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Clinical Concepts

Benefits of Physical Activity for Knee Osteoarthritis

A Brief Review

Beverly Anne Egan, BS; and Janet C. Mentes, PhD, APRN, BC

AbstrACt

Osteoarthritis (OA) is the second most prevalent health condition in commu- nity-dwelling adults 65 and older, with

27 million older Americans affected. Ap-

proximately half of community-dwelling

women (54%) and men (43%) older than

65 have OA, and the percentage with

symptomatic knee OA rises to more than 60% among older adults who are over- weight. This article examines major risk factors for knee OA and nursing interven- tions to help older adults with knee OA minimize disease symptoms. Significant health benefits of physical activity for the prevention of obesity, delay of onset of physical limitation, and importance to normal joint health for older adults with OA are emphasized. Nursing recommen- dations for physical activity in older adults with OA are detailed. Social and environ- mental barriers inhibiting older adults from achieving their weight loss and ex- ercise goals are discussed. Resources sup- porting physical activity in older adults with OA are provided.

O steoarthritis (OA) is the second most prevalent health

condition in community-dwelling adults 65 and older (Federal Inter- agency Forum on Aging-Related Statistics, 2010), with 27 million older Americans affected (Helmick et al., 2008). Approximately half of community-dwelling women (54%) and men (43%) older than age 65 have OA, and the percentage with symptomatic OA of the knee rises to more than 60% among older adults who are overweight (Murphy et al., 2008). Although not fatal, OA is associated with pain, stiff- ness, decreased physical functioning, incontinence, depression, and overall poorer quality of life for affected older adults (Arthritis Foundation, 2008). Often, coping with other major health conditions, such as congestive heart failure or chronic respiratory disease with an overlay of OA precipitates a cascading decline in function for older adults, result- ing in social isolation and depres- sion (Fried, Storer, King, & Lodder, 1991; Theis, Murphy, Hootman,

ABOUT THE AUTHORS

Ms. Egan is a nurse, Santa Monica UCLA Medical Center gerontology unit, and Dr. Mentes is Associate Professor, University of California Los Angeles, School of Nursing, Los Angeles, California. The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support. Address correspondence to Janet C. Mentes, PhD, APRN, BC, Associate Professor, University of California Los Angeles, School of Nursing, 5-262 Factor Building, PO Box 956919, Los Angeles, CA 90095-6919; e-mail: jmentes@sonnet.ucla.edu. Posted: August 23, 2010

doi:10.3928/00989134-20100730-03

Journal of GerontoloGical nursinG • Vol. 36, no. 9, 2010

© 2010 iStockphoto.com/Eileen Hart
© 2010 iStockphoto.com/Eileen Hart

Helmick, & Sacks, 2010). Nurses can intervene at any point of the decline to improve function and quality of life. The purpose of this article is to discuss the major risk factors for knee OA and nursing interventions to help older adults with knee OA minimize disease symptoms. OA is a progressive and debilitat- ing disease that commonly affects the hand, knee, hip, and spine joints (Goldring & Goldring, 2006). Elements of joints, such as the synovial lining, periarticular bone, and supportive connecting tissues, are adversely modified by OA with structural changes including continu-

ous loss of articular cartilage, forma- tion of new bone at joint margins, increased thickness of the subchon- dral plate, and growth of subchondral bone cysts. In addition, calcified cartilage forms at the attachments of the surrounding subchondral bone and articular hyaline cartilage. These structural alterations manifest in symptoms of pain, stiffness, and loss of mobility. Several current studies of healthy young and old adults who underwent magnetic resonance imaging of their joints revealed that joint changes man- ifest earlier than thought (Ding, Jones, Wluka, & Cicuttini, 2010). Early signs of joint degeneration are associated with smoking; vitamin D deficiency; and increased levels of lipids, leptin, and inflammation and are thought to be potentially reversible at a younger age (Ding et al., 2010). The investiga- tors concluded that early intervention could possibly avert or reverse some of the joint deterioration that may progress to OA (Ding et al., 2010).

risk fACtors

Major risk factors for OA are older age, overweight and obesity, physi- cal inactivity, previous joint injury, repeated overuse of certain joints, and heredity (Ding et al., 2010). After age 50, women are more likely than men to be affected by OA (Lawrence et al., 1998). Of these factors, overweight and obesity and physical inactivity are two risks that can be minimized.

Overweight Being overweight or obese is rec- ognized as a major risk factor for OA, particularly OA of the knee. Nation- ally, 70.8% of adults older than 60 are identified as overweight, and 32.9% are identified as obese (Wang, Miller, Messier, & Nicklas, 2007). Obesity, defined as a body mass index (BMI) >30 kg/m 2 , can cause severe health implications, including increased risk for additional chronic illnesses, impaired quality of life, and increased mortality (Villareal, Apovian, Kush- ner, & Klein, 2005).

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A recent study of older adults liv- ing in rural North Carolina suggested

that adults have a 50% lifetime risk of developing knee OA by age 85, and for those who are overweight, the risk rises to 67% (Murphy et al., 2008). However, current opinions concerning the link between obesity and knee OA are evolving and suggest that BMI as

a measure of obesity/overweight only

reveals part of the relationship (Sowers & Karvonen-Gutierrez, 2010). It has been assumed that the shearing force of additional weight is the mechanism for deterioration of the knee joint; however, the use of BMI to deter- mine obesity is problematic because it does not adequately characterize the amount and strength of lean muscle mass (Sowers & Karvonen- Gutierrez, 2010). Since muscle strength and increased muscle mass are thought to be protective against cartilage loss in middle-aged and older adults, it is important to know the overweight older adult’s fitness level. An additional emerging opinion concerning the link between obesity and knee OA is that the metabolic and inflammatory environment as- sociated with obesity may contribute to knee OA through direct joint degradation or mediation of local inflammatory processes (Sowers & Karvonen-Gutierrez, 2010). This is a compelling finding because OA had previously been considered a disease of “wear and tear” rather than influ- enced by inflammatory processes.

Physical Inactivity

Another major risk factor for OA

is physical inactivity. According to the

National Health Interview Survey, the percentage of people 45 and older who reported engaging in regular leisure time physical activity declines with age (Federal Interagency Forum on Aging-Related Statistics, 2010). In 2007-2008, approximately 22% of people 65 and older—25% of those 65 to 74, 21% of those 75 to 84, and 11% of those 85 and older—reported engaging in regular physical activity (Federal Interagency Forum on Ag-

ing-Related Statistics, 2010). Although these statistics may not be representa- tive of the general population with arthritis, these data show that many older adults are not including physical activity in their daily lives. The health benefits of physical activity are well established, includ- ing prevention of obesity, delay of onset of physical limitation, and importance to normal joint health (Hootman, Macera, Ham, Helmick, & Sniezek, 2003). Vigorous activ- ity has been associated with better joint health in people age 50 to 79 (Racunica et al., 2007), and Ding et al. (2010) reported that women who were regular walkers were less likely to have early signs of joint abnormal- ities, such as cartilage degeneration. Although there are conflicting data on the effect of quadriceps strength on knee OA, older adults with a higher muscle mass, presumably from regular exercise, have decreased cartilage loss, suggesting that in- creased muscle mass and strength protect joints from degenerative changes (Ding et al., 2010).

The Vicious Cycle of Body Weight and Physical Inactivity Many overweight older adults with OA choose not to exercise because of joint pain and fear of exacerbating their symptoms. Consequently, lack of physical activity leads to continued weight gain, which further stresses ar- thritic joints and worsens symptoms. Studies show that for every pound of weight loss, there is a 4-pound reduc- tion in load exerted on the knee, with further reduction of pain with as little as 15 pounds of weight loss (Messier, Gutekunst, Davis, & DeVita, 2005). Aerobic and resistance exercise have been shown to reduce pain and dis- ability among those with OA, while increasing physical performance; however, individuals with arthritis are often wary of exercise because activity can initially increase pain or because they inaccurately believe physical activity will worsen their arthritis (Hootman et al., 2003). Furthermore,

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tAblE
tAblE

ACtivity rECommEndAtions for oldEr Adults

type of Exercise/ Activity

 

duration/frequency

suggested Activities

Aerobic

   

Moderate

30

minutes, 5 or more days per week

Dancing, swimming or water exercises, jogging, bik- ing, brisk walking, household chores, gym workout at an intensity of 5 to 6 on a 10-point scale a

Vigorous

20

minutes, 3 or more days per week

Performing same activities as for moderate but at an intensity of 7 to 8 on a 10-point scale a

Strengthening

2

to 3 days per week for 8 to 10 muscle groups

Using household items (e.g., can of soup), light hand weights, or weight machines to exercise major muscle groups. Examples for home exercise include wall push-ups, toe stands, and use of resistance bands. In- tensity of 5 on a 10-point scale for 10 to 15 repetitions.

Flexibility

At least 10 minutes, 2 or more days per week

Stretching most joints (e.g., shoulder, hip, knee, back, elbow, wrist, ankle); performing yoga.

Balance

3

or more days per week until exercises completed

Standing on one foot; performing yoga and/or tai chi.

Sources. Nelson et al. (2007), Partners in Care Foundation (2000), and Resnick (2001). a Intensity is graded on a 10-point scale where 0 = sitting and 10 = all-out effort. Moderate activity produces noticeable increases in heart rate and breathing, and vigorous activity produces large increases in heart rate and breathing.

older adults with OA may not be counseled by their health providers to lose weight or exercise, despite the fact that such advice is the best predic- tor of weight loss attempts (Fontaine, Haaz, & Bartlett, 2007; Houston, Nicklas, & Zizza, 2009). A summary of a Cochrane review examining exercise for OA of the knee discov- ered small, statistically significant benefit for exercise effects on pain and self-reported physical function (Lin, Taylor, Bierma-Zeinstra, & Mather, 2010). However, it is unclear how of- ten exercise prescriptions are given to older adults, and when recommended, whether the type and duration of exercise is well specified.

soCiAl And EnvironmEntAl bArriErs to ExErCisE And WEight loss

Understanding the factors affect- ing physical activity and exercise behavior is a necessary first step toward identifying the needs of and intervention strategies for people with arthritis. Several social and environmental barriers hamper older

adults from achieving their weight loss and exercise goals, including low motivation, lack of social support, low self-efficacy, and unsafe environ- ments in which to exercise. Howarth, Inman, Lingard, McCaskie, and Gerrand (2010) studied barriers faced by obese individuals with OA of the knee to achieve weight loss. Among the 35 participants, 89% had at some point attempted to lose weight, of which 87.5% tried to lose weight through diet alone. A majority (89%) of participants reported that lack of motivation was their greatest barrier to achieving weight loss, with only 28% reporting knee pain to be their greatest barrier to weight loss. Pa- tients with higher BMIs (>40 kg/m 2 ) expressed a preference for a weight loss support group (Howarth et al.,

2010).

This evidence highlights the im- portance of the use of support groups for exercise or weight reduction. Older adults may become more mo- tivated to lose weight if they have the social support of a structured group and are informed about ways to live

Journal of GerontoloGical nursinG • Vol. 36, no. 9, 2010

a more active lifestyle that promotes weight loss. Other group programs, such as People with Arthritis Can Exercise (PACE), a community- based exercise program developed by the Arthritis Foundation, can be implemented to promote physical activity that prevents disease pro- gression. Schoster, Callahan, Meier, Mielenz, and DiMartino (2005) found that individuals with OA reported re- ceiving considerable support through exercising with a group with other people who have arthritis. Two key motivational factors that helped them continue attending the exercise classes were confidence that they could safe- ly perform different types of exercise (i.e., self-efficacy) and flexibility to exercise at their own pace during the class (Schoster et al., 2005). Glass, Rasmussen, and Schwartz (2006) examined unsafe neighbor- hood environments as a barrier for weight reduction. A total of 1,140 community-dwelling men and wom- en (ages 50 to 70) from 65 neighbor- hoods in Baltimore, Maryland, were randomly selected to participate in

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the study. Results indicated that 38% were obese and that despite indi- vidual socioeconomic and behavioral risk factors, participants who lived in more dangerous neighborhoods were two times as likely to be obese than those living in the least dangerous neighborhoods. The authors con- cluded that patterns of obesity are influenced by neighborhood condi- tions. Through education, reducing crime rates, and increasing public safety, communities can reduce envi- ronmental and sociological hazards that impact the health of its residents (Glass et al., 2006).

age groups, participating in exer- cise is crucial to preventing chronic illness and improving quality of life (Weight-control Information Network, 2008). Therefore, com- munity leaders need to develop strategies to decrease environmental barriers, such as crime and fear of violence, that encourage inactivity, obesity, and arthritis. To promote physical activity, communities can strive to improve access to places where people can be active, such as accessible walking trails and classes at gyms or senior centers.

Although diet and weight reduction are important aspects of a treatment plan for older adults with osteoarthritis, increasing physical activity may be the best first treatment intervention.

Crime and violence within com- munities cause significant barri- ers to physical activity for older adults. Environments that have high crime rates and limited safe places for outdoor physical activity, including sidewalks and streets for walking and jogging, restrict older adults from living active lifestyles. Maslow’s hierarchy of needs can further explain the barriers that older adults face within their com- munities that restrict them from being physically active and place them at greater risk for obesity and arthritis (Alfonzo, 2005). When a population is exposed to stressors such as inadequate and unsafe shelter and unhealthy food, they are unable to partake in healthy lifestyle choices that do not seem vital to immediate survival. Com- munity members who live in fear of violence are less likely to participate in exercise, which may seem like a leisurely and expendable aspect of their lifestyle. However, for all

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nursing intErvEntions for ostEoArthritis

As health care providers for older adults, nurses are in a position to promote physical activity and weight loss among overweight and obese patients with knee OA. Although diet and weight reduction are im- portant aspects of a treatment plan for older adults with OA, increas- ing physical activity may be the best first treatment intervention, espe- cially when implementing several lifestyle changes concurrently may be challenging for an older adult. Current research demonstrates that the relationship between obesity and OA is more complicated than simply the effect of excess weight on joints (Sowers & Karvonen-Gutierrez, 2010). Muscle size and strength is an important factor in protecting joints, even in older adults. Findings that early signs of joint deterioration can be reversed in younger adults suggest that prevention of OA may be pos- sible if one becomes physically active

as a younger adult and maintains this habit into older age (Ding et al., 2010). Current American College of Sports Medicine and American Heart Association recommendations for older adults with chronic condi- tions or functional limitation, with suggested activities, are listed in the Table (Nelson et al., 2007). With these recommendations in mind, nurses can implement several simple interventions to encourage older adults to decrease the incidence or manage the symptoms of OA.

Plant the Seed Nurses should always evalu- ate their patients’ physical activity levels, regardless of their weight. Discussions about weight and ex- ercise are often value laden and dif- ficult to initiate, but it is important for nurses to have a discussion and “plant the seed” for beginning a life- time of physical activity at a point when prevention may be possible. Nurses should not assume that older adults who are overweight or obese have been counseled to exercise; preventive strategies can be over- looked because of providers’ beliefs that older adults cannot change or are “too old” to begin an exercise regimen (Resnick, 2001).

Individualized Exercise Assessment A standard recommendation for increasing activity is to encour- age older adults to walk. However, without conducting a personalized assessment, as recommended by Resnick (2001) and Resnick et al. (2008), the likelihood of an older adult following through on any recommendation to increase physi- cal activity is low. Older adults with specific health concerns related to OA and comorbid conditions, such as pain, low endurance, or fatigue, require a preliminary health assess- ment and an individualized activity prescription. Ideally, the assessment and prescription are carried out within the context of an interdis- ciplinary team (physician, nurse,

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physical or exercise therapist) with

a focus on identifying ways for the

l Replace shoes after walking ap- proximately 500 miles.

older adult to exercise and not on potential risks (Resnick et al., 2008).

In addition, people with medial compartment knee OA should wear

Resources

Activity versus Exercise Older adults can increase their activity levels in many ways. If the term exercise is used, some may not believe themselves capable of an exercise regimen, possibly because they equate exercise with vigorous activity at a gym. In fact, moderate activity is recommended for people with knee and hip OA, including gardening, dancing, swimming, walking, golfing, and bicycling (Hootman et al., 2003). It is chal- lenging to help individuals with OA choose the best type of physical

activity that will be fun and sustain- able, yet not place excessive strain on their joints. In addition, if the person has a sedentary lifestyle, ac- tivity may need to be incorporated gradually. Nurses need to assess the level of exercise that can make

flexible shoes with laterally wedged insoles, and those with lateral compartment knee OA should wear supportive shoes with medially wedged insoles (Gross, 2010). The rocker-bottom style of shoes that have been advertised to improve exercise workouts are not the best choice for older adults. The design may cause anterior-to-posterior instability, causing the person to fall forward or backward when shift- ing the center of gravity suddenly (Gross, 2010).

Many print and electronic resources are available for health care providers to distribute or for older adults to access. Depending on the older adult’s technology skills, written materials or vid- eos demonstrating exercises can

a

difference for the patient’s OA

be accessed and downloaded to

symptoms (Hootman et al., 2003). Participating in everyday activities, such as walking a little farther to the car when in a parking lot, climb- ing the stairs instead of using the elevator (however, descending stairs should be avoided), and walking to a favorite store on a regular basis, can be an easy way for older adults to increase daily activity.

cell phones, netbooks, or iPods ® . The National Institute of Aging (NIA) has developed exercise/ac- tivity guidelines specifically for older adults (http://www.nia. nih.gov/HealthInformation/ Publications/ExerciseGuide), and the U.S. Department of Health and Human Services has published adult physical activity guide-

Gearing Up Once the older adult has made a commitment to begin increasing ac- tivity, he or she should consider the appropriate footwear, which can be overwhelming given the number of choices. Several tips can be helpful for those with knee OA:

lines (http://www.health.gov/ paguidelines/guidelines/default. aspx). Additional resources related to exercise and activity for older adults can be found on the NIA website (http://www.nia.nih.gov). An evidence-based program for frail older adults, Healthy Moves for Aging Well, is available in seven

 

l

Avoid shoes with elevated heels.

languages on the Partners in Care

l

Select shoes with sufficient

Foundation website at http://www.

 

room for toes; the older adult should be able to wiggle the toes up and down freely.

picf.org/landing_pages/22,3.html.

In recommending use of electronic resources, nurses should caution

 

l

Wear shoes with thicker sole material of moderate stiffness for shock absorption.

older adults to look for current information on reliable websites.

Journal of GerontoloGical nursinG • Vol. 36, no. 9, 2010

summAry

By being more active, older adults with knee OA may decrease their pain and the risk of functional impairment or disability. They can safely achieve recommended levels of physical activity by choosing joint-friendly types of moderate activity and making an activity plan for themselves. Nurses can help by counseling their adult and older adult patients to increase their activity and by recommend- ing an individualized exercise assessment and prescription that includes activities the older adult enjoys, are the right intensity, and will hold their interest. Multiple resources are available to support older adults’ ongoing participation in enjoyable physical activity.

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