1. health and fitness
2. disease
3. arthritis

236 – Knee Arthritis & Obesity By Flavia Yazigi (LEC) This session will teach you step by step how to design an aquatic program for obese adults with knee osteoarthritis. Learn how to identify and assess pain and other factors. Establish methods and develop strategies for creating a successful program for this population. Osteoarthritis (OA) is a progressive, degenerative disease of the whole joint: ¡ Cartilage degeneration ¡ Unbalance in subchondral bone turnover can lead to thickened, bone sclerosis (contributes to cartilage loss and joint space narrowing) ¡ Synovial Inflammation ¡ Osteophyte formation (bony outgrowths) KOA Signs and Symptoms ¡ Persistent pain ¡ Morning stiffness < 30 min ¡ Functional impairment ¡ Clinical Signs ¡ Restricted movement ¡ Crepitus ¡ Bony enlargement ¡ Bony tenderness ¡ No palpable warmth ¡ Occasional effusion ¡
Variable degrees of inflammation without systemic effects KOA Epidemiology Osteoarthritis (OA) is the most prevalent rheumatic disease and represents a great risk to the quality of life of the individual due to its effect on lower extremity based activities (such as walking up and down stairs, climbing and squatting)[1, 2] and the consequent loss of autonomy. In general OA affects knees, hips, hands and spine joints; however, the knees are the most commonly affected weight bearing joint[3]. Knee osteoarthritis (KOA) can compromise an individual’s quality of life and exhaust considerable healthcare resources, making this rheumatic disease a stand out among the public health problems in many countries[4, 5]. KOA can occur in both joints of the knee, patellofemoral and tibiofemoral joints, but it is more common in the medial tibiofemoral compartment, most likely because the medial compartment bears 60–80% of the compressive loads in the neutrally aligned knee during normal walking[6] and because of the higher frequency of varus malalignment[7]. Knee Osteoarthritis and Obesity Knee Osteoarthritis (KOA) is highly prevalent in obese individuals[8]. There is a bidirectional interaction between KOA and obesity where weight load exacerbates mechanical pain, a symptom that markedly affects the individual’s quality of life. Mechanical pain can cause irritability, sleeplessness, depression[9], and physical and psychological changes that may aggravate the disease, providing a general loss of functionality and, thereafter, inactivity. The majority of patients with KOA do not achieve 1
Kdh7@hotmail.com agua-­‐fla@hotmail.com the recommended levels of physical activity[10, 11], which can lead to weight gain and obesity[12]. The combination of obesity and KOA creates a vicious cycle of pain, physical activity reduction, loss of functionality, and disease progression leading to more physical activity avoidance[13], weight gain and increased pain. These cycles can be worsened with depressive symptoms, which are associated with obesity and KOA symptoms[9, 14, 15], where each can trigger and influence the other, further compromising the quality of life. The OARSI recommendations[16] for weight loss in the treatment of KOA are gaining increasing importance [17-­‐20] because it provides a reduction in the load exerted on the knee during daily activities and can decrease the pro-­‐inflammatory action of cytokines and adipokines, which are strongly activated by obesity[17-­‐20]. Furthermore, in addition to reductions in pain manifestation, obesity is a controllable risk factor and decreasing its occurrence should contribute to a reduction in KOA progression. For a general weight loss program, the ACSM guidelines[21] recommend a reduction of 5-­‐10% of initial weight over 3-­‐6 months by an intervention of moderate to intense aerobic exercise, resistance-­‐training and behavior intervention. In cases of KOA, Messier and coworkers (2005)[18] reported that a weight reduction of 1 kg was associated with a knee load reduction of 4 units per step; a clinically meaningful reduction when considered over the many steps performed each day. Current goals of KOA treatment: ¡
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Control pain and other symptoms Improve joint and general function Maintain normal body weight Achieve a healthy lifestyle Exercise on Knee Osteoarthritis Exercise is an effective non-­‐pharmacological treatment for the management of KOA and is recommended by the Osteoarthritis Research Society International (OARSI)[11, 16, 22], by the American College of Rheumatology (ACR)[23] and by the European League Against Rheumatism (EULAR)[24]. Several reports indicate that an exercise program for KOA should be a broad intervention, including: ¡ Cardiorespiratory training[23, 25]; ¡ Lower limb strengthening [26-­‐28]; ¡ Flexibility[29, 30]; ¡ Gait training[31]; ¡ Balance and posture training[32]; ¡ Weight reduction (in cases of obesity)[16]; ¡ Patient education[22, 23]; ¡ Psychological approach [14, 25]. Walking, as well other weight bearing movements, is the most common exercise pattern recommended for obese individuals when initiating their weight loss exercise program, however, the existence of knee pain and other KOA symptoms could be a constraint for exercise motivation and adherence, especially if symptoms of depression are also present[9]. In this way, aquatic exercise has been suggested for obese individuals with KOA. 2
Kdh7@hotmail.com agua-­‐fla@hotmail.com Advantages of Aquatic exercise for obese individuals with KOA ¡ Mechanical overload reduction; in case of obesity, AE provides a cardiorespiratory workout with less mechanical pain due the buoyancy action ¡ Hydrostatic pressure can improve peripheral circulation[33] and act on nerve endings and, when combined with muscle relaxation due to the buoyancy of water, can provide pain reduction ¡ Aerobic exercise is known to improve mental health by reducing anxiety, depression, and negative mood and by improving self-­‐esteem and cognitive function. Improvements in mental health lead to better pain tolerance. ¡ Hydrostatic pressure can reduce edema 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Gabriel SE, Michaud K: Epidemiological studies in incidence, prevalence, mortality, and comorbidity of the rheumatic diseases. Arthritis Res Ther 2009, 11:229.3 Arden N, Nevitt MC: Osteoarthritis: epidemiology. Best Pract Res Clin Rheumatol 2006, 20:3-­‐25.1 Williams F, Spector T: Osteoarthritis. Medicine 2006, 34:364-­‐368.9 Zhang Y, Jordan JM: Epidemiology of osteoarthritis. Clin Geriatr Med 2010, 26:355-­‐369.3 Jordan JM, Helmick CG, Renner JB, Luta G, Dragomir AD, Woodard J, Fang F, Schwartz TA, Abbate LM, Callahan LF, et al: Prevalence of knee symptoms and radiographic and symptomatic knee osteoarthritis in African Americans and Caucasians: the Johnston County Osteoarthritis Project. J Rheumatol 2007, 34:172-­‐180.1 Andriacchi TP: Dynamics of knee malalignment. Orthop Clin North Am 1994, 25:395-­‐403.3 Winby CR, Lloyd DG, Besier TF, Kirk TB: Muscle and external load contribution to knee joint contact loads during normal gait. J Biomech 2009, 42:2294-­‐2300.14 Martin KR, Kuh D, Harris TB, Guralnik JM, Coggon D, Wills AK: Body mass index, occupational activity, and leisure-­‐time physical activity: an exploration of risk factors and modifiers for knee osteoarthritis in the 1946 British birth cohort. BMC Musculoskelet Disord 2013, 14:219 Pereira D, Severo M, Barros H, Branco J, Santos R, Ramos E: The effect of depressive symptoms on the association between radiographic osteoarthritis and knee pain: a cross-­‐sectional study. BMC Musculoskelet Disord 2013, 14:214.1 Farr JN, Going SB, Lohman TG, Rankin L, Kasle S, Cornett M, Cussler E: Physical activity levels in patients with early knee osteoarthritis measured by accelerometry. Arthritis Rheum 2008, 59:1229-­‐1236.9 Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, Bierma-­‐Zeinstra S, Brandt KD, Croft P, Doherty M, et al: OARSI recommendations for the management of hip and knee osteoarthritis, part I: critical appraisal of existing treatment guidelines and systematic review of current research evidence. Osteoarthritis Cartilage 2007, 15:981-­‐1000.9 Flegal KM, Carroll MD, Ogden CL, Johnson CL: Prevalence and trends in obesity among US adults, 1999-­‐2000. JAMA 2002, 288:1723-­‐1727.14 Pisters MF, Veenhof C, van Dijk GM, Dekker J: Avoidance of activity and limitations in activities in patients with osteoarthritis of the hip or knee: a 5 year follow-­‐up study on the mediating role of reduced muscle strength. Osteoarthritis Cartilage 2014, 22:171-­‐177.2 Scopaz KA, Piva SR, Wisniewski S, Fitzgerald GK: Relationships of fear, anxiety, and depression with physical function in patients with knee osteoarthritis. Arch Phys Med Rehabil 2009, 90:1866-­‐
1873.11 Wadden TA, Foster GD: Weight and Lifestyle Inventory (WALI). Obesity (Silver Spring) 2006, 14 Suppl 2:99S-­‐118S Zhang W, Nuki G, Moskowitz RW, Abramson S, Altman RD, Arden NK, Bierma-­‐Zeinstra S, Brandt KD, Croft P, Doherty M, et al: OARSI recommendations for the management of hip and knee 3
Kdh7@hotmail.com agua-­‐fla@hotmail.com 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. osteoarthritis: part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage 2010, 18:476-­‐499.4 Coggon D, Reading I, Croft P, McLaren M, Barrett D, Cooper C: Knee osteoarthritis and obesity. Int J Obes Relat Metab Disord 2001, 25:622-­‐627.5 Messier SP, Gutekunst DJ, Davis C, DeVita P: Weight loss reduces knee-­‐joint loads in overweight and obese older adults with knee osteoarthritis. Arthritis Rheum 2005, 52:2026-­‐2032.7 Vartiainen P, Bragge T, Lyytinen T, Hakkarainen M, Karjalainen PA, Arokoski JP: Kinematic and kinetic changes in obese gait in bariatric surgery-­‐induced weight loss. J Biomech 2012, 45:1769-­‐
1774.10 Harding GT, Hubley-­‐Kozey CL, Dunbar MJ, Stanish WD, Astephen Wilson JL: Body mass index affects knee joint mechanics during gait differently with and without moderate knee osteoarthritis. Osteoarthritis Cartilage 2012, 20:1234-­‐1242.11 American College of Sports Medicine (ACSM): ACSM's Guidelines for Exercise Testing and Prescription. 8th edn: Lippincott Williams & Wilkins; 2009. Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, Bierma-­‐Zeinstra S, Brandt KD, Croft P, Doherty M, et al: OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-­‐based, expert consensus guidelines. Osteoarthritis Cartilage 2008, 16:137-­‐162.2 Hochberg MC, Altman RD, April KT, Benkhalti M, Guyatt G, McGowan J, Towheed T, Welch V, Wells G, Tugwell P: American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken) 2012, 64:465-­‐474.4 Jordan KM, Arden NK, Doherty M, Bannwarth B, Bijlsma JW, Dieppe P, Gunther K, Hauselmann H, Herrero-­‐Beaumont G, Kaklamanis P, et al: EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis 2003, 62:1145-­‐1155.12 Creamer P, Lethbridge-­‐Cejku M, Hochberg MC: Factors associated with functional impairment in symptomatic knee osteoarthritis. Rheumatology (Oxford) 2000, 39:490-­‐496.5 Ratzlaff CR, Liang MH: New developments in osteoarthritis. Prevention of injury-­‐related knee osteoarthritis: opportunities for the primary and secondary prevention of knee osteoarthritis. Arthritis Res Ther 2010, 12:215.4 Wang X, Miller GD, Messier SP, Nicklas BJ: Knee strength maintained despite loss of lean body mass during weight loss in older obese adults with knee osteoarthritis. J Gerontol A Biol Sci Med Sci 2007, 62:866-­‐871.8 Lim BW, Hinman RS, Wrigley TV, Sharma L, Bennell KL: Does knee malalignment mediate the effects of quadriceps strengthening on knee adduction moment, pain, and function in medial knee osteoarthritis? A randomized controlled trial. Arthritis Rheum 2008, 59:943-­‐951.7 Messier SP, Loeser RF, Hoover JL, Semble EL, Wise CM: Osteoarthritis of the knee: effects on gait, strength, and flexibility. Arch Phys Med Rehabil 1992, 73:29-­‐36.1 Bennell KL, Hinman RS: A review of the clinical evidence for exercise in osteoarthritis of the hip and knee. J Sci Med Sport 2011, 14:4-­‐9.1 Reeves ND, Bowling FL: Conservative biomechanical strategies for knee osteoarthritis. Nat Rev Rheumatol 2011, 7:113-­‐122.2 Cibere J, Bellamy N, Thorne A, Esdaile JM, McGorm KJ, Chalmers A, Huang S, Peloso P, Shojania K, Singer J, et al: Reliability of the knee examination in osteoarthritis: effect of standardization. Arthritis Rheum 2004, 50:458-­‐468.2 Onodera S, Miyachi M, Nishimura M, Yamamoto K, Yamaguchi H, Takahashi K, In JY, Amaoka H, Yoshioka A, Matsui T, Hara H: Effects of water depth on abdominal [correction of abdominails] aorta and inferior vena cava during standing in water. J Gravit Physiol 2001, 8:P59-­‐60.1 4
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