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Physical Activity Guidelines For Osteoarthritis Patients

The paradigm about the prohibition to do physical activity in osteoarthritis patients has been left. Now, physical activity is considered part of the non-pharmacological therapy of osteoarthritis.

Physical Activity Guidelines For Osteoarthritis Patients
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Previously, physical activity in osteoarthritis was debated because of the hypothesis of the "wear and tear" phenomenon stated that the heavier physical activity carried out, the degeneration process is also more severe. Therefore, clinicians often do not allow their patients to do physical activity. However, based on recent studies, this hypothesis has been left, and physical activity has been reported to be effective for treating osteoarthritis.

Benefits of Physical Activity for Osteoarthritis

Joint immobility can reduce joint flexibility so that it can cause gait disorders, pain, and dysfunction. Physical activity for osteoarthritis patients can increase the joint ranges of motion (ROM) and improve the muscle structure and soft tissue around the joints, which causes improvements in tissue circulation, gait, and reduce pain.

Several studies have reported on the effectiveness of physical activity in osteoarthritis patients. One of them is a systematic review by Nelson et al. This review recommended that mild aerobic exercise is useful for the management of knee and pelvic osteoarthritis.

A literature review also stated that land-based and water-based aerobic physical activity, and progressive strengthening exercise, are effective in reducing pain and improving joint function in osteoarthritis. Even, it stated that physical activity's effects are equivalent to analgesic drugs. However, it should be noted that the available scientific evidence mostly supports the knee and pelvic osteoarthritis, but not enough for another joint osteoarthritis. 

Types of Physical Activity for Osteoarthritis Patients

Several physical therapy programs can be given to osteoarthritis patients. The latest guidelines from the European League Against Rheumatism (EULAR) in 2018 recommend that physical activity be part of standard management for patients with knee and hip osteoarthritis.

Aerobic Exercises
A consensus in 2004 reported that in three randomized controlled trials (RCTs) analyzed, aerobic walking exercises were beneficial in reducing pain intensity and improving function in patients with knee osteoarthritis.

Aerobic exercise is a physical activity that aims to increase the metabolism of aerobic oxygen to produce energy. This exercise can be performed at moderate to high intensity.
ASCM-AHA recommends that patients do routine 30-60 minutes/day for ≥ 5 days/week for moderate-intensity exercises, such as brisk walking, swimming, and relaxed cycling. As for high-intensity exercises, such as jogging, fast swimming, and fast cycling, it is recommended to do 20-60 minutes/day for ≥ 3-5 days/week.

Resistance training
Resistance training is a form of exercise that aims to improve muscle mass, tone, strength, and endurance. The way to do this exercise is by contracting the muscles against a given external resistance.

In patients with knee and pelvic osteoarthritis, quadriceps, hip abductor, hip extensors, and hamstring muscles play an essential role in the movement, so they should be the target of exercise.

The ASCM-AHA guide recommends that this exercise be performed with a frequency of 2-3 days/week for each large muscle group with moderate-high intensity, i.e., with repetition at least 6 to 12 times. In elderly patients, the intensity of exercise is reduced to very low intensity, namely repetition according to the ability of the patient, with no minimum limit. 

Flexibility Training
Flexibility exercises (stretching) are exercises that aim to improve the range of motion, strength, balance, and endurance of the patient. Exercises such as stretches, forward bend, yoga, and pilates are some examples of flexibility exercises.

This exercise can be performed for ≥ 2 - 3 days/week withholding time stretching 10-30 seconds. For older people, holding stretches for 30-60 seconds is recommended. Stretching can be performed to the point where the patient feels uncomfortable.

An existing study showed that osteoarthritis patients who do yoga have complaints of pain, physical function, and better mobility compared to patients without physical activity. Other studies also showed the effectiveness of pilates in reducing pain and improving disability compared to other conventional therapeutic exercises.

Neuromotor Exercise
Neuromotor training is an exercise balance, coordination, walking, and proprioceptive. Tai chi and Qigong are one example of this practice. Performing neuromotor exercise every ≥ 20-30 minutes/day for ≥ 2 - 3 days/week is recommended.

The American College of Sports Medicine admit this method in 2011, so studies regarding this exercise are still not as many as other types of physical activity. However, Wang et al.'s study showed that the Taichi program 2 times/week for 12 weeks could reduce pain and depression, and improve the physical function of osteoarthritis patients.

Selection of Physical Activity in Osteoarthritis Patients

European League Against Rheumatism (EULAR) states that applying the combination of various types of physical activity is more recommended, rather than the use of only one type of physical activity. However, select physical activity type in osteoarthritis patients must consider the age, mobility, and comorbidity of each patient.

For patients with severe osteoarthritis or obese patients, aquatic exercise is more beneficial than land-based exercise because it can reduce the force imposed on the joints, especially in the early stages of management. Also, in these patients, resistance training while seated, even with severe intensity, can be more tolerated than weight-bearing aerobic exercise.

For obese patients who are undergoing a diet program, resistance training is very important to minimize the loss of lean muscle mass, which will cause muscle weakness.

In general, high-impact physical activity should be avoided because studies in experimental animals show a deteriorating effect on the joints. In addition, EULAR recommends using the "24-hour rule", where if after physical activity, there is pain that persists within 24 hours, then the intensity of physical activity must be reduced.

Physical activity in osteoarthritis patients can be done in the form of individual physiotherapy, group classes under supervision, or carried out independently at home. All three methods are equally effective in reducing pain symptoms, although medical staff supervision is reported to have better outcomes.

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