A ‘mismatch of information’: Exercising with osteoarthritis a matter of hurt vs. harm
Click Here to Manage Email Alerts
As a seemingly ever-increasing body of data support physical activity in patients with osteoarthritis, a growing discussion is addressing the distinction between pain and harm, and how the two are experienced by those with the disease.
Specifically, the debate starts with the extent and nature of physical activity that is acceptable for any given patient with hip or knee OA, and how much pain is acceptable for those patients to experience as a result. However, it also extends into the doctor-patient conversation surrounding hurt vs. harm.
“Too many people are still told to be less active when diagnosed with osteoarthritis,” Howard Luks, MD, an orthopedic surgeon and sports medicine specialist at Symphony Medical, in New York, tweeted in February as part of a larger discussion on “hurt vs. harm” in OA. “They think that pain means harm. Less activity won’t protect the hip/knee, and their overall health will suffer dramatically in as little as 2 weeks.”
Like many health care professionals, Lisa Carlesso, PT, PhD, associate professor in the School of Rehabilitation Science at McMaster University, in Hamilton, Canada, encourages her patients with OA to be active and exercise. However, she acknowledged that this is not the only message patients receive.
“In contrast to that, people with OA are often given cautionary advice about overloading joints, and the associated pain,” she said. “It is easy to see how that kind of conflicting messaging could be difficult for patients to navigate.”
In addition, some patients may have a long history of regular exercise while others are starting from scratch. Addressing each patient’s thresholds for activity and pain is critical to finding the balance between acceptable aches and pains and potentially harmful overuse.
However, the conversation does not stop there.
“Many people do not realize how complex pain is,” Carlesso said. “It is not just about an acute injury from a hard workout and the pain associated with that. It is also about chronic pain like we see in hip and knee OA, where it is less about the association with tissue damage or loss of cartilage. It is a different kind of pain altogether.”
For Luks, it may come down to the basic idea that moving is generally healthier than not moving.
“The take-home message is that being active will not cause arthritis to worsen in severity — meaning, more loss of cartilage,” Luks told Healio. “It might cause more pain, but the pain does not always imply that you are harming yourself. The risks associated with being inactive are far more severe and consequential than the risk of worsening your arthritis.”
Whether rheumatologists are effectively communicating that message is the subject of intense discussion.
‘Outdated narrative’
In a study published in Osteoarthritis and Cartilage, Nissen and colleagues assessed clinicians’ attitudes and beliefs regarding physical activity as a therapy in patients with hip or knee OA.
“Clinicians’ attitudes and beliefs about physical activity and exercise therapy in OA seem to reflect an outdated narrative which describes OA as a wear-and-tear disease with inevitable disease progression to joint replacement surgery,” the researchers concluded. According to Nissen and colleagues, clinicians should instead adopt a new narrative, — one that reflects the latest “knowledge and evidence-based practice” regarding the use of exercise as a first-line therapy for, as is recommended in the most recent guidelines.
“An interesting point in this study was that some clinicians may be telling patients that exercise should be without pain,” Carlesso said.
Even more troubling, she added, is that many clinicians expressed a lack of knowledge about the particulars of physical activity and exercise that are appropriate for patients with OA.
“There is a gap in terms of translation of current understanding of disease, the importance of exercise and the impact of loading on joint health,” Carlesso said.
According to Luks, it is not just health care providers, but also friends and family members who sometimes perpetuate these messages.
“The mechanistic view of arthritic progression is firmly entrenched in both the lay public, as well as allied health care professionals,” Luks said.
Abigail L. Gilbert MD, an assistant professor at the University of North Carolina School of Medicine’s division of rheumatology, allergy and immunology, described a similar phenomenon in her own practice.
“I am unsure where my patients are hearing the message that they should be less active with OA,” she said. “Perhaps their parents and grandparents or other older relatives or friends told them many years ago that they should limit activity due to OA.”
Still, if there is one point Carlesso would like to convey, it is that there are “really very few safety concerns” associated with exercise in patients with OA.
“It is 100% safe for patients with OA to load their joints,” she said. “We see patients participating in a range of activities, from walking to running.”
Driving home this directive among the myriad other pieces of advice patients with OA are receiving, from seemingly all directions, can be a challenge for any rheumatologist.
‘Quite impactful in a negative way’
“It is very common that my patients will look surprised when I recommend physical activity as treatment for osteoarthritis,” Gilbert said. “Many will tell me they avoid running as they are worried about developing knee OA and are concerned running will increase that risk, when studies have shown running does not increase the risk for developing knee OA in the future.”
With this in mind, rheumatologists should consider every word they say to a patient, and how that patient may perceive the message.
“You can tell a patient, ‘The guidelines say exercise is good,’” Carlesso said. “But in that same appointment, the clinician might say that the X-ray looks terrible and that there is bone on bone. This makes the patient afraid to go load that joint in any way. Clinicians are still using language that is quite impactful on patients in a negative way.”
Although semantics can be critical in these conversations, Carlesso acknowledged that there are systemic factors that can also influence the exchanges in the clinic.
“We have limited time with our patients,” she said. “It is difficult to cover so many priorities meaningfully in a 15-minute visit.”
Even if the subject of exercise comes up, time constraints often limit the conversation to a declaration as simple as, “Exercise is recommended, go do it,” Carlesso said.
The conversation needs to be much more nuanced, she added.
“How fit is the patient to start? How motivated are they? Do they have questions, concerns or fears about an exercise regimen?” Carlesso said. “How quickly should they progress? What type of exercise is best for this individual patient? There are so many facets to it that we usually do not have time to cover.”
According to Gilbert, it is important to help patients understand that there may be pain for as long as 4 to 6 weeks at the outset of an exercise regimen.
“But I let them know that if they stick with it, their pain should start to decrease,” she said. “It can be hard to distinguish between pain from healthy exercise and pain from an injury or overdoing things.”
In these cases, Gilbert emphasizes the importance of starting gradually, for example, by walking for 10 minutes a day and then adding a few minutes every week.
“If you have severe pain, swelling or redness you should be evaluated by a physician,” she said. “It is common to have soreness the day after. Pain that starts with exercise and does not resolve after you stop may be a sign of an injury or you are doing too much too soon.”
Gilbert stressed that health care providers should be aware of all recommendations surrounding activity in OA.
“We also need to ensure patients are hearing this message as well,” she said.
However, the existence of a recommendation does not necessarily translate to use in clinical practice, according to Luks.
“It is a published statistic that it may take upwards of 17 years for changes in recommendations to work their way through the health care system and change the advice given to our patients,” he said. “The data on the causation and progression of arthrosis has changed. The fact that walking and strength training can diminish inflammation, improve mobility and counter the pain associated with OA and rheumatoid arthritis has not been mainstreamed as of yet.”
As rheumatologists work to bring updated information to their patients, another significant part of the conversation is the nature of pain itself.
‘Mismatch of information’
According to Carlesso, it is important to draw a distinction between a healthy person experiencing pain after exercising and the type of pain felt by a patient with chronic OA.
“If I sprain my ankle and I have acute pain and swelling, my body is providing me with pain as a protective mechanism to help me heal,” she said. “Pain does not serve that purpose in the same way with chronic illness.”
Patients with chronic pain continue to feel that pain because the nervous system adapts to the chronicity of it, Carlesso said.
“The nervous system becomes more susceptible to being triggered,” she said. “Stimuli that were previously not painful can be translated into a painful experience much more easily.”
In other words, the level of stimuli that may trigger pain in an individual without a chronic pain condition is higher than the levels that trigger pain in patients with these chronic diseases.
“The pain does not necessarily mean that there is something sinister going on at the joint level,” Carlesso said.
What occurs, according to Carlesso, is a “mismatch of information” regarding what is happening in the joint.
“This is why we can say that exercising with pain can be safe,” she said.
However, there are qualifications.
“It is not to say you should exercise regardless of pain,” Carlesso said. “If the pain is a 10 out of 10, that is different than if you are experiencing discomfort or pain at lower levels.”
If the pain is mild, “there should not be much worry about” with regard to disease progression, according to Luks.
“If the pain is severe, activities should be adjusted accordingly to manage the pain,” he added.
For Luks, playing the long game is critical for patients with OA and the general population alike.
“Most people stop being active because they feel they might be harming themselves,” he said. “One thing that most joint replacement surgeons will tell you is that people who maintain flexibility, strength and cardiorespiratory status tend to keep their natural joints longer than those who are more sedentary.”
The good news is that most practitioners and patients are generally aware of the mind and body benefits of movement and fitness. For Luks, then, it is important to keep the message simple for the patient population, as well.
“Pain does not always imply harm,” he said. “People who have OA or RA should expect some discomfort every now and then.”
References:
Nissen N, et al. Osteoarthritis Cartilage. 2022;doi:10.1016/j.joca.2021.11.008.
Cottrell E, et al. BMC Fam Pract. 2010;doi:10.1186/1471-2296-11-4.
Collapse
Click Here to Manage Email Alerts