Core Treatment 2: Exercise & Physical Activity

STANDARD 5

Individualized exercise and physical activity programs should be integrated into the care plan for people with osteoarthritis (OA) of the hip or knee. Individualized programs provide support and information on progressive exercises and how to modify those activities as symptoms change. These programs focus on improving strength, endurance and function which will help support regular movement and improve overall health. Use of shared decision-making techniques will ensure the individual’s priorities, values and preferences are considered when setting their wellness goals.
Home 9 Clinician Standards: 5. Exercise & Physical Activity

OVERVIEW

Key Messages for Exercise & Physical Activity

  • Individuals with OA often experience weakness in lower extremities which may lead to functional and mobility decline over time – a sedentary lifestyle is a major risk factor of OA as it aggravates symptoms
  • Regular exercise and physical activity should be built into a care plan using shared decision making to select treatments that suit the goals and baseline fitness of the individual
  • Most recommended exercises and physical activities for hip and knee OA target lower extremities, including trunk/core, gluteal, quadriceps, hamstring, and calf muscles
  • Prescribed movement can be suggested as independent work, or as a part of joining structured programs, and when safe the individual can gradually progress the intensity, frequency, and duration over time

INTRODUCTION

Individuals with osteoarthritis (OA) of the hip or knee often experience weakness in their lower extremities1,21de Zwart AH, Dekker J, Lems WF, Roorda LD, Van Der Esch M, Van Der Leeden M. Factors associated with upper leg muscle strength in knee osteoarthritis: A scoping review. Journal of rehabilitation medicine. 2018;50(2):140-50.
2Øiestad BE, Juhl CB, Eitzen I, Thorlund JB. Knee extensor muscle weakness is a risk factor for development of knee osteoarthritis. A systematic review and meta-analysis. Osteoarthritis and Cartilage. 2015;23(2):171-7.
which, combined with poor neuromuscular function, may lead to functional and mobility decline over time. A sedentary lifestyle is one of the major risk factors of OA as it aggravates symptoms and contributes to a lower quality of life.33Musumeci G, Aiello FC, Szychlinska MA, Di Rosa M, Castrogiovanni P, Mobasheri A. Osteoarthritis in the XXIst century: Risk factors and behaviours that influence disease onset and progression. International Journal of Molecular Sciences. 2015;16(3):6093-112. Physical deconditioning due to inactivity not only exacerbates symptoms but can also negatively impact overall health.1,41de Zwart AH, Dekker J, Lems WF, Roorda LD, Van Der Esch M, Van Der Leeden M. Factors associated with upper leg muscle strength in knee osteoarthritis: A scoping review. Journal of rehabilitation medicine. 2018;50(2):140-50.
4Bowden JL, Hunter DJ, Deveza LA, Duong V, Dziedzic KS, Allen KD, et al. Core and adjunctive interventions for osteoarthritis: Efficacy and models for implementation. Nature Reviews Rheumatology. 2020;16(8):434-47.

Regular exercise and physical activity are among the most effective conservative treatments to improve symptoms and maintain physical fitness in people with OA of the hip or knee.4,54Bowden JL, Hunter DJ, Deveza LA, Duong V, Dziedzic KS, Allen KD, et al. Core and adjunctive interventions for osteoarthritis: Efficacy and models for implementation. Nature Reviews Rheumatology. 2020;16(8):434-47.
5Rice D, McNair P, Huysmans E, Letzen J, Finan P. Best evidence rehabilitation for chronic pain part 5: Osteoarthritis. Journal of Clinical Medicine. 2019;8(11):1769.
Exercise and physical activity are related but not equal and have a variety of benefits and components (see below).

Self-management strategies (Standard 3) should be discussed in conjunction with introduction of exercise prescription and physical activity programs. If the individual with OA gains confidence in understanding their body and options for modifying their exercises and physical activities, they will be better able to safely exercise and carry out their day-to-day activities.

Understanding Prescribed Exercise vs. Physical Activity

Prescribed Exercise
Physical Activity
Defining Features
  • Purposeful movements
  • Targeted to specific body parts
  • Structured movements
  • Repetitive movements
  • Any leisurely action or task performed in everyday environments
  • Encourages movement of all body parts
  • For improving overall health and wellness
  • No structure
  • Not targeted
  • Not purposefully repetitive
Examples
  • 6 week arthritis pool therapy program
  • GLA:D® program
  • Gardening
  • Walking to the store
Benefits
  • Helps reduce OA symptoms including severity of pain and mobility restrictions
  • Reduce medication dependency
  • Improve mental health and cognitive function
  • Protects joints from further deterioration
  • Weight bearing exercise can significantly improve the health of the cartilage of the affected joint
  • Some structured programs will allow for individual self-referral
  • Self-select and self-modify readily
Prescriptions should include
  • Education on safe practices
  • Steps for improving levels of exercise and physical activity
  • Support to lead an active lifestyle
  • Education to understanding the specific exercises and why they were chosen
  • Education on how physical activity impacts joint pain, particularly impact vs. non-impact
Prescriptions may include
  • Range of motion
  • Targeted muscle strengthening
  • Neuromuscular training
  • Aerobic exercises
  • Activities that help to increase heart rate and level of exertion. This can include:
    • Moderate activities
    • Vigorous activities when safe to do so.

PRESCRIBING MOVEMENT

During care planning with an individual, the Primary Clinician should offer options for exercise and physical activity to address strength and flexibility, in balance with cardiovascular fitness. Alternatively, depending on the scope of the Primary Clinician’s expertise, they can refer to other clinicians, in particular those qualified and experienced in prescribed exercise to develop a targeted exercise program. Most recommended exercises and physical activities for hip and knee OA target lower extremities, including trunk/core, gluteal, quadriceps, hamstring, and calf muscles.

It is important to use shared decision-making techniques to build movement into a care plan. If the individual is choosing exercise and activity they are interested in, they will be more likely to enjoy and complete them. A well-rounded movement plan:4,64Bowden JL, Hunter DJ, Deveza LA, Duong V, Dziedzic KS, Allen KD, et al. Core and adjunctive interventions for osteoarthritis: Efficacy and models for implementation. Nature Reviews Rheumatology. 2020;16(8):434-47.
6Holden MA, Button K, Collins NJ, Henrotin Y, Hinman RS, Larsen JB, et al. Guidance for implementing best practice therapeutic exercise for people with knee and hip osteoarthritis: what does the current evidence base tell us? Arthritis Care & Research. 2020;Accepted for publication.

  • Accommodates for the individual’s baseline wellness;
  • Addresses the individual’s:
    • Needs
    • Goals
    • Symptoms
    • Socioeconomic status
    • Preferences and
    • Values
  • Has a preliminary plan for progression
  • Collects outcome measures
  • And incorporates:
    • Daily movement goals (see below)
    • Education on safe practices:
      • Recovery strategies
      • Pain tracking and managing strategies
      • Pacing and modification strategies and
    • Strategies to improve motivation to maintain an active lifestyle

Prescribed movement can be suggested as independent work for the individual or as part of joining structured programs. The Tables of Examples for the Conservative OA Treatments provides a variety of categorized examples of independent or structured programs. Structured programs may be offered on-site or virtually, with individual supervision or in a group setting. Note that structured programs may incur costs. The individual’s socioeconomic status should be considered before selecting treatment options.

Over time, work with the individual with OA to safely and gradually progress the intensity, frequency and duration of an exercise or physical activity. Build relationships with the community-based exercise program providers in the area to ensure individuals with OA are directed to the program that is most applicable to their needs.

Movement Target

With clinician approval for medical safety a target of 150 minutes of moderate to vigorous aerobic movement per week is recommended7,87Canadian Society for Exercise Physiology. Canadian 24-hour movement guidelines: An integration of physical activity, sedentary behavior, and sleep Ottawa, Ontario: Canadian Society for Exercise Physiology; 2021 [Available from: https://csepguidelines.ca/].
8World Health Organization. WHO guidelines on physical activity and sedentary behavior. Geneva; 2020.
.

Moderate Movement
Vigorous Movement
Description
Individuals can carry a conversation while performing these movements.
Individuals would feel a little out of breath during conversation while performing these movements.
Examples
i.e. Brisk walking, biking, household chores, yard work and dancing.
i.e. Faster-paced walking, biking uphill and swimming.
INTRODUCTION
Individuals with osteoarthritis (OA) of the hip or knee often experience weakness in their lower extremities1,21de Zwart AH, Dekker J, Lems WF, Roorda LD, Van Der Esch M, Van Der Leeden M. Factors associated with upper leg muscle strength in knee osteoarthritis: A scoping review. Journal of rehabilitation medicine. 2018;50(2):140-50.
2Øiestad BE, Juhl CB, Eitzen I, Thorlund JB. Knee extensor muscle weakness is a risk factor for development of knee osteoarthritis. A systematic review and meta-analysis. Osteoarthritis and Cartilage. 2015;23(2):171-7.
which, combined with poor neuromuscular function, may lead to functional and mobility decline over time. A sedentary lifestyle is one of the major risk factors of OA as it aggravates symptoms and contributes to a lower quality of life.33Musumeci G, Aiello FC, Szychlinska MA, Di Rosa M, Castrogiovanni P, Mobasheri A. Osteoarthritis in the XXIst century: Risk factors and behaviours that influence disease onset and progression. International Journal of Molecular Sciences. 2015;16(3):6093-112. Physical deconditioning due to inactivity not only exacerbates symptoms but can also negatively impact overall health.1,41de Zwart AH, Dekker J, Lems WF, Roorda LD, Van Der Esch M, Van Der Leeden M. Factors associated with upper leg muscle strength in knee osteoarthritis: A scoping review. Journal of rehabilitation medicine. 2018;50(2):140-50.
4Bowden JL, Hunter DJ, Deveza LA, Duong V, Dziedzic KS, Allen KD, et al. Core and adjunctive interventions for osteoarthritis: Efficacy and models for implementation. Nature Reviews Rheumatology. 2020;16(8):434-47.

Regular exercise and physical activity are among the most effective conservative treatments to improve symptoms and maintain physical fitness in people with OA of the hip or knee.4,54Bowden JL, Hunter DJ, Deveza LA, Duong V, Dziedzic KS, Allen KD, et al. Core and adjunctive interventions for osteoarthritis: Efficacy and models for implementation. Nature Reviews Rheumatology. 2020;16(8):434-47.
5Rice D, McNair P, Huysmans E, Letzen J, Finan P. Best evidence rehabilitation for chronic pain part 5: Osteoarthritis. Journal of Clinical Medicine. 2019;8(11):1769.
Exercise and physical activity are related but not equal and have a variety of benefits and components (see below).

Self-management strategies (Standard 3) should be discussed in conjunction with introduction of exercise prescription and physical activity programs. If the individual with OA gains confidence in understanding their body and options for modifying their exercises and physical activities, they will be better able to safely exercise and carry out their day-to-day activities.

Understanding Prescribed Exercise vs. Physical Activity

Prescribed Exercise

Physical Activity

Defining Features

  • Purposeful movements
  • Targeted to specific body parts
  • Structured movements
  • Repetitive movements
  • Any leisurely action or task performed in everyday environments
  • Encourages movement of all body parts
  • For improving overall health and wellness
  • No structure
  • Not targeted
  • Not purposefully repetitive

Examples

  • 6 week arthritis pool therapy program
  • GLA:D® program
  • Gardening
  • Walking to the store

Benefits

  • Helps reduce OA symptoms including severity of pain and mobility restrictions
  • Reduce medication dependency
  • Improve mental health and cognitive function
  • Protects joints from further deterioration
  • Weight bearing exercise can significantly improve the health of the cartilage of the affected joint
  • Some structured programs will allow for individual self-referral
  • Self-select and self-modify readily

Prescriptions should include

  • Education on safe practices
  • Steps for improving levels of exercise and physical activity
  • Support to lead an active lifestyle
  • Education to understanding the specific exercises and why they were chosen
  • Education on how physical activity impacts joint pain, particularly impact vs. non-impact

Prescriptions may include

  • Range of motion
  • Targeted muscle strengthening
  • Neuromuscular training
  • Aerobic exercises
  • Activities that help to increase heart rate and level of exertion. This can include:
    • Moderate activities
    • Vigorous activities when safe to do so.

PRESCRIBING MOVEMENT
During care planning with an individual, the Primary Clinician should offer options for exercise and physical activity to address strength and flexibility, in balance with cardiovascular fitness. Alternatively, depending on the scope of the Primary Clinician’s expertise, they can refer to other clinicians, in particular those qualified and experienced in prescribed exercise to develop a targeted exercise program. Most recommended exercises and physical activities for hip and knee OA target lower extremities, including trunk/core, gluteal, quadriceps, hamstring, and calf muscles.

It is important to use shared decision-making techniques to build movement into a care plan. If the individual is choosing exercise and activity they are interested in, they will be more likely to enjoy and complete them. A well-rounded movement plan:4,64Bowden JL, Hunter DJ, Deveza LA, Duong V, Dziedzic KS, Allen KD, et al. Core and adjunctive interventions for osteoarthritis: Efficacy and models for implementation. Nature Reviews Rheumatology. 2020;16(8):434-47.
6Holden MA, Button K, Collins NJ, Henrotin Y, Hinman RS, Larsen JB, et al. Guidance for implementing best practice therapeutic exercise for people with knee and hip osteoarthritis: what does the current evidence base tell us? Arthritis Care & Research. 2020;Accepted for publication.

  • Accommodates for the individual’s baseline wellness;
  • Addresses the individual’s:
    • Needs
    • Goals
    • Symptoms
    • Socioeconomic status
    • Preferences and
    • Values
  • Has a preliminary plan for progression
  • Collects outcome measures
  • And incorporates:
    • Daily movement goals (see below)
    • Education on safe practices:
      • Recovery strategies
      • Pain tracking and managing strategies
      • Pacing and modification strategies and
    • Strategies to improve motivation to maintain an active lifestyle

Prescribed movement can be suggested as independent work for the individual or as part of joining structured programs. The Tables of Examples for the Conservative OA Treatments provides a variety of categorized examples of independent or structured programs. Structured programs may be offered on-site or virtually, with individual supervision or in a group setting. Note that structured programs may incur costs. The individual’s socioeconomic status should be considered before selecting treatment options.

Over time, work with the individual with OA to safely and gradually progress the intensity, frequency and duration of an exercise or physical activity. Build relationships with the community-based exercise program providers in the area to ensure individuals with OA are directed to the program that is most applicable to their needs.

Movement Target

With clinician approval for medical safety a target of 150 minutes of moderate to vigorous aerobic movement per week is recommended7,87Canadian Society for Exercise Physiology. Canadian 24-hour movement guidelines: An integration of physical activity, sedentary behavior, and sleep Ottawa, Ontario: Canadian Society for Exercise Physiology; 2021 [Available from: https://csepguidelines.ca/].
8World Health Organization. WHO guidelines on physical activity and sedentary behavior. Geneva; 2020.
.

Moderate Movement
Vigorous Movement
Description
Individuals can carry a conversation while performing these movements.
Individuals would feel a little out of breath during conversation while performing these movements.
Examples
i.e. Brisk walking, biking, household chores, yard work and dancing.
i.e. Faster-paced walking, biking uphill and swimming.
Q

Referral Between Clinicians

Q

Components of Prescribed Exercise Programs

Q

Shared Decision Making

Q

Alberta Referral Directory

Q

OA Self Management Toolkit

Q

Self-Management