Managing osteoarthritis with an exercise and lifestyle intervention - CHAIN programme

3,922 views
3,813 views

Published on

Managing osteoarthritis with an exercise and lifestyle intervention.

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
3,922
On SlideShare
0
From Embeds
0
Number of Embeds
2,510
Actions
Shares
0
Downloads
0
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide
  • Look at things differentlyCurrent approaches not working – need to question are assumptions and are interventionsBefore we further discuss why certain exercise is beneficial for osteoarthritis, let us first consider whether our traditional beliefs that osteoarthritis is a joint disease. Conventionally osteoarthritis (OA) is a described as a chronic degenerative joint disorder. It is most frequent in the lower extremity, especially the hip joint, where pathological joint impact and shear forces as well as posttraumatic risk factors cause early cartilage degeneration and “joint aging” [1]. The predominant symptoms are pain, a decreased joint range of motion (ROM) and stiffness, periarticular muscle weakness and atrophy, joint effusion and swelling, and physical disability. However, despite the high prevalence of the disease, the pathogenesis and the reasons for its progression are not entirely understood. If modern medicine with all its resources hasn’t been able to find the cause, could we be barking up the wrong tree in our approach to understanding it’s causes.
  • Primary or idiopathic osteoarthritis starts later in life when activity levels fall and muscle weakness begins. Perhaps it is giving up the exercise that is the factor in its development. There is evidence that muscle wasting in the limb can be detected before other signs of osteoarthritis develop. This leads to the possibility that the muscle wasting is an important indicator to the early detection of osteoarthritis, and should be addressed in its treatment.Commonly, OA is characterised by structural changes of the entire joint. Partial to full thickness loss of articular cartilage, subchondral bone sclerosis, osteophyte formation, and thickening of the capsule are the typical clinical and radiological signs. Although radiological changes of OA constantly progress with age, clinical features do not necessarily correlate with radiological findings [2]. As there is no cure for OA, besides different symptom reducing drugs as well as joint preserving and replacement surgery, potentially amenable factors in the prevention and treatment of the disease such as muscle function should be investigated.  
  • It is generally accepted that muscle weakness in OA is due to its atrophy, which to date has been believed to be secondary to joint pain (arthrogenic muscle inhibition) [3, 4]. Recent studies, however, suggest that age-related decrease of muscle volume is a risk factor for OA [5–11]. Thus, as muscle weakness could be targeted by a strengthening program, the question has been raised whether exercise and sports can be used to prevent and symptomatically treat OA.
  • Have sent you the paperExercise is therefore the only action, which can break the destructive cycle. Professional cyclists are the best example. Osteoarthritis of the hip is relatively common in the peleton. The cause is secondary to avasclar necrosis cased by hip fractures or steroid abuse. Despite arthritic hips many professional cyclists ride at the highest level and win. Floyd Landis even won the Tour de France with an arthritic hip. Not bad function, however he was later stripped of his title for abusing steroids! Cycling (a low impact exercise) is the key but other factors about a cyclist are also important. They have a low BMI, don’t smoke, don’t drink, eat a Mediterranean diet and avoid all forms of high impact exercise.  So why is cycling so good? Firstly it’s low impact. Secondly it allows high reps. If you cycle at 50-100 rpm for 30 minutes you complete 1500-3000 reps. Try doing that with any other exercise! Exercise regimes and programs previously used for the treatment of osteoarthritis may have been ineffective as the dose was too low. Cycling also loads the hip and knee differently from walking, so it can mobilize the joint without causing pain. It’s just like a physiotherapist mobilizing a stiff joint using passive movement and accessory movement techniques. The accessory movements of the joint provide afferent input, stimulating the mechanoreceptors around the hip and knee joints, causing down regulation of pain sensation.
  • Talk through the watt bike here and also our proposed researchAlthough many studies investigated the effect of different exercise types, hardly any study can be found investigating the effect of different kinds of sports on OA. Current knowledge supports practicing sports that avoid sudden peak stresses but improve muscle function and contribute to the stabilisation of the affected joints. Sports that fulfil these criteria and are regularly recommended to people suffering from OA and are low-impact sports such as cycling, nordic walking, and aquajogging.  However, data on the short and long-term effect of theses types of sport in OA are scarce, and therefore clinical research is needed. When it comes to exercise programs, both low- and high-resistance training with or without weight bearing has been shown to have beneficial effects. The treatment for someone with stiff and painful hips and knees due to early arthritis is to become a cyclist. Cycle for a minimum of 30 minutes per day every on a static or road bike. Stop smoking and alcohol completely as both decrease the blood supply to the joint, change to a Mediterranean 5 fruit and vegetables a day diet as fat storage disorders are associated with avascular necroisis of joints and it will help to lower your BMI. Our initial studies suggest that in most people their arthritic symptoms are relieved or significantly reduced within 90 days. Studies are planned to quantify the effect of this programme. One of the most useful tools could be the wattbike. It is used by British Cycling in schools to identify future cycling Olympic talent and by cyclists in training to improve their pedaling technique. As it measures the power and strength of each leg individually it allows a quantative measure of muscle strength in the affected limb. A training programme as above can then be put in place to correct the imbalance and any improvement made measured. If this programme can be shown to be effective it will offer an alternative to medical interventions that are currently the only option for some patients. In an ideal world completion of the programme might be considered before referral to hospital, as it would give the patient and GP knowledge as to whether all that could be done to relive symptoms and reduce progression of disease had been done. 30 minutes of cycling every day may keep the doctor away, save the planet, the health economy and be fun.
  • What your legs are doing:Moving from point A to point B - As you start to drive with your left leg the graph moves anti-clockwise from A to B. The left leg begins to apply force to the pedals, the right leg is finishing the drive phase and beginning the recovery.Moving from point B to point C -The most powerful part of the left-leg drive. Most riders normally reach their most powerful point just after the horizontal. As the left leg gets towards vertical again (point C) the power normally starts to come off as the rider transitions from left-leg drive to right-leg.Moving from point C to point D - The right leg begins to apply force to the pedals, the left leg is finishing the drive phase and beginning the recoveryMoving from point D to point A - The most powerful part of the right-leg drive. Most riders normally reach their most powerful point just after the horizontal. As the right leg gets towards vertical again (point A) the power normally starts to come off as the rider transitions from right-leg drive to left-leg.
  • Managing osteoarthritis with an exercise and lifestyle intervention - CHAIN programme

    1. 1. @twwainwright enhancedrecoveryblog.com OSTEOARTHRITIS & HIP AND KNEE REPLACEMENT Session 2 – Implementing the NICE guidelines. CHAIN as an example
    2. 2. @twwainwright enhancedrecoveryblog.com 2
    3. 3. @twwainwright enhancedrecoveryblog.com CHAIN Programme Tom Wainwright 5th December 2013
    4. 4. @twwainwright enhancedrecoveryblog.com 4 Introduction: Osteoarthritis • Approximately 9 million adults suffer from osteoarthritis in the UK • Osteoarthritis is most associated with ageing and the likelihood of being affected increases as we get older. • The CHAIN programme is an important opportunity to find a way to reduce the associated pain and improve people’s quality of life and delay or remove the need for surgical intervention.
    5. 5. @twwainwright enhancedrecoveryblog.com 5 Hip Osteoarthritis • Hip osteoarthritis (OA) is responsible for hip pain, stiffness, and dysfunction during activities of daily living and is the most common reason for a total hip replacement. • It has been estimated that 3% of the adult population, and 8% of people aged over 60 years are affected by hip OA. • There is no known cure for OA and therefore, clinical management of hip OA largely focuses on alleviating pain and maximizing function.
    6. 6. @twwainwright enhancedrecoveryblog.com 6 Traditional beliefs about OA • Conventionally OA is described as a chronic degenerative joint disorder. • However, the pathogenesis and the reasons for its progression are not entirely understood. • If modern medicine with all its resources hasn’t been able to find the cause, could we be barking up the wrong tree…..
    7. 7. @twwainwright enhancedrecoveryblog.com 7 OA starts later in life when activity levels fall and muscle weakness begins • Perhaps it is giving up the exercise and the natural loss of motor units that are factors in its development • Muscle wasting in the limb can be detected before other signs of osteoarthritis develop. • Possibility that the muscle wasting is an important indicator to the early detection of osteoarthritis, and should be addressed in its treatment.
    8. 8. @twwainwright enhancedrecoveryblog.com 8 Muscle weakness in OA • Generally accepted that muscle weakness in OA is due to its atrophy, which to date has been believed to be secondary to joint pain (arthrogenic muscle inhibition). • Recent studies suggest that age-related decrease of muscle volume is a risk factor for OA. • Thus, as muscle weakness could be targeted by a strengthening program, the question is raised whether exercise and sports can be used to prevent and symptomatically treat OA.
    9. 9. @twwainwright enhancedrecoveryblog.com 9 The aims of CHAIN programme • To promote the effective ongoing self- management of early osteoarthritis of the hip • Education and Advice • Exercise • Lifestyle and general health • Community links • Monitoring of symptoms
    10. 10. @twwainwright enhancedrecoveryblog.com 10 1 National Clinical Guideline Centre Full Guideline Osteoarthritis: the care and management of osteoarthritis in adults Clinical guideline Methods, evidence and recommendations 9 August 2013 Draft for consultation Commissioned by the National Institute for Health and Care Excellence Three Core Treatments for OA • Education, advice and access to information • Exercise: Local muscle strengthening and aerobic fitness training • Weight loss if overweight or obese
    11. 11. @twwainwright enhancedrecoveryblog.com 11 • Unilateral hip OA is characterized by generalized muscle weakness of the affected leg. • The mechanisms underlying muscle weakness are multifactorial, and include, in order based on strength and amount of available evidence, a combination of • Reduced muscle size (atrophy) • Muscle inhibition • Decreased muscle quality • The findings of this review suggest the need to address the issue of muscle weakness in the clinical management of hip OA.
    12. 12. @twwainwright enhancedrecoveryblog.com 12
    13. 13. @twwainwright enhancedrecoveryblog.com 13 Participants in both groups significantly improved in the timed chair rise, in the 6-minute walk test, in the range of walking speeds, in the amount of overall pain relief, and in aerobic capacity. No differences between groups were found. Daily pain reports suggested that cycling did not increase acute pain in either group. What does cycling have to offer?
    14. 14. @twwainwright enhancedrecoveryblog.com 14 Cycling with hip pain
    15. 15. @twwainwright enhancedrecoveryblog.com 15 Optimising pain relief and pacing
    16. 16. @twwainwright enhancedrecoveryblog.com 16 Why cycling? • It mobilises the hip joint • It strengthens the muscles which support the hip joint • Static group cycling allows mixed groups to exercise together • Cycling is accessible and can be built into your regular routine • Fun!
    17. 17. @twwainwright enhancedrecoveryblog.com 17 How and why might cycling work? Analgesic effects • Repetitive joint mobilisation – Stimulation of mechanoreceptors and reduction of pain through pain gate and descending inhibition • Psychological – Activation of descending inhibition and reduction of centrally mediated responses to pain • Cardiovascular – Production of natural opiates • Sleep – Exercise improves sleep quality which in turn can reduce pain Mechanical effects • Muscle strengthening • Altered joint loading – changes to COG, GRF, impact, velocity vectors • End range repetitive movements • Contributes to weight loss
    18. 18. @twwainwright enhancedrecoveryblog.com 18 Group exercise is more effective than home-alone exercise for people with osteoarthritis
    19. 19. @twwainwright enhancedrecoveryblog.com 19 Exercise reduces pain and improves physical function for people awaiting hip replacement surgery
    20. 20. @twwainwright enhancedrecoveryblog.com 20
    21. 21. @twwainwright enhancedrecoveryblog.com 21 Preoperative greater knee extensor strength of the operated site is associated with better physical function at 12 weeks post-op
    22. 22. @twwainwright enhancedrecoveryblog.com 22 CHAIN – The programme Week 1 Individual assessment • Introduction • Watt bike assessment • Goal setting • Questionnaires Week 2-7 Group education and cycling programme • Different Education topic each week • Spinning session Week 8 Individual assessment • Re-assessment • Watt bike assessment • Planning for future
    23. 23. @twwainwright enhancedrecoveryblog.com 23
    24. 24. @twwainwright enhancedrecoveryblog.com 24 Spinning timetable Key Rest/Easy Riding Increasing Resistance Increasing Leg Speed Seated/Standing Climb Jumps Week One Week Two Week Three Week Four Week Five Week Six Time Take water when needed Take water when needed Take water when needed Take water when needed Take water when needed Take water when needed 1:00:00 Bike set up / easy riding Bike set up / easy riding Bike set up / easy riding Bike set up / easy riding Bike set up / easy riding Bike set up / easy riding2:00:00 3:00:00 4:00:00 Increase leg speed 30 secs on 30 secs off Increase resistance 1/4 turn each minute Increase leg speed 45 secs on, 15 secs off Increase leg speed 60 secs on, 30 secs off 5:00:00 6:00:00 Increase resistance 1/8 turn each minute 7:00:00 8:00:00 Increase resistance 1/8 turn each minute Increase leg speed 30 secs on 30 secs off Easy ride (reduce resistance by 1/2 turn)9:00:00 10:00:00 Easy ride (reduce resistance by 1/2 turn) Increase resistance 1/8 turn each minute Seated climb 11:00:00 Rest / water break 12:00:00 Rest / water break Rest / water break Easy ride (reduce resistance by 1/2 turn) Jumps 45 secs up, 15 secs down 13:00:00 Increase resistance 1/8 turn each minute Increase resistance 1/8 turn each minute Increase leg speed 30 secs on 30 secs off 14:00:00 Increase leg speed 30 secs on 30 secs off Increase leg speed 45 secs on, 15 secs off 15:00:00 16:00:00 17:00:00 Rest / water break Easy ride (reduce resistance by 1/2 turn) Easy ride (reduce resistance by 1/2 turn)18:00:00 Increase leg speed 30 seconds on 30 seconds off (4 minutes total) Seated climb Seated climb Standing climb 19:00:00 Rest / water break Increase resistance 1/8 turn each minute 20:00:00 Increase resistance 1/8 turn each minute Easy ride (reduce resistance by 1/2 turn) Increase resistance 1/4 turn each minute 21:00:00 Easy ride (reduce resistance by 1/2 turn)22:00:00 Rest / water break Increase leg speed 30 secs on 30 secs off 23:00:00 Increase leg speed 30 seconds on 30 seconds off, increase resistance by 1/8 turn each minute Increase leg speed 30 secs on 30 secs off Jumps 45 secs up, 15 secs down 24:00:00 Easy ride (reduce resistance by 1/2 turn) Increase leg speed 45 secs on, 15 secs off 25:00:00 26:00:00 Increase leg speed 30 secs on 60 secs off Standing climb 27:00:00 Easy ride (reduce resistance by 1/2 turn) Standing climb 28:00:00 Rest / water break Easy ride Easy ride 29:00:00 Cooldown / stretch Cooldown / stretch Cooldown / stretch Cooldown / stretch Cooldown / stretch Stretch 30:00:00
    25. 25. @twwainwright enhancedrecoveryblog.com 25 WARM UP AND EASY RIDING INCREASE RESISTANCE EASY INCREASE/DECREASE LEG SPEED INCREASE/DECREASE LEG SPEEED EASYEASY PERCEIVEDEFFORTLEVEL 10 9 8 7 6 5 4 3 2 1 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10 10.5 11 11.5 12 12.5 13 13.5 1 4 14.5 15 15.5 16 16.5 17 17.5 18 18.5 19 19.5 20 20.5 21 21.5 22 22.5 23 23.5 24 24.5 25 25.5 26 26.5 27 27.5 28 28.5 29 29.5 30 TIME (MINUTES) WARM UP INCREASE RESISTANCE EASY INCREASE RESISTANCE EASY INCREASE RESISTANCE EASY INCREASE LEG SPEED EASY 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10 10.5 11 11.5 12 12.5 13 13.5 14 14.5 15 15.5 16 16.5 17 17.5 18 18.5 19 19.5 20 20.5 21 21.5 22 22.5 23 23.5 24 24.5 25 25.5 26 26.5 27 27.5 28 28.5 29 29.5 30 TIME (MINUTES) WARM UP INCREASE LEG SPEED INCREASE RESISTANCE EASY INCREASE LEG SPEED EASY INCREASE RESISTANCE INCREASE LEG SPEED EASY 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10 10.5 11 11.5 12 12.5 13 13.5 14 14.5 15 15.5 16 16.5 17 17.5 18 18.5 19 19.5 20 20.5 21 21.5 22 22.5 23 23.5 24 24.5 25 25.5 26 26.5 27 27.5 28 28.5 29 29.5 30 TIME (MINUTES)
    26. 26. @twwainwright enhancedrecoveryblog.com 26 WARM UP INCREASE RESISTANCE INCREASE/DECREASE LEG SPEEED EASY INCREASE/DECREASE LEG SPEEED SEATED CLIMB EASY INCREASE/DECREASE LEG SPEEED SEATED CLIMB EASY 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10 10.5 11 11.5 12 12.5 13 13.5 14 14.5 15 15.5 16 16.5 17 17.5 18 18.5 19 19.5 20 20.5 21 21.5 22 22.5 23 23.5 24 24.5 25 25.5 26 26.5 27 27.5 28 28.5 29 29.5 30 TIME (MINUTES) WARM UP INCREASE LEG SPEED EASY INCREASE RESISTANCE INCREASE LEG SPEED SEATED CLIMB EASY JUMPS STANDING CLIMB EASY 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10 10.5 11 11.5 12 12.5 13 13.5 14 14.5 15 15.5 16 16.5 17 17.5 18 18.5 19 19.5 20 20.5 21 21.5 22 22.5 23 23.5 24 24.5 25 25.5 26 26.5 27 27.5 28 28.5 29 29.5 30 TIME (MINUTES) WARM UP INCREASE LEG SPEED SEATED CLIMB JUMPS STANDING CLIMB INCREASE RSISTANCE INCREASE LEG SPEED EASY 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10 10.5 11 11.5 12 12.5 13 13.5 14 14.5 15 15.5 16 16.5 17 17.5 18 18.5 19 19.5 20 20.5 21 21.5 22 22.5 23 23.5 24 24.5 25 25.5 26 26.5 27 27.5 28 28.5 29 29.5 30 TIME (MINUTES)
    27. 27. @twwainwright enhancedrecoveryblog.com 27 Initial Assessment – Why we used the Watt bike
    28. 28. @twwainwright enhancedrecoveryblog.com 28 Pre and POST programme review
    29. 29. @twwainwright enhancedrecoveryblog.com 29 Muscles used when cycling
    30. 30. @twwainwright enhancedrecoveryblog.com 30 Analysing Power: The Watt Bike Polar View Point A - Both pedals are in a vertical line. Your left leg is at the highest point; your right leg is vertical at its lowest point. Point B - Both pedals are horizontal, the left leg on the drive phase – the right leg on the recovery phase Point C - Both pedals are vertical. Your left leg is at the bottom of the revolution and your right leg is at the top Point D - Both pedals are horizontal, the right leg on the drive phase – the left leg on the recovery phase
    31. 31. @twwainwright enhancedrecoveryblog.com 31 The Figure of Eight - Beginner • This cyclist losing too much pedal momentum on the transition from right-leg to left-leg (point 1) and left-leg to right-leg (point 2). With virtually no pull up during the recovery.
    32. 32. @twwainwright enhancedrecoveryblog.com 32 The Peanut - Good • This cyclist maintains some pedal momentum between leg drives. However, there is still a noticeable loss of momentum – especially since at point 2 there is a larger dead spot than at point 1.
    33. 33. @twwainwright enhancedrecoveryblog.com 33 The Sausage - Elite • This cyclist has a large rounded shape, which is consistent, balanced between each leg, and they maintain good pedal momentum throughout. Typical shape of a strong drive and a balanced recovery.
    34. 34. @twwainwright enhancedrecoveryblog.com 34 Losing pedal momentum – pull up during the recovery
    35. 35. @twwainwright enhancedrecoveryblog.com 35 Angle to force peak is equal but very different forces generated
    36. 36. @twwainwright enhancedrecoveryblog.com 36 Uneven pedaling – Force Peak and Force differences between legs
    37. 37. @twwainwright enhancedrecoveryblog.com 37 Consistent difference between legs
    38. 38. @twwainwright enhancedrecoveryblog.com 38 Right leg painful to start with but then eases
    39. 39. @twwainwright enhancedrecoveryblog.com 39 CHAIN – first 30 participants n Mean Median Range Age (years) 29 59 60 39 - 72 BMI 22 28 26 22 - 44 Oxford Hip Score at start of programme 29 33 33 13 - 46 n Male Female Gender 30 12 18 n Osteo- arthritis Post Traumatic No diagnosis Other Primary Diagnosis 27 23 1 2 1
    40. 40. @twwainwright enhancedrecoveryblog.com 40 CHAIN – POMs POM n Average pre score Average post score Health Gain Improved Unchanged Worsened EQ5DVAS 28 71 82 11 22 5 1 EQ5D Index 29 0.689 0.734 0.045 18 2 9 Oxford 29 33 38 5 23 3 3 Harris 27 66 74 8 19 3 5 Sit to stand 29 16 12 4 25 1 3 Non- arthritic hip score 24 54 61 7 18 2 4
    41. 41. @twwainwright enhancedrecoveryblog.com 41 CHAIN - Oxford Hip Score
    42. 42. @twwainwright enhancedrecoveryblog.com 42 CHAIN - EQ5D VAS
    43. 43. @twwainwright enhancedrecoveryblog.com 43 CHAIN – Harris Hip Score
    44. 44. @twwainwright enhancedrecoveryblog.com 44 CHAIN – Sit to stand test
    45. 45. @twwainwright enhancedrecoveryblog.com 45 CHAIN – Non-arthritic Hip Score
    46. 46. @twwainwright enhancedrecoveryblog.com 46 CHAIN – most useful aspects • Learning how to set up bike • Introduction to cycling as a lifestyle • Weight loss • Social interaction • More mobility in hip joint • Reduced pain • Learning about effects of exercise, nutrition and analgesics
    47. 47. @twwainwright enhancedrecoveryblog.com 47 CHAIN – Patient achievements • Flexibility and mobility improved • Weight loss • Able to walk distances without pain • Reduced analgesics • Feel fitter/healthier/stronger • Avoiding hip replacement for now • Sleeping improved • All participants recommend programme
    48. 48. @twwainwright enhancedrecoveryblog.com 48 Continuing to exercise post programme
    49. 49. @twwainwright enhancedrecoveryblog.com 49 Questions?

    ×