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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
American Geriatrics Society Panel on Exercise and Osteoarthritis
INTRODUCTION
the U.S. are healthy and physically active, others suffer In response to mounting evidence that a program of in- with chronic illnesses and require some assistance (family, creased physical activity is a useful component in the man- friends, and public support systems) to manage their ev- agement of osteoarthritis (OA) in older adults, the Board of eryday lives.4,5 Approximately one quarter of all patients Directors of the American Geriatrics Society (AGS), along seen by primary care physicians present with musculoskel- with a multidisciplinary panel of experts, recommended that etal conditions6 and, among those age 65 years and older, the AGS take the lead in promoting exercise prescription for the most prevalent articular disease is OA.7 Addressing the OA patients in the primary care setting. This project, culmi- health care needs of this rapidly expanding population is a nating in the publication of these practice recommendations, parallels the Society’s clinical practice guidelines on the man- The conspicuous presence of OA in the older popula- agement of chronic pain in older persons.1 tion has many believing that chronic pain and functional The purpose of this document is to provide an evi- difficulties are immutable consequences of aging. OA, the denced-based review that explains why a physically active most common form of arthritis, is associated with consid- life style benefits older adults with OA and to provide erable disability.8 Symptomatic OA causes pain, limits practical strategies and exercise guidelines for this expand- daily activities, and reduces quality of life.8,9 The majority ing patient population. These practice recommendations of those burdened with OA are elderly; in fact, about half are derived from the existing literature and by consensus of all persons age 65 and over are affected by OA.10 The among a panel of experts from many disciplines: geriat- fallacy that undercuts the mistaken belief that symptom- rics, internal medicine, orthopedics, physical therapy and atic OA is caused by aging is revealed in the following an- rehabilitation, exercise physiology, nursing, and pharmacy.
ecdote. An older man visits his doctor complaining of dif- A literature search involving a full-text computer search of ficulty with getting out of a chair and walking because of Index Medicus and MEDLINE using the terms osteoarthri- persistent pain in one of his knees. The doctor replies, tis, exercise, and aging was first conducted. An extensive “Well you’re 75, this is just part of growing old.” The as- manual search using the bibliographies of the publications tute patient replies, “My other knee is just as old and it located through the computer search was also undertaken.
A study was included in this review if the publication An emerging body of evidence shows that light- to made an implicit or explicit claim regarding osteoarthritis moderate-intensity physical activity may play a preventive or research designed to evaluate the effects of exercise on and possibly a restorative role in combating declines in physiologic or functional parameters in older adults. Mem- health and functional capacity caused by chronic diseases bers of the multidisciplinary panel reviewed successive drafts such as OA.12–17 Regular physical activity modifies risk of the report summarizing their findings, and the final factors for chronic diseases prevalent in the older popu- draft was submitted for review and comment by experts lation,18,19 improves psychologic health,10 and promotes routinely involved in the care of older adults.
functional independence.20–33 Physical inactivity is recog- Americans 65 years or older represent an expanding nized as a risk factor for many diseases prevalent in the proportion of the United States (U.S.) population, and older population (coronary artery disease, diabetes melli- their numbers will increase rapidly as the baby-boom gen- tus, and obesity), and increasing physical activity in seden- eration ages.2,3 Although the majority of older people in tary OA patients may reduce morbidity and mortality.34–38Evidence indicates that quadriceps muscle weakness is a riskfactor for knee OA, which is often the consequence of inac-tivity.35 Furthermore, inactivity may contribute to the mor- Reviewed and approved by the AGS Clinical Practice Committee and the bidity associated with a variety of other chronic diseases, most notably diabetes mellitus, cerebrovascular disease, Address correspondence and reprint requests to Nancy Lundebjerg, Senior coronary artery disease, congestive heart failure, osteoporo- Director, Professional Education and Publications, American Geriatrics Society, 350 Fifth Avenue, New York, NY 10118.
sis, and depression. The superimposition of any of these 2001 by the American Geriatrics Society EXERCISE AND OSTEOARTHRITIS
conditions on several age-related changes only compounds and 50 in men.55,56 OA affects about 50% of persons age the negative effects of OA on the older person’s functional 65 and older, and this prevalence increases to 85% in the independence. Encouraging regular exercise may reduce group age 75 and older.57,58 In the Framingham Osteoar- the physical impairments and the burden of comorbidities, thritis Study, Felson and colleagues56 found that 27% of and thus improve the OA patient’s quality of life.36 the people age 63 to 70 years had knee OA diagnosed ra- Comprehensive management of the patient with OA diographically, and among those 80 years or older, the should involve non-pharmacological interventions in com- prevalence increased to 44%. In 1997, researchers found bination with medications. Medications such as analgesics that nearly 12% of people age 65 years and older said that and nonsteroidal anti-inflammatory drugs (NSAIDs) should their activities were limited because of arthritis.1 This not be used alone as the primary therapy but instead number is likely to grow proportionally as elderly people should be used in conjunction with non-pharmacologic comprise an increasingly greater share of the U.S. popula- measures.11,39,40 These include education about joint pro- tection, weight-loss counseling for obese people, develop- Gender also influences the prevalence and incidence ment of pain-coping skills, enhancement of social support, of OA. Isolated hand and knee OA are common in wo- application of heat or cold to painful joints, exercises that men, whereas the prevalence of hip disease is higher in strengthen muscles, and the use of a cane or a walker. De- men.44,45,49,50,54 Prospective, longitudinal studies have ex- veloping an exercise program aimed at alleviating pain amined the relationship between body weight and OA.
and improving overall physical fitness is especially impor- Data from the Framingham Knee Osteoarthritis Study, tant, because the primary concern for many OA patients is which followed 1,420 persons for more than 30 years, in- maintenance of functional independence.12,41,42 dicate that overweight men and women are at higher riskfor developing symptomatic and radiographic OA than OA RISK FACTORS, INCIDENCE, AND
those less obese.53,59 Similarly, both the Baltimore Longitu- PREVALENCE: IMPLICATIONS FOR TREATMENT
dinal Study of Aging and the Swedish study demonstrated Osteoarthritis is a major cause of chronic pain and disabil- that obesity increased the risk for developing OA.60,61 Felson ity in the older population. Even though there is much that and colleagues also reported that weight reduction reduces we still do not understand about the pathophysiology of pain, further supporting the relationship between obesity OA, our current understanding is sufficient to direct thera- and OA.62 Although the exact mechanisms remain unclear, peutic interventions. Research in the underlying mecha- several investigators speculate that excessive body weight nisms of OA have identified several risk factors. The data increases the biomechanical stresses across weight-bearing suggest that, as with atherosclerotic heart disease, the risk joints, which eventually results in cartilage damage.63–65 of developing symptomatic OA is influenced by the pres- Although some data support this teleologic hypothesis, a ence of multiple risk factors. Reducing or eliminating these direct relationship between weight loss and reduced OA risk factors may reduce the symptoms and disability asso- morbidity is less convincing. A small limited number of ciated with OA. Table 1 lists the major risk factors of knee randomized clinical trials provide preliminary data suggest- OA in older adults.11 Some factors, such as age, gender, ing that a reduction in OA symptoms is correlated more and inheritance are immutable, but others are modifiable.
strongly with reduced body fat mass than with reduced to- Obesity, muscle weakness, joint laxity, and altered biome- tal body weight.56,66 Slemenda and colleagues67,68 reported chanics are some risk factors potentially amenable to non- that reduced strength, relative to body weight, may play a pharmacologic measures. An understanding of the ways role in the development of OA. These preliminary data these risk factors affect the course of OA provides clini- could indicate that reduced total body fat and increased cians with the rationale for targeting their interventions muscle strength may be relevant to the development of for OA patients and increases the likelihood that these pa- OA. These data suggest that interventions designed to strengthen the muscles and reduce total body fat may be The incidence and prevalence of OA at different ana- effective methods for reducing pain and improving func- tomic regions vary, depending on whether this condition is defined by clinical symptoms, radiologic findings, or a A history of joint trauma, the presence of bony defor- combination of the two.43–46 Although all peripheral joints mities, or joint instability are also risk factors for OA.9 Ev- may be affected, OA of the knee has been the focus of idence from a variety of cross-sectional and longitudinal studies suggests that major trauma to a joint increases the Age is the most consistent risk factor for both radio- risk for developing OA.69–73 Consistently, the evidence sug- graphic and symptomatic OA at all articular sites.46 The gests a strong relationship between joint damage and the prevalence of OA increases after the age of 40 in women Table 1. Major Risk Factors for Osteoarthritis
Poor joint biomechanics (i.e., joint laxity) AMERICAN GERIATRICS SOCIETY
Recent studies report that muscle weakness and re- tant physiologic parameters related to functional capacity in duced joint proprioception are risk factors for developing older adults with OA. More recent randomized, controlled OA. In patients with knee OA, quadriceps weakness is long-term trials confirm these earlier findings.75,74,102,104 common. Because of decreased joint stability and shock- Given the positive health and functional benefits associ- absorbing capacity, muscle weakness contributes to dis- ated with exercise and the fact that inactivity contributes ability.74 Until recently, this disuse muscle atrophy was to disability,102 it is evident that promoting physical activity thought to develop because patients avoid loading painful should be an integral component of the management of OA.
joints. Slemenda and colleagues67 examined this relation-ship between muscle strength and knee OA in a popula- MANAGEMENT OF SYMPTOMATIC OA
tion of randomly selected community-dwelling older adults To date, no definitive treatment or cure for OA has been age 65 years and older. They reported that in those with- identified. The management of OA includes patient educa- out a history of knee pain, isolated quadriceps weakness tion, therapeutic modalities, exercise, and medications in was strongly associated with radiographic knee OA. The parallel. Treatment goals include pain control, maximizing findings from subsequent studies68,75,76 suggest that quadri- functional independence and improving quality of life within ceps weakness may be a risk factor for knee OA.
the constraints imposed by both OA and comorbidities.40,105 Although proprioception declines with age, several re- ports demonstrate that diminished position sense contributes Patient Education and OA
to the development of OA.77–80 Pai and colleagues showed Patient education is an important component of effective that knee proprioception was significantly diminished in arthritis rehabilitation. Counseling programs have been older adults with knee OA when compared with their found to be effective in reducing the pain and disability as- counterparts without OA.77 Whether reduced propriocep- sociated with OA.106–110 Formal community-based pro- tion causes or is a consequence of OA remains unknown.
grams to which the primary practitioner can refer OA pa- Highlighting the importance of these factors are the find- tients are also available in many locations. In addition, the ings from several studies that demonstrated strengthening Arthritis Foundation publishes educational brochures and and aerobic exercise programs designed to improve muscle videotapes for patients and, in many communities, offers strength and joint proprioception reduce pain and improve courses that teach practical techniques to reduce pain and mobility in patients with OA.75,76,81–83 improve function and general health. The Arthritis Foun- The relationship between levels of physical activity dation maintains a Web site (http://www.arthritis.org) and and the risk of OA has been well studied. In general, mod- erate amounts of recreational physical activity do not in-crease the risk of OA.84–86 However, participation in occu- Therapeutic Modalities
pations requiring strenuous physical activity or intense Modalities, such as heat, cold, sound, and electricity are competitive sports activity throughout life may contribute adjunctive interventions that are used with exercise and to the development of OA.59,87–89 Nevertheless, the results medications. While little scientific data demonstrate the ef- of many studies suggest that older adults, even those with ficacy of any specific modality in OA treatment, topical ap- OA, can reduce their morbidity by regularly participating plications of heat and cold have been used for thousands of years. The physiologic effects of thermal modalities includemuscle relaxation and decreased pain. However, because BENEFITS OF PHYSICAL ACTIVITY FOR
adverse effects can occur with the application of heat and OA PATIENTS
cold, a comprehensive medical evaluation is necessary prior Published reviews outline the effects of exercise training in to using these modalities. The physiologic effects and gen- the OA population.90,91 The details of selected randomized, eral precautions of these modalities are outlined in Table 3.
controlled studies are presented in Table 2,42 which also listsmany of the benefits of increased physical activity for OA EXERCISE ASSESSMENT AND PRESCRIPTION
patients. Although many researchers who have studied this Pain, swelling, limited range of motion, muscle weakness, question conclude that exercise training does not impact the postural or gait instability, and poor cardiovascular fitness pathological process of arthritis,30–32,60,76,82,92–95 a notable and are significant physical impairments associated with OA.
consistent finding across the OA literature is that exercise Interestingly, sedentary people without arthritis have many training does not exacerbate pain or disease progression and of these same problems, which suggests that physical inac- is effective in decreasing pain and improving function.
tivity plays an important role in the symptoms and signs Moreover, the evidence from well-controlled clinical trials associated with OA. A potential barrier to recommending suggests that regular physical activity can provide older OA regular physical activity to patients with OA is the belief patients with the same physical, psychologic, and functional that exercise will exacerbate joint symptoms. The results benefits observed in the general population. Chief among the of randomized, controlled clinical trials, however, indicate functional benefits produced by increasing physical activity that increased physical activity does not produce or exac- is improved postural and gait stability, which may reduce erbate joint symptoms and, in fact, confers significant falls in this at-risk population.76,96–100 These findings are sig- nificant because emerging research data implicate muscleweakness as a risk factor for OA67,68,101 and suggest that Patient Screening
physical inactivity exacerbates disability in OA patients.102 A comprehensive evaluation is the initial step in designing a Short-term studies show that aerobic exercise82,103 and physical activity program individualized for the patient strength-training programs17,83,100 effectively improve impor- with OA. The information obtained provides the founda- EXERCISE AND OSTEOARTHRITIS
exercise groups least affected knee at 30 ↑ In exercisers ( ↑ ↑ ↓ In aerobic group ( ↓ No. swollen joints in aerobic group ( ↑ Distance 70 m in exercise group but 17 m in control group ( ↓ in exercisers ( ↓ in exercisers ( Slight Significant Both exercise groups reported less disability Both exercise groups did better than controls Both exercise groups reported significantly ↑ (21%) extension strength in exercise groups least affected knee at 3 mos ( No difference between groups Table 2. Effects of Exercise Training in Osteoarthritis Patients: Randomized, Controlled Trials
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↑ walk velocity in exercise group at 0.05) ↓ in exercise group at 3 mos and 0.05); no change in control group ↑ in exercise group at 1 yr ↓ night pain in exercise group at 0.01) ↓ Pain in exercise group during last wk and last mo ( ↓ Use of paracetamol in exercise group (P aerobic capacity (measurement of aerobic fitness).
older adults with joint disease: an evidence based approach. Rheum Dis Clin North Am 2000;26: Table 2. Continued
SOURCE: Adapted with permission from O’Grady M, Fletcher J, Ortiz S. Therapeutic and physical fitness exercise prescription for EXERCISE AND OSTEOARTHRITIS
Table 3. Thermal Modalities: General Physiologic Effects & Precautions
tion for developing an appropriate exercise prescription for adults, only three included exercise stress test as part of each patient. Assessment objectives can be divided into two their screening procedures.10,14,16,28,29,119–127 In the largest of broad categories: arthritis-related factors (current medica- these studies, 70 subjects were screened with exercise stress tions, joint pain, inflammation, stability, and range of mo- testing; five subjects were excluded because of a resting tion) and impairments associated with inactivity (altered blood pressure Ͼ 160/100, and eight were excluded because body composition, muscle weakness, and poor cardio- of positive exercise stress test results.28,29 vascular fitness). The assessment should include a search Although serious cardiovascular events can occur with for any subclinical or undetected health problems or physical exertion, these usually occur during high-intensity conditions that could be exacerbated by exercise. In addi- activities. This risk should be considered in light of the fact tion, reviewing the patient’s expectations along with his or that regular physical activity of moderate intensity lowers the her financial and social resources may improve long-term risk of mortality from cardiovascular disease and can be adherence.112–116 When all these factors are considered, an safely implemented in patients with a low risk for such events.
exercise prescription can be offered that accommodates tothe specific needs and circumstances of the patient.
How to Start
The first step in designing an exercise program for the OA
The Need For Graded Exercise Testing
patient is to understand which functional problems are As many older adults may have cardiovascular disease, a most important to the patient. Once disabilities have been complete history and physical examination are needed be-fore prescribing increased physical activity. Contraindica-tions to exercise are presented in Table 4; in general, they Table 4. Contraindications to Exercise by the Osteoarthritis
are not different from those applicable to younger, health- ier adults.117 Opinions differ regarding the need for a phy-sician-supervised exercise stress test. Cardiovascular re- sponse to exercise should be considered for patients withsignificant risk factors. Such testing assesses cardiac re- sponse to exercise and helps to establish an individual’s initial aerobic exercise prescription.118 False positives do occur with exercise stress testing, and there are no consen- sus recommendations concerning the need to obtain this costly and inconvenient test in older adults who do not have significant cardiovascular disease risk factors. In a re- view of 14 studies (11 different training protocols) exam- ining the effects of high-intensity strength training in older AMERICAN GERIATRICS SOCIETY
inventoried and prioritized, the patient and clinician can To be most useful and clear, each exercise prescription set specific short- and long-term goals, which will deter- specifies exercise intensity, volume, frequency, and pro- mine the exercises to be prescribed. Involving the patient in the process enhances long-term adherence.112–116 Initially, the program should involve exercises that ad- • Intensity defines the amount of muscular effort or ex- dress the impairments (pain, limited joint range of motion, ertion put forth during the activity. The intensity of or muscle weakness) contributing to functional problems.
an activity is typically expressed as a percentage of the As soon as these impairments begin to improve, a general- individual’s maximal capacity. Traditionally, the in- ized fitness program designed to improve health and func- tensity specified in an exercise program is submaxi- tional capacity should begin. Shortly after therapeutic ex- mal (i.e., at levels below the individual’s full capacity).
ercise is initiated, fitness training can begin and continue • Volume describes how long the exercise is to be per- in parallel. The clinician should reinforce the goals and formed. For endurance training, volume may be ex- benefits of exercise and familiarize the patient with the pressed as the amount of time (in number of minutes specifics of the exercise prescription (intensity, volume, per exercise session or accumulated minutes per and frequency) and precautions. The latter might include, week) the person is engaged in aerobic exercises. For for example, warnings that physical performance and dis- resistance training, volume may be expressed as the ease activity can vary from day to day, and that signs of number of sets and number of repetitions per set to excessive exercise stress include joint pain during activity, pain lasting more than 1 to 2 hours after exercise, swell- • Frequency may be expressed as the number of exer- ing, fatigue, and weakness. Patients who are aware of their body’s response to exercise and equipped to adjust their • Progression, or the gradual application of the overload training program to avoid immobility may have better principle as adaptation occurs, depends on the individ- long-term adherence with a physical activity program.
ual’s response to exercise. Although the initial timeneeded for adaptation to the stress of exercise has notbeen identified, the range may be 2 to 3 months for Basic Exercise Principles and Prescription Components
most older arthritic adults with reduced physiologic re- The basic components for any physical activity program are serve. Progression can be manipulated by changing the exercises to improve flexibility, strength, and endurance.
intensity, volume, or frequency of training.
Table 5 presents basic recommendations. The training pa-rameters should be individualized for each patient, but all The greatest amount of force that a muscle or group of programs are based on general guidelines, as follows.
muscles can generate defines strength. A variety of meth- All exercise prescriptions aimed at improving joint ods have been developed to measure strength. The most flexibility, muscle strength, or endurance are based on the commonly used strength measurement is the one repetition overload principle: when musculoskeletal tissues are sub- maximum or 1RM, defined as the maximum amount of jected to unaccustomed physiologic stresses, they will resistance that can be lifted through a full range of motion adapt and increase their capacity. Overload can be accom- only once. Typically, the intensity of a strength training plished by increasing the exercise intensity, volume, or fre- program is expressed as a percentage of 1RM. The amount quency, or a combination of these factors.42 of strength gain depends on the individual’s initial level of Table 5. Training Parameters: General Guidelines
key muscle group; hold contraction 1–6 sec NOTE: 1 RM ϭ one repetition maximum (measurement of isotonic or dynamic strength); MCV ϭ maximal voluntary contraction (measurement of isometric strength);RPE ϭ rating of perceived exertion; HR max ϭ age-predicted heart rate maximum; VO max ϭ maximal aerobic capacity (measurement of aerobic fitness).
EXERCISE AND OSTEOARTHRITIS
strength and potential and on the training intensity, fre- the objectives of such exercises are to decrease stiffness, in- crease joint mobility, and prevent soft-tissue contractures.
The type of muscle contraction, static or dynamic, dif- Flexibility exercises are often done during the warm-up pe- ferentiates training techniques. A static or isometric con- riod or in conjunction with resistance or aerobic activities.
traction does not change muscle length or move a joint. Iso- To improve joint range of motion in the OA patient, metric strength training occurs when the force of the muscle static stretching is recommended. This stretching technique cannot overcome the applied external resistance (i.e., hold- moves muscles, joints, and periarticular tissues through a ing a heavy tray). Strength increases occur primarily at the range of motion that is comfortable for the patient but that angle where the muscle was trained, with less improve- produces some resistances to further movement. Joints, es- ment at other angles. This drawback limits the usefulness pecially those that are painful, should not be over stretched of isometric exercise as the sole form of strength training.
(i.e., stretched to a point that elicits pain), as this may Dynamic training is more useful for the person with compromise stability. All movement should be through the OA. A dynamic contraction both changes muscle length fullest possible pain-free range. The application of heat prior and moves the joint. Dynamic contractions are further to stretching may help reduce pain and increase motion.
classified as isotonic or isokinetic. Isokinetic muscle con- According to the American College of Sports and Med- tractions are performed on sophisticated machines that icine (ACSM), a flexibility program can begin with one apply variable resistance throughout the range of mo- stretching exercise per muscle group and should be per- tion. Isokinetic training, which has been studied in OA formed at least 3 times per week.136 With improvement, the patients,130–132 shows no significant advantages over iso- number of repetitions per muscle group can be gradually in- tonic strengthening programs. Therefore, from a practical creased to 4 to 10 repetitions.137 This general static stretch- standpoint, isotonic is the recommended form of dynamic ing program should involve the major muscle and tendon strength training for OA patients. An isotonic muscle con- groups in the upper and lower extremities (Table 6).
traction is characterized by variable joint speed exertedagainst a constant resistance (i.e., free-weight bench press Static Stretching Exercise: General Recommendations
exercise). Isotonic exercise closely corresponds to everydayactivities, and strengthening isotonic muscle contractions • Exercise daily when pain and stiffness are minimal therefore are recommended for OA patients.
All exercise sessions should have three phases, each of • Exercises can be preceded by a warm shower or by which is essential for reducing the potential for injury and application of superficial moist heat.
maximizing benefit. The first phase is a warm-up period in- • Relax before beginning stretching exercises.
volving repetitive low-intensity range-of-motion exercises; • Perform movements slowly and extend the range of warm-up lasts 5 to 10 minutes. This phase is important be- motion that is both comfortable and produces a cause a proper warm-up prepares the body for more vigor- slight subjective sensation of resistance. Breathe dur- ous activity. The second phase is the training period, which provides the overload stimulus to increase joint range of • Hold this terminal stretch position for 10 to 30 sec- motion, muscle strength, or aerobic capacity, or a combi- onds before slowly returning the joint or muscle nation of these. The final phase, cool-down, lasts 5 minutes and typically involves static stretching of the muscles.
• Modify the stretching exercises to avoid pain or Exercise and other non-pharmacologic interventions when the joint is inflamed (decrease the extent of are used in parallel with medications to reduce pain and joint range of motion or the duration of holding the improve function in the older OA patient. The manage- ment of symptomatic OA should be adjusted to the needsof the individual patient; an algorithmic approach, though STRENGTH TRAINING
limited, nonetheless helps to organize this complex processinto a series of steps (Figure 1). The algorithm highlights General Principles
the importance of modifiable risk factors in the design of Strength, an important factor in the performance of daily treatment plans that accommodate the heterogeneity of activities, is an important part of a comprehensive rehabili- the older OA population and yet facilitates simultaneous tation program for the older adult with OA. The aging pro- implementation of several therapeutic interventions. Such cess, burdens of chronic disease, malnutrition, and inactivity an approach helps to reduce the latency for reducing pain due to OA pain138 all contribute to reduced muscle mass (sar- and improving function in older symptomatic OA patients.
copenia) and weakness.90,139 Studies have shown that resis-tance training reverses many age-related physiologic changesand can improve function.94,140–142 The objectives of strength FLEXIBILITY (RANGE-OF-MOTION) EXERCISES
training are to increase the strength of muscles that support General Principles
the affected joints. The strength training of the individualOA patient should be based on the following principles: Joint mobility is important to health and to maximal jointrange of motion, enhanced muscle performance,95 reduced • Specific exercises should be selected on the basis of risk for injury,95,133 and improved cartilage nutrition.134 the patient’s joint stability and degree of pain and Flexibility exercises, typically the first step when beginning an exercise program,34,104 increase the length and elasticity • Muscles should not be exercised to fatigue.
of muscles and periarticular tissues.135 For the OA patient, • Exercise resistance must be submaximal.
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Figure 1. Steps in managing osteoarthritis in the older patient.
• Inflamed joints should be isometrically strengthened joint instability and pain decrease, the patient’s exercise and involved in only a few repetitions; movements program should gradually shift to dynamic (isotonic) training, as these muscle contractions are used during the • Joint pain lasting 1 hour after exercise and joint performance of activities of daily living.
swelling indicate excessive activity.
Isometric Strength Training Recommendations
Isometric Strengthening
• Exercises: Include exercises that involve the major General Principles
• Intensity: Introductory, isometric contractions should Isometric strengthening is indicated when joints are acutely be performed at low intensity. To establish the exer- inflamed or unstable. Isometric contractions produce low cise intensity, ask the patient to maximally contract articular pressures83 and are well tolerated by OA patients the muscles targeted for strengthening.42,129 This is with swollen, painful joints. These exercises can improve the patient’s maximal voluntary contraction and ini- muscle strength and static endurance. They prepare the tial training intensity should begin at approximately joint for more dynamic movements and are, therefore, typ- 30% of this maximal effort. As tolerated by the pa- ical starting points for most strengthening programs.
tient, the intensity should gradually increase to 75% Data indicate that strength increases occur when iso- of the maximal voluntary contraction.
metric contractions are performed at the muscles’ resting • Volume: The contraction should be held for no length.143,144 Strength improvements occur primarily at the longer that 6 seconds. Initially, one contraction per angle the muscle was trained, with less improvement at muscle group should be performed, and the number different angles145–147 which hinders the usefulness of this of repetitions should be gradually increased to eight exercise form if the goal is to improve overall function. As EXERCISE AND OSTEOARTHRITIS
• Intensity: Resistance should begin at 40% of the patient’s Table 6. Key Muscle Groups Targeted for Stretching and
1RM. Maximum resistance should be 80% 1RM.
Strengthening Exercises
• Volume: The beginner should complete one set of four to six repetitions. Exercisers should avoid mus- • Frequency: The frequency of training should be a • Progression: The progression of resistance training intensity and volume should be gradual to allow time for adaptation. A 5% to 10% increase per week in the amount of resistance used for training Strength Training for Symptomatic Knee OA: An Example
For the medically stable or robust older adult with symp- tomatic knee OA, some basic exercises aimed at improving quadriceps strength are outlined in Table 7. For those pa- tients with a number of medical problems, the clinician should consider referral to an experienced therapist.
Dorsiflexors, plantar flexorsInverters, everterToe flexors, extensors AEROBIC TRAINING
General Principles
Aerobic exercise has numerous physiologic benefits that • The patient should be instructed to breathe during alleviate the deteriorations of aging. These include improved each contraction. Twenty seconds of rest between maximal aerobic capacity (measurement of aerobic fit- ness),14,15,126,149 insulin action,150 body composition,151 and • Frequency: Exercises should be performed twice daily plasma lipoprotein lipid profiles.75,76,152 Regular aerobic during acute inflammatory periods. The number of exercise also reduces blood pressure.153 Meredith and col- these exercises should be gradually increased to five leagues138 showed that moderate-intensity training (70% to 10 times per day, as tolerated by the patient.
of maximal heart rate), performed 45 minutes per day, 3 • Progression: Initially, contractions should be per- days per week for 3 months produced similar aerobic formed at muscle lengths tolerable to the patient. As gains in both sedentary young and older adults. The mech- pain and inflammation decrease, contractions should anisms for adaptation to aerobic conditioning differ be- be performed at different muscle lengths and joint an- tween young and old adults, but improvement in skeletal gles.145 As strength develops, resistance may be added muscle oxidative capacity and glycogen store are more (i.e., contractions against an immovable weight).
• Precaution: Contraction Ͼ 10 seconds can increase The ACSM has set forth standards for the quantity and quality of exercises for developing and improving car-diovascular fitness in an older population.137 The overloadprinciple is applied to improve an individual’s aerobic fit- Isotonic Training
ness (VO max). (This principle states that the intensity, frequency, and volume of aerobic exercise must be greater General Principles
than normal daily activities.) The ACSM recommends that Isotonic muscle contractions are used to perform activities aerobic activities should involve dynamic repetitive move- of daily living. Isotonic strength training has been shown to produce positive effects on energy metabolism,139 insu-lin action,111 bone density,18 and functional status18,20,21,141 Aerobic Exercise Recommendations
in healthy older adults. In the absence of inflammationand joint instability, this exercise form is well tolerated by • Exercises: Activity selection depends on several OA patients. Recently, the ACSM published isotonic strength factors: the patient’s current disease activity, joint training guidelines. Their recommendations, based on sci- stability, and resources and interests. The patient entific research, are the basis of the exercise recommenda- should choose a variety of exercise options, to pre- tions for OA patients outlined below.
vent overuse of specific joints and to avoid exerciseboredom. Examples of aerobic exercise are bicy- OA Isotonic Exercise Recommendations
cling, swimming, low-impact aerobics (i.e., walking, Because older OA sufferers with a sedentary lifestyle are dance, or Tai Chi), or exercising on equipment such likely to have diminished physiologic reserve these exer- as treadmills or rowing machines. Other more utili- cises should not proceed to muscle fatigue.
tarian activities, such as walking the dog, mowingthe lawn, raking leaves, or playing golf, are also • Exercises: Resistance training should involve eight considered aerobic exercise and should be encour- to 10 exercises involving the major muscle groups.
aged. Aquatic exercise is a good choice for OA pa- AMERICAN GERIATRICS SOCIETY
Perform motion 5–7 times 3–5 times a day slowly relax; rest 2–3 sec between squeezes that knee is bent; slowly lift foot until lower leg; rest 2–3 sec between motions speed of the motion and depth of knee bend Table 7. Home-Based Exercises Designed to Improve Knee Extensor Strength
NOTE: Never hold breath during any exercises.
EXERCISE AND OSTEOARTHRITIS
tients; pool exercises performed in warm water (86 ЊF) the patient gradually works up to the desired activ- provide analgesia for painful muscles and joints.
ity level and avoids excessive amounts of activity.
Moreover, the buoyancy of the aquatic environmentreduces joint loading, enhances pain-free motion, and Pharmacologic Therapy
provides resistance for strengthening muscle groups Most authorities agree that the treatment for OA pain around arthritic joints. In addition, pool therapy is should be comprehensive, including both non-pharmaco- commonly a group activity that may help reduce a logic and, when necessary, pharmacologic approaches.1 patient’s depression and feelings of isolation. High- They also agree that non-pharmacologic therapy should be impact aerobic training involves rapid application of considered the initial treatment and that pharmacologic loads across joint structures and should be avoided, agents, such as analgesics and NSAIDs, should be used as as recent research suggests that the magnitude of adjunctive therapy.158 Drug therapy for the treatment of joint loading may not be as important in producing OA pain is most effective when used in conjunction with a pain or damage as the rate of joint loading.42 coordinated program encompassing appropriate non-phar- • Intensity: Several valid tools are useful for selecting macologic strategies.1 Primary physicians who are prescrib- an appropriate exercise intensity, the gold-standard ing exercise for OA patients are encouraged to regularly re- view the literature on pain management for up-to-date establishing a patient’s VO max is costly and some- information on the pharmacologic management of pain.
times difficult to obtain. Practical tools that can be Acetaminophen should be considered the preferred first- helpful in determining appropriate exercise intensity line pharmacologic treatment for mild to moderate pain of OA.1,159–161 Acetaminophen has been shown to provide sign) age in years), rating of perceived exertion pain relief comparable to that achieved with NSAIDs,162,163 (RPE: a 15-point ordinal scale, 6 to 20), or the “talk without the potential for the gastrointestinal (GI) side ef- test” (whether an exerciser can converse comfort- fects associated with the use of NSAIDs.164,165 The daily dos- ably during the activity without getting short of age of acetaminophen should not exceed 4 grams per day.
breath).154,155 Exercise intensity is considered low to As an alternative to acetaminophen, a trial of an NSAID (available over the counter [OTC] or by prescrip- tion) might be of benefit.166–171 There is also considerable with 50–75% being 70–105), 2) an RPE between 10 risk of drug-drug interactions and drug-disease interac- and 13, and 3) a positive “talk test.” The aerobic tions (e.g., congestive heart failure, hypertension, and he- exercise intensity should then range between HR patic and renal disease) with the NSAIDs. Physicians treat- 50% to 60%, RPE 10 and 12, or positive on the ing OA patients therefore need to take detailed medication “talk test.” For many OA patients, especially those histories, including questions about OTC medication use, taking medications that control heart rate, the “talk in order to provide optimal care and recommendations. It test” or RPE is the simplest method for determining has been reported that adverse events with nonselective NSAIDs are more frequent than with any other drug • Volume: The recommended volume for the beginner class.172 It is important to remember that elderly persons is a minimum of 20 to 30 minutes per day. Some are at high risk for side effects of NSAIDs, including GI, older, sedentary adults are unable to complete 20 to platelet, and nephrotoxic effects. Accordingly, NSAIDs 30 minutes of continuous aerobic activity at low to should not be used in high doses for long periods of time.1 moderate intensity. An acceptable alternative is four If a patient has a history of gastroduodenal ulcers or to five shorter exercise bouts (each, a minimum of 5 of GI bleeding, or develops GI symptoms, one of the new minutes) performed at slightly higher intensities (i.e., cyclooxygenase (COX-2) inhibitors or selective NSAIDs should be considered.173,174 The new COX-2 inhibitors cumulating between 60 and 90 minutes of moderate have been demonstrated to be as effective as traditional level physical activity over the course of a week has NSAIDs in the management of OA pain. The two cur- been included in recent recommendations from the rently available COX-2 inhibitors, celecoxib and rofe- ACSM. As fitness improves, exercise bouts can be coxib, have been shown to be as effective as nonselective lengthened gradually to 20 to 30 minutes of contin- NSAIDs for mild-to-moderate pain in patients with knee or hip OA.175,176 However, caution is advised in prescrib- • Frequency: The initial frequency of training should ing a COX-2 (as well as other NSAIDs), as there is the po- be at least 3 days but no more than 4 days per week.
tential for renal complications. There is evidence that rofe- Frequency of five times per week is not recom- coxib tends to cause fluid retention in older adults and mended because of increased risk for injury.
that, in addition, taking it without aspirin carries in- • Progression: The progression of aerobic training in- creased cardiovascular risk in this population.177,178 The tensity and volume should be gradual to allow time choice of agents for treating OA patients with preexisting for adaptation (i.e., 2 to 3 months). Following this renal insufficiency requires careful consideration.179,180 initial phase of aerobic training, a 2.5% increase per For patients with OA of the knee and other joints who week in the intensity or volume may be compatible have mild to moderate pain, topical formulations of anal- with the reduced physiologic reserve associated with gesics or counterirritants (e.g., methyl salicylate or capsai- cin cream, menthol) might be beneficial.181–184 Expert geri- • Precautions: Musculoskeletal injuries are prevent- atricians have indicated that pharmacologic modalities for able. More often than not, injuries can be avoided if OA pain, besides acetaminophen, NSAIDs, and opioids, AMERICAN GERIATRICS SOCIETY
include topical formulations of these agents and intraartic- Research services were provided by Sue Radcliff, Inde- ular injections of corticosteroids or hyaluronic acid.160 pendent Researcher, Denver, CO, USA. Editorial services Intraarticular therapy is an alternate approach to pain were provided by Barbara B. Reitt, PhD, ELS(D) of Reitt management in those individuals who either have not ob- Editing Services. Additional research and administrative tained relief through systemic medications or in whom support was provided by Adrienne Prassas and Nancy Lun- oral NSAIDs are contraindicated. This is especially true debjerg, Professional Education and Publications, American for patients with OA of the knee. Intraarticular adminis- Geriatrics Society, New York, NY, USA.
tration of glucocorticoids (e.g., triamcinolone hexace- The following organizations with special interest and tonide) has been beneficial in treating acute episodes of expertise in the management of osteoarthritis and exercise pain, especially when there is evidence of inflammation in older person provided expert review of an earlier ver- and joint effusion.185,186 More recently, the intraarticular sion of the guidelines: American Academy of Family Physi- administration of hyaluronic acid preparations has been cians, American Academy of Orthopaedic Surgeons, Amer- shown to have efficacy in relieving pain that is not ade- ican Academy of Physical Medicine and Rehabilitation, quately relieved with non-invasive, non-pharmacologic American Nurses Association, and the American Physical and pharmacologic therapies.187–189 Other agents that have shown benefit in treating the pain associated with OA of Funding was provided as an unrestricted educational the knee include glucosamine and chondroitin.190,191 How- grant from McNeil Consumer Health Care, Fort Washing- ever, additional studies are necessary to demonstrate long- term safety and efficacy of these agents.
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