Elsevier

Joint Bone Spine

Volume 73, Issue 4, July 2006, Pages 442-455
Joint Bone Spine

Recommendations
Osteoarthritis of the knee and hip and activity: a systematic international review and synthesis (OASIS)

https://doi.org/10.1016/j.jbspin.2006.03.001Get rights and content

Abstract

The goal of this study was to determine which activities in four domains, daily life, exercises, sports and occupational activities, should be recommended, in favor or against, for the patient suffering from knee or hip OA.

Methods

Scientific literature was searched in Medline, Embase and Cochrane databases for articles in French or English, reporting original data. The articles were evaluated with standardized epidemiological criteria. Seventy-two articles were retained. Recommendations were graded according to the level of scientific evidence (A high, B moderate, C clinical consensus) and were formulated for primary care.

Conclusions and recommendations

For activity of daily life (ADL), the OASIS group states with a moderate level of scientific evidence, that ADL are a risk factor for knee OA and that risk increases with intensity and duration of activity. The group concludes that healthy subjects as well as OA patients in general can pursue a high level of physical activity, provided the activity is not painful and does not predispose to trauma (grade B). Radiographic or clinical OA is not a contraindication to promoting activity in patients who have a sedentary lifestyle (grade C). For exercises and other structured activities pursued with a goal of health improvement, the group states with a high level of scientific evidence that they have a favourable effect on pain and function in the sedentary knee OA patient. The OASIS group recommends the practice of exercises and other structured activities for the sedentary patient with knee OA (grade A). Static exercises are not favored over dynamic exercises, availability, preference and tolerance being the criteria for the choice of an exercise (grade A). As results deteriorate when exercises are stopped, they should be performed at a frequency of between one and three times per week (grade B). Professional assistance can be useful in improving initial compliance and perseverance (grade B). There is no scientific argument to support halting exercise in case of an OA flare-up (grade C). For sports and recreational activity, the group states with a high degree of scientific evidence, that these activities are a risk factor for knee and hip OA and that the risk correlates with intensity and duration of exposure. The group also states, with a high degree of scientific evidence, that the risk of OA associated with sport is lesser than that associated with a history of trauma and overweight. No firm conclusion could be drawn about the possible protective role of sports such as cycling, swimming or golf. The OASIS group recommends that athletes should be informed that joint trauma is a greater risk factor than the practice of sport (Grade A). The high level athlete should be informed that the risk of OA is associated with the duration and intensity of exposure (Grade B). The OA patient can continue to engage regularly in recreational sports as long as the activity does not cause pain (Grade C). The OA patient who practices a sport at risk for joint trauma should be encouraged to change sport (Grade C). For occupational activity, the OASIS group states with a high level of scientific evidence that there is a relationship between occupational activity and OA of the knee and hip. The precise nature of biomechanical stresses leading to OA remains unclear but factors such as high loads on the joint, unnatural body position, heavy lifting, climbing and jumping may contribute to knee and hip OA. The group recommends that taking an occupational history should always be part of managing the OA patient (Grade B). In the knee or hip OA patient, work-related activity that produces or maintains pain should be avoided (Grade B). Physicians should be alerted by the early knee and hip signs and symptoms in workers exposed to stresses that are known or supposed to favour knee or hip OA (Grade C).

Introduction

Throughout life, human beings seek to maintain an active lifestyle that includes some level of sports, , free of joint pain or limitation. As one of the problems affecting the joints, osteoarthritis (OA) constitutes a real threat to this legitimate goal. It is no longer necessary to underline the prevalence of osteoarthritis in an aging population, the level of painful disability it causes or its ever-increasing socio-economic cost [1]. In spite of advances in research and some promising new therapies, the unavoidable fact is that at this time there is no treatment that can prevent or cure osteoarthritis. Costly prosthetic surgery remains the only option for the severely handicapped patient. Primary and secondary prevention of OA are, therefore, especially important. Identification and prevention of possible risk factors for OA such as obesity, joint trauma, certain malformations or deformities and overuse related to occupation or sport, have become the subject of numerous research projects [2].

The harmful or beneficial role of physical activity remains difficult to define with any degree of precision. Joint function implies two distinct forces, load transfer and movement. The effect of mechanical factors on cartilage metabolism is complex since high, sustained load and conversely the absence of load, are both manifestly harmful while moderate, intermittent load appears to be beneficial and essential to healthy joint function. [3]. These opposing effects of joint activity are to be found in the pathogenesis of osteoarthritis. Excessive mechanical stresses are an obvious risk factor while at the same time, exercise may be a protective factor and is generally recommended for the patient with OA [4], [5], [6], [7]. Joint mobilization without excessive load would be ideal but in practice, precise recommendations in this direction are difficult to formulate. As for identifying specific activities that might be harmful or beneficial to the joints, the situation remains unclear. Adding to the complexity of the situation are issues relating to the joint involved, the type, intensity and duration of activity, whether the joint is normal or arthritic and the stage of progression of OA.

By means of a systematic literature review, the goal of this study was to determine if it is possible to recommend or to advise against certain activities for the patient suffering from knee or hip OA. Our aim was to determine the effect of joint activity as a function of the normal or arthritic condition of the joint and of the clinical and radiographic stages of OA. With a view to their usefulness in the management of the OA patient in primary care, recommendations were developed taking into account the levels of supporting scientific evidence. The work of the OASIS group originated in two observations made in clinical practice guidelines for the management and the treatment of knee and hip osteoarthritis [4], [5], [8]. The first observation concerns the lack of attention given to the various activities of the patient with OA. Clinical practice guidelines in general consider the role of obesity as a risk factor for knee and hip OA and of certain exercises as beneficial for the patient with OA. On the other hand, the guidelines devote little attention to the impact of occupational and sports related activities on the arthritic patient who regularly engages in them. Given that half of osteoarthritis patients now experience onset of the disease before the age of retirement, it would seem not only pertinent, but essential that physicians be able to provide advice to prevent worsening of the condition or, indeed, to prevent onset altogether [1], [9]. The second observation concerns the cross-sectional nature of patient management recommendations as opposed to a long-term approach to a chronic problem such as osteoarthritis. The disease takes many years to appear, evolving either progressively or as a series of flare-ups and manifesting either symptomatically or without symptoms. The natural history of OA is as yet poorly understood, which may explain why clinical practice guidelines focus primarily on the patient at the time of consultation. Participants in the OASIS group felt that, even in the absence of convincing data on the natural history of OA, the time has come to lay the groundwork for a preventive approach that, while it may not prevent the onset of the disease (primary prevention), is designed to slow its progression (secondary prevention). Conclusions and recommendations formulated by the OASIS group thus have implications clinically as well as for research.

Section snippets

Categorization of osteoarthritis and activity

This review was limited to studies of human OA of the knee and hip and included tibio-femoral and patello-femoral OA, knee instability, hip dysplasia, and multiple OA involving at least one knee or one hip. All clinical and radiographic manifestations of osteoarthritis, from silent to incapacitating, were included. Post-traumatic and secondary osteoarthritis and post-surgical conditions were not included in this review. The main problem encountered in analyzing the literature was in the

OA and Activity of daily life (ADL)

Activities of daily life (ADL) include housekeeping, shopping, do-it-yourself projects, gardening and recreational walking. In the articles selected, ADL were often intermingled with the other areas of activity considered in this study. We distinguished ADL from structured activity, by the therapeutic nature of the latter in sedentary subjects, and from sports by the intention of authors when including competitive or professional athletes as study subjects. ADL vary significantly with

Acknowledgements

The authors are grateful to the Laboratoires Expanscience, Courbevoie, France, and the Nukleus Agency for having made this literature review and synthesis possible. Thanks go in particular to Philippe Coste, Bernard Savarieau, Chantal Rousseaux, Véronique Gordin and Karyn Wagner.

The publication costs of this article were covered by the Laboratories Expanscience.

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