Why OA Patients Don’t Exercise, and How to Help Them
OACS Forum focuses on exercise behavior for osteoarthritis.
By Jill Tyrer | Oct. 2, 2021
Exercise is proven to be an effective treatment for osteoarthritis (OA). But most people have trouble doing it on a regular basis, even when they understand it can ease their OA.
The Arthritis Foundation’s recent OA Clinical Studies (OACS) Forum, “Physical Activity and Exercise Behavior Change,” featured international scientific experts discussing this paradox, its reasons and possible solutions.
Because activities like walking are available, accessible and most people can do them, exercise as a treatment has long been viewed as empowering for OA patients. But when you consider all the factors and behaviors involved in actually exercising regularly long-term, it’s much more complex, burdensome, and resource intensive than it might seem, forum presenters said.
People with OA often have other complicating conditions, such as heart disease, obesity or depression, that makes exercise more difficult both physically and mentally. Plus, the patient must make the time to exercise; have transportation to get to a workout space; have appropriate equipment and shoes or have the money to buy them, and then be able to change into them. He or she also has to know how to do the exercise (or know someone who can show him) — and he must repeat this all on a regular basis. A host of less tangible factors also play a role, including past experiences and beliefs about exercise, confidence in one’s ability to do it, plus demographic, geographic, socioeconomic and other influences.
Discussion leader Jackie Whittaker, PhD, assistant professor in the department of physical therapy at the University of British Columbia and a research scientist for the Arthritis Research Centre in Canada explained: “There’s an intervention. And then there’s the behavior that the person receiving the treatment has to do to actually receive the benefit of that intervention. Both the intervention and that behavior need to be considered in the design, delivery, evaluation and implementation of exercise-based interventions.”
Benefits Are Clear
Evidence since the late 1990s has been clear that exercise is an effective treatment for OA, said Kelli Allen, PhD, professor of medicine in Rheumatology, Allergy and Immunology at the University of North Carolina; co-director of research at the Osteoarthritis Action Alliance; and a research health scientist at the Durham VA Medical Center.
Exercise — meaning “planned, structured, repetitive, intentional movement intended to improve or maintain physical fitness” — is included in medical guidelines for treating OA. Regular exercise with a specific purpose, “dose” and intensity can result in meaningful improvements in pain, mobility and quality of life, said Shannon Mihalko, PhD, a professor in the Department of Health and Exercise Science at Wake Forest University in North Carolina.
But, she adds, “these successful outcomes are clearly linked to adherence.” And even people who understand and accept the importance of exercise for their arthritis have trouble sticking with it long term, as research has shown.
Barriers to Success
Research has shown that certain OA patients are less likely to get 150 minutes of moderate intensity exercise a week, as recommended by the Department of Health and Human Services. These include women, older people, those with a higher body mass index, nonwhite people and those with depressive symptoms, who are not working or who have more knee pain and stiffness, said Allen.
Even those who are more inclined to exercise face a multitude of barriers, added Rana Hinman, PhD, a professor and research physiotherapist and at the Centre for Health, Exercise & Sports Medicine at the University of Melbourne in Australia. These range from financial to transportation to environmental barriers, such as lacking a place to walk or having to surmount hills or stairs.
One of the biggest barriers, though, is that many patients simply don’t know that exercise can help their OA. In fact, “People with osteoarthritis believe people with osteoarthritis shouldn’t exercise because they’re not capable,” Hinman said. “They think having OA pain means they shouldn’t exercise and that it may actually be harmful.” That’s especially true of people who have comorbidities common with OA, like obesity.
“These attitudes may drive them to seek out surgery without trying nonsurgical interventions,” Hinman added. But surgery is riskier, more costly and may be less necessary if the person exercises.
Strategies for Success
Health care providers play a key role in helping patients understand the benefits of exercise and help them succeed, said Hinman, but how they do so is important.
For example, written resources can remind patients that exercise will help, and they need specific instructions about what to do, how to do it and how often. Exercise plans must be tailored to each patient’s needs and barriers; recommending a program they can’t afford or can’t access, for example, won’t help them, she added.
Patients also must have realistic expectations and timeframes; they won’t see results overnight, so it’s important they are motivated to adhere to the program. Testimonials, ways to track their progress and other resources may make them more optimistic about and motivated to exercise.
Considering how the health care provider implements the plan also is important, said Linda Li, PhD, a professor and director of the Arthritis, Joint Health and Knowledge Translation Research Program at the University of British Columbia in Canada. They need time to understand a patient’s barriers and needs and to tailor a plan for that person. In her research, using technology like an activity tracker combined with education, support and physical therapy counseling via phone helped people increase their activity level, she said. But more research is needed to find ways for patients to take a greater role.
Self-efficacy — self-confidence in one’s ability — is key, Mihalko said. People need help to stick with exercise long-term on their own. Some possible strategies: Practice activities they’ll be doing after an organized program ends. Teach them to monitor and review their own progress. Help them figure out solutions when problems arrive; for example, when your car won’t start so you can’t get to the gym or when your exercise buddy cancels.
“Talk very explicitly about what’s going to happen. Where are you going to go? What resources are out there for you?” she said.
“A lot of our programs are interventionist-led. They’re prescriptive,” Mihalko said. “Education is important. But once they have that, they have to understand how to keep moving forward, how to overcome barriers on their own, how to monitor their own progress.”
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