Exercise Therapy as Treatment for Osteoarthritis
Abstract & Commentary
Synopsis: Your patients with OA should try different exercises of any type until they find one, and then another, and then another that they can do—even for a few minutes each day.
Source: van Baar ME, et al. Arthritis Rheum 1999;42: 1361-1369.
To review the effectiveness of exercise therapy in patients with osteoarthritis (OA) of the hip or knee, a computerized literature search of MEDLINE, Embase, and Cinahl was carried out. Randomized clinical trials (RCTs) on exercise therapy for OA of the hip or knee were selected if treatment had been randomly allocated and if pain, self-reported disability, observed disability, or patients’ global assessment of effect had been used as outcome measures. The validity of trials was systematically assessed by independent reviewers. Effect sizes and power estimates were calculated. A best evidence synthesis was conducted, weighting the studies with respect to their validity and power.
Six of the 11 assessed trials satisfied at least 50% of the validity criteria. Two trials had sufficient power to detect medium-sized effects. Effect sizes indicated small to moderate beneficial effects of exercise therapy on pain, small beneficial effects on both disability outcome measures, and moderate to great beneficial effects according to patients’ global assessment of effect.
Comment by john la puma, md, facp
This was a rigorous, careful, well-intended, apparently without bias, specific, clear, detailed study.
van Baar and colleagues note that although exercise therapy appears in recent treatment guidelines for OA of the hip and knee, newly published RCTs and more rigorous review methodology yield better recommendations. So, van Baar et al carefully picked over the evidence for an intervention that relatively few physicians even find in their therapeutic arsenal—exercise therapy. They found only six trials that met accepted, thoughtful validity criteria. Sufficient sample size, adherence to recommendations, controls for co-interventions, and an intention to treat analysis, together with blinded outcome assessments were recommended for future investigators.
Exercise therapy is defined as a range of activities intended to improve strength, range of motion, endurance, balance, coordination, posture, motor function, or motor development. It can be performed actively, passively, or against resistance. Aerobic, resistance, and other types of exercise were included. Only four trials studied the differences between various exercise therapies, and none pointed to one type of exercise or one location being better than another. In addition to the benefits above, a small beneficial effect on walking performance was also gleaned.
Few systematic data were available on long-term effects of exercise therapy, and since "use it or lose it" is so commonly observed in clinical practice and at the gym, a relevant clinical question is "Does a little help?" Muscles atrophy if they are not used, and everyone who has taken a few weeks off and then moved back to a previous workout knows that muscle strength fades all too quickly.
If exercise were a pill, it would be called penicillin. If only it could be bottled, instead of planned, structured, and repeated over and over again. There are no shortcuts, however. Your patients with OA should try different exercises of any type until they find one, and then another, and then another that they can do—even for a few minutes each day. Their hips and knees (and hearts and minds) will be healthier for it. (Dr. La Puma is Professor of Nutrition, Kendall College, Director, C.H.E.F. Clinic, C.H.E.F. Skills Research, Alexian Brothers Medical Center, Elk Grove Village, Ill.)
Exercise therapy is defined as a range of activities intended to improve:
a. strength.
b. balance.
c. motor function.
d. All of the above
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