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Running from to , the study treated London-area men and women with an average age of All study participants received physical therapy as well as medications such as ibuprofen or acetaminophen, but 86 of the patients also received surgery consisting of lavage and arthroscopic debridement at LHSC. At several time intervals post-treatment, the researchers found both patient groups experienced comparable improvements in joint pain, stiffness, and function, but surgery provided no additional benefit.
Orthopedic surgeon and study co-author Dr. Bob Litchfield emphasizes this study addresses only arthritis-related knee problems. If this particular technique is not working for this subgroup of patients, we better come up with something else that does.
A study demonstrating similar results to this study was broadly dismissed by the medical community, and arthroscopic surgery of the knee remains a common treatment for joint pain and stiffness. But in this latest study the researchers conclude "based on the available evidence, we believe that the resources currently allocated towards arthroscopic surgery for osteoarthritis would be better directed elsewhere.
Funding for this study was provided by the Canadian Institutes of Health Research. Interviews with the co-authors and study patient Steve Studenny who had surgery, and video of arthroscopic surgery and physiotherapy can be downloaded off the internet at:. You will find folders with b-roll and clips from Dr. Litchfield and Steve Studenny, a study participant as well as a zip file with all of the video and a pdf of the NEJM study.
Clip 1 "The study enrolled patients with moderate to severe osteoarthritis of the knee. The patients were randomly assigned to either receive surgery plus best medical therapy, or best medical therapy alone. They were followed for two years and during that time they were assessed using a standardized measure for the severity of osteoarthritis.
And the primary end point of the study was the score on this measure at the end of two years and what the trial found was no effect of surgery that was superior to medical therapy alone. Clip 2 "We think this study really provides definitive evidence that the procedure is ineffective.
Many orthopedic surgeons did not accept the result and there were many criticisms of the methodology used in that trial, specifically the study was conducted by a single surgeon in a Veterans administration hospital in Houston Texas, so naturally patients were older male veterans as opposed to the more generalized patient population that we studied in our study. So the patient population that we evaluated included both men and women and the average age of 60 and they're more representative of the typical patient with osteoarthritis that would have this procedure.
Clip 3 "Well I think this is a procedure many people felt was effective and we now know isn't effective and I think the resources that are being directly towards arthroscopic surgery for osteoarthritis should be directly elsewhere. And I want to make the distinction, that this study is not saying arthroscopic surgery isn't a useful treatment. It's a very good treatment for many conditions, but it seems osteoarthritis of the knee is not one of them.
Clip 1 "This is a study of community-based patients. These are patients that would present to a clinic such as ours in orthopedics, sport medicine with complaints of knee pain. Therefore, the results from these studies show that individuals who had normal joints and participated in low-impact exercises did not have an increased risk of developing OA of the knee or hip as they aged, independent of joint injury. Whilst there is some evidence suggesting an increased risk with activity this has not been adequately disentangled from injury.
In this light there is no good evidence supporting a deleterious effect of exercise on joints in the setting of normal joints and moderate activity. In contrast, there does seem to be an association between elite sports participation and an increased risk of OA.
However, the nature of the sport is very important to the degree of risk. The sports with major risk are those that involve repetitive, high intensity, high impact forces through the affected joints, especially where there is a high associated risk of injury.
Categorizing exercise into different levels of impact is somewhat arbitrary but relates to the extent of compressive loading during the activity. Common examples of high-impact exercise include running, dance exercise, tennis, racquetball, and squash. This is in contrast to low- to moderate-impact exercises such as walking, swimming, stair climbing, rowing, and cross-country skiing.
A Finnish group examined hospital admission rates over 21 years for OA hip, knee or ankle for over male ex-athletes Kujala et al. They divided the cohort into endurance long-distance running, cross-country skiing , team soccer, ice hockey, basketball, track and field , and power boxing, wrestling, weight-lifting, throwing sports. All three groups had higher incidences of OA-related admissions, with power and team sports having admissions at an earlier age. Soccer players and weight-lifters had higher risk, which was due at least partly to knee injuries in the former and high body mass index at age 20 in the latter Kujala et al.
The former power-sport competitors had the highest odds ratios for hip disability, whereas only the team-sport players had a high risk for knee disability, again perhaps reflecting the injury-prone nature of these sports Kettunen et al. A Swedish retrospective cohort reported both hip and knee radiographic OA associations in 71 elite and non-elite players with a mean age of 55 and compared the rates with those of age-matched controls Lindberg et al.
For the knee, the prevalence of OA was The data from studies of runners indicate that the distance run and intensity may play a role. In a retrospective cohort study, examinations were performed in and on a number of former athletes: The athletes had a mean age of 42 years at the second examination.
Age and number of miles run per week in were the positive predictors of radiographic OA. Radiographic hip and knee OA rates were significantly higher in the former athletes compared with controls of a similar age, with a tendency to more patellofemoral OA in the runners.
No clear risk factors were seen within the ex-athlete groups, although the tennis players tended to have more osteophytes at the tibiofemoral joints and hip, but the runners had more patellofemoral joint disease. In contrast, in a retrospective cohort study, the rates of radiographic hip OA in 60 ex-marathon runners were not higher than in controls, although the timing of radiographs differed for the two groups Puranen et al. A study comparing university level cross-country runners with similar-level swimmers found no difference in levels of hip and knee pain but x-ray examinations were not performed Sohn et al.
A small prospective study of 17 male runners nine were marathon runners compared with controls found no difference in radiographic OA at the hip, knee, ankle or feet Panush et al. At baseline, 41 runners aged 50—72 years and averaging 25 miles a week were compared with controls matched for age, sex, years of education, and occupation Lane et al.
There were no differences in clinical and radiographic OA findings in the knee and lumbar spine. Follow-up of this cohort at 5 Lane et al. For the runners, regression analysis disclosed that the predictors of progression of radiographic knee OA were baseline radiographic score and a faster pace per mile. Hip radiographs taken 9 years later also showed no differences in OA between the groups Lane et al. Thus elite athletes who perform their activities with high impact and high stress to the joints appear to have an increased risk for OA in the hips and knees compared with age-matched controls Kujala et al.
Again the concomitant presence or likelihood of joint injury increases the risk of developing OA. When considering the impact of weight-bearing activity on the joint tissues there is a preponderant focus on cartilage as this pertains to OA. In general, though, the effect of exercise on load-bearing joints extends beyond cartilage, and exercise is known to have advantageous trophic effects on periarticular bone and muscle in particular, and also tendon, at least in men Magnusson et al.
Hyaline articular cartilage provides the articulating surface of synovial joints. Many studies suggest that articular cartilage is mechano-adaptive; that is, the biosynthetic activity of chondrocytes is responsive to mechanical stimuli and can alter the morphology and composition of cartilage Carter et al.
Other studies suggest that excessive mechanical force can have a deleterious effect on the prevalence of OA Kujala et al. Due to the pluripotent effects of mechanical loading on articular cartilage, physical activities may play an important role in either the causation of or protection against OA. Prolonged immobilization in animals leads to reductions in articular cartilage thickness, although it does not necessarily become osteoarthritic surface remains smooth and no osteophytes or erosions develop Vanwanseele et al.
Similarly, in humans the absence of normal joint loading due to spinal cord injury results in rates of cartilage thinning that are higher than those observed in persons with OA Vanwanseele et al. Thus cartilage undergoes atrophy in the absence of mechanical stimulation.
In animal studies, physical activity has been shown to have varying effects on articular cartilage Jurvelin et al.
Overexercised animals have been found to develop glycosaminoglycan depletion Komulainen et al. In humans, there are data supporting both directions of effect of physical activity, and it is not understood how both could be true.
To test this effect in humans, Jones and colleagues studied 92 children ranging in age from 9—18 and evaluated their cartilage thickness on MRI initially cross-sectionally, followed by a longitudinal assessment of 74 of the same cohort Jones et al. They reported that self-reported activity prior to the MR examination was related to articular cartilage volume and that the effect of physical activity was mediated, in part, by its relation to muscle strength.
The longitudinal observation suggested that participants who were above the median for average intensity of sport gained more cartilage than did those below the median. It should be noted that these observations were in children and that analysis of cartilage volume does not permit separation of the effect on cartilage development thickness from bone growth epiphyseal joint area.
Vigorous self-reported activity in children was associated with greater accrual of cartilage in tibial but not patellar cartilage compared with children with no reports of vigorous activity Jones et al. What may be more relevant to disease occurrence is whether activity in middle or older years affects cartilage thickness at a time when the person is at highest risk of disease.
This may suggest that load bearing may have a greater influence on the articular surface area than on cartilage thickness. Animal studies corroborate the evidence that weight-bearing physical activity appears to protect against the development of OA Otterness et al. This finding may suggest a protective effect on the development of OA in persons at high risk of developing OA, but another study found no significant difference in the in vivo deformational behavior of cartilage between athletes weight-lifters, sprinters and non-athletic controls Eckstein et al.
In a longitudinal study of younger community-based participants, Foley et al. The benefits of recreational exercise are not distinct from that prescribed as part of a therapeutic intervention. Exercise has been a central component of any effort to conservatively manage OA. Exercises can be prescribed to facilitate weight loss, preserve joint range of motion, improve strength, improve functional performance, and reduce symptoms Ettinger et al.
Persons with OA capable of exercise have been recommended to be encouraged to partake in a low-impact aerobic exercise program walking, biking, swimming or other aquatic exercise Roddy et al. Aquatic exercise is preferable to land-based exercise as the body's buoyancy greatly limits the compressive load that the knee must sustain.
Seated bicycling can similarly partially unload the knee and keep it stable while it is exercised through a large range of motion. The rationale behind the promotion of low-impact exercise is that it will encourage the benefits of exercise whilst avoiding the potentially damaging influences of high-impact activities. Quadriceps weakness is common among patients with knee OA, in whom it had been believed to be a manifestation of disuse atrophy which develops because of unloading of the painful extremity Hurley, Some studies, however, have indicated that quadriceps weakness may be present in persons with radiographic changes of OA who have no history of knee pain, and in whom lower extremity muscle mass is increased, rather than decreased Slemenda et al.
Quadriceps weakness was hence considered a risk factor for the development of knee OA, presumably by decreasing stability of the knee joint and reducing the shock-attenuating capacity of the muscle Slemenda et al. The role of exercise therapy was the subject of a systematic review that concluded that there is evidence of beneficial effects of exercise therapy in patients with OA of the knee van Baar et al.
Quadriceps strengthening exercises were found to lead to improvements in pain and function. Most strengthening exercise regimens were recommended to begin with isometric exercises and then advance to isotonic resistance exercises as tolerated.
It is important to individualize exercise therapy for hip or knee OA, particularly considering individual patient preference, and ensure that adequate advice and education to promote increased physical activity is provided American Geriatrics Society Panel on Exercise and Osteoarthritis , ; Roddy et al.
As adherence is the main predictor of long-term outcome from exercise in hip or knee OA, strategies to improve adherence should be adopted, such as long-term monitoring. Similarly, patients should do exercise they enjoy to promote long-term participation. Some exercises are likely to be harmful in the long term, particularly those that involve high velocity impact running, step aerobics, etc.
Based upon current evidence, individuals with normal joints and no joint injury should be actively encouraged to exercise regularly both for benefits as they pertain to the joints and other health benefits. There is no strong evidence to suggest that vigorous low-impact exercise is associated with an accelerated rate of development of OA. The current evidence in persons who participate in elite sports activity, particularly in sporting groups susceptible to joint injury, suggests that these groups are at increased risk for OA as a result of their participation, but it is unclear whether participation in the absence of injury is harmful.
When considering the individual risk of OA development it is important to consider the type of sports participation, its intensity and extent of joint impact, the existence of concomitant joint injury, family history of OA and body weight, as well as occupational risk.
Exercise has, and will continue to play, an important role in both the pathogenesis and management of OA. National Center for Biotechnology Information , U. Journal List J Anat v. David J Hunter 1, 2 and Felix Eckstein 3, 4.
Author information Article notes Copyright and License information Disclaimer. Accepted Oct This article has been cited by other articles in PMC. Abstract Exercise remains an extremely popular leisure time activity in many countries throughout the western world. Introduction Exercise remains an extremely popular leisure-time activity in many countries throughout the Western world and has for many become part of the modern lifestyle.
The purpose of the current review is to consider the potential effect of exercise on the onset and progression of joint disease, specifically to: Open in a separate window.
Risk factors for OA OA is perhaps best understood as resulting from excessive mechanical stress applied in the context of systemic susceptibility see Fig.
Mechanical factors increasing risk for progression Local mechanical factors such as the adduction moment , malalignment , meniscal damage , bone marrow lesions , and altered quadriceps strength potentially put the knee joint at increased risk of progression of OA Felson, b.
Obesity From a public health perspective the largest modifiable risk factor for knee OA is body weight. Joint injury Occupation When considering the role of exercise on OA, the effects of activity on load-bearing joints can also be investigated by exploring insights from occupational activity and its respective impact on OA joints.
Joint injury from sports Consideration of the role of exercise in OA needs to pay heed to the potential overlap with sports injury.
Risk of OA from sports participation Recent years have witnessed an enormous increase in the popularity of recreational exercise. Exercise and cartilage When considering the impact of weight-bearing activity on the joint tissues there is a preponderant focus on cartilage as this pertains to OA. Exercise as a tool in the therapeutic armoury The benefits of recreational exercise are not distinct from that prescribed as part of a therapeutic intervention.
Concluding remarks Based upon current evidence, individuals with normal joints and no joint injury should be actively encouraged to exercise regularly both for benefits as they pertain to the joints and other health benefits. Rotational changes at the knee after ACL injury cause cartilage thinning.
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Aug 10, Osteoarthritis is the most common form of arthritis. They're the top choice of treatment for people with OA because they're effective and. A rheumatologist, a doctor who specializes in arthritis and other related conditions, can help if there are any questions about the diagnosis. Top of Page. Treating Osteoarthritis of the Knee: Popular supplements don't work. Osteoarthritis is the most common type of arthritis, affecting 1 in 10 Canadian adults.