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Osteoarthritis of the Knee And Exercise


most common joint disease of humans ... risk factors include age, major trauma, repetitive joint use, and obesity ... crepitus, joint warmth, periarticular ... – PowerPoint PPT presentation

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Title: Osteoarthritis of the Knee And Exercise

Osteoarthritis of the Knee And Exercise
  • Holly Gluth Pursley, M.D.
  • Resident Grand Rounds
  • March 30, 1999

  • most common joint disease of humans
  • among the elderly, osteoarthritis (OA) is a
    leading cause of disability in developed
  • risk factors include age, major trauma,
    repetitive joint use, and obesity
  • highest quintile of BMI have RR for developing OA
    in the ensuing 36 years of 1.5 for males and 2.1
    for females

  • joints most commonly involved clinically include
    the metatarsophalangeal joint of the great toe,
    the hip joint, and the knee joint
  • disease is usually limited to either one joint or
    the same joint bilaterally, although more than
    one joint may be affected

Osteoarthritis Pain
  • joint pain has been described as a deep ache
    localized to the involved joint
  • usually OA pain is aggravated by use and relieved
    by rest
  • stiffness of the involved joint may occur on
    arising in the a.m. or after a period of
    inactivity (pain usually lasts ?20 minutes)

Osteoarthritis Pain
  • articular cartilage is aneural
  • joint pain may arise from stretching of nerve
    endings in the periosteum covering osteophytes
  • pain may arise from microfractures in the
    subchondral bone or from medullary hypertension
    caused by distortion of blood flow through
    thickened subchondral trabeculae

Osteoarthritis Pain
  • Synovitis may cause pain
  • phagocytosis of shards of cartilage and bone
    from the abraded joint surface or from cartilage
    release of soluble matrix macromolecules or
    crystals of calcium pyrophosphate or
  • immune complexes containing antigens derived
    from cartilage matrix may be sequestered in
    collagenous joint tissue

  • may have localized tenderness and bony or soft
    tissue swelling
  • bony crepitus, joint warmth, periarticular muscle
  • synovial effusions if present are usually not
  • gross deformity, bony hypertrophy, subluxation,
    and marked loss of joint motion

Radiographic Osteoarthritis
  • in early stages of OA the radiograph may be
  • joint space narrowing becomes evident as
    articular cartilage is lost
  • subchondral bony sclerosis
  • subchondral cysts
  • osteophytosis

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Radiographic Osteoarthritis
  • spur formation at the joint margins is a
    radiographic sign of OA, but spurring alone
    without joint space narrowing or clinical
    evidence of pain and swelling does not meet the
    criteria for OA of the knee

Knee Osteoarthritis
  • may involve medial or lateral femoratibial
    compartment and or patellafemoral compartment
  • varus (bow-leg) deformity (medial compartment)
  • valgus (knock-knee) deformity (lateral
  • shug sign- patellofemoral OA

Clinical Questions
  • Will running increase the risk for developing OA
    of the knees later in life?
  • Does exercise improve morbidity in older patients
    with known knee OA?
  • If yes, what type of exercise (aerobic or
    resistance training)?

Case Presentation I
  • 29 yo female with no sig PMHx trains for a
    marathon and continues running on average 15
    miles per week
  • PMHx above no h/o knee trauma/injury
  • Meds oral contraceptive pills, multivitamin
  • ROS negative
  • PE B/P110/70 HR60 RR14 wt128 lbs
  • wdwn, rrrømrg, bbs cta, no jt swelling,
  • no ttp, no crepitus

Case Presentation II
  • 92 yo female with longstanding h/o knee OA has
    daily pain in knees upon wakening in the a.m. and
    upon prolonged walking, stair climbing,
    entering/exiting vehicles
  • PMHx nsaid induced peptic ulcer disease,
    systolic htn, osteoporosis
  • Meds Tylenol XS, Celebrex, Cytotec, Atenolol,
    HCTZ, Fosamax, Calcium VitD

Case Presentation II cont.
  • ROS negative
  • PE B/P 150/80 HR75 RR18 wt140 lbs
  • wdwn elderly female nad
  • rrr I/VI sem LUSB
  • bbs, cta
  • knees bilat crepitus, genu valgus deformity

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The Relationship of Running to Osteoarthritis of
the Knee and Hip and Bone Mineral Density of the
Lumbar Spine A 9 Year Longitudinal Study
  • Nancy E. Lane, John W. Oehlert, Daniel A. Bloch,
    and James F. Fries
  • The Journal of Rheumatology 1998 252

Lane et al.
  • Objective
  • to determine the associations between running and
    radiographic hip OA, the progression of
    radiographic hip OA, the progression of
    radiographic knee OA, and changes in bone mineral
    density after a 9 year follow-up in 28 members of
    a running club aged 60-77 years and 27 nonrunner

Lane et al.
  • prospective 9 year longitudinal study
  • performed through the Stanford Arthritis Center
  • runners were obtained from the 50-Plus Runners
    Association and controls from the Lipid Research
    Clinic Study from the Stanford University

Lane et al.
  • all subjects underwent rheumatologic examination
  • bilateral weight bearing knee joint radiographs
    were taken in 1984, 1986, 1989, and 1993
  • 1984 and 1993 radiographs were compared for
    progression of OA

Lane et al.
  • Radiographs were scored in pairs by two readers
  • readers were blinded as to year of radiographs,
    name of subject, or group status
  • all joints were evaluated and scored as 0, 1, 2,
    or 3 for osteophyte formation, medial and
    lateral joint space narrowing, and subchondral

Lane et al.
  • Results
  • mean age of runners and nonrunners was 66 years
  • runners reported running 221 minutes per week in
    1984 but declined by 43 over a 9 year period to
    107 minutes per week
  • average miles run per week from 1984 to 1993
    declined 30 from 25.3 miles/wk to 17.9 miles/wk

Lane et al.
  • radiographic progression over the 9 year period
    for knee osteophytes showed a statistically
    significant increase of 178 in runners and 142
    in nonrunners
  • progression of joint space narrowing in the knee
    occurred in both groups over the 9 year study
  • this difference was significant in the nonrunner

Lane et al.
  • Multivariate analysis indicated that the
    following were associated with radiologic
    progression of knee OA
  • a high 1984 total knee radiographic score
  • a higher BMI
  • a faster pace per mile
  • female sex

Lane et al.
  • Conclusion
  • Runners averaging 66 years of age have
    not experienced accelerated development of
    radiographic OA of the knee compared to nonrunner

Lane et al.
  • Limitations
  • only 55 of the original 98 subjects were reported
  • possible selection bias using only healthy
    runners who could run regularly at age 55 years
    (a select group)
  • small sample size

  • Several animal models have been studied to
    determine the relationship between exercise and
  • Whether a correlation can be made between
    hamster, beagle dog, sheep, and rabbit models and
    humans is questionable.

Exercise Protects Against Articular Cartilage
Degeneration in the Hamster
  • Ivan G. Otterness, James D. Eskra, Marcia L.
    Bliven, Anne K. Shay, Jean-Pierre Pelletier, and
    A.J. Milici
  • Arthritis and Rheumatism 1998 41 11

Otterness et al.
  • Objective
  • To determine the effects of exercise on the
    composition of articular cartilage and synovial
    fluid and on the development of cartilage

Otterness et al.
  • Methods
  • 2.5 mo old group-housed hamsters were compared
    with 5.5 mo old hamsters that had undergone 3
    months of daily wheel running exercise (6-12
    km/day) or 3 mo of sedentary, individually housed

Otterness et al.
  • The condition of the femoral condyles was
    determined by SEM in 12 exercising hamsters, 12
    sedentary hamsters, and 6 controls.
  • The content of proteoglycan, hyaluronic acid,
    hydroxyproline and proline in synovial fluid and
    patellar cartilage was measured.

Otterness et al.
  • Results
  • by SEM the femoral articular cartilage was smooth
    and undulating in young controls and older
    exercising hamsters
  • femoral condyles were fibrillated in all 12
    sedentary hamsters

Otterness et al.
  • Results cont
  • no difference in the patellar cartilage content
    between the 3 groups, but the proteoglycan
    content and synthesis were lower in the patellar
    cartilage of the sedentary group
  • synovial fluid volume was decreased in the
    sedentary group compared with the young controls
    or older exercising hamsters

Otterness et al.
  • Conclusions
  • a sedentary lifestyle in the hamster leads to a
    lower proteoglycan content in the cartilage and a
    lower synovial fluid volume
  • theses changes are associated with cartilage
    fibrillation, pitting, and fissuring
  • daily exercise prevents early cartilage
    degeneration and maintains normal articular

Otterness et al.
  • Limitations
  • Applicability to humans?
  • Is muscle weakness resulting from lack of
    exercise contributing to the occurrence of
    cartilage degeneration in this model?
  • What are the long-term consequences of the
    cartilage fibrillation, pitting, and fissuring?

Long-Distance Running Causes Site-Dependent
Decrease of Cartilage Glycosaminoglycan Content
in the Knee Joints of Beagle Dogs
  • Jari Arokoski, Ilkka Kiviranta, Jukka Jurvelin,
    Markku Tammi, and Heikki J. Helminen
  • Arthritis and Rheumatism 1993 3610

Arokoski et al.
  • Objective
  • To study the effects of of a long-term (1 year)
    program of running exercise (up to 40 km/day) on
    the thickness and glycosaminoglycan (GAG) content
    of articular cartilage in the knee and humeral
    head cartilage of young dogs

Arokoski et al.
  • Methods
  • 20 beagle dogs separated into 10 in the control
    group and 10 in the experimental (runner) group
  • runner and control dogs had similar body weights

Arokoski et al.
  • exercise program was begun when runner dogs were
    15 wks old, using a treadmill with a 15º incline
  • running distance was gradually increased until
    the daily distance was 40 km/day
  • samples for histologic analysis were obtained
    from 12 different locations of the joints

Arokoski et al.
  • Conclusions
  • GAG depletion caused by 40 km/day running
    exercise is restricted to prominent
    weight-bearing areas of the joint and begins from
    the superficial cartilage without signs of
  • with time, the loss of GAG may affect the
    condition of articular cartilage

Arokoski et al.
  • Limitations
  • Applicability to humans?
  • Early degenerative changes vs. adaptation?

Effect of Prolonged Walking on the Joints of Sheep
  • Eric L. Radin, David Eyre, Jon L. Kelman, and
    Alan L. Schiller
  • Arthritis and Rheumatism 1979 22 649

Radin et al.
  • This study was performed secondary to veterinary
    literature suggesting that animals housed on
    cement floors were more prone to the development
    of osteoarthrosis than animals housed on dirt.

Radin et al.
  • Methods
  • 8 adult sheep were subjected to 4 hours per day
    of slow steady walking in a concrete floored
    circular chute
  • 4 control sheep were walked in a similar chute
    which had a floor of woodchips

Radin et al.
  • experimental animals were housed on tarmac
  • control animals were kept pastured
  • animals were sacrificed at 12, 18, 24, and 30

Radin et al.
  • Results
  • after 9 months, experimental sheep limped
  • serial x-rays showed calcification of knee and
    elbow ligaments, but no evidence of joint space
    narrowing, subchondral sclerosis, or osteophyte
  • mild to moderate cartilage fibrillation was
    present in the experimental sheeps knees and

Radin et al.
  • a significant decrease in hexosamine content was
    seen in weightbearing articular cartilage
  • hexosamine levels were unchanged in the
    non-weightbearing articular cartilage

Radin et al.
  • Conclusions
  • Prolonged repetitive impulsive loading has an
    effect both on weightbearing articular cartilage
    and on the architecture of its underlying bone.

The Effect of Running on the Osteoarthritic
Joint An Experimental Matched-Pair Study with
  • T. Videman
  • Rheumatology and Rehabilitation 1982 211

  • Objective
  • To examine the effects of teadmill running on
    experimentally produced unilateral osteoarthritis
    of the knee in a matched-pair study with rabbits

  • Methods
  • experimental OA was produced in the right hind
    limb of adult rabbits by an immobilization
  • mobility was estimated at the end of the follow
    up period after immobilization (5 to 18 mo)
  • assessment of radiographic changes from
    posteroanterior and side views was made

  • 12 nearly identical pairs with respect to
    mobility and radiographic stage were chosen after
    the follow up
  • 1 rabbit was randomly chosen from each pair to
    run on a treadmill 3x/day, 5days/wk, for 14 weeks
  • after 10 to 11 weeks, 2 pairs were excluded
    secondary to injury and death

  • the knee joints of 5 rabbits of both groups were
    studied histologically
  • the joint appearance of the other 5 pairs was
    recorded photographically
  • photos were assessed independently
  • tibia and femur were evaluated separately for
    degenerative changes

  • Results
  • No clear differences were found between the
    exercised and control groups of the study with
    respect to mobility measurements, radiographic
    and macroscopic examination.
  • No clear histological differences were found
    between groups.

  • Conclusions
  • Running neither made the OA joints healthy nor
    damaged them.
  • Joint motion did not increase the progression of
    OA in rabbits

  • Can we assume that there is an association
    between pain from osteoarthritis of the knee and
    radiographic features?

Association of Radiographic Features of
Osteoarthritis of the Knee with Knee Pain Data
from the Baltimore Longitudinal Study of Aging
  • Margaret Lethbridge-Çejku, William W. Scott, Jr.,
    Ralph Reichle, Walter H. Ettinger, Alan
    Zonderman, Paul Costa, Chris C. Plato, Jordan D.
    Tobin, and Marc C. Hochberg
  • Arthritis Care and Research 1995 83

Lethbridge-Çejku et al.
  • Objective
  • To examine the association between self reported
    knee pain and radiographic features of OA of the

Lethbridge-Çejku et al.
  • Methods
  • subjects were participants in the Baltimore
    Longitudinal Study of Aging, a multidisciplinary
    research project conducted at the Gerontology
    Research Center of the National Institute on

Lethbridge-Çejku et al.
  • participants were community-dwelling volunteers
    of middle class to upper middle class
    socioeconomic status
  • participants underwent biomedical, physiological,
    and psychological testing at biennial visits

Lethbridge-Çejku et al.
  • subjects completed questionnaires and underwent a
    standing radiograph of both knees at the same
    biennial visit between 1984 and 1989
  • questions included Have you ever had pain in and
    around your knee on most days for at least one
    month? and If yes, when did you last have this

Lethbridge-Çejku et al.
  • all knee radiographs were evaluated for the
    features of knee OA in 1992 and 1993 using the
    Kellgren-Lawrence grading system, and grading
    scales for features such as osteophytes, joint
    space narrowing, and subchondral sclerosis

Lethbridge-Çejku et al.
  • Kellgren-Lawrence grading system
  • 0normal
  • 1doubtful narrowing of joint space and
    possible osteophytic lipping
  • 2definite osteophytes and possible narrowing of
    joint space
  • 3moderate multiple osteophytes, definite joint
    space narrowing, and some sclerosis and possible
    deformity of bone ends
  • 4large osteophytes, marked joint space
    narrowing, severe sclerosis, and definite
    deformity of bony ends

Lethbridge-Çejku et al.
  • definite OA was a Kellgren-Lawrence grade of 2 or
  • each knee was also assigned a score of 0-3
    (absent-large) for the individual features of
  • joint space narrowing was graded 0-3
  • subchondral sclerosis scored 0 or 1 (absent or
  • BMI was calculated

Lethbridge-Çejku et al.
  • Results
  • Both ever never pain and current knee pain were
    significantly associated with the presence of
    definite knee OA (Kellgren-Lawrence grade ?2).
  • A direct relationship was found between all
    measures of severity of radiographic OA and knee

Lethbridge-Çejku et al.
  • Conclusion
  • Radiographic features of knee OA are
    significantly associated with knee pain.

Lethbridge-Çejku et al.
  • Limitations
  • subjects did not represent a random sample
  • no radiographs taken of the patellofemoral joint
  • only use of plain radiographs, not additional
    imaging studies
  • unable to explain the absence of pain in some
    subjects with definite knee OA

  • What about the risk of knee OA for runners
    compared to other sports?

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Knee Osteoarthritis in Former Runners, Soccer
Players, Weight Lifters, and Shooters
  • Urho M. Kujala, Jyrki Kettunen, Heli Paananen,
    Teuvo Aalto, Michele C. Battié, Olli Impivaara,
    Tapio Videman, and Seppo Sarna
  • Arthritis and Rheumatism 1995 384

Kujala et al.
  • Objective
  • To determine the relationship between different
    physical loading conditions and findings of knee

Kujala et al.
  • Methods
  • 117 male former top-level athletes (age range
    45-68 years)
  • all had represented Finland at least once between
    1920 and 1965 in Olympic games, in world or
    European Championships, or in intercountry
  • 28 former long distance runners, 31 soccer
    players, 29 weight lifters, 29 shooters

Kujala et al.
  • A history of lifetime occupational and athletic
    knee loading, knee injuries, and knee symptoms
    was obtained
  • Subjects were examined clinically and
    radiographically for knee findings of OA
  • BMI was calculated at age 20 years
  • Interview, clinical exams, and radiologic
    readings were performed independently
  • Investigators were blinded to results obtained by
    other methods

Kujala et al.
  • mean length of competitive involvement (minimum
    training 3x/wk) ranged from 9.8-14.5 yrs
    (individual range 2-36 yrs)
  • injuries were recorded in 3 runners, 12 soccer
    players, 6 weight lifters, and 1 shooter
  • injuries included 17 meniscal and ligamentous
    injuries, 1 contusion, 1 fracture, and 3
    undefined injuries

Kujala et al.
  • disability was scored for each knee
  • anteroposterior standing (weight-bearing) knee
    radiographs and lateral weight-bearing knee
    radiographs were obtained

Kujala et al.
  • Results
  • prevalence of tibiofemoral or patellofemoral OA
    based on radiographic exam was
  • 3 in shooters
  • 29 in soccer players
  • 31 in weight lifters
  • 14 in runners

Kujala et al.
  • The risk for knee OA was increased in
  • subjects with previous knee injury (OR 4.73, 95
    CI 1.32-17.0)
  • high BMI at 20 yoa (OR 1.76/unit of increased
    BMI, 95 CI 1.26-2.45)
  • previous participation in heavy work (OR
    1.08/work-year, 95 CI 1.02-1.13)
  • kneeling or squatting work (OR 1.10/work-year,
    95 CI 1.02-1.20)
  • subjects participating in soccer (OR 5.21, 95
    CI 1.14-23.8)

Kujala et al.
  • Conclusions
  • soccer players and weight lifters are at
    increased risk of developing premature knee OA
  • increased risk explained in part by knee injuries
    in soccer players and by high body mass in weight
  • running seems to be devoid of adverse effects
    leading to knee degeneration, compared with
    sports in which injuries frequently occur

Kujala et al.
  • Limitations
  • no female participants
  • limited number of subjects

Relationship of Running to Musculoskeletal Pain
with Age (A Six- Year Longitudinal Study)
  • James F. Fries, Gurkirpal Singh, Dianne Morfeld,
    Peter ODriscoll, and Helen Hubert
  • Arthritis and Rheumatism 1996 391

Fries et al.
  • Objective
  • To determine whether long-distance running,
    maintained for many years, is associated with
    increased musculoskeletal pain with age

Fries et al.
  • 2 main sequences which may contribute to poor
    musculoskeletal pain outcomes
  • 1) contemporary view of OA - patient
    characteristics, biologic factors, and risk
    factors such as obesity and injuries
  • 2) a larger set of risk factors, including
    sedentary lifestyle, obesity, injuries,
    psychological status, and other lifestyle factors

Fries et al.
  • Methods
  • participants were members of Fifty-Plus Runners
  • typical participant had run 16,869 miles over an
    average of 12.4 years prior to enrolling in study
  • Lipid Research Clinics Study from the Stanford
    University community provided controls

Fries et al.
  • 537 runners club members and 423 controls
  • all provided info on exercise history,
    musculoskeletal injuries, medical history, and
    dietary history
  • Stanford Health Assessment Questionnaire (HAQ)
    was completed annually
  • HAQ assesses function in 8 areas dressing and
    grooming, arising, eating, walking, hygiene,
    reach, grip, and activities

Fries et al.
  • each area of HAQ scored 0 to 3 (no difficulty
    to unable to perform)
  • disability index was obtained from averaged
    scores on each of the 8 functional areas
  • pain scale on HAQ no pain to severe pain
  • Have you ever had pain or stiffness in your
    muscles and joints in the past week? If yes, how
    severe has it been?

Fries et al.
  • Results
  • no progressive increase in joint pain or
    stiffness in heavily exercising individuals
    compared with more sedentary individuals over a 6
    year period from average age 60 to 66 years
  • morbidity associated with increasing age is
    decreased by regular exercise

Fries et al.
  • Limitations
  • pain variable is subjective
  • differences between the participant cohorts
    suggesting either self-selection into the runner
    group or beneficial effects from an average of 15
    years of running before 1987, or both

Is Running Associated with Degenerative Joint
  • Richard S. Panush, Carolyn Schmidt, Jacques R.
    Caldwell, Lawrence Edwards, Seldon Longley,
    Richard Yonker, Ella Webster, Janet Nauman, John
    Stork, Holger Pettersson
  • JAMA 1986 2559

Panush et al.
  • Objective
  • To compare populations of male runners and
    nonrunners to determine whether long-term,
    relatively high-mileage running was associated
    with premature degenerative joint disease in the
    lower extremities

Panush et al.
  • Methods
  • 35 male volunteers, all at least 50 yoa
  • runners ran a minimum of 32 km(20 mi)/wk for at
    least the past 5 consecutive years
  • nonrunners did not run daily and were within 10
    of their suggested normal body weight
  • nonrunners were sedentary except for one golfer
    and one who played tennis occasionally

Panush et al.
  • detailed questionnaire completed regarding
    medical history, musculoskeletal history, running
    history, and history of injuries related to
    running or other recreational activities
  • physical exam of lower extremities was completed
    by a rheumatologist
  • radiographs of hips, knees (standing
    anteroposterior and lateral views), and feet
  • exams and data analyses blinded

Panush et al.
  • Results
  • age, height, and weight were comparable for
    runners and nonrunners
  • runners had run a mean of 12 yrs and 44.8 km (28
    mi)/wk and had accumulated 27,749 mean lifetime
    km (17,343 mi)
  • 53 of runners were marathon runners

Panush et al.
  • Musculoskeletal histories and physical findings
    were comparable among runners and nonrunners
  • no statistically significant differences between
    groups except for internal rotation of the hip
    (runners had greater motion than nonrunners,
  • no statistically significant differences between
    groups regarding osteophytes, cartilage
    thickness, or grades of degenerative change in
    the lower extremity joints

Panush et al.
  • Conclusions
  • within the limits of this study, reasonably
    long-duration, high mileage running need not be
    associated with premature degenerative joint
    disease of the lower extremities
  • study suggests no discernible deleterious
    musculoskeletal consequences for individuals, at
    least into their 50s, who have averaged running
    12 yrs at 28mi/wk, including marathons

Panush et al.
  • Limitations
  • lack of female runners
  • data reflect observations at only a single point
    in time
  • possible self-selection bias

  • Should I advise my older patients who have
    osteoarthritis of the knee to exercise to improve
    their knee OA?
  • If so, what type of exercise should I suggest?
  • The FAST study has some answers.

A Randomized Trial Comparing Aerobic Exercise and
Resistance Exercise with a Health Education
Program in Older Adults with Knee Osteoarthritis
The Fitness Arthritis and Seniors Trial (FAST)
  • Walter H. Ettinger, Jr., M.D. Robert Burns,
    M.D. Stephen P. Messier, PhD. William
    Applegate, M.D. et al.
  • JAMA 1997 2771.

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Ettinger et al.
  • Study recognized OA as a common nonfatal
    condition, and as a cause of pain and activity
    limitations in older people
  • Authors also recognized that the goals of therapy
    are to reduce pain and improve disability and
    quality of life

Ettinger et al.
  • Objective
  • To determine whether two types of exercise
    (aerobic exercise and resistance exercise)
    improved self-reported disability, physical
    performance, and pain in older persons with
    physical disability from knee OA over an 18 month
  • Study performed 2º to questions about efficacy
    and safety of exercise for Tx of knee OA

Ettinger et al.
  • What types of exercise are most beneficial in
    reducing pain and disability in people with knee
  • Will older people with knee OA comply with
    longterm exercise programs?
  • What are the effects of exercise above and beyond
    the effects of patient education, attention, and
  • Are there benefits to exercise therapy beyond the
    psychosocial effects?
  • Is longterm exercise harmful to people with OA?

Ettinger et al.
  • Methods
  • randomized, single blind clinical trial lasting
    18 mo conducted at 2 academic medical centers
  • 439 community-dwelling adults, aged 60 yrs or
    older, with radiographically evident knee OA,
    pain, and self-reported disability
  • interventions included an aerobic exercise
    program, a resistance exercise program, and a
    health education program

Ettinger et al.
  • 1º outcome was self-reported disability score
  • 2º outcomes were knee pain score (1-6),
    performance measures of physical function, x-ray
    score, aerobic capacity, and knee muscle strength

Ettinger et al.
  • aerobic exercise training 3 mo facility based
    walking program, then a 15 mo home based walking
  • each aerobic session lasted 1 hour 3x/wk
  • 10 min warm-up (slow walking calisthenics)
  • 40 min stimulus (walking at 50-70 HR reserve)
  • 10 min cool-down (slow walking and 3 flexibility

Ettinger et al.
  • resistance exercise training 3 mo facility based
    program and 15 mo home based
  • resistance training session lasted 1 hour
  • 2 sets of 12 repetitions of 9 exercises 3d/wk for
    18 mo
  • 9 exercises leg extension, leg curl, step up,
    heel raise, chest fly, upright row, military
    press, biceps curl, pelvic tilt
  • weight increased in stepwise fashion as long as 2
    sets of 10 repetitions completed

Ettinger et al.
  • Health education group served as a comparison to
    the 2 exercise interventions
  • provided attention, social interactions, and
    education about OA
  • months 1-3, monthly one and a half hour education
    sessions led by a trained nurse
  • months 4-18, phone contacts about well-being and
    OA disease

Ettinger et al.
  • Follow-up data occurred at months 3, 9, and 18
  • 1º outcome of self-reported disability was
    measured using a questionnaire assessing
    difficulties with ADL using a Likert scale from 1
    (usually done with no difficulty) to 5 (unable to
  • 2º outcomes included physical performance
    testing, graded exercise treadmill test and
    oxygen uptake, strength testing, knee x-rays,
    rating knee pain

Ettinger et al.
  • Results
  • 117 subjects completed aerobic exercise training
  • 120 completed resistance exercise training
  • 127 completed health education program
  • 6 adverse events occurred
  • participants in aerobic exercise and resistance
    exercise groups reported less disability than
    those in education group

Ettinger et al.
  • After 18 months in the trial, there was a 10
    difference in the summary disability score
    between health education group and aerobic
    exercise group (plt.001).
  • After 18 months, an 8 difference in the summary
    disability was seen between the resistance
    training group and health education group

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Ettinger et al.
  • Conclusions
  • Older people with symptomatic knee OA who
    participated in an aerobic or resistance exercise
    program had modest but consistent improvements in
    self-reported pain and disability and better
    scores on performance measures of function
    compared with those in the health education

Ettinger et al.
  • Conclusions
  • Exercise is beneficial for a large segment of the
    older population with knee OA
  • Moderate exercise does not worsen OA
  • Longterm compliance may be more important than
    the type of exercise performed in achieving
    health benefits of exercise in older disabled

Ettinger et al.
  • Limitations
  • lack of complete compliance over 18 months

  • Animal models show conflicting data concerning
    exercise and the risk for OA.
  • The reviewed studies performed in humans show no
    increased risk for runners in developing OA of
    the knees when compared with controls.
  • Older individuals with knee OA (not endstage)
    benefit from exercise (aerobic walking exercise
    and resistance training).

What to look for
  • (Arthritis, Diet and Activity Promotion Trial)
  • an ongoing 2 year single blind randomized
    clinical trial researching whether weight loss
    alone or in addition to exercise improves pain
    and physical function in knee OA

  • Dr. Richard Loeser, Dept. of Rheumatology
  • Dr. Michael Pursley, husband extraordinaire

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