medicine & Science in Sports & Exercise, 2000;32(9):1534-1540.
  16. Deyle GD, Henderson N, Matekel RL et al.  “Effectiveness of Manual Physical Therapy and Exercise in Osteoarthritis of the Knee.” Annals of Internal Medicine, February 1, 2000; 132(3): 173-181.
  17. Hartman CA, Manos TM, Winter C, Hartman DM, Li B, Smith JC. “Effects of T’ai Chi Training on Function and Quality of Life Indicators in Older Adults with Osteoarthritis.” JAGS, 2000; 48:1553-1559.
  18. McNair PJ, Marshall RN, Maguire K.  “Swelling of the Knee Joint:  Effects of Exercise on Quadriceps Muscle Strength.”  Arch Phys Med Rehabil 1996; 77(9):896-899.
  19. Sullivan DH, Wall PT, Bariola JR, Bopp MM, Frost YM. “Progressive Resistance Muscle Strength Training of Hospitalized Frail Elderly.” American Journal of Physical Medicine and Rehabilitation, 2001;80:503-509.