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What are my treatment options for Knee Osteoarthritis?
Exercise & Activity
Exercise is the one non-surgical treatment that has consistently been shown to reduce the symptoms of arthritis whilst also improving function, and without any significant risks or side effects.
But how and why does it help?
Stronger muscles
Stronger thigh muscles have been shown to have a protective effect for the development and progression of knee OA. An increase in muscle mass has also been shown to reduce the amount of fatty chemicals which are circulating in our body, thereby reducing the risk and development of arthritis as well as a host of other chronic diseases. People who do regular exercises to maintain muscle strength after the age of 40 are also significantly less likely to develop frailty in old age, and have a marked increase in active years into older age. Also, stronger muscles can better support our joints, and can reduce the sensation of instability or giving way and improve our walking patterns or gait.
Better control and sensory awareness of our joints
Research has shown that exercise helps to increase joint sensory awareness and joint position sense (also known as proprioception) which helps us to use our joints more efficiently, thereby improving function and potentially reducing pain.
Increased bone density
Weightbearing and strengthening exercises have been shown to increase bone density, which can help to reduce the risk of osteopenia (brittle bones). Painful bone marrow lesions (swelling and fluid within the bone) are associated with pain in osteoarthritis in the hip and knee, and are particularly at risk of developing in women with lower bone density. Therefore, methods to increase bone density may help to reduce the risk of these painful bone marrow lesions developing.
Increased cartilage health and thickness
Exercise has been shown to result in improved nutrition of cartilage, improved flow of nutrients in and out of cartilage, thicker joint fluid (which better lubricates the joint), an increase in cells which help to build and repair cartilage, and thicker joint cartilage. Conversely, inactivity has been shown to lead to thinner cartilage, even after relatively short periods.
Reduced frailty and improved balance
Regular weightbearing and strengthening exercise is linked with a notable reduction in frailty in older years, as well as improvements in balance which may reduce the risk of falling.
Reduced inflammation and pain
Research has demonstrated that inflammatory chemicals in joints and circulating blood are both reduced following exercise, and pain is also consistently reduced following exercise. Many people find that their joint pain and stiffness is much better after a period of walking or gentle to moderate exercise.
Reduced body fat
Obesity is one of the single biggest factors that can predict the development and progression of osteoarthritis, but we now understand that this is not necessarily only due to the increased load this additional weight places on our joints, but may be more to do with the inflammatory chemicals that can damage joint cartilage and are present at much higher levels in fatty tissue.
Reduced risk of other health problems
Exercise can reduce the risk of development or progression of a wide range of other health conditions that may also impact on joint health, such as diabetes, obesity, and high cholesterol: High blood sugars, high cholesterol, and obesity all contribute to higher levels of inflammatory chemicals in the body, which all have a negative impact on cartilage health.
What sort of Exercise is best?
Research shows that an exercise programme that includes both strengthening exercises and cardiovascular exercise, like walking, is the best combination for improving osteoarthritic symptoms, resulting in consistent improvements in both pain and function.
Any exercise programme should follow a “graded loading” approach to help build up the tolerance of the joint to load and activity in a gradual way, without overloading it and causing a flare in pain and inflammation or swelling.
Exercises to improve knee mobility:
Exercises to improve strength:
Strong muscles help to support the joint, and have been shown to have a protective effect for the development and progression of knee OA.
This is a good gentle strengthening exercise programme from Versus Arthritis, which is ideal for beginners: Let's Move with Leon Session 4: Strength – lower body - YouTube
The NHS fitness studio also has some more advanced strengthening exercises that may be of benefit if you find the Versus Arthritis exercises too easy: Legs workout video - NHS (www.nhs.uk)
Exercise to improve cardiovascular fitness:
Exercise that gets your heart rate up has also shown to be particularly useful for the management of osteoarthritis. When it comes to arthritis affecting the joints in the legs, like the hip and knee, weight bearing exercise like walking is particularly beneficial since the cyclical loading and unloading of the joint helps to improve bone density and cartilage health.
Versus Arthritis has designed a cardiovascular exercise programme you can follow at home, which may be useful to help you to get started: Let's Move with Leon - Session 7: Cardiovascular and respiratory fitness - YouTube
The NHS Fitness studio also has a selection of cardiovascular exercise videos that may be useful: Aerobic exercise videos - NHS (www.nhs.uk)
The importance of a "graded loading" approach to exercise and activity:
Remember, you should follow a “graded loading” approach with any exercise, such as a walking programme, to help build up the tolerance of the joint to load and activity in a gradual way, without overloading it and causing a flare in pain and inflammation or swelling. Exposing your joint to exercise loads in a gradual way allows it to adapt and become accustomed to those loads so it can better tolerate them in the future. It is through this process of graded exposure that it is possible to see significant improvements in walking and exercise tolerance, even in those with severely arthritic joints.
Establishing a base-line level of activity:
It is well known that if you “do too much” it is relatively easy to provoke the symptoms of an osteoarthritic knee or hip, and cause the joint to become more painful and swollen. It is therefore important to monitor symptoms, and always work at a level below the point of “irritation and inflammation”. This involves carefully assessing what your current exercise tolerance is, and making sure you don’t exceed this to avoid worsening your symptoms. You must therefore try to establish what your “base-line” level of exercise tolerance is, which is generally considered to be the amount of exercise you can perform without causing a significant worsening of your symptoms.
Below is some guidance on helping you to establish what your “base-line” is:
- Mild discomfort during an activity is fine, but symptoms should settle within 20 to 40 minutes after finishing the activity.
- Pain which persists for several hours, or pain that is worse at night in bed or the following day after an activity should generally be avoided.
- An increase in joint swelling is also generally a sign that the joint has been irritated by the activity.
Graded loading programmes:
Once you have established your “base-line” level of exercise tolerance, you can then try to gradually increase this over the course of several weeks and months. This is called a “graded loading programme”, and involves making small increases in the amount of exercise you are performing every 3-6 weeks, to allow the joint adequate time between each increment to adapt to the new level of load before increasing the load again with another increment.
An example of a “graded loading programme” is shown below for illustration purposes:
Baseline level of activity (without symptoms being made worse) = 20 minutes walking on flat surface
Weeks 1-3: 20-minute walk, 2-3 times weekly
Weeks 4-6: 23-minute walk, 2-3 times weekly
Week 7-8: 27-minute walk, 2-3 times weekly
Week 9-11: 32-minute walk, 2-3 times weekly
Week 12-15: 30-minute walk on uneven ground with small gradients/hills.
Week 16-18: 35-minute walk on uneven ground with small gradients/hills.
The speed at which you increase the distance and the difficulty of the terrain will vary from person to person. You may find that you can increase your distance every 2 weeks, or that you can increase the amount of time you are walking by 5 or 10 minute increments if your joint is not particularly irritable. You might find you need to only increase walking time by 1 or 2 minutes each week, or that you can only increase it once every 4 or 6 weeks. You have to be guided by your own symptoms. If you symptoms are aggravated after the activity, then it is a sign that it was perhaps a little too much, and the distance/time should be reduced back to the previous level.
The importance of activity pacing in symptom management:
Actvity pacing techniques are useful to consider if either:
you are not able to to complete activities you enjoy because of pain
or
you can complete activities but you suffer for doing so for a few days afterwards.
Pacing involves breaking bigger activities down into smaller chunks to achieve your goal. The short video below explains how to pace your activities.
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Treatment options: Weight Loss
Treatment options for Knee Osteoarthritis
Treatment options: Weight Loss