We have seen from previous blogs that many people suffer with osteoarthritis of the knee and that this can be a painful condition. So what exercise programmes are most beneficial for reducting pain and reducing patient reported disability?
Fortunately a team based in Denmark undertook a systematic review to identify the optimal exercise programme, characterized by type and intensity of exercise, length of program, duration of individual supervised sessions, and number of sessions per week, for reducing pain and patient-reported disability in knee osteoarthritis (OA).
Here’s what they did
They searched the literature for studies published up to May 2012 in the following bibliographic databases with no restriction on publication year or language: Medline via PubMed, EMBase via OVID, CINAHL (including preCINAHL) via EBSCO, PEDro, and the Cochrane Central Register of Controlled Trials.
To be included studies must have involved participants with (explicitly stated) OA in either one or both knees, as defined by the American College of Rheumatology (ACR) criteria. Trials that included patients with knee and/or hip OA were included if separate data on the knee were available. The outcomes for evaluation of clinical efficacy were pain and disability, as recommended by Outcome Measures in Rheumatology III.
A meta-analysis of included randomized controlled trials was performed. Standardized mean differences (SMDs) were combined using a random-effects model. Study-level covariates were applied in meta-regression analyses in order to reduce between-study heterogeneity.
Here’s what they found
- Forty-eight trials were included.
- Pain reduction:
- Similar effects were found for aerobic, resistance, and performance exercise (SMD 0.67, 0.62, and 0.48, respectively; P 0.733).
- These single-type exercise programmes were more efficacious than programmes that included different exercise types (SMD 0.61 versus 0.16; P < 0.001).
- Aerobic exercise: pain relief increased with an increased number of supervised sessions (slope 0.022 [95% confidence interval 0.002, 0.043]).
- Quadriceps-specific exercise was more effective than lower limb exercise (SMD 0.85 versus 0.39; P 0.005).
- Supervised exercise performed at least 3 times a week (SMD 0.68 versus 0.41; P 0.017) gave best improvements.
- No impact of intensity, duration of individual sessions, or patient characteristics was found.
- Patient-reported disability: Similar results were found for the effect on patient-reported disability.
The authors concluded
Optimal exercise programmes should have one aim and focus on improving aerobic capacity, quadriceps muscle strength, or lower extremity performance. Such programs have a similar effect regardless of patient characteristics, including radiographic severity and baseline pain.
For best results the programme should be supervised and carried out 3 times a week
The Musculoskeletal Elf’s view
This well conducted systematic review and meta-analysis has interesting findings, for best results the exercise programme should be supervised, carried out 3 times weekly, and comprise at least 12 sessions and should focus on single exercise types. Interestingly these results found no support for individualization of exercise programs based on patient characteristics. For example, the effect of exercise therapy in reducing pain was not associated with the severity of knee OA.
Although the methods indicate that no language restrictions were applied it appears that 10 trials were excluded due to language. However, the 8 available abstracts of the excluded trials indicated that those trials showed similar effects of exercise therapy in reducing pain and disability compared to the included trials.
What do you think?
- Do you precribe single type exercise programmes such as muscle strength, aerobic exercise and strength training or do you combine them?
- Do you prescribe programmes that are supervised 3 times per week for 12 weeks?
- Do you prescribe individualised exercise programmes?
- Will the results of this review alter your practice?
- So what if patients have poor aerobic capacity? Is it possible to undertake muscle strength, aerobic exercise and strength training on different days in order to achieve the best effect?
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Links
- Juhl C, Christensen R, Roos EM, Zhang W, Lund H Impact of exercise type and dose on pain and disability in knee osteoarthritis: a systematic review and meta-regression analysis of randomized controlled trials. Arthritis Rheumatol. 2014 Mar;66(3):622-36. doi: 10.1002/art.38290. [abstract]
- PRISMA statement
- EQUATOR Network
What exercise type and dose for pain and disability in knee osteoarthritis? http://t.co/jOM2KpIJhX
I think the big problem with an evidence based approach is that certain things don’t lend themselves well to empirical OR observational study. As evidence based approaches always seem to be based upon looking at existing research, it stands to reason that people get tunnel vision and ignore approaches that have never been deemed suitable for research – because of the inadequacies of the evidence based model rather than lack of sound logic and observed outcomes of a given approach!
I would argue that before prescribing any kind of treatment you need to know what you’re treating. Else you stand to do more harm than good. Research has led to a situation where doctors don’t actually bother to find a cause for peoples joint pain – in the over 45’s the presence of pain is all that’s needed. How then can you prescribe treatment when you don’t actually have a detailed diagnosis!
So, what is OA? What is it that you’re trying to treat with exercise?
I would argue that very often it will be muscle imbalance. Research has shown that weak quads are common, but a muscle imbalance is never isolated to one muscle/joint. You need to look further afield for the full story.
When you do prescribe exercise – why is it working?
It stands to reason that if muscle imbalance (stressed soft tissue due to abnormal strain) then the fitter a person is (in terms of strength, strength endurance and aerobic fitness) the better they’ll cope with the dysfunction. In many cases this could be enough to shift a ‘pathalogical imabalance’ back to ‘functional imbalance’ state. The patient could become largely symptom free – and this often happens with knee OA without any professional intervention. Changes in lifestyle can be enough to shift between pathalogical and functional state.
However, by the same token, if someone exercises on an existing muscle imbalance the likelihood is that they’ll re-enforce the bad movement patterns and make the underlying imbalance worse. For a while, the improved fitness might help them cope better, but as the imbalance worsens it can be a ticking time bomb – eventually RSI’s will occur and the joint will once again become symptomatic – perhaps taking out other joints this time!
To my mind, you have to combine corrective exercise (to address the imbalance) along with general fitness (to help people better cope with the dysfunction). That means basing all of the training program upon detailed knowledge of the individual patient’s muscle imbalances (regardless of root cause of pain, there WILL be muscle imbalances – 100% guaranteed, and correcting them can only help).
This isn’t easy to do and requires skill rather than ‘check lists’ (so is costly). You can’t create a generic treatment plan and you can’t distill it down into something that can be evaluated by empirical study. Therefore, it’s deemed not to exist, physiotherapists aren’t adequately trained and treatable joint pain goes untreated.
Personal Trainers tend to have more experience and get better results with this kind of thing. Mainly because they work with people over a long period of time and see the long term outcomes of their interventions. Still, results are limited due to lack of understanding and research. Mainstream health care no longer even has muscle imbalance on the radar.
The solution, currently, lies in the patient becoming their own expert and learning to diagnose and treat their own muscle imbalances. The necessary raw material is freely available online. The fact that there are no ‘evidence based’ cures, does not mean that there aren’t cures!