What are safe exercises for osteoarthritis?

The EULAR Association (The European League Against Rheumatism), in 2018, issued recommendations on safe exercise for osteoarthritis sufferers. Sufferers of osteoarthritis or joint disorders, both due to calcification and inflammation, tend to reduce physical activity/exercise and become increasingly inactive/sedentary.

Safe Exercises for Osteoarthritis
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Some causes that make osteoarthritis patients more sedentary are less information about the disease conditions and the type of safe physical activity. Unresolved symptoms (pain, stiffness), fear of physical activity that makes symptoms worse, lack of exercise habits, and lack of support from the environment around the patient, also cause osteoarthritis patients to limit physical activity.

Sedentary is a condition when a person's daily activities produce a metabolic energy level of less than three metabolic equivalent methods (MET). Generally, in this condition, daily activities are carried out in a sitting or lying position and rarely exercise.

EULAR 2018 Recommendations 

The main principle emphasized by the EULAR association is that regular exercise must be an important part of joint disease management. Exercise variations must be comprehensive and include aerobic exercise, muscle strengthening, flexibility, and neuromotor. The realization of exercise must be adjusted to the interests, physical abilities of patients, and the availability of sports facilities.

EULAR recommends that all medical personnel involved in treating joint cases collaborate with those who are competent in providing sports management, such as physical therapists. Therefore, the therapist or competent medical personnel can provide the right dose of exercise, evaluate the clinical condition routinely, and modify the exercise if there are contraindications to the exercise.

For long-term goals, the therapist can educate the patient so that the patient takes the initiative to exercise and can modify the goals and portions of the exercise independently.

Safe Physical Activities for People with Osteoarthritis

Physical activity is the movement of the body by skeletal muscles, which increases energy production beyond basal energy levels. Physical activity can be related to daily life at home, work, hobbies, and mobility. Exercise is a physical activity that is structured, planned, and carried out repeatedly to improve physical fitness.

In daily activities, osteoarthritis sufferers are encouraged to avoid movements that provoke pain. Suggested exercises for osteoarthritis sufferers include aerobic exercise, muscle strengthening exercises, flexibility exercises, and functional neuromotor exercises. The combination of these exercises provides the best and most effective results in reducing joint pain in the lower limbs, as well as increasing the physical abilities and activity of patients.

1. Aerobic Exercise

Aerobic exercise can increase physical fitness due to an increase in maximum oxygen uptake (VO2max). Vo2max is the uptake of maximum oxygen by the body's muscles at the maximum physical performance (units in ml/kg/min). Vo2max is a parameter of fitness and physical health. The higher the value means that a person is fit, has good stamina in activities or sports, and reduces the risk of death from cardiovascular disease.

A meta-analysis study with 2024 subjects stated that with regular running exercises, an increase in Vo2max of 7.1 ml/min/kg, and HDL levels of 3.3 mg/dl, it also decreased 3.3 kg of body weight.

a. Frequency 
Recommendations for frequency of aerobic exercise for sufferers of osteoarthritis are:
  • ≥5 days/week for moderate-intensity
  • ≥3 days/week for severe-intensity
  • 3-5 days/week for a combination of moderate and severe intensity

b. Intensity 
The intensity category of aerobic exercise can be measured through the percentage of maximum heart rate. The maximum heart rate is obtained using the formula 220 minus age. Measurements were taken after the patient exercised.
  • The low-intensity of exercise if a person's heart rate per minute <63% of the maximum heart rate.
  • Medium-intensity if 64-76%,
  • High-intensity if 77 - 95%.
Recommendations for aerobic exercise intensity for osteoarthritis sufferers are:
  • Very Low-intensity if there are complaints of mild pain
  • Low-intensity and gradually increased to moderate intensity when in sedentary conditions
  • Moderate to High intensity if the condition without pain complaints.
c. Duration
The recommended duration of aerobic exercise for sufferers of osteoarthritis are:
  • 30-60 minutes / day (150 minutes / week) if moderate intensity
  • 20 - 60 minutes / day (75 minutes / week) if the intensity is high
  • ≥20 minutes / day (150 minutes / week) if sedentary
In the condition that the patient is unable to do the exercises continuously and directly, then the total duration of the exercise can be divided several times per day (2-3 times in 1 day) so that the exercise becomes ≥10 minutes per session. If the duration of the exercise is less than 10 minutes, then the benefits of exercise are not significant.

d. Types and Patterns
The recommended movement patterns are those that use large leg muscle groups, do not have a significant impact on the joints, with continuous and rhythmic types of movements such as walking, biking, and swimming.

e. Volume
The recommended volume of aerobic exercise reaches 500-1000 MET minutes/week. The metabolic equivalent method (MET) is an index of the energy released by the body during an activity.
  • MET 1–2,9 categorized as light activity,
  • MET 3–5,9 categorized as moderate activity,
  • and MET> 6 categorized as strenuous activity.
Example calculation: If in the morning running activity is 7 MET, carried out for 30 minutes, three days per week. So 7 METs x 30 minutes x 3 days = 630 MET/minute/week.

The volume of exercise can also be measured by the number of steps, where if it is recommended to reach ≥7000 walking steps per day. Do 2000 steps per day as a preliminary exercise, then add 2000 steps per day until reach ≥7000 steps per day if unable to reach the target of ≥7000

f. The progressiveness
It is achieved by increasing the duration, frequency, or intensity of the exercise, to achieve the desired training goals. In the maintenance phase, exercise continues to reduce the risk of musculoskeletal injury or cardiovascular cases.

2. Muscle Strengthening Exercises

Various studies show that in patients with osteoarthritis occurs atrophy of muscle mass and reduced muscle strength. Therefore strengthening exercises of postural muscles and lower extremities (hip flexors, hip extensors, knee flexors, knee extensors, and calf muscles) help reduce pain, improve kinematics of motion and functional activity (rise from a chair, walk up and downstairs).

A meta-analysis study by Latham et al., including 907 osteoarthritis sufferers over the age of 65 found that lower limb muscle strengthening exercises had a moderate effect on increasing strength, functional ability, and pain relief.

a. Frequency
Strengthening of the lower limb and postural muscle groups need to be trained 2-3 days/week.

b. Intensity
The intensity of the training load must be determined by first calculating the maximum load, that is, the load that can be lifted in a controlled motion, or also called a maximum repetition (1 MR). After knowing one's maximum load, strengthening exercises are performed by calculating the percentage of 1 MR, which is very light intensity if 10% of 1 MR, mild intensity if 10–50% of 1 MR, moderate-intensity if 60–70% of 1 MR, and the intensity are hefty when> 80% of 1 MR.

The recommended intensity of muscle-strengthening exercises for osteoarthritis sufferers are:
  • In the initial stage or sedentary conditions, a very light load (10% of 1 MR) can be performed
  • Intensity can be increased to 10-50% of 1 MR if there is an increase in muscle strength and endurance.
  • If there is no pain and someone is trained, then the intensity of IMM), with the number of reps reduced. Adjustments in intensity, repetition, and interval periods are important to note and do to reduce the risk of exacerbation of acute pain during exercise
  • If the exercise is intended to increase muscle power, then the burden needs to be reduced to 20-50% of 1MR.

c. Duration 

There are no specific recommendations on the duration of muscle strengthening exercises. However, various studies suggest strengthening exercises in osteoarthritis sufferers can be done 2-9 months (average three months).

d. Types and Patterns
The exercises focus on using large muscle groups of the lower and postural limbs. It can be performed with or without sports equipment.

e. Volume
Regular repetition of motion is counted in sets, where a set consists of 8–12 or 10-15 repetitions if the aim of the exercise is muscle strength and explosive power. Alternatively, if the aim of the exercise is muscle endurance, then a set consists of 15-20 repetitions.

The recommended set of exercises are:
  • 1 set for the elderly or beginner population
  • ″ two sets if the goal of the exercise is muscle endurance
  • 2-4 sets if the goal of the exercise is muscle strength
It is recommended that there is a break of 2-3 minutes intervals between sets. Then, before strengthening exercises on the same muscle group, rest and intervals of ≥48 hours are recommended.

f. Progressiveness
  • Exercise progression for muscle strength can be done by increasing the intensity (very mild to mild, moderate, then severe),
  • or add reps (8 to 12),
  • Alternatively, by increasing the frequency of exercise per week (2 days to 3 days per week).

3. Flexibility Training

The inflammation process can occur in the joints or the soft tissues around the joints. This can cause effusion, edema, and soft tissue adhesion, leading to a reduced scope of joint motion. The scope of joint motion needs to be improved through flexibility training, or therapy, by a competent therapist or profession. Flexibility training is important because it can reduce soft tissue adhesion, increase joint range of motion, reduce muscle workload while on the move, reduce pain, and improve physical abilities.

a. Frequency
The recommendation of exercise flexibility frequency for osteoarthritis sufferers is routine every day or at least 2-3 days/week.

b. Intensity 
Muscle stretching is performed until there is a slight tension/discomfort at the end of the joint motion. Each training session is expected to reach the full range of joint motion.

c. Duration 
Flexibility exercises are carried out for 10-30 seconds, stretching in the young adult population. Whereas in the elderly population, stretching is 30-60 seconds.

d. Types and Patterns 
Muscle flexibility or stretching exercises will be more beneficial if the muscles are flexed first through mild or moderate aerobic exercise, or can be given a warm modality (heat pack). Then keep in mind the presence of swelling or adhesion of soft tissue around the tendon or joint that might affect joint motion.

e. Volume
Muscle and joint stretches are generally obtained when exercise reaches 1 minute per movement. Stretching can be performed 2-4 times of repetition.

f. Progressiveness 
There are no specific criteria for training progression. The target of the exercise is to achieve a full range of joint motion.

4. Neuromotor Functional Exercise

Neuromotor functional exercise is an exercise that combines several motor skills such as balance, agility, proprioception, coordination, and mobility. Examples are yoga practice, tai chi, balance training, or mobilization exercises. Some studies have found that neuromotor functional exercise can reduce knee pain, stiff joints, the risk of falls, and improve the ability to move joints.

A meta-analysis of 7 studies by Yan et al. included 348 joint calcification patients compared Tai Chi interventions and controls (active non-sports therapy) for 12 weeks. The results of the study were 12 weeks of Tai Chi, reducing complaints of joint pain and stiffness and increasing physical ability to move. The reduced WOMAC value indicates this for pain by 34.0%, joint stiffness of 32.2%, and 36.4%, which shows better clinical condition.

Therefore, Bushman et al. and Wang et al. suggested that this exercise be added as part of comprehensive rehabilitation in addition to aerobic exercise, muscle strengthening, and flexibility in calcification sufferers.

a. Frequency 
Exercise 2-3 days/week.

b. Intensity
There is no guidance on the intensity that gives effective results.

c. Duration 
20-30 minutes / day.

d. Types and Patterns 
The exercises carried out aim to improve balance, agility, proprioception, coordination, and mobility. The pattern of practice is very dependent on the type of exercise that is followed, such as yoga and tai-chi. Balance exercises can be done by walking on a balance board or an uneven surface. Turning or stopping quickly also includes functional exercise.

e. Volume 
There are no guidelines on effective training doses.

f. Progressiveness 
Generally,  the contours changing of the pedestal and body position (sitting, standing on a soft surface, standing one foot), combining motion with the upper limb or contralateral side, changing the direction of movement, or increasing the distance that needs to be achieved increase the level of difficulty.

Safe Exercises Dosages for People with Osteoarthritis

  • The dose of exercise given must be individualized because each patient's response is different to exercise. Exercise adjustments also need to be done if there are conditions of pain or inflammation.
  • If the duration of pain is more than 24 hours, the exercise intensity must be reduced
  • If in an acute phase of inflammation, avoid training tests or exercises that have a great impact on the joints
  • Doing exercises only when the pain is mild (based on patient perception)

The EULAR Association recommends that exercise be an integral and inseparable part of the comprehensive management of patients with calcification.

Ideally, recommended exercises include aerobic exercise, muscle strengthening, flexibility, and functional neuromotor. In its realization, it is strongly recommended that patients with calcification get the joint assessment, prescribing, and modification of exercise doses as well as routine evaluations by physical therapists or medical personnel who are competent in the field of sports.

It is important to consider that variations of exercise must be adjusted to the interests, physical abilities of sufferers, and the availability of sports facilities.

The purpose of the above exercises is to help sufferers control pain, improve their ability and physical fitness so that patients can move back.

Safe exercise is accompanied by providing sufficient information about the condition of the illness and proper medical management, so it is expected that the quality of life of patients will improve.