~ ~ ~ ~ ~ ~ ~ ~~~

OSTEOARTHRITIS 0889-857)</99$8.00 + .OO

EXERCISE IN THE TREATMENT

OF OSTEOARTHRITIS
Marian A. Minor, PT, PhD

Exercise may be the most effective, malleable, and inexpensive

modality available to achieve optimal outcomes for people with osteo-
thritis (OA). Exercise, in a variety of forms, has proved to be integral in
(1) achieving therapeutic goals,12,14, 15, 17, 33, 41, 55 (2) improving general
health and reducing secondary disability14,41 and (3) modifying possible
risk factors in disease progre~sion.'~,27, The potential benefits of appro-
priate exercise in the treatment of OA span the process of potential
disablement in this disease (Fig. 1).Despite the evidence supporting this
accessible and economic modality, most rheumatologic recommenda-
tions for management of OA provide detailed discussions of pharmaco-
logic and surgical interventions, while mentioning in only general terms
"physical therapy and exercise" or "rehabilitation" as additional treat-
ment options. In order to explicate the use and effectiveness of exercise
in OA, this article presents the rationale for use of the three major
categories of exercise-range of motion (ROM)/flexibility, strength, and
aerobic/cardiovascular exercise-in the treatment of OA.
People with OA receive exercise recommendations from health care
providers and exercise professionals in clinical and community-based
settings. Physical and occupational therapists prescribe therapeutic exer-
cise to reduce pain, irnpairment~,4~* 62 and improve function. Health/
fitness instructors, and now the Public Health Service47, recommend
programs of exercise and physical activity to promote health and physi-
cal fitness. The goals, benefits, and contents of the exercise programs
from both sources often overlap; distinctions blur as certified fitness

From the Department of Physical Therapy, School of Health Related Professions, School
of Medicine, University of Missouri, Columbia, Missouri

RHEUMATIC DISEASE CLINICS OF NORTH AMERICA

VOLUME 25 * NUMBER 2 * MAY 1999 397

398 MINOR

cartilage degeneration Pain fatigue Usocial activity

bony stiffening stifhess nADL’s nquality of life
bony sclerosis weakness aphysical activity cv de-conditioning
osteophytes joint instability poor sleep uhealth risks
joint effusion loss of motion depression inactivity
muscle weakness nempioyment

Impairment Functional Disability

Pathology ~

- Limitation -
t t t t
D cartilage nutrition/ a pain uwalking speed ohealth status
remodeling Ostrengthiendurance ugait Dphysical fitness
D synovial blood flow D ROM @L oquality of life
a swelling u CT elasticity nphysical activity social activity
osteophytes (?) odepression, anxiety
shock attenuation
R muscle strength

professionals engage in exercise testing and prescription, and therapists

move into community settings.
Many people with OA can succeed in community exercise programs
with guidance from a knowledgeable and experienced instructor on
site. For others, professional consultation with a knowledgeable health
professional can be a crucial first step in the development and adoption
of a safe and effective exercise habit. Undoubtedly, the best interests of
the person with OA are served when the exercise experience arises from
the melding of knowledge of the disease, rehabilitation, kinesiology,
exercise physiology, and exercise behavior in an accessible, enjoyable,
and affordable setting. Such collaboration provides a supportive environ-
ment in which the person with OA can experience success and learn to
maintain self-directed regular exercise and appropriate physical activity.
The goals of this article are to provide information about the pur-
pose, effectiveness, and content of a variety of exercise modalities that
benefit people with OA, and to persuade the reader of the value of
exercise recommendations, monitoring, and follow-up to promote health
and reduce the impact of OA. Because hip and knee OA are the major
disabling diagnoses and have been the focus of OA exercise research, the
majority of current evidence speaks to these two conditions; however,
information about exercise in spinal arthritis, when available, will also
be presented.
 EXERCISE IN THE TREATMENT OF OSTEOARTHRITIS 399

THERAPEUTIC EXERCISE

Traditionally, therapeutic exercise is an exercise program provided

by a physical or occupational therapist, based on individualized assess-
ment, and designed to meet specific treatment-related goals in the do-
mains of impairment or functional limitation (see Fig. 1). The patient
carries out the regimen in a clinical setting with supervision (individual
or group), or in an unsupervised home program. Good practice requires
periodic review of the patient's status and revision of the exercise pro-
gram as needed. Most frequently, treatment goals are to: reduce impair-
ments in strength, range of motion, flexibility and/or endurance; reduce
pain; improve or maintain function; protect joints from further damage;
and prepare the individual to safely participate in more vigorous or
prolonged physical activity or aerobic exercise. Treatment includes mus-
cle conditioning for increased strength and endurance, range of motion
and flexibility exercises, as well as accompanying instructions in posture,
positioning, joint protection, and use of external devices (canes, orthot-
ics). Therapeutic exercise provided by a health professional also may
include assessment and prescription of cardiovascular/endurance activi-
ties in addition to the traditional musculoskeletal focus.

PHYSICAL ACTIVITY AND EXERCISE FOR HEALTH

AND PHYSICAL FITNESS

The concept of exercise prescription and physical fitness, specifically

cardiovascular fitness, was first employed medically by exercise physiol-
ogists in cardiac rehabilitation programs. Exercise is prescribed to
achieve cardiovascular goals such as decreased heart rate, increased
stroke volume, higher levels of high-density lipoprotein (HDL) and
lower levels of low-density lipoprotein (LDL) cholesterol, lower triglyc-
eride levels, and reduction in hypertension. The American College of
Sports Medicine (ACSM) has been a key professional organization in
furthering the science and application of exercise physiology principles
in cardiopulmonary rehabilitation and disease prevention.
The ACSM provides certification and continuing education, funds
research, publishes books and a scientific journal, issues official stands
on a variety of exercise and fitness related topics, and supports the
National Coalition for Promoting Physical Activity (NCPPA). Cardiac
rehabilitation programs and many community-based health and fitness
facilities employ ACSM-certified staff and follow ACSM policies and
procedures, including the recommendations for physical activity for
health and conditioning exercise for physical fitness. The ACSM recom-
mends that individuals exercise at an intensity of 60% to 80% of their
age-predicted maximal heart rate (220 - age = age-predicted maximal
heart rate) for 30 to 60 minutes, 3 to 5 days a week.47The greater the
intensity, the less duration and frequency required. Recommendations
for physical activity to promote health have been published by the
400 MINOR

Surgeon General of the United States.62Within these broad guidelines,

the challenge for each person is to determine the proper exercise mix,
taking into consideration individual needs and limitations.
There also is growing recognition in the exercise and sports medi-
cine community that health and fitness are achievable with a less intense
regimen than previously thoughP7, and that this level of activity is
important and feasible for people with a variety of chronic and disabling
conditions. For example, A C S M S Guide to Exercise Testing and Prescription
for People with Chronic Diseases and Disabilities' was published in 1997.
This volume contains guidelines for exercise testing and training for
people with a variety of chronic and disabling conditions including
diabetes, cerebral palsy, spinal cord injury, Parkinsonism, multiple sclero-
sis, and arthritis. An adequate level of habitual physical activity for all
people, including people with arthritis, has become a public health prior-
ity.

THERAPEUTIC EXERCISE INTERVENTIONS

The person with OA seeks care when pain is severe or when

function is compromised. Attention is directed to the affected joint or
joints and treatment, which often includes medication, heat or cold, and
therapeutic exercise, is initiated. Of all the physical interventions, exer-
cise is the most effective nonpharmacologic modality for reduction of
joint pain and impairments.8, 5o However, improvement in function
and general health require more than a single joint approach. OA in one
joint is a multiple-joint problem; range of motion and strength deficits
are generally found in adjacent joints and bilaterally. For example, the
ankle, which is rarely a site of OA, commonly demonstrates limited
motion and strength in patients with knee OA. Lower extremity pain
and decreased motion result in gait deviations that include diminished
push-off, decreased limb loading at heel strike, and a reduction in range
of motion of the ankle.29,39 Such gait deviations lead to deconditioning
of calf musculature and loss of motion at the ankle. Adequate motion,
strength, endurance, and power at the ankle are crucial for gait, balance,
stair climbing, and arising from a chair. These attributes are quickly lost
with the onset of hip or knee pain and stiffness.
Lower extremity impairments have been linked to the reduced
ability of older adults to use public transportation and climb stairs:
perform household chores, and shop and engage in leisure activities."
These impairments progress, often unnoticed, until pain and loss of
function have become pronounced and disability is e~ident.2~ The long-
term consequences of lower extremity impairments have been docu-
mented in longitudinal studies in which baseline lower extremity joint
impairment or self-reported pain contributed significantly to future dis-
ability status.26*
30
 EXERCISE IN THE TREATMENT OF OSTEOARTHRITIS 401

RANGE OF MOTION/FLEXIBILITY

A consistent finding with respect to lower extremity range of motion

in subjects with unilateral OA of the knee is decreased range of motion
of the hip and ankle, as well as the knee, of the involved limb, and
significantly limited motion of all three joints in the uninvolved contra-
lateral limb. When older persons with knee OA were compared to non-
arthritic controls, range of motion of all joints in both lower limbs was
dimini~hed.~~, 39 OA of the hip commonly results in decreased range of
motion, with a tendency for the hip to be held in a somewhat flexed,
abducted, and externally rotated position, with the knee in flexion.
Bergstrom et a1 reported that hip motion was limited in 84% of the
individuals who had lower extremity complaint^.^ Decreased hip range
of motion is associated with pain, loss of function, limitations in physical
a~tivity:~decreased walking speed, decreased stride length, and in-
creased energy expenditure." A maximum walking speed of only 3 kph
(1.8 mph) is common with hip OA and decreased hip m0tion.2~Loss of
knee extension reduces walking efficiency, and knee flexion limited to
90 degrees interferes with using stairs, or transferring to a toilet or bath
tub.2Moreover, decreased range of motion at the hip and knee increases
the risk for injury and falls. To recover balance from a stumble during
walking, the individual must be able to rapidly produce, while weight-
bearing, nearly 50 degrees of hip flexion and 90 degrees of knee flexion.*l
Joint motion is also chondroprotective. Cartilage requires regular
motion with compression and decompression for adequate nutrition and
to stimulate remodeling and repair.7*9, 25 Prolonged immobilization and
avoidance of weight-bearing result in cartilage atrophy. Daily exercise
that includes complete active range of motion and periods of weight-
bearing and nonweight-bearing is the optimal prescription for mainte-
nance of cartilage ~iability.~, 9, 25 During periods when weight-bearing
is temporarily contraindicated or when immobilization of the joint is
necessary, there is evidence that provision of the alternate activity (i.e.,
either weight-bearing or joint motion) will help to maintain cartilage
health.25An interesting relationship between regular joint motion and
osteophyte development was suggested by a study that reported in-
creased osteophyte formation at the knees of persons who stopped
running compared to those who continued to run.Those who stopped
running did so for reasons other than joint pain or stiffness.4o
Adequate flexibility and elasticity in periarticular soft tissues also
are important in protecting the joint from damaging stress. In a series of
studies designed to determine the relative shock-attenuating properties
of articular cartilage, synovial fluid, periarticular soft tissue, and bone,
it was demonstrated that the compliance of these tissues decreased the
peak impact load on joints. The components that contributed signifi-
cantly to this attentuation were the joint capsule, ligaments, synovial
tissue, and bone. Although it is often assumed that cartilage is the most
important component, these studies showed that articular cartilage and
synovial fluid had little effect on shock atten~ation.~~ It appears that, to
402 MINOR

some degree, joints can be protected from damaging peak forces by

maintaining or improving the compliance of periarticular soft tissue (i.e.,
joint capsule and periarticular ligaments). Muscle is also a significant
mechanism for shock absorption, as discussed below.
Adequate joint ROM and soft tissue flexibility are central to comfort,
safety, and function, and stretching or flexibility exercises are a key
element in exercise programs for people with OA. A therapeutic exercise
program with increased range of motion as a specific goal includes, but
is not limited to, stretching and flexibility exercises. Strengthening and
endurance exercises are incorporated to help achieve and maintain mo-
tion and increase function. Exercise studies that have measured range of
motion show that increased motion may be achieved with an active
exercise routine, and is associated with improvements in pain and
55 For example, the low intensity, recreational 6-week Arthritis
Foundation group aquatic program has been shown to increase hip
ROM.58A blanket recommendation to stretch is not advisable, however.
Involved joints which are lax, vulnerable to injury due to effusion, or
which are deformed or malaligned are easily overstretched and should
be protected.

MUSCLE STRENGTH

In a descriptive study of persons with knee OA, diminished lower

extremity strength was clearly associated with increased disability? In
the presence of knee OA, knee extension strength declines in both the
affected and unaffected knee. Static and dynamic strength deficits of up
to 60% and marked functional limitation have been demonstrated.16,35
A study investigating knee joint motion, strength, and gait in older
persons who had undergone unilateral total knee arthroplasty 1 year
previously found significant impairments in lower-extremity range of
motion, muscle performance, and gait even in individuals who were
considered to be “rehabilitation successes.” During walking, active knee
range of motion was less than expected, range of motion and angular
velocity of knee and hip were less on the affected side and greater on
the unaffected side, and joint loading was less at heel strike on the
affected side and greater and more rapid on the unaffected side. Push-
off, gait velocity, and stride length were diminished bilaterally in the
joint replacement group.29Therapeutic programs to strengthen knee
extension and flexion have resulted in significant strength gains as
well as decreased pain and improved function.s,15, 55 Strengthening
170

programs, which include hips, knees, and ankles’” 15, 32 or use resistance
in regimens that include variable dynamic and static training15,l7 have
resulted in improvements in strength and significant improvements in
functional areas, such as balance, gait, and independence.
One of the most interesting findings related to knee strength and
OA is that deficits in strength of knee extensors occur among women
with radiographic knee OA even in the absence of a history of pain and
 EXERCISE IN THE TREATMENT OF OSTEOARTHmIS 403

that the weakness is not necessarily associated with muscle atrophy.57

The authors of this study suggested that knee extensor weakness may
be owing to muscle dysfunction associated with OA, and that it is a
possible risk factor for the initiation and progression of knee OA. The
phenomenon of arthrogenous muscle inhibition (AMI), resulting in dimi-
nution of the strength of voluntary contraction of muscles acting across
the involved joint, may partly explain knee extensor weakness in OA.
AM1 has been demonstrated with joint effusions as well as in patients
with OA without effusions or painz7Early onset muscle weakness and
AM1 may be important factors in OA progression by causing decreased
joint stability, poorly coordinated neuromuscular reflexes, and early on-
set fatigue in lower extremity musculature.
The importance of shock attenuation in protecting cartilage from
peak forces of impact loading is supported by studies of Radin and
A study performed with bovine cartilage preparations demon-
strated that sudden impact loading (in contrast to motion under continu-
ous load) led to cartilage damage. Sudden impact loads significantly
increased the coefficient of friction at the cartilage surfaces. This friction
continued to increase over time and cartilage was severely damaged,
with exposure to subchondral bone occurring with 2-3 days of continu-
ous motion. On the other hand, motion even under large loads resulted
in only a transient increase in the coefficient of friction and no cartilage
damage occurred. The authors suggested that the dramatic wear of
articular cartilage after repeated impact loading may be a result of the
"squeeze out" of interstitial fluid, with temporary high shear (friction)
when motion was resumed; or that the compressive stress damaged the
structure and integrity of the cartilage, making it more vulnerable to
shear stress.52
In addition to tissue compliance (mentioned above), neuromuscular
responsiveness also is a primary shock attenuating me~hanism.~, 53 The
importance of neuromuscular readiness in attenuating impact was dem-
onstrated by an experiment that measured the timing of muscular re-
sponse and force of impact when research subjects had varying amounts
of time to prepare for an unexpected feet-first landing.31The findings
clearly showed that inadequate neuromuscular readiness was consis-
tently related to greater impact and reported discomfort. In this experi-
ment, subjects were healthy young men and the experimental results
only measured neuromuscular readiness for impact. Shock attenuation
in people with a healthy locomotor system is about 30% higher than in
people with joint disease.63This increased transmission of force through
the skeleton places a person with OA at increased risk for damaging joint
stress during the course of daily life, particularly as the muscles fatigue.
The other requirements for neuromuscular attenuation of impact
are an adequately conditioned muscle mass and the ability to generate
force quickly. The necessary components-muscle mass, contractile ve-
locity, force production, endurance for repetitive motions, and motor
skill-are often compromised by the consequences of joint pathology,
pain, and inactivity. To optimize the neuromuscular capacity to protect
404 MINOR

joints from sudden impact loading and to attenuate impact, it is neces-

sary to include muscular conditioning (concentric and eccentric strength
and endurance at functional speeds) and motor skill learning in the
exercise program.
The functional threshold for lower extremity strength has yet to be
determined; however, reports from studies that have assessed knee
strength as a percentage of body weight suggest that isokinetic strength
measured at velocities between 60" and 180"/second should be 20% to
30% of body weight for knee extension and 20% to 25% for knee
flexion.29,39 Isometric knee extensor strength lower than 10 kgF (mea-
sured with the hip at neutral and knee at 90") corresponded to marked
disability in persons with OA of the knee.38
Strength training is well documented as an effective component in
rehabilitation, reducing impairment, improving function and protecting
the joint from pathologic stress and loading. Strength training for the
knee has been studied more extensively than for the hip; however,
exercise programs for hip OA have produced significant improvements
in strength and function.22

CARDIOVASCULAR HEALTH

Inactivity is as important as smoking, obesity, and elevated choles-

terol in increasing the likelihood of coronary artery disease, atherosclero-
sis, hypertension, diabetes, and some types of cancer.47Impressive evi-
dence from studies by Blair et a1 show that regular physical activity
improves health for people of all ages, and that increasing physical
activity improves health at any age.5, People who exercise regularly live
longer and are healthier than people who are sedentary. The challenge
for persons with OA is how to find and maintain a safe and effective
conditioning routine.
OA restricts physical activity both directly and indirectly. Pain,
stiffness, fear of doing harm, and complying with suggestions from
others to avoid strenuous and weight-bearing activities, encourages a
sedentary lifestyle. Nearly 12% of persons greater than 65 years of age
report limitation of activity owing to arthritis.'jl Arthritis, primarily OA,
is the major reason for activity limitation in this age group, and is
reported slightly more frequently than heart disease. People with OA
are less active and tend to be less fit, in both musculoskeletal and
cardiovascular status, than their noninvolved peers.3*14, 42, 48, 54 In contrast
to the traditional belief that older persons with hip or knee OA should
avoid vigorous and weight-bearing exercise, exercise studies have re-
ported that many with symptomatic joints can safely participate in
appropriate conditioning exercise programs to improve physical fitness
and overall health status without exacerbation of disease symptoms.32,
41, 55 These studies have reported good subject retention and, notably,

maintenance of exercise behaviors.

In a randomized, controlled trial of aerobic exercise, 80 persons with
 EXERCISE IN THE TREATMENT OF OSTEOARTHRITlS 405

symptomatic OA of hip or knee participated in 12 weeks of aerobic

walking, aerobic pool exercise, or nonaerobic range of motion exercise.
The aerobic exercise groups showed significant improvement over the
control group in aerobic capacity, exercise tolerance, and daily physical
activity. All groups showed similar clinical improvements in joint symp-
toms and self-reported pain. Medication use was similar between groups
and remained stable through the study period.41
A randomized, controlled trial of fitness walking in patients with
OA of the knee evaluated functional status, pain, and medication use in
more than 100 persons. The 8-week walking program included flexibility
and strengthening exercises as warm-up, and gradual progression of
walking from 5 to 30 minutes three times a week in a supervised
~etting.3~ The walking group showed significant improvements over the
controls in walking distance, self-reported physical activity, and pain,
with no increase in the use of medication.
A randomized, controlled trial of 439 community-dwelling adults
with knee OA compared 18 months of aerobic walking with programs
of resistance exercise and of health education, respectively, for their
effects on self-reported disability, physical performance, aerobic capacity
strength, radiographic signs, and pain.55In comparison with the educa-
tion group, both exercise groups improved in physical performance,
pain, and knee flexion strength. The aerobic exercise group showed
additional improvement in aerobic capacity. No differences were ob-
served in radiographic scores among the treatment groups. An analysis
of outcomes by percentage of exercise sessions performed (percent com-
pliance) showed that significant improvements in disability, pain and
6-minute walk scores were associated with increasing compliance (>79'/0
in aerobic group; >74% in resistance training group).

WALKING FOR EXERCISE WITH OSTEOARTHRITIS

Walking is a safe, effective, and accessible form of cardiovascular

exercise for people with knee, hip, and spinal OA. Studies of hip joint
contact pressures show that free speed walking produces minimal pres-
sures, much lower than those generated by isometric or standing dy-
namic hip exercises.34* Studies of patients with knee effusion have
shown that synovial blood flow increases with dynamic exercise, both
walking and cycling.28Prior notions that weight-bearing (i.e., walking)
is harmful and non-weight-bearing and isometric exercises are "safe"
are being revised.19,34, 60 Impact forces during walking also can be attenu-
ated and joint loading reduced by the use of visoelastic materials in
shoe soles and 63
Viscoelastic insoles were shown to decrease the shock measured at
the proximal tibia by 42% in subjects walking at 4 kph (2.4 mph).63This
suggests the importance of counseling about the use of proper footwear
during exercise. Light-weight athletic shoes that include the following
features: variable lacing, hindfoot control, a midsole of shock absorbing
406 MINOR

materials, and a continuous sole, offer excellent support and shock-

attenuating properties. Shock absorption may be increased with the
addition of an insole of viscoelastic materials. Insoles of this type are
available in stores that sell athletic shoes and range in price from $20-
$30. For some people, mild control of pronation and shock absorption
from commercially available shoes and insoles may decrease knee and
hip discomfort associated with walking. For others, more biomechanical
correction afforded by semi-rigid and rigid orthoses may be required.
It should be noted that faster walking speeds increase biomechanical
stress on knee joints. In normal knees, this is not a harmful load, and
walking or running do not damage healthy joint^.^ In the presence of
malalignment, joint instability, or diminished proprioception/ however,
increasing walking speeds may produce undesirable joint forces.
Schnitzer et a156 studied the effects on gait of an anti-inflammatory,
nonsteroidal drug. They found that as pain was reduced, faster walking
speeds produced increased loading of the knee. In this sample of patients
with genu varus, pain relief and increased gait velocity were associated
with increased loading of the medial compartment, increased compres-
sive force, and associated stretching of lateral supporting structures.
These results suggest that the usual desired outcome of increased walk-
ing speed may not be desirable if attention is not paid to lower extremity
biomechanics. The authors concluded that biomechanical status must be
attended to in any treatment program. This may include prescription of
supportive footwear, rigid or semi-rigid orthotics, wedged insoles, use
of a cane in the contralateral hand and/or strengthening of the muscles
controlling the knee.8,56

EXERCISE RECOMMENDATIONS

It is important to recognize the distinction between physical activity

to improve or maintain health and exercise training to improve physical
fitness. Physical activity is defined as any bodily movement produced
by skeletal muscles that results in a caloric expenditure.” Exercise is a
subcategory of physical activity. It is planned, structured, repetitive, and
results in improvement or maintenance of one or more facets of physical
fitness (cardiovascular fitness, muscle strength, muscle endurance, flexi-
bility, and body composition).” Early investigations in exercise science
often studied athletes and active young men. Consequently, much of the
information about prescribing exercise to improve fitness indicated that
fairly intense exercise regimens were needed. However, epidemiologic
studies of health risk factors and exercise research in less fit PO ulations
Ed
reveal important information6 relevant to health and fitness o persons
with musculoskeletal impairments and limitations in mobility. It is not
necessary for a person to participate in an intense, highly regimented
exercise program or to attain a high level of athletic fitness to improve
health status. Even sedentary persons with low fitness levels who adopt
 EXERCISE IN THE TREATMENT OF OSTEOARTHRITIS 407

low intensity but regular physical activity significantly decrease their

risk for a number of degenerative and potentially fatal condition^.^,

Physical Activity for Health

Current recommendations for regular physical activity and exercise

as proposed by the American College of Sports Medicine and the Centers
for Disease Control and Prevention (CDC) include specific recommenda-
tions for health and for physical fitness.62Guidelines for improving
health are couched in terms of regular physical activity rather than
specific exercise and recommend whole body, dynamic activity per-
formed at low to moderate intensity on most days of the week, accumu-
lating 30 minutes of moderate physical activity on each exercise day.47
(Table 1-Physical Activity for Health Benefits). This is good news for
many older persons with arthritis who are not able to safely engage in
long duration or high-intensity physical activities. This also is important
information for health care providers, who now can recommend safe
and effective exercise to improve health and prevent unnecessary disabil-
ity for almost everyone. Patient support and self-management education
must be provided to assure success.

Table 1. RECOMMENDATIONS FOR PHYSICAL ACTIVITY AND EXERCISE

~ ~

Physical Activity for Health Benefits

Purpose: Establish a habit of regular physical activity to promote health
Mode: Aerobic activity
Frequency: Most days of the week
Intensity: 40-60% maxV02 = 50-70% MHR = W E 3-4 (see Table 3 for ”Light and
Moderate Activities”)
Duration: 30 minutes accumulation of moderate activity during the day
Exercise Training for Physical Fitness
~~ ~

Purpose: Increase cardiovascular and muscular fitness through regular

physiologic overload
1. Exercise Training for Cardiovascular Fitness
Mode: Aerobic activity
Frequency: %5 days/week
Intensity: 5670% maxV02 = 6WO% MHR = W E = M (see Table 3 for
“Moderate to Vigorous Activities”)
Duration: 20-60 minutes continuous
2. Exercise Training for Muscular Fitness (strength and endurance)
Mode: Resistance exercise (free weights, machines, elastic bands)
Frequency: 2-3 days/week
Volume: 8-10 exercises; 8-12 lifts of a load that can be lifted correctly and
produce local fatigue in 8-12 repetitions; 1-3 sets as tolerated

W E = rating of perceived exertion (0-10);MHR = age-predicted maximal heart rate (220 - age);
maxVOz = maximal oxygen uptake.
Datafrom Pate RR, Pratt M, Blair SN, et al: Physical activity and public health. A recommendation
from the Centers for Disease Control and Prevention and the American College of Sports Medicine.
JAMA 273402407, 1995; and US Department of Health and Human Services: Physical Activity and
Health: A report of the Surgeon General. Atlanta, GA, US Department of Health and Human Services,
Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health
Promotion, 1996.
408 MINOR

Exercise for Physical Fitness

In contrast, guidelines for improving physical fitness, both cardio-

vascular and musculoskeletal, continue to recommend continuous exer-
cise bouts at moderate levels of intensity and longer duration6*(Table 1
-Exercise Training for Physical Fitness).

EXERCISE STRESS TESTING

In addition to a modified prescription for lower levels of exercise,

recommendations for exercise testing prior to exercise also have been
revised. Current guidelines state that men less than 50 years of age and
women less than 40 who are asymptomatic and have no more than one
cardiovascular risk factor can begin a moderate intensity exercise pro-
gram with medical clearance, and do not require physician-supervised
cardiovascular stress testingz0 Table 2 details the revised guidelines,
cardiovascular risk factors, and definitions of moderate and intense
exercise. Table 3 provides examples of activities and exercises by inten-
sity.
On the other hand, initiation of a vigorous exercise program does
merit exercise stress testing in sedentary men older than 50 and women
older than 40. It is important that novice exercisers understand the risks
imposed by vigorous, rather than moderate, intensity exercise, and learn

Table 2. GUIDELINES FOR EXERCISE STRESS TESTJNG

Perform Supervised Exercise Stress Test for:
1. Apparently healthy: men 240; women 250 for vigorous exercise only
2. Persons at risk with no symptoms: all ages for vigorous exercise only
3. Persons at risk with symptoms and disease: all ages for moderate and vigorous
exercise
4. There is no requirement to perform maximal or diagnostic exercise stress testing with
healthy or nonsymptomatic people for participation in moderate intensity aerobic
exercise
Cardiovascular Disease Risk Factors (s 2 = at Risk)
Hypertension (BP 2160/90 mm Hg)
Serum cholesterol 2240 mg/dl (6.2 mmol/L)
Cigarette smoking
Diabetes mellitus
Family history
Definitions of Intensity
Moderate-well within current capacity; sustainable comfortably for 60 minutes; slow
progression; noncompetitive activity. 4540% maxVOl = 50-75% MHR = RPE 3-4
Vigorous-substantial challenge; fatigue within 20 minutes; >60% maxVO, = >75%
MHR = WE >5

WE = rating of perceived exertion (0-10);MHR = age-predicted maximal heart rate; maxVOz =

maximal oxygen uptake.
Datafioom Gordon NF, Kohl HW,Scott CB, et al: Reassessment of the guidelines for exercise testing.
Sports Med 13293-302,1992,
 EXERCISE IN THE TREATMENT OF OSTEOARTHIUTIS 409

Table 3. EXAMPLES OF LIGHT, MODERATE, AND VIGOROUS PHYSICAL ACTIVITIES

Light (3 MET Moderate 3-6 MET Vigorous 6-8.5 MET
-4 kc8Umiff 4-7 kcaUmin 2 7 kcaUmin

Baking 2.4 Warm-up calisthenics 5.1 Aerobic dance (high

Cooking 3.3 Circuit resistance training intensity) 9.2
Vacuuming 4.4 with free weights 5.8 Backpacking (no pack) 8.2
Laundry 4.5 Cycling: 5.5 rnph = 4.4 Circuit resistance training
Cleaning windows 4.0 9 mph = 6.8 with equipment 6.3-9.0
Mopping floors 4.2 Aerobic dance (low Swimming:
Car washing 4.8 intensity) 6.7 backstroke = 11.5
Food shopping 4.2 Walking: 3 mph = 5.0 sidestroke = 8.3
Walking: 2 mph = 3.6 3.5 mph = 6.1 breaststroke = 11.0
2.5 mph = 4.4 outdoors on hills, grass, crawl, slow = 8.9
Light stretching yoga 4.2 or uneven ground = Mowing lawn, hand mower
Indoor bike <5 mph = 4.0 5.5 7.6
Swimming (slow treading) 4.2 Walking briskly uphill or
with a load 8.2
Racquet sports, basketball
10.0

Intensity is expressed in kcal/min for a 150 pound adult.

MET = metabolic equivaIent, or multiple of the resting metabolic rate of oxygen uptake; 1 MET
= oxygen uptake at rest, approximately 3.6 ml * kg-'a mir-'. METs express the multiple of resting
oxygen uptake required to perform an activity. For example, activity at 3 METs is three times the
resting energy expenditure and is considered light work; exercise at 7 METS requires seven times the
energy expenditure of rest and is considered vigorous work.
Data porn McArdle WD, Katch FI, Katch V L Exercise Physiology: Energy, Nutrition and Human
Performance. Baltimore, William & Wilkins, 1996, Appendix D.

methods for self-monitoring and regulating exercise intensity. A heart

rate as a percentage of maximal is often suggested; however, measure-
ment error makes an exercise pulse a questionable guide for self-moni-
toring. Use of a rating of perceived exertion scale (WE) or the simple
talk test may be more useful and valid indicators of an individual's
current exertion.

PHYSICAL FITNESS AS AN OUTCOME MEASURE

In light of current evidence of the public health problem of inactivity

and the major contribution of OA to inactivity and poor fitness, a
compelling case can be made for considering physical fitness and physi-
cal activity levels as important outcome measures in OA.'O Particularly
in the older, retired population, an individual's ability and willingness
to be as physically active as needed to maintain fitness and general
health may be a more salient indicator of disease impact and/or treat-
ment efficacy than many of the current measures of disability and
health status. Although retirees often report more time spent performing
leisure-time activities than older adults who are still employed, it has
been documented that this tends to be sedentary activity.@Self-report of
ability to perform activities of daily living and household chores is slow
to reflect impairment and functional loss. Whereas physical activity,
mobility, and social activity may show significant disability, the individu-
410 MINOR

al's assessment of capability to be independent at home often remains

high.
Self-report of physical activity cannot be relied upon to predict
fitness. Older people tend to overestimate vigor and amount of physical
activity, and to answer nonspecific questions regarding physical activity
with responses that correlate poorly with their cardiovascular status.
Therefore, assessment of cardiovascular and musculoskeletal fitness can
provide revealing information about the adequacy of physical activity
and serve as baseline information for exercise recommendations and
monitors of progress. A number of submaximal fitness tests are available
for this purpose. The 5-minute walk49and a one stage treadmill test at
a self-selected walking speed43have been validated for people with
arthritis.

EXERCISE GOALS AND SAFETY

Persons with OA are a heterogeneous population, ranging widely
in age, disease, impairments, functional goals, and interests. Some are
interested in, and capable of, performing exercise programs with a goal
of improving physical fitness. The conditioning exercise studies reported
to date have employed the parameters of intensity, duration, and fre-
quency recommended for cardiovascular and muscular fitness. Some
individuals with OA may need individualized exercise instruction and
support to be able to participate in cardiovascular or pulmonary rehabili-
tation or weight management programs. Others may not be candidates
for fitness training programs but can be educated and encouraged to
adopt appropriate daily activity habits to improve or maintain health,
improve function, and reduce their risk of inactivity-related illness.
Whichever activity/exercise program is adopted, it is important that
novice exercisers be given a positive outlook regarding their ability to
exercise successfully and safely.
There is increasing evidence that participation in conditioning levels
of both aerobic/endurance and strengthening exercise can be safely
sustained by people with OA. In a study of 100 people between the ages
of 68 and 85, approximately 50% of whom reported mild to moderate
osteoarthritis, 6 months of resistance and/or aerobic exercise resulted in
improved strength and end~rance.'~ Joint symptoms fluctuated similarly
over time in all groups and in those with and without arthritis. The rate
of musculoskeletal injuries that required reduction or discontinuation of
exercise for at least 1 week was 0.48 per 1000 hours of exercise. The
authors concluded that properly performed conditioning exercise does
not exacerbate joint symptoms, and that joint symptoms fluctuate over
time, with or without exercise or arthritis.

COMPREHENSIVE EXERCISE PROGRAM

A comprehensive routine can be arranged using the three phases of
an exercise program: warm-up; aerobic period; and cool-down. Within
 EXERCISE IN THE TREATMENT OF OSTEOARTHRITIS 411

this framework, it is possible to include individualized, therapeutic

exercises to improve or maintain flexibility, ROM, muscle strength and
endurance, as well as cardiovascular fitness and health. Specific thera-
peutic goals and arthritis-related considerations for joint protection, pro-
gressive grading, and self-management strategies also are easily incorpo-
rated."

Warm-up or Pre-aerobic Component

This segment provides a neuromuscular and cardiovascular warm-

up immediately prior to an aerobic exercise or as a pre-aerobic exercise
routine to prepare the body for more vigorous activity The warm-
up routine can be designed to incorporate individualized ROM and
strengthening exercise and can serve as the traditional home exercise
program.

Aerobic Component

The aerobic exercise component provides the stimulus for adapta-

tion and training of cardiovascular efficiency, muscular endurance, and
activity tolerance. Aerobic exercise activities that have demonstrated
safety and effectiveness in OA include walking, aquatic aerobic exercise,
and stationary cycling.13,33, 41, 55

Cool-down Component

Once a person is performing 10 minutes or more of aerobic activity

at an intensity of 70% or more of age-predicted maximal heart rate
(moderate intensity), a 3- to 5-minute active cool-down is recommended.
As with the warm-up period, low-intensity cool-down activities can be
designed and used in a daily program that provides general as well
as therapeutic benefit. Arthritis-related considerations for aerobic and
strengthening exercise programs are listed in Table 4.

CONCLUSION

The crucial role of regular levels of adequate physical activity and

exercise in promoting health and preventing disease in persons with OA
has been recognized more widely in the public health community than
by medical practitioner^.^^ It is expected that dissemination of research
findings regarding marked deconditioning, the increased risk for cardio-
vascular disease, and the role of exercise in successful weight manage-
ment will encourage all health care providers to consider the impact of
OA on the individual's ability to accumulate adequate amounts of physi-
412 MINOR

Table 4. ARTHRITIS-RELATED CONSIDERATIONS FOR EXERCISE

General
maintain proper body weight
maintain range of motion and flexibility
condition lower extremity musculature for strength, endurance, and
neuromuscular readiness
if necessary for pain management, exercise in water, on a bicycle, or on a rowing
machine

- alternate weight-bearing and non-weight-bearing activities throughout the day

select shoes and insoles for shock attenuation
use semi-rigid or rigid orthoses for biomechanical correction
Hip or Knee OA
~~~~~~~~~~~~~~

use a cane on contralateral side and with reciprocal gait pattern

carry loads no more than 10% body weight and on same side as affected hip
minimize use of stairs, one-legged stance, low seating
avoid maximal isometric and high velocity muscle contraction
select moderate walking speed that does not exacerbate joint symptoms
perform neuromuscular warm-up prior to walking
Lumbar SDinal Sfenosis18, 46

avoid spinal extension

perform low back flexion a>ndabdominal strengthening exercises
address lower extremity flexibility and strength deficits
institute progressive walking program (begin in water, if necessary for pain)

cal activity to maintain health. In 1989, it was found that individuals

who reported moderate levels of activity and fitness had half the risk of
death and disease than of people who were sedentary.6In 1995, it was
reported that by increasing physical activity levels, people could im-
prove health status and reduce the risk of disease at any age.5 Current
recommendations disseminated by the ACSM and CDC for the accumu-
lation of 30 minutes of moderate physical activity on most days of the
week place a feasible and effective treatment well within the capabilities
of most people with OA. Impairments and functional limitations may
serve as obstacles in the path of achieving this goal, and must be
recognized and addressed by health care providers in a comprehensive
treatment plan that includes both therapeutic and community-based
exercise.
Exercise plays a role in primary (aerobic and strength training
exercise to maintain proper weight and quadriceps strength), secondary
(strengthening and ROM exercise), and tertiary (reducing risk of inactiv-
ity-related diseases and disorders) prevention in OA. Encouragement
and support of the person with OA to explore community-based oppor-
tunities for physical activity and recreational exercise is also a responsi-
bility of the medical team. This support may vary from simply being
knowledgeable about local exercise opportunities, to providing consulta-
tive services to local exercise providers to increase appropriate exercise
programming for people with OA. In the same manner that self-manage-
 EXERCISE IN THE TREATMENT OF OSTEOARTHRITIS 413

ment education has proved to be an effective and accepted arthritis

exercise also must be recognized and understood for its
many contributions to improved outcomes for people with OA.

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Address reprint requests to

Marian A. Minor, PT, PhD
Department of Physical Therapy
106 Lewis Hall
University of Missouri
Columbia, MO 65211

e-mail: minorm@missouri.edu