Patient guidelines for weight-resistance training in osteoarthritis

INTRODUCTION — Weight-resistance exercises may be used as part of the therapeutic regimen in patients with osteoarthritis (OA). General guidelines for patients with OA who are performing such training are reviewed here.

GUIDELINES FOR PATIENTS — Patients should be given general guidelines to follow when weight-resistance exercises are prescribed for the treatment of OA. The following contains information for patients, including considerations for planning an exercise program and strategies for performing exercises effectively and safely.

General considerations

●Before starting any weight-resistance program, get clearance from your general practitioner. Strengthening exercises are strongly recommended for people with knee and hip OA and shown to decrease pain and increase strength and function. It is safe to move and to exercise when you follow a well-designed exercise program.

●Consult with a health care professional such as a physiotherapist or exercise physiologist experienced in OA care to find out which exercises are best for you and what you should expect and to discuss any limitations. The exercise program should be tailored to your needs and consider your personal circumstances. Most programs include a combination of low-impact cardiovascular exercise (eg, walking, cycling, rowing, and deep-water running), stretching, and strengthening exercises. Exercises to improve balance may also be beneficial (eg, tai chi, yoga, dance).

●Ideally, you should be supervised at the beginning to ensure that you are doing the exercises correctly and progressing at an appropriate rate. It is a good idea to have regular monitoring appointments with your exercise therapist if you do not have direct supervision while you are exercising. These visits may be gradually spaced until no supervision is needed.

●You can do your exercise regimen in a gym, at home, or at an outdoor space such as a park. A gym has a greater diversity of equipment and classes and may offer supervision. However, you do not need to join a gym to do weight-resistance training. You can do exercises at home using dumbbells, resistance bands, or even your own body weight.

●You should aim to exercise two or more times per week. An overall goal for physical activity for people in general regardless of having OA or not is a total of at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity activity per week.

●Finding a training partner or joining an exercise group (eg, tai chi, aqua aerobics, etc) can help you maintain interest and motivation and make exercise a social experience.

●It is normal to expect some pain with exercise (eg, muscle aches), especially after starting a new exercise or progressing the exercise. It is important to learn how to differentiate this from an OA pain flare up.

●Discuss with your health care professional about modifications in your exercise program in case of a pain flare up.

●Exercise at times of the day when you feel most energetic, your OA symptoms are better, and when you are not in a hurry. Incorporate exercise into your routine and make it a healthy habit for life.

●If you are overweight, consider incorporating a weight-loss program through diet and cardiovascular exercise. This will reduce the weightbearing loads placed on the joints. A combination of exercises and weight loss for people who are overweight or obese is better than either intervention alone to relieve knee OA pain and improve function.

●Keep yourself educated on the latest trends in exercise. Try different exercises and see which ones you enjoy more. Consider free weights as well as machines, as they have different benefits.

●Incorporate recreational activities of your choice into an exercise program; activities could include walking, golfing, bicycling, hiking, or swimming. Tai chi is also a good exercise option for improving strength, balance, and general well-being. Exercises involving high impact on the joints such as running or jumping are usually discouraged, although recreational running may be acceptable if it does not exacerbate your symptoms. Make sure you are wearing supportive shoes.

●Discuss with your physiotherapist or exercise physiologist about your preferences for exercise to enhance long-term adherence.

General guidelines for performing exercises

Below are some general guidelines for performing exercises. An individualized exercise program is encouraged and can be discussed with your health care professional.

●Always warm up before starting your workout routine. This facilitates circulation and prepares the joints for activity. A proper warm-up includes walking or cycling for 10 minutes. Remember to stay hydrated.

●Once you have warmed up, do some light stretching exercises. This promotes greater flexibility and range of motion. Stretching can also provide some relief from the stiffness associated with OA. Static stretches are usually better than ballistic stretches (ie, static stretches are stretches that are held without bouncing for 20 to 30 seconds while ballistic stretches are stretches that are done with bouncing involved). Do not go beyond your range of motion. Overstretching can place excessive strain on muscles, ligaments, and joints.

●Become familiar with your limitations. There is a tendency to become overanxious to get back into shape if you are feeling unfit. Start out with light weights. Any exercise progression should consider gradually and gently increasing the resistance and number of repetitions.

●Always maintain proper body alignment. When in an upright position, try to stand tall, keep your knees slightly bent to reduce stress on the lower back, keep abdominal muscles tight, keep your head facing forward and not off to one side, and always stay focused when you are working out with weights. Whenever possible, use mirrors to check your form and body alignment. You will gain greater results from using proper technique, good body alignment, full muscle contractions, and a slow, steady pace.

●"Closed-chain" exercises (when your hand or foot is fixed to an object or stationary) with weightbearing is generally a safe option to be included in your initial exercise routine (eg, sit-to-stand exercises, squats, push-ups).

●Move the weights in a smooth and steady motion without any sudden or jerky movements.

●Avoid locking (fully straightening) your knees and elbows at the end phase of an exercise. Always try to keep a small amount of flexion to reduce strain on the joints.

●Make sure you breathe normally while exercising; do not hold your breath while you are lifting weights or stretching as it can increase your chest and blood pressure. Exhale while you are lifting the weight and inhale when lowering it.

●Try to achieve a balance in opposing muscle groups. For example, if you can do a biceps curl with 20 pounds, you should be able to do a triceps extension with the same amount of weight. This type of balance in muscle groups provides greater stability in joints.

●Orthopedic braces prescribed by a clinician should be worn during exercise unless otherwise prescribed. Cloth or neoprene braces provide inadequate support to joints and, at most, provide warmth and some proprioceptive stimulation. Wraps function in the same way that cloth and neoprene braces work. Gloves are critical for providing padding to the hands and for assisting in improving gripping power. Straps are excellent for relieving strain on the fingers and wrists. Taping can provide adequate support if done by a qualified trainer. Taping also provides adequate proprioceptive stimulation. Contrary to popular belief, weight belts provide inadequate support and should be used only for their proprioceptive benefits. Weightlifting belts may provide a false sense of support and may lead people to believe that they can lift excessive loads, especially during squats or deadlifts.

●Application of heat and cold packs to affected joints may be used for mild discomfort before and after exercise. Heat packs may be applied to painful joints before exercising. Cold packs can be applied after exercising to reduce swelling and muscle soreness; they should be applied for around 20 minutes.

●Wear proper shoes while exercising and do not forget your orthotics if your health professional recommended them to you.

●Pick cushioned surfaces, such as carpet, grass, exercise mats, or sand, on which to exercise. Cushioned surfaces reduce the shock impact of the joints of the lower extremities.

●Pause or modify weight-resistance exercises if you are experiencing an OA pain flare or an increase in discomfort. Activities may be resumed as the pain subsides. An alternative for these situations is to do water- instead of a land-based workout.

●If you feel unusual pain or your pain increases beyond what is normal for you (generally above two points on a scale from 0 to 10), you should review your exercise routine with your exercise therapist. Stop exercising and visit your doctor if you experience new onset of any of the following: joint popping, locking, or giving way; severe joint pain; abdominal or chest pain; or shortness of breath.

●Always end an exercise session with an active cool-down, such as walking or cycling slowly. An active cool-down will reduce the onset of delayed muscle soreness, will slowly decrease an elevated heart rate, and will prevent blood from pooling in lower extremities, which can lead to dizziness.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Osteoarthritis".)

SUMMARY AND RECOMMENDATIONS

●General considerations – Patients should obtain clearance from their general practitioner before starting a weight-resistance exercise program for osteoarthritis (OA). A physiotherapist or exercise physiologist experienced in OA care can provide additional exercise advice.

Patients should select an exercise facility with appropriate supervision and equipment and pay attention to other health issues that may affect exercise safety and performance, including medications, time of day, and overweight and other medical conditions. (See 'General considerations' above.)

●Guidelines for exercise – Patients should warm up before starting the workout, incorporate stretching, prioritize proper technique for each exercise, and continue use of prescribed braces or orthoses and proper shoes during exercise. Exercise sessions should end with an active cool-down.

Patients may experience mild increased discomfort around the joint after doing exercises, which is normal and likely to subside in the following one to two days. If you feel unusual pain or your pain increases beyond what is normal for you (generally above 2 points on a scale from 0 to 10), you should review your exercise routine with your exercise therapist. Exercise should be suspended if you experience new onset of joint popping, locking, or giving way; abdominal or chest pain; or shortness of breath. (See 'General guidelines for performing exercises' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Kenneth C Kalunian, MD, who contributed to an earlier version of this topic review.