Osteoarthritis of the Knee And Exercise

1
Osteoarthritis of the Knee And Exercise

• Holly Gluth Pursley, M.D.
• Resident Grand Rounds
• March 30, 1999

2
Osteoarthritis

• most common joint disease of humans
• among the elderly, osteoarthritis (OA) is a
  leading cause of disability in developed
  countries
• 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

3
Osteoarthritis

• 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

4
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)

5
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

6
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
  hydroxyapatite
• immune complexes containing antigens derived
  from cartilage matrix may be sequestered in
  collagenous joint tissue

7
Osteoarthritis

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

8
Radiographic Osteoarthritis

• in early stages of OA the radiograph may be
  normal
• 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

11
Knee Osteoarthritis

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

12
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)?

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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

14
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

15
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

18
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
  controls

19
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
  community

20
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

21
Lane et al.

• Radiographs were scored in pairs by two readers
  independently
• 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
  sclerosis

22
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

23
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
  period
• this difference was significant in the nonrunner
  group

24
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

25
Lane et al.

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

26
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

27

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

28
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

29
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
  degeneration

30
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
  living

31
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.

32
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

33
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

34
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
  cartilage

35
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?

36
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

37
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

38
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

39
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

40
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
  degeneration
• with time, the loss of GAG may affect the
  condition of articular cartilage

41
Arokoski et al.

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

42
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

43
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.

44
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

45
Radin et al.

• experimental animals were housed on tarmac
• control animals were kept pastured
• animals were sacrificed at 12, 18, 24, and 30
  months

46
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
  formation
• mild to moderate cartilage fibrillation was
  present in the experimental sheeps knees and
  elbows

47
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

48
Radin et al.

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

49
The Effect of Running on the Osteoarthritic
Joint An Experimental Matched-Pair Study with
Rabbits

• T. Videman
• Rheumatology and Rehabilitation 1982 211

50
Videman

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

51
Videman

• Methods
• experimental OA was produced in the right hind
  limb of adult rabbits by an immobilization
  technique
• 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

52
Videman

• 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

53
Videman

• 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

54
Videman

• 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.

55
Videman

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

56

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

57
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

58
Lethbridge-Çejku et al.

• Objective
• To examine the association between self reported
  knee pain and radiographic features of OA of the
  knee

59
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
  Aging

60
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

61
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
  pain?

62
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

63
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

64
Lethbridge-Çejku et al.

• definite OA was a Kellgren-Lawrence grade of 2 or
  higher
• each knee was also assigned a score of 0-3
  (absent-large) for the individual features of
  osteophytes
• joint space narrowing was graded 0-3
  (none-severe)
• subchondral sclerosis scored 0 or 1 (absent or
  present)
• BMI was calculated

65
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
  pain.

66
Lethbridge-Çejku et al.

• Conclusion
• Radiographic features of knee OA are
  significantly associated with knee pain.

67
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

68

• 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

73
Kujala et al.

• Objective
• To determine the relationship between different
  physical loading conditions and findings of knee
  OA

74
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
  competitions
• 28 former long distance runners, 31 soccer
  players, 29 weight lifters, 29 shooters

75
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

76
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

77
Kujala et al.

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

78
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

79
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)

80
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
  lifters
• running seems to be devoid of adverse effects
  leading to knee degeneration, compared with
  sports in which injuries frequently occur

81
Kujala et al.

• Limitations
• no female participants
• limited number of subjects

82
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

83
Fries et al.

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

84
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
  

85
Fries et al.

• Methods
• participants were members of Fifty-Plus Runners
  Association
• 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

86
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

87
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?

88
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

89
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

90
Is Running Associated with Degenerative Joint
Disease?

• 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

91
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

92
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

93
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
  obtained
• exams and data analyses blinded

94
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

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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,
  plt.05)
• no statistically significant differences between
  groups regarding osteophytes, cartilage
  thickness, or grades of degenerative change in
  the lower extremity joints

96
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

97
Panush et al.

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

98

• 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.

99
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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101
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

102
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
  period
• Study performed 2º to questions about efficacy
  and safety of exercise for Tx of knee OA

103
Ettinger et al.

• What types of exercise are most beneficial in
  reducing pain and disability in people with knee
  OA?
• 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
  socialization?
• Are there benefits to exercise therapy beyond the
  psychosocial effects?
• Is longterm exercise harmful to people with OA?

104
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

105
Ettinger et al.

• 1º outcome was self-reported disability score
  (1-5)
• 2º outcomes were knee pain score (1-6),
  performance measures of physical function, x-ray
  score, aerobic capacity, and knee muscle strength

106
Ettinger et al.

• aerobic exercise training 3 mo facility based
  walking program, then a 15 mo home based walking
  program
• 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
  exercises)

107
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

108
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

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• Follow-up data occurred at months 3, 9, and 18
  post-randomization
• 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
  do)
• 2º outcomes included physical performance
  testing, graded exercise treadmill test and
  oxygen uptake, strength testing, knee x-rays,
  rating knee pain

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• 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

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• 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
  (p.003).

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• 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
  program.

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• 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
  people

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• Limitations
• lack of complete compliance over 18 months

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Summary

• 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).

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What to look for

• ADAPT
• (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

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Acknowledgements

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

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