Dr Barry J Sheane advises
Populations of the world are increasing, partly but significantly due to falling mortality rates due to advances in treatments for cancer, cardiovascular disease and infectious diseases. Rheumatic disease has also felt the benefit of modern scientific developments, particularly in rheumatoid arthritis where the ‘biological’ medications offer many a chance of remission and even cure. Unfortunately, and as I have previously written in these pages, there is no single or combination of medications that can treat osteoarthritis (OA), save commonly used pain-killers (‘analgesia’). While analgesia can improve an OA sufferer’s quality of life, used alone it is unable to decelerate or reverse degeneration of the joint. Many researchers and scientists working in the field of OA believe that treatments that can re-grow or repair damaged cartilage, a feature of OA, might have potential, yet such treatments remain, at best, 5 to 10 years away. What hope, then, is there for someone suffering from hip or knee OA?
Thankfully, there is a treatment for OA, however, patients tend to be less adherent to this prescription, and doctors not so diligent or encouraging when it comes to persisting with the prescribed treatment. The treatment I am referring to is exercise, but please don’t turn the page just yet at the thought of another health professional carping on about the benefits of exercise and dietary change! Both doctors and patients want ‘quick fixes’ for illnesses, and patients are accustomed to prompt returns to health after an antibiotic, an anti-inflammatory drug, or surgery. That is one of the reasons a prescription for exercise in OA is often less than successful at achieving a reduction in pain and an increase in joint function; the fix (exercise) for OA is not quick.
Exercise requires motivation, a shift in one’s routine or schedule and sometimes monetary cost. For patients with OA, movement of the affected joint brings pain and discomfort, a significant deterrent in prescription adherence. But the evidence for exercise as a treatment for OA is overwhelming, directly by strengthening supporting muscles surrounding the OA joints and indirectly by assisting with weight loss. Even for those with severe OA, the medical evidence supports pursuit of exercise as it can delay the need for joint replacement and reduce pain.
What is exercise and how can it benefit my OA?
When I tell patients that exercise is one of the primary treatments for OA, often eyes will start to glaze over. This is because many people equate Exercise with participation in elite sport seen on TV like the Tour de France or the Olympic Games. On the contrary, the World Health Organization informs us that, to maintain health, we should all partake in a minimum of 150 minutes per week of ‘moderate physical activity’ (http://www.who.int/dietphysicalactivity/pa/en/). Activities that qualify include: housework, brisk walking, gardening and walking domestic animals: not exactly the Olympic Games but undeniably attainable by the vast majority of OA patients. The activity should induce a ‘noticeable increase in heart rate’. Most of us (this author included) do not achieve this recommended weekly minimum of 150 minutes, too often citing work or domestic commitments as barriers to achievement. Yet the scientific evidence has shown that Exercise in OA reduces pain and increases physical function, with weight loss an added benefit. In fact, exercise-induced pain relief is the equivalent of that achieved with many over-the-counter pain killers.
Where and how do I start an exercise programme?
For patients who have never pursued any type of regular physical activity, there are a number of options. Walking, cycling (including use of an exercise bike) and/or pool-based exercise are good starting points. These activities will help strengthen the muscles of the lower limbs, further helping with OA. Even if you can’t swim, ‘pool walking’ (walking up and down the shallow end of a heated swimming pool) allows calories to be burned assisting weight loss, the water’s buoyancy takes some of the body’s weight off the joints and the warmth of the water assists flexibility.
Exercise regimens should ideally include aerobic-type activity (where your heart rate increases and calories are burned) as well as strengthening and flexibility exercises. A physiotherapist has expertise in providing advice on all of these facets of exercise and an assessment is a good investment.
When starting to exercise for the first time, it is important to set realistic goals, to be patient regarding your progress and to choose an activity that you will enjoy pursuing. Start off your programme by completing 5 minutes of your chosen exercise. Aim for small increments in your duration of Exercise (e.g. increase the session duration by 3 to 5 minutes once every fortnight). ‘Start low, go slow’ is a useful motto.
Whether you choose to exercise on your own, with a partner or in a class is purely a personal preference and your choice should foster long-term adherence to regular physical activity.
Am I causing more joint damage by exercising?
The answer to that question is a resounding ‘No’. While pain in the OA joint can increase upon uptake of an Exercise programme, this should decline pretty quickly over a few weeks. If you are particularly concerned about the onset of pain during your exercise then, with the consent of your treating doctor, take a painkiller 30 minutes to an hour before your session to allow the joints maximal benefit from your activity.
Indications that your exercise programme may be too intensive include the presence of severe pain during the activity, failure of the pain to subside within a few hours of the activity and increased pain the following day. If this happens, reduce the intensity of your activity to a level that does not induce these adverse symptoms and slowly escalate the programme from there.
In conclusion, exercise is a proven treatment in OA but unlike modern medicine, it may not deliver a ‘quick fix’. Patients require motivation and determination to succeed. With the right attitude and support from family and healthcare professionals alike, both pain and physical function can improve when a prescription for OA is followed, as well as one’s mood and sense of wellbeing. Remember: Start low and go slow. Good luck!
NB Please inform your GP before partaking in any new exercise regimen.
Dr Barry Sheane is Consultant Rheumatologist with The Sports Surgery Clinic, Santry, Dublin 9