Exercise: Rx for overcoming osteoarthritis

Exercising may be the last thing you want to do when your joints are stiff and achy. But it's crucial for easing pain and staying active.

Osteoarthritis is a chronic and progressive disease characterized by loss of the cartilage that covers and protects the ends of the bones where they meet at a joint. Without this protective coating, bone rubs against bone, causing irritation and inflammation. The result is pain and stiffness in the joint and often pain in the muscles and ligaments that surround it.

Osteoarthritis is the leading cause of disability in the United States, affecting more than 22 million adults. Nearly equal numbers of women and men have the condition, but women tend to develop symptoms after age 55, about 10 years later than men do. It most often affects the hips, knees, spine, and hands.

Because most people diagnosed with osteoarthritis are older — about half of those over 65 have it to some degree — it's long been considered a normal part of aging that reflects a lifetime of wear and tear on cartilage. But experts now know that many factors besides age are involved. Osteoarthritis risk can be inherited. An injury or disease may also kick off the deterioration. The rate of progression depends on genetics, biomechanical forces, and biological and chemical processes, all of which vary from person to person.

Excess weight is strongly linked to osteoarthritis, because it places added stress on the knees, hips, and spine. An ongoing study of people living in Framingham, Mass., found that people who were overweight as young adults had a higher rate of knee osteoarthritis in their 30s and 40s. Compared with the thinnest women, the heaviest women were twice as likely to get osteoarthritis and three times as vulnerable to severe knee osteoarthritis. In the Nurses' Health Study, women who were the heaviest at age 18 had up to seven times greater risk for severe hip osteoarthritis as those who were lightest.

Shoes and knee osteoarthritis

Two-thirds of people with knee osteoarthritis are women, and high heels are one of the causes, according to Dr. D. Casey Kerrigan, at the University of Virginia, who studies the impact of shoes on women's health. In an interview published in the October 2006 Journal of Women's Health, Kerrigan said her studies have shown that high heels place abnormal stress on both the front and back of the knee. Even a modest one-and-one-half-inch heel increases pressure, or torque, in two common sites for osteoarthritic damage: the joint beneath the undersurface of the kneecap (the patellofemoral compartment) and the joint surfaces on the inner side of the knee (the medial compartment). So what's a woman to wear? Kerrigan suggests a fairly flat shoe with little arch support that allows the foot to strike the ground and move forward as naturally as possible.

Proper treatment includes exercise

There's no cure for osteoarthritis, but there is a lot you can do to slow its progression, reduce pain, and maintain or improve function. Losing weight can be particularly helpful if you're overweight or obese. You can often relieve pain with over-the-counter analgesics such as acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs), including ibuprofen and aspirin. The use of canes, splints, or braces may be necessary to protect a joint from further injury.

But if there's one prescription an individual with osteoarthritis should take every day, it's exercise. Regular exercise strengthens muscles and improves flexibility and balance. It not only helps ease pain and stiffness but also improves overall health. It's also good for your mood and for staving off other conditions prevalent in older age.

In guidelines published in the June 2001 Journal of the American Geriatrics Society, the American Geriatrics Society (AGS) recommends exercise as an integral part of treatment for osteoarthritis in people ages 65 and over. After reviewing the evidence, the group also concluded that moderate-intensity exercise does not — as some have feared — increase the risk for osteoarthritis, although strenuous physical activity or participation in competitive sports throughout life might.

Research suggests that older women may be able to prevent osteoarthritis pain by getting as little as one to two hours of moderately intense physical activity each week (Arthritis Research and Therapy, online edition, March 29, 2007). Lack of exercise may contribute directly to osteoarthritis, especially by causing the atrophy of supportive and shock-absorbing muscles, such as those surrounding the knee.

The basic components of the exercise prescription are activities that improve flexibility, muscle strength, and endurance. Exercise should be individually tailored, to prevent injury and aggravation of the osteoarthritis. That usually means starting with an evaluation by a physician, physical therapist, or other health professional experienced in the management of osteoarthritis. The activities your clinician recommends — and his or her advice on how much and how often to exercise — will depend on various factors, including which joints are involved, how severe the pain is, how fit you are, and whether you have other medical conditions.

Flexibility (range-of-motion) exercises

The first step is flexibility exercise to improve joint mobility, reduce stiffness, and help prevent tightening of the tissues around the joint.

Flexibility exercises gently stretch and lengthen the muscles and move the joints through a range of motion that's comfortable — you should not feel pain — but produces a sensation of resistance. You should perform these exercises (see examples) when you are feeling the least pain and stiffness — for example, after a warm shower or at the end of the day. If you take a pain reliever, do your stretching when the drug is having its strongest effect. You can start with just one or two exercises a day, three times a week, but try to work up to performing several, at least once a day.

Inner leg stretch.

Sit with your knees bent and the soles of your feet together. Draw your heels close to your body. Holding the shins or ankles with your hands, slowly bend your upper body forward and gently press your knees down with your elbows. Hold for 20 to 30 seconds.

Hip and lower back stretch.

Lie flat on your back with legs extended. Keep your neck on the floor but look down toward your chest. Bend both knees and clasp them with your hands, pulling your knees toward your shoulders as far as they will comfortably go. Breathe in deeply and exhale, bringing the knees closer as you breathe out. Hold for 20 to 30 seconds while breathing normally.

Double hip rotation.

Lie on your back with your knees bent and feet flat on the floor. Keeping your shoulders on the floor, gently lower your knees to one side and turn your head to the opposite side. Hold for 20 to 30 seconds. Bring your knees back to the center and repeat on the other side.

Strength (resistance) training

By strengthening muscles, you protect and support affected joints and improve overall function. Inactivity due to osteoarthritis, as well as aging in general, can reduce muscle mass, contributing to frailty and weakness.

Strength training involves contracting the muscles against resistance. The resistance can be from your own body or from hand or ankle weights or resistance bands. Your clinician will recommend specific exercises based on the condition of your joints and your level of pain. According to the AGS guidelines, muscles should not be exercised to the point of fatigue. Start with four to six repetitions rather than the eight to 12 normally associated with resistance training. If you have joint pain that lasts more than an hour after you exercise, you're probably overdoing it. You should not do strength training more than two days per week.

Chair stand.

Rest a chair against a wall. Sit at the front of the chair, knees bent, feet flat on the floor. Lean back in a half-reclining position with your arms crossed and your hands on your shoulders. Keeping your head, neck, and back straight, bring your upper body forward, and then stand up slowly. Pause. Sit back down slowly and return to your original position. Repeat four to six times; build up gradually to eight to 12 repetitions.

Hip extension.

Holding onto the back of a chair for balance, bend your trunk forward and slowly raise your right leg straight behind you. Lift it as high as you can without bending your knee or pitching forward. Pause. Slowly lower the leg, returning to the starting position. Do four to six repetitions. Repeat with the left leg. Build up gradually to eight to 12 repetitions. For added resistance, wear an ankle weight on the leg you are lifting.

Bridge.

Lie on your back with your knees bent and your feet flat on the floor. Place your palms flat on the floor next to your hips. Keep your back straight as you lift your buttocks as high as you can off the mat, using your hands for balance only. Pause. Lower your buttocks not quite to the floor, then lift again. Repeat four to six times; gradually build up to eight to 12 repetitions.

Endurance (or aerobic) exercise

Low-impact aerobic exercise improves cardiovascular and overall function, contributes to your sense of well-being, helps control weight, and builds muscles while protecting joints. Good choices include bicycling, walking, swimming, rowing, and the use of an elliptical trainer. Avoid activities that put too much strain on the joints, such as running and sports that involve jumping, quick turns, or sudden stops — tennis and basketball, for example. Swimming and pool exercises have several advantages for people with osteoarthritis. Warm water is soothing to muscles and joints. The buoyancy of water reduces the load on your joints, and water provides resistance, which adds to muscle strength. Try to work your way up to 30 minutes of low-impact aerobic exercise at least four times a week.