Osteoarthritis and Cartilage 23 (2015) 31e33
Editorial
Physical activity and osteoarthritis e considerations at the population and clinical level
Keywords: Physical activity Osteoarthritis Intervention Guidelines Models of care Physical activity as vital sign
Physical activity is a highly recommended public health and clinical management intervention for secondary and tertiary prevention of osteoarthritis (OA)1e5. However, in terms of the value or harm of physical activity for the primary prevention or delay of onset of OA, there are few studies and the findings to date are somewhat conflicting6. That said, OA does not develop in a silo. Most individuals with chronic disease have more than one condition, and OA is frequently concomitant with conditions such as cardiovascular disease and diabetes, where physical activity is important for prevention7. Further, obesity is a risk factor for OA and physical activity is beneficial for managing obesity. So despite the dearth of solid empirical evidence supporting physical activity as primary prevention for OA, specifically, it must be considered for its other benefits. Physical activity is well documented as a useful non-pharmacological behavioral intervention for reducing the symptoms and progression of OA in individuals who have already been diagnosed with the condition, particularly in knee and hip joints1,2,8. In fact, there is no shortage of endorsement or guidance for the use of physical activity as an effective therapeutic modality for OA; rather, a significant shortage appears in the assessment and implementation of physical activity in clinic settings and with the individual patient2. Other chronic diseases such as cardiovascular disease and hypertension have been associated with high rates of morbidity and mortality and exorbitant healthcare costs and utilization historically; however, the prevalence and utilization rates for these conditions have substantially improved in recent decades following effective campaigns to promote awareness and reduce the incidence of unhealthy lifestyle behaviors. The most effective efforts have required involvement across sectors including healthcare, and community-based and environmental settings, as well as risk factors and behaviors, including tobacco use, poor diet, obesity, and physical inactivity7. Similar efforts would reasonably and significantly impact primary and secondary prevention of OA. In 2010, the Centers for Disease Control and Prevention (CDC) and the Arthritis Foundation (AF) published A National Public Health Agenda for Osteoarthritis to serve as a blueprint for action to reduce
the burden of the most common form of arthritis in the United States (US)1. The goals of the Agenda were to ensure the availability of evidence-based intervention strategies, establish supportive policies and strategic alliances, and to initiate needed research. These goals are now being advanced by the Osteoarthritis Action Alliance (OAAA), a coalition of concerned organizations committed to working together to implement the Agenda's recommendations4,5. Four intervention strategies for addressing OA were determined to be ready for public health dissemination: self management, injury prevention, weight management, and physical activity, specifically in the form of low impact, moderate intensity aerobic activities and muscle strengthening exercises1,5. The recommended physical activity guidelines for adults were endorsed with special considerations for people with chronic conditions such as OA1. These considerations include noting that any activity is better than none, that the person with OA should do activity according to their abilities, and that they should be under the care of a healthcare provider. The OAAA Physical Activity Working Group is focused on expanding the availability of physical activity as a public health intervention by providing guidance on implementing evidence-based physical activity programs in community settings and promoting an existing online resource, the Implementation Guide, which outlines strategies for improving convenience and access to physical activity4,9. In terms of clinical care, physical activity is an important nonpharmacologic intervention in most recommendations and guidelines for the management of OA2. In a systematic review of 16 articles from the US, Canada, Europe and Asia that described recommendations for the management of OA, 12 of the guidelines endorsed low-impact land-based or water-based aerobic physical activity, especially for knee or hip OA2. In addition, some groups recommended strengthening and endurance exercises and/or flexibility/range of motion exercises2. The evidence supports pain reduction and improvement in physical function with effects comparable to those reported for non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics3. As a result of the emphasis of physical activity in most guidelines, it is included prominently in the clinical programs and initiatives that have been started around the globe focused on the comprehensive management of OA in the clinical setting3,8,10e13. In 2004, members of the Alberta Orthopaedic Society along with the Alberta Bone and Joint Health Institute initiated an innovative, comprehensive, fully integrated model of care for severe OA requiring knee and hip replacement that has since improved efficiency of the healthcare system, raised quality of service and provided greater access to care for patients. Alberta's model was
http://dx.doi.org/10.1016/j.joca.2014.09.027 1063-4584/© 2014 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.
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Editorial / Osteoarthritis and Cartilage 23 (2015) 31e33
implemented provincially and has since led to additional evolutions in care and infrastructure nationally13. Better Management of OsteoArthritis (BOA) was introduced in Sweden in 2008 to standardize and improve care and management of patients with hip and knee OA10. Key elements from this program were factors in the development of an evidence-based, individualized, non-surgical treatment program for patients with mild to moderate knee and/or hip OA in Denmark, Good Life with osteoArthritis in Denmark (GLA:D)11. In Australia, a model of care for people with OA using a chronic disease management approach was developed by the Agency for Clinical Innovation, the Osteoarthritis Chronic Care Program (OACCP)12. In 2012, the US Bone and Joint Initiative convened the Chronic Osteoarthritis Management Initiative (COAMI) and a Call to Action was issued calling for a new vision for chronic OA management8. Despite the worldwide endorsement of clinical and public health groups and the evidence of the value of physical activity in terms of secondary and tertiary prevention of OA, there are still many unanswered questions in this area. The preponderance of data is related to knee OA, followed by hip OA. Few studies examine physical activity of OA in other joint sites3. Most studies are shortterm and focused on mild-to-moderate OA. And there is limited information about the amount and intensity of exercise that is optimal3. Becoming physically active is extremely challenging for all populations regardless of health status and, in OA, is often compounded by the presence of joint pain or concerns that physical activity will worsen pain or other symptoms. As attention focuses more on chronic diseases as the foremost challenge to global health, physical inactivity is included on the short list of risk factors that can be effectively addressed7. The article by Peeters and colleagues6 published in this issue of the journal stimulates numerous interesting questions regarding leisure time physical activity and its association with the onset of OA: Is a person more or less likely to get OA if they participate in leisure-time physical activity in middle age? Does a person's participation in physical activity during their late 40s and early 50s compared with participation during their mid to late 50s make a difference in whether or not they have OA at a later point in life? Does the amount and intensity level of physical activity a person engages in contribute to arthritis? Peeters et al.6 report findings from a longitudinal study examining the influence of timing and amount of self-reported walking and moderate and/or vigorous leisure-time activities with the report of non-specified joint pain or stiffness in mid-age Australian women6. The study utilizes life-course modeling techniques to compare whether the effect of physical activity is cumulative with the various midlife age periods that were examined contributing equal importance vs whether physical activity in certain periods is more important than others or whether physical activity in one particular mid-life period is critical in relation to reporting joint pain or stiffness later in life. Associations were found between lower odds of selfreported non-specified joint pain or stiffness in women aged 56e64 with higher levels of self-reported physical activity between the age of 47 and 58, with activity from ages 52e58 appearing more important than at ages 47e526. Although the study has clearly defined limitations in terms of the outcome (reporting non-specified joint pain or stiffness rather than a diagnosis of OA), the physical activity measure (assessing self-report of activities occurring over only the previous week), and generalizability (only women were in the study), it underscores the need for more research exploring the role of physical activity in the prevention or delay of the onset of arthritis. Notwithstanding the many unanswered questions regarding physical activity, it is nevertheless important for better outcomes in numerous chronic diseases to encourage people to be less sedentary through clinical and community endeavors. Most individuals, including those with OA, require support, encouragement,
education, and opportunity to incorporate physical activity into their lives successfully. In clinic settings, physical activity should be assessed as a vital sign14 and subsequently incorporated into models of care15 as readily as prescription medications and traditional therapies are currently. Environmental policies and community programs should be established to make physical activity the easy, even default, choice. Public awareness campaigns should integrate physical activity messages across common chronic conditions. And, professional and advocacy organizations committed to OA care and research, such as the Osteoarthritis Research Society International (OARSI), COAMI, OAAA, and arthritis-focused voluntary health agencies worldwide, should support these clinical and community efforts and call for more research to address these important issues surrounding physical activity and OA. Conflict of interest The authors have no conflict of interest.
References 1. Lubar D, White PH, Callahan LF, Chang RW, Helmick CG, Lappin DR, et al. A national public health agenda for osteoarthritis 2010. Semin Arthritis Rheum 2010;39(5):323e6. 2. Nelson AE, Allen KD, Golightly YM, Goode AP, Jordan JM. A systematic review of recommendations and guidelines for the management of osteoarthritis: the chronic osteoarthritis management initiative of the U.S. bone and joint initiative. Semin Arthritis Rheum 2014;43(6):701e12. 3. Golightly YM, Allen KD, Caine DJ. A comprehensive review of the effectiveness of different exercise programs for patients with osteoarthritis. Phys Sportsmed 2012;40(4):52e65. 4. Waterman MB, White PH. Utilizing the national physical activity plan to create a disease-specific approach: environmental and policy strategies to increase physical activity among adults with arthritis. J Phys Act Health 2014;11(3):487e8. 5. White PH, Waterman M. Making osteoarthritis a public health priority. Am J Nurs 2012;112(3 Suppl 1):S20e5. 6. Peeters GG, Pisters M, Mishra GG, Brown WJ. The influence of long-term exposure and timing of physical activity on new joint pain and stiffness in mid-age women. Osteoarthritis Cartilage 2014;23(1):34e40, http://dx.doi.org/10.1016/ j.joca.2014.06.040. 7. Bauer UE, Briss PA, Goodman RA, Bowman BA. Prevention of chronic disease in the 21st century: elimination of the leading preventable causes of premature death and disability in the USA. Lancet 2014;384(9937):45e52. 8. A Call to Action from the Chronic Osteoarthritis Management Initiative (COAMI): a New Vision for Chronic Osteoarthritis Management. United States Bone and Joint Initiative (USBJI); 2012. 9. OA Action Alliance. Available from: http://www.oaaction.unc. edu; 2014. 10. Thorstensson C, Dahlberg L, Garellick G. The BOA-register e Annual Report 2012. Sweden: Better Management of Patients with OsteoArthritis (BOA); 2013. 11. Skou ST, Odgaard A, Rasmussen JO, Roos EM. Group education and exercise is feasible in knee and hip osteoarthritis. Dan Med J 2012;59(12):A4554. 12. Osteoarthritis Chronic Care Program First Annual Report: 2011e2012. New South Wales, Australia: Agency for Clinical Innovation; 2012. 13. Frank C, Marshall D, Faris P, Smith C, for the Alberta Bone and Joint Health Institute. Essay for the CIHR/CMAJ award: improving access to hip and knee replacement and its quality by adopting a new model of care in Alberta. CMAJ 2011;183(6):E347e50.
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14. Grant RW, Schmittdiel JA, Neugebauer RS, Uratsu CS, Sternfeld B. Exercise as a vital sign: a quasi-experimental analysis of a health system intervention to collect patient-reported exercise levels. J Gen Intern Med 2014;29(2):341e8. 15. Parekh AK, Kronick R, Tavenner M. Optimizing health for persons with multiple chronic conditions. JAMA 2014 Sep 24;312(12):1199e200. L.F. Callahan* Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC, USA Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
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K.R. Ambrose Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC, USA * Address correspondence and reprint requests to: L.F. Callahan, Thurston Arthritis Research Center, University of North Carolina, 3300 Thurston Building, CB 7280, Chapel Hill, NC 27599-7280, USA. E-mail address:
[email protected] (L.F. Callahan).
8 September 2014
