Interview conducted by April Cashin-Garbutt, BA Hons (Cantab)
How does exercise help to reduce pain in osteoarthritis patients?
Exercise helps to keep the surrounding muscles strong to protect the joint, and also reduces stiffness that people frequently experience in the morning or after periods of inactivity. Joints are meant to move, so keeping them mobile will assist with joint health, maintain range of movement and enhance stability.
People who exercise regularly generally feel more self-confident and manage their condition more effectively than those that avoid exercise and physical activity. Additionally, exercise and activity will help to maintain a healthy bodyweight which will also assist with pain control.
What types of exercise are effective at managing pain in patients with osteoarthritis?
A variety of exercise types can be beneficial. A combination of activities that strengthen muscles, maintain soft tissue extensibility and improve balance and co-ordination will all help. However, exercise doesn’t need to be complicated to be beneficial – even walking will help to manage symptoms.
It’s also important that people maintain their general cardiovascular fitness and a healthy bodyweight – there is a direct link between being overweight and pain and progression of osteoarthritis.
Are there any types of exercise osteoarthritis patients should avoid?
Lower impact activities are likely to be more beneficial and tolerated better than higher impact exercise. So things such as walking, swimming, t’ai chi and aquarobics for example are all appropriate activities.
However, irrespective of exercise type people should ensure that the level and complexity of exercise is appropriate for them. Any physical activity will result in exacerbations of symptoms if people do not pace themselves appropriately and set realistic goals.
How important is a supportive environment in encouraging patients to keep on exercising as a way to manage their pain?
As with any lifestyle change, maintaining exercise participation is notoriously difficult. Many people will adhere to an activity regimen for a period of time but will frequently lose motivation and discontinue in the longer term.
We need to ensure that there are appropriate community-based, affordable facilities to support people to exercise. Many people want to exercise in groups, which they can enjoy as a social activity; and they want the support of an appropriately qualified facilitator.
It’s not enough to simply advise people to exercise, they need to develop the skills to manage their exercise appropriately, experience the benefits (and difficulties) of maintaining a programme before becoming independent self-managers.
We are also looking at using multimedia messaging and online monitoring tailored to an individual’s personal motivations and goals to determine whether this enhances long-term motivation and exercise participation.
How frequently should patients with osteoarthritis exercise to achieve the maximum benefits?
Exercise recommendations for older people suggest that 30 cumulative minutes of moderate intensity exercise on most days of the week is important for a healthy lifestyle. However for many people with osteoarthritis, particularly those that are currently inactive, this may seem like an unachievable target.
The simple fact is that any amount of activity is better than none; starting slowly and gradually building up activity levels is the best way to become active without aggravating joint pain. It is likely that if somebody starts any new activity they will experience slight pain or discomfort, but this should ease quickly without the need for analgesics. If the pain is prolonged it probably indicates that the exercise level was too high, so the next time they should try doing half the amount and gradually increase the intensity over time.
We are also becoming increasingly aware of the importance of non-sedentary time; people with osteoarthritis can experience rapid stiffening of their joints when not moving, so standing regularly can also help – this may particularly be an issue for desk workers.
Why do you think many people don’t always feel safe exercising in classes run by support workers? What can be done to change this?
We’ve undertaken some work that suggests there is a perception amongst people with osteoarthritis that community-based support workers may not be sufficiently trained to manage their condition safely and effectively, and are therefore reluctant to exercise in these environments.
Interestingly another piece of work with support workers showed they would like to receive more extensive training in osteoarthritis to understand the disease process more and therefore plan, implement and modify exercise programmes more effectively. Furthermore they wanted to know the implications of joint replacement surgery and how this impacted on the rehabilitation and management of people with prosthetic joints.
We are currently working with Skills Active, the officially recognised and licensed organisation that sets standards for skills and training for the fitness sector, and have developed National Occupational Standards for Osteoarthritis, and a training course that will assist individuals to meet these standards. This means that exercise professionals can achieve quality education and training in managing osteoarthritis, and people with the condition can work with individuals who have the appropriate level of training, and therefore be more confident that they are receiving the best quality management for their condition.
How important is real world research in developing treatments for osteoarthritis?
There is currently some excellent and essential research looking at improving our understanding of the role of genetics in disease development; innovative ways of treating osteoarthritis, including potential use of stem cell to enable cartilage growth; and development of new drugs that target pain producing molecules. However, realistically it will be a long time before these things, if successful, are developed sufficiently to influence routine management.
As such the work that we do is really important for the millions of people who currently experience pain and disability from osteoarthritis. We are fortunate in that our research has real, immediate benefits for individuals who participate, and also has the potential to influence practice in a timelier manner than bench-based research.
Please could you give an overview of your research being funded by Arthritis Research UK? What stage are you currently at and what do you hope to achieve?
I’m currently mid-way through a 5-year post-doctoral Career Development Fellowship, funded by medical research charity Arthritis Research UK, investigating community based management of osteoarthritis. We have completed a series of pieces of work to determine patient’s perceptions of community management of osteoarthritis; the training needs of community based support workers; and have developed nationally recognised Standards of Care and a training course for support workers.
The next piece of work will consist of a community-based pilot study using appropriately trained support workers to manage people with OA rather than the traditional healthcare professional within primary or secondary care. This will hopefully lead into a large scale trial of an alternative model of care.
What do you think the future holds for osteoarthritis treatments and do you think exercise will play a large role in the management of symptoms going forwards?
It would be nice to think that we will have more successful surgical, pharmacological and non-pharmacological treatments available for people with osteoarthritis. In my particular area of expertise – exercise and self-management – I think we need to think very carefully about how we provide effective and cost-effective interventions.
The current healthcare system cannot provide long-term exercise support for everyone; there is a place for more integration between the health and leisure/fitness sectors if we consider more innovative models of care. Furthermore I believe we need to embrace multimedia technologies, and consider individualisation of motivational support packages to facilitate long-term engagement with exercise and physical activity.
Where can readers find more information?
More information regarding some of Nicola’s work can be found at http://people.uwe.ac.uk/Pages/person.aspx?accountname=campus%5cn2-walsh.
About Dr Nicola Walsh
Nicola is a Chartered Physiotherapist and an Associate Professor in Musculoskeletal Rehabilitation at UWE Bristol. She worked clinically and in education before being awarded her PhD from King’s College, University of London in 2009.
She is currently the recipient of an Arthritis Research UK Career Development Fellowship (2011-2016) which enables her to undertake research into osteoarthritis on a full-time basis.
Nicola is working on a variety of projects in osteoarthritis, including the clinically and cost-effective management of multiple joint presentation – a randomised controlled trial; individuals preferences for multiple joint pain management; motor imagery in osteoarthritis; influence of exercise on psychosocial traits in osteoarthritis; and developing online resources for self-management of osteoarthritis. Nicola has published widely and presented her work nationally and internationally.
About National Arthritis Week
October 7th is the start of Arthritis Research UK’s National Arthritis Week.
The charity is asking people to make their own Joint Effort pledge: either support the charity’s work by raising money, by sharing your experiences of arthritis in their National Arthritis Survey or by finding out more about the realities of living with arthritis.
For further information about how you can make your Joint Effort pledge, visit www.nationalarthritisweek.org.uk or call us on 0300 790 0444.
About Arthritis Research UK
Arthritis Research UK is the leading authority on arthritis in the UK, conducting scientific and medical research into all types of arthritis and related musculoskeletal conditions.
It is the UK’s fourth largest medical research charity and the only charity solely committed to funding high quality research into the cause, treatment and cure of arthritis.