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Arthritis and Exercise: the Essentials

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Arthritis and Exercise: the Essentials Arthritis and Exercise THE ESSENTIALS The role, benefits and outcomes of exercise for hip and knee osteoarthritis and rheumatoid arthritis Arthritis and Exercise: The Essentials ABSTRACT Objective The paper was drafted by members of the Both in Australia and worldwide, Arthritis Australia’s Expert Advisory Panel, osteoarthritis and rheumatoid arthritis and reviewed and revised by all panel are major causes of disability and chronic members until consensus was reached. pain. Research has established exercise as Arthritis Australia’s Board, Scientific Advisory a safe and recommended treatment for Committee and Affiliate Healthy Lifestyle these arthritides. Despite evidence and Coordinators all reviewed the paper and clinical guidelines, both consumers and provided further input. health practitioners report confusion and uncertainty around the prescription of, and Results participation in, exercise. Five core components of effective exercise The purpose of this paper is to programs were identified and explored: provide clear, evidence-based practical assessment; education; exercise prescription; recommendations about the role of exercise monitoring and reporting; and behaviour in the management of osteoarthritis change strategies. Evidence for each and rheumatoid arthritis as a guide for was reviewed, summarised and practical consumers, health professionals and recommendations made. exercise & fitness professionals. These recommendations will also underpin the development of criteria that can be used Conclusions to evaluate whether current and proposed Substantial evidence supports the key role community exercise programs are suitable of exercise in the successful management of for people with these arthritides. osteoarthritis and rheumatoid arthritis. By compiling evidence-based recommendations Methods on exercise for these forms of arthritis, this Arthritis Australia established an expert document provides a national resource for advisory panel to guide the process. A consumers, health professionals and exercise narrative review of current literature was & fitness professionals to guide exercise conducted, focusing on Cochrane and prescription and evaluate whether current systematic reviews including meta-analysis of and proposed community exercise programs results available up to April 2014. are suitable for people with arthritis. ARTHRITIS AND EXERCISE 3 THE ESSENTIALS Index Arthritis and Exercise: The Essentials 3 Abstract 3 Introduction 5 1. Arthritis: The magnitude of the problem 5 2. The role of exercise for arthritis 6 3. Core principles of exercise prescription 8 4. Core components of exercise prescription 8 4.1 Assessment 8 4.2 Education 10 4.3 Exercise prescription 13 4.4 Monitoring and reporting 18 4.5 Behaviour change strategies 18 Conclusion 19 References 20 Appendix A 23 Appendix B 24 Appendix C 25 Appendix D 26 Appendix E 27 Expert Advisory Panel 29 ARTHRITIS AND EXERCISE 4 THE ESSENTIALS Arthritis and Exercise: The Essentials Introduction of preventing and managing arthritis and improving the quality of life for people living Put simply, exercise is good for arthritis. with the condition. The strength of the evidence comes in various levels but there is no doubt that people with arthritis can experience improvements in their 1. Arthritis: The magnitude of condition and overall wellbeing by participating the problem in regular, appropriate exercise. Worldwide, arthritis is a major cause of disability Yet significant confusion about the benefit and and chronic pain. In Australia in 2012 there safety of exercise for people with arthritis still were an estimated 6.1 million people with exists within the community, reflected in the arthritis and other musculoskeletal conditions, large number of exercise-related calls to our of which 1.9 million have osteoarthritis (OA) national Arthritis Helpline. Health consumers and 0.5 million have rheumatoid arthritis (RA). frequently report fear of exacerbating This prevalence is predicted to rise substantially, symptoms, and a lack of knowledge about particularly for OA, as the population ages what to do and how to get started, ultimately and rates of obesity increase [2]. By 2032 resulting in lower than optimal levels of physical it is projected that 8.7 million Australians activity. Australian GPs have also told us, via our will have arthritis and other musculoskeletal Voice of GP survey [1], that they lack confidence conditions, an increase of 43% [2]. Arthritis and in prescribing the most appropriate exercise for musculoskeletal conditions have been identified their patients who have arthritis. Recognising by the Australian Government as a National this uncertainty, Arthritis Australia has worked Health Priority Area since 2002 [2]. with a group of experts to bring together this Osteoarthritis and RA can both be extremely guide for consumers, health professionals and debilitating, with pain and physical dysfunction exercise & fitness professionals. leading to significant loss of quality of life. Its purpose is to provide clear, evidence- People with OA and RA report pain, difficulty based recommendations about the role of performing activities of daily living, sleep exercise in the prevention of arthritis and problems and fatigue. They present with ongoing management of individuals with the a range of physical impairments including condition. These recommendations will drive joint stiffness, muscle weakness, altered the development of criteria that can be used proprioception, reduced balance and to evaluate whether current and proposed gait abnormalities. In addition to these, community exercise programs are suitable for psychological impairments such as depression people with arthritis. and anxiety are common. There is no cure for hip or knee OA, and joint replacement surgery We hope that by pulling together this is a costly treatment option reserved for severe information we can offer a significant disease. The direct health care cost of OA opportunity for the fitness industry to link and RA combined in Australia in 2012 was with health sector professionals such as estimated at $4.25 billion. In addition to this physiotherapists and exercise physiologists. For cost is the significant loss of productivity, carer these allied health professionals we believe costs, travel costs and aids [2]. that creating and strengthening referral pathways into suitable evidence-based exercise programs will greatly assist the overall objective ARTHRITIS AND EXERCISE 5 THE ESSENTIALS 2. The role of exercise for cure for RA. Clinical guidelines recommend arthritis regular participation in exercise alongside pharmacological treatments [12-15]. Exercise Exercise: any physical activity that is planned, therapy is likely to have a role in combating structured, repetitive, and purposeful in the the adverse effects of RA on muscle strength, sense that the improvement or maintenance of endurance and aerobic capacity. British one or more components of physical fitness is Rheumatology Guidelines [13] conclude that the objective. This activity can be supervised or exercise is effective not only in improving unsupervised, as well as prescribed, advised or function but also in reducing the rate of bone [3] self-initiated . loss and the risk of cardiovascular disease. All current clinical guidelines [4-8] recommend However, while exercise is recommended for exercise in the management of hip and RA, the evidence base is still relatively limited knee OA, irrespective of patient age, joint (Table 1). For example, the Royal Australian involved, radiographic disease severity, pain College of General Practitioners Guidelines for intensity, functional levels and co-morbidities. RA rate the level of evidence to support the Results of systematic reviews evaluating the role of exercise in early RA as Level C meaning effects of exercise are shown in Table 1. A that there is some evidence but that care recent systematic review incorporating a trial should be taken in its application [12]. A 2009 sequential analysis and network meta-analysis Cochrane review of dynamic exercise programs found that since 2002 sufficient evidence has (aerobic training and/or strength training) been accrued to show the significant benefits in patients with RA, which included 8 trials of exercise interventions over no exercise (575 participants), concluded that there was control for lower limb OA [9]. However, most moderate quality evidence that aerobic training of the evidence about the effects of exercise combined with muscle strengthening had a relates to osteoarthritis at the knee with fewer positive effect on aerobic capacity, functional trials investigating osteoarthritis at the hip. A ability and muscle strength [16]. The effect of recent Cochrane review of exercise for OA of exercise has not been investigated in early RA the hip found both slight reduction in pain and and can only be extrapolated from results in improved physical function both immediately established RA [12]. [10] after intervention, and 3-6 months later . Ten The main goals of exercise in both patients high-quality studies were included in the review, with OA and with RA are to reduce pain, and the effect sizes were considered small for improve physical function and optimise both improvements. Exercise interventions are participation in social, domestic, occupational [11] often not well described in study reports . and recreational pursuits [17, 18]. Regular Given the difficulty in designing a realistic exercise can improve physical impairments sham for exercise
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