NIHR: osteoarthritis can benefit from exercise

Why was this study needed?

Osteoarthritis is the most common form of joint disease, affecting at least eight million people in the UK. It can affect any joint, but it most commonly affects the knees, hips, neck, back, toes and fingers.

Exercise is recommended by the National Institute for Health and Care Excellence (NICE) to reduce joint pain and improve mobility in people with osteoarthritis, and some studies have shown that exercise has additional benefits: it can also boost emotional wellbeing and lead to greater self-reliance, reduced disability and helplessness.

As there is no summary of the evidence to link physical, emotional and behavioural effects of osteoarthritis, and the potential of exercise to address these, the researchers reviewed evidence on the impact of exercise on people’s pain, physical and emotional wellbeing, and aimed to determine the most effective ways to deliver exercise in this population.

What did this study do?

This study identified 21 randomised controlled trials (2,372 people) evaluating the effects of exercise on physical and mental health of men and women aged over 45 with hip and/or knee osteoarthritis. These were conducted in high-income countries including Europe. It also included a synthesis of qualitative evidence from patient interviews (12 studies, 197 participants). This research included studies that had asked about perceptions of exercise and effects on pain and wellbeing alongside an exercise intervention.

The trials differed by the population and participants examined, and by the type, setting and time period of the exercise intervention. Most interventions (15 studies) were delivered by trained professionals who were either fitness/exercise instructors or physiotherapists. The variations in study characteristics made it hard for the researchers to draw clear general conclusions. Overall risk of bias in the trials was low, but because people knew they were taking part in exercise, this may have increased any perceived benefits.

What did it find?

• Exercise reduced pain by 6 per cent (95 per cent confidence interval [CI] -9 to -4 per cent; 9 studies, 1,058 participants, moderate quality). This equated to a reduction in pain score from 6.5 to 5.3 on a scale of 0 to 20. There was no difference in physical function (absolute reduction of 5.6 per cent; 95 per cent CI ‑7.6 per cent to 2.0 per cent; 13 studies, 1,599 participants, moderate quality).
• Exercise may slightly improve people’s belief in their own capabilities (1.66 per cent improvement; 95 per cent CI 1.08 to 2.20; 11 studies, 1,138 participants, low quality) and symptoms of depression (2.4 per cent reduction; 95 per cent CI -0.47 to ‑0.5; 7 studies, 919 participants, moderate quality) but no effect on anxiety.
• Social function increased by 7.9 per cent (95 per cent CI 4.1 to 11.6; 5 studies, 576 participants, low quality). This equated to an improvement in social function score from 73.6 to 81.5 on a scale of 0 to100.
• Interviews with participants found that pain, joint stiffness, tiredness, other illnesses and people’s views of their physical fitness restricted the type and amount of exercise they felt able to do. Pain during exercise was also often thought to be causing additional joint damage, so people avoided activity for fear of causing more harm.
• Participants also said that clear instructions from healthcare professionals outlining exactly what exercises to do, what to avoid, and what they might experience during the exercise helped to reassure them that exercise is safe and beneficial. Most interviewees thought that rehab programmes that included a way to participate in exercise had physical, emotional and social benefits. Providing exercise recommendations that are tailored to individual preferences, abilities and needs was also important.

What does current guidance say on this issue?

The 2014 NICE guideline on osteoarthritis recommends exercise, irrespective of age, other conditions, pain severity or disability. This should include local muscle strengthening and general aerobic fitness and, for hip osteoarthritis, stretching and manipulation.

What are the implications?

This review adds evidence that could help healthcare professionals encourage more effective uptake of exercise in this group. It reinforces the benefits of exercise for people with arthritis with slight improvements in pain and function, indicating how these could be maximised.

Specific suggestions are that rehab programmes could educate people about the causes and potential disease course of osteoarthritis, challenging beliefs that exercise causes harm and reassuring people that it is safe and beneficial. The researchers suggest that advice is tailored to each individual patient. 

The full NIHR Signal and additional expert commentary was published on 21 August 2018.

Expert view: David Rogers clinical lead functional restoration service, advanced practice physiotherapist, Royal Orthopaedic Hospital, Birmingham

This review provides some useful information relating to clinical practice. It reaffirms clinical guidance on the modest beneficial effects of exercise on lower limb osteoarthritis in improving pain scores, self-belief and social function. 

It highlights the role of health beliefs in people engaging in exercise, recognising that people who think their joint pain is due to harm and damage will therefore avoid exercise, for fear of causing more harm or damage. 

Trained professionals therefore play an important role in addressing these unhelpful beliefs by providing clear advice to people with lower limb osteoarthritis that exercise is safe and beneficial. If they fail to do this, people are less likely to engage in exercise treatment. 

It also confirms the importance of tailoring any exercise treatments to people’s individual needs and preferences, rather than providing generic advice.

Although more research is needed, this evidence confirms that treatment of lower limb osteoarthritis is not just about prescribing exercise, it should include addressing unhelpful health beliefs about exercise and tailoring to peoples’ individual preferences. Physiotherapists should therefore be aware of these factors when treating people with lower limb osteoarthritis if they are to make the most of their clinical encounters.

Citation and funding: Hurley M, Dickson K, Hallett R, et al. Exercise interventions and patient beliefs for people with hip, knee or hip and knee osteoarthritis: a mixed methods review. Cochrane Database Syst Rev. 2018;(4):CD010842.This project was supported by an Educational Grant, Number 20163 from Arthritis Research UK.

Bibliography: NICE. Osteoarthritis: care and management. CG177. London: National Institute for Health and Care Excellence; 2014. NIHR DC. Moving forward – physiotherapy for musculoskeletal health and wellbeing. Themed review. Southampton: National Institute for Health Research Dissemination Centre; 2018.