If your knee hurts, keep exercising, says expert

If you take up exercise later in life, as a treatment for joint or hip pain, you should expect a small, temporary increase in pain.[2] But if you proceed sensibly, you will be rewarded with pain relief similar [5] to that of a non-steroidal anti-inflammatory drug, such as ibuprofen, and twice [1] that of a non-prescription painkiller, such as paracetamol. In fact, the pain relief from taking up exercise is large enough that many people put their knee or hip surgery on hold.[7]

Participants in the Danish GLA:D study. The Conversation

Ewa M Roos, The Conversation March 20, 2018

Physical activity is important for good health and is prescribed by doctors to treat a range of diseases, including diabetes and cardiovascular disease. But many people don’t follow this advice because of aching joints and the fear that exercise may harm these joints.

Paradoxically, the last 20 years of research has found that exercise is a good pain reliever.[5] Today, exercise is recommended [1] worldwide as a treatment for painful joints in middle-aged and older people. However, recommending is one thing. Putting this recommendation into practice is something else altogether.

Most people experience a 10% pain increase [2] when they start to exercise – some experience more, others less. This is not a warning sign but the body signalling that you are doing something you are not used to. Our bodies, including bone, muscle and cartilage are great at adapting and their quality improves [3] when we exercise.

How much pain relief you will get depends on how much exercise you do. In our study [4] of 10,000 people with knee and hip osteoarthritis, we found that people who exercised twice a week for six weeks experienced 25% pain relief,[4] on average.

Earlier research also shows that people who exercise in groups, supervised by a physiotherapist, experience greater pain relief [5] than those who exercise at home, unsupervised. Reasons for this difference may be that we work harder and dare to do more when guided by a physiotherapist with specialist knowledge.

To get the most from exercise, you should feel short of breath, or sweat a little, and increase the level of difficulty of the exercises as your body gets stronger.

Two simple rules

You can exercise safely by following two simple pain rules.[6] One, the pain you experience after exercise should be at a level that is tolerable. And, two, you shouldn’t experience any increase in pain from day to day.

Pain should be assessed daily after exercise on a zero-to-ten scale. On this scale, zero to two is considered “safe”, two to five “acceptable”, and five to ten “avoid”.

Let’s say your usual pain is three, and after exercising you rate it five. That’s fine. If your usual pain is three and after exercising you rate it a seven, you have done too much and should cut back the next time.

If your pain goes up to five after exercising, but the next morning is back at three – your usual morning pain – that’s fine. If your pain goes up to five after exercising, and is still at four or five the next morning (that is, more than your usual morning pain), you have done too much and should cut back. Keep at it, but at a lower level.

Exercising with arthritis

Interestingly, our research shows that it is safe to exercise with severe arthritis. When people with severe or bone-on-bone arthritis followed these two simple pain rules, 95% of all exercise sessions [6] were performed with acceptable pain, and pain was relieved after a few weeks.

In a recent study,[7] we enrolled people with mostly severe arthritis who fulfilled all the criteria to have a knee replacement op. All the participants received information on arthritis and its treatments, including self-help advice. They also took part in supervised exercise sessions twice weekly for eight weeks, and saw a dietitian if they were overweight.

Half of the participants were randomised to have their knee replaced. Among those not having their joint replaced immediately, only a quarter [7] chose to have their joint replaced within a year. In other words, the pain relief that people experienced as a result of the exercise was enough for three-quarters of the participants to delay surgery for at least a year.

Exercise, especially when supervised, provides effective pain relief, but requires physical effort and sweat. Passive treatments, such as manual therapy, deep tissue massage and muscle stretches, given by a physiotherapist, doesn’t seem to work for people with hip [8] or knee pain.[9]

Ewa M Roos
Professor of Muscle and Joint Health, University of Southern Denmark
Disclosure statement
Ewa M. Roos receives funding from Swedish Research Council, EU, EIT Health and a number of smaller national funds including the Swedish and Danish Rheumatism Associations, Health Care Regions Skåne and Southern Denmark.

Source The Conversation


The Conversation

Professor Ewa Roos from Denmark discusses the strong evidence for exercise in helping people with hip and knee arthritis and how a successful program was developed in Denmark. La Trobe Sport and Exercise Medicine Research Centre is now happily assisting physiotherapists in Australia to provide the same program – GLA:D Australia. TREK Group. Youtube Jan 4, 2017

1. OARSI guidelines for the non-surgical management of knee osteoarthritis, McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM, Hawker GA, Henrotin Y, Hunter DJ, Kawaguchi H, Kwoh K, Lohmander S, Rannou F, Roos EM, Underwood M. Osteoarthritis Cartilage. 2014 Mar;22(3):363-88. doi: 10.1016/j.joca.2014.01.003. Epub 2014 Jan 24.

2. Pain trajectory and exercise-induced pain flares during 8 weeks of neuromuscular exercise in individuals with knee and hip pain, Sandal LF, Roos EM, Bøgesvang SJ, Thorlund JB. Osteoarthritis Cartilage. 2016 Apr;24(4):589-92. doi: 10.1016/j.joca.2015.11.002. Epub 2015 Nov 10.

3. Positive effects of moderate exercise on glycosaminoglycan content in knee cartilage: a four-month, randomized, controlled trial in patients at risk of osteoarthritis, Roos EM, Dahlberg L. Arthritis Rheum. 2005 Nov;52(11):3507-14.

4. Good Life with osteoArthritis in Denmark (GLA:D™): evidence-based education and supervised neuromuscular exercise delivered by certified physiotherapists nationwide, Skou ST, Roos EM. BMC Musculoskelet Disord. 2017 Feb 7;18(1):72. doi: 10.1186/s12891-017-1439-y.

5. Exercise for osteoarthritis of the knee, Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Cochrane Database Syst Rev. 2015 Jan 9;1:CD004376. doi: 10.1002/14651858.CD004376.pub3.

6. Feasibility of neuromuscular training in patients with severe hip or knee OA: the individualized goal-based NEMEX-TJR training program, Ageberg E, Link A, Roos EM. BMC Musculoskelet Disord. 2010 Jun 17;11:126. doi: 10.1186/1471-2474-11-126.

7. A Randomized, Controlled Trial of Total Knee Replacement, Skou ST, Roos EM, Laursen MB, Rathleff MS, Arendt-Nielsen L, Simonsen O, Rasmussen S. N Engl J Med. 2015 Oct 22;373(17):1597-606. doi: 10.1056/NEJMoa1505467.

8. Effect of physical therapy on pain and function in patients with hip osteoarthritis: a randomized clinical trial, Bennell KL, Egerton T, Martin J, Abbott JH, Metcalf B, McManus F, Sims K, Pua YH, Wrigley TV, Forbes A, Smith C, Harris A, Buchbinder R. JAMA. 2014 May 21;311(19):1987-97. doi: 10.1001/jama.2014.4591.

9. Physical therapy vs internet-based exercise training for patients with knee osteoarthritis: results of a randomized controlled trial, Allen KD, Arbeeva L, Callahan LF, Golightly YM, Goode AP, Heiderscheit BC, Huffman KM, Severson HH, Schwartz TA. Osteoarthritis Cartilage. 2018 Mar;26(3):383-396. doi: 10.1016/j.joca.2017.12.008. Epub 2018 Jan 5.

  Further reading

A consensus-based process identifying physical therapy and exercise treatments for patients with degenerative meniscal tears and knee OA: the TeMPO physical therapy interventions and home exercise program, Clare E. Safran-Norton, James K. Sullivan, James J. Irrgang, Hannah M. Kerman, Kim L. Bennell, Gary Calabrese, Leigh Dechaves, Brian Deluca, Alexandra B. Gil, Madhuri Kale, Brittney Luc-Harkey, Faith Selzer, Derek Sople, Peter Tonsoline, Elena Losina & Jeffrey N. Katz. BMC Musculoskelet Disord 20, 514 (2019) doi:10.1186/s12891-019-2872-x. Full Text

The TeMPO trial (treatment of meniscal tears in osteoarthritis): rationale and design features for a four arm randomized controlled clinical trial, Sullivan JK, Irrgang JJ, Losina E, Safran-Norton C, Collins J, Shrestha S, Selzer F, Bennell K, Bisson L, Chen AT, Dawson CK, Gil AB, Jones MH, Kluczynski MA, Lafferty K, Lange J, Lape EC, Leddy J, Mares AV, Spindler K, Turczyk J, Katz JN. BMC Musculoskelet Disord. 2018 Dec 1;19(1):429. doi: 10.1186/s12891-018-2327-9. Full text

Effects of quadriceps functional exercise with isometric contraction in the treatment of knee osteoarthritis, Huang L, Guo B, Xu F, Zhao J. Int J Rheum Dis. 2018 May;21(5):952-959. doi: 10.1111/1756-185X.13082. Epub 2017 May 25.

Effects of neuromuscular training (NEMEX-TJR) on patient-reported outcomes and physical function in severe primary hip or knee osteoarthritis: a controlled before-and-after study, Ageberg E, Nilsdotter A, Kosek E, Roos EM. BMC Musculoskelet Disord. 2013 Aug 8;14:232. doi: 10.1186/1471-2474-14-232. Full text

Also see
Got osteoarthritis? Get moving Medical Xpress
Quadriceps exercise relieves pain in knee osteoarthritis Medical Xpress
Building a Walking Workout Arthritis Foundation
Physical Activity for Arthritis Centers for Disease Control and Prevention
A new way to treat knee and hip osteoarthritis in the Hunter The Newcastle Herald
National strategy launched to improve osteoarthritis care 9News.com.au

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