Osteoarthritis Pain in the Knee (Adobe Stock)

Osteoarthritis (OA) is the most common joint disorder in the industrialized world. The joints most commonly affected by OA are the knee, hip, hand, foot, and spine.1 Knee OA is the most common and persistent cause of mobility dependency and disability; its prevalence is estimated at over 250 million, or 3.6% of the world’s population.2

Osteoarthritis is a disease of the whole joint, involving cartilage—soft tissue within the joint—and the underlying bone. Current thinking indicates there are at least 2 pathways of disease development, biomechanical (excessive joint loads), and physiological (excessive inflammation). Osteoarthritis pain comes from the highly innervated soft tissue and underlying bone. Osteoarthritis affects people differently. In some, it may progress quickly, but for most people, joint damage develops gradually over years. In some people, OA is relatively mild and interferes little with day-to-day life; in others, it causes significant pain and disability. Symptoms of knee OA include stiffness, swelling, and pain, which make it hard to walk, climb, and get in and out of chairs and bathtubs.

 

How do we reduce osteoarthritis pain?

Pathway to Reduction of Pain in Osteoarthritis Patients
Figure 1. Model developed for IDEA and used for WE-CAN indicating the pathways by which intensive weight loss and exercise can decrease joint loads and inflammation leading to decreased pain and improved mobility and health-related quality of life.

Clinical guidelines strongly encourage exercise and weight management to relieve pain and improve function.3 However, many physicians who treat people with knee OA have no practical means to implement these behavioral interventions as recommended by numerous OA treatment guidelines.

Dr. Messier and a team of researchers at Wake Forest University conducted the Intensive Diet and Exercise for Arthritis (IDEA) trial where they compared diet-induced weight-loss (D) and exercise (E) interventions, separately and in combination (D+E). In that trial, an intensive diet-induced weight loss of 10% combined with exercise was significantly more effective at reducing pain in men and women with symptomatic knee OA than either the diet intervention or exercise intervention alone (Figure 1).4,5

IDEA was an efficacy study implemented in a university setting under rigorously monitored and controlled conditions. Thus, the clinically important question is:

Can this successful solution to a pervasive public health problem be adapted for real-world clinical and community settings?

Our new study aims to develop a systematic, practical, cost-effective diet-induced weight loss and exercise intervention implemented in community settings and to determine its effectiveness in reducing pain and improving other clinical outcomes in persons with knee OA.

Weight-loss and Exercise for Communities with Arthritis in North Carolina (WE-CAN) is the first long-term trial of diet-induced weight loss and exercise in older adults with knee OA implemented under pragmatic conditions in both rural and urban communities. The WE-CAN study is a combined effort from the Wake Forest University Department of Health and Exercise Science and the University of North Carolina Thurston Arthritis Research Center, with collaborators from Wake Forest School of Medicine, Haywood Regional Medical Center, East Carolina University, Harvard Medical School, and the University of Sydney Australia. This 18-month intervention trial builds on the results of IDEA. The intent of the WE-CAN trial is to translate this highly beneficial, long-term intervention for a major chronic health condition to geographically and socioeconomically diverse community settings across the state of North Carolina (Figure 2).

Osteoarthritis WE-CAN intervention site locations in North Carolina
Figure 2. WE-CAN intervention site locations in North Carolina (shaded): Haywood County (west), Forsyth County (central), and Johnston County (east).

This study will establish the effectiveness of a community program that will serve as a blueprint and exemplar for clinicians and public health officials in urban and rural communities who wish to implement a weight loss and exercise program designed to reduce knee pain and improve other clinical outcomes in overweight and obese adults with knee OA.

 

Intensive diet-induced weight loss

The dietary plan is characterized by frequency of contacts, methods to induce caloric restriction, and behavioral strategies. Losing 10% of baseline body weight is necessary for a moderate to large clinical effect. IDEA participants who lost more than 10% of baseline body weight had greater reductions in pain and improvement in function than participants who lost between 5 and 10%.3 Based on IDEA, most participants will reach their weight-loss goal after 9 months. Once it is achieved, they may self-select to begin weight maintenance or continue to lose weight using safe, healthy nutrition practices, provided the participant is motivated to continue losing weight and has not reached a level associated with possible health hazards.6,7 The intervention staff members conduct group and individual sessions throughout the 18 months. Content emphasizes nutrition and behavioral strategies to attain the weight-loss goal and will be presented to participants in their preferred contact method.

 

Exercise

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The exercise component includes 60-minute sessions 3 days per week for 18 months at one of the designated community facilities. The prescribed exercise program consists of four phases: aerobic (15 min), resistance-training (20 min), a second aerobic (15 min), and cool-down (10 min). Walking is the primary mode of aerobic training. Strength training is particularly relevant to offset any loss of muscle and bone mass resulting from weight loss. Depending on the resources available at each community facility, machines, Thera-bands™, free weights, or the participants’ own body weight are used for resistance. In addition to the 3 scheduled days, participants are encouraged to exercise most other days of the week on their own. Monthly exercise logs are used to monitor progress. Our protocol is consistent with the American College of Sports Medicine (ACSM) guidelines for exercise for older adults.8

 

The challenge of weight management and exercise

Exercise and weight loss have been shown to work well9 for pain relief and the combination is most efficacious4,5, yet health practitioners often do not refer patients to community programs, either because they do not exist or because non-pharmacologic alternatives are not part of the treatment plan.10 Intensive weight loss combined with exercise reduces abnormal stress on knees by decreasing joint loads and reduces abnormal physiology by lowering inflammation; both result in less pain and less disability.4

Losing weight and maintaining weight loss are both difficult and people are often unsuccessful. Biological changes fight attempts to lose weight. In an attempt to defend higher weights, the body behaves in “starvation mode” as it increases feelings of hunger, suppresses satiety, and slows metabolic rate.11 The mean weight loss goal of 10% in IDEA was exceeded, in part, because participants received regular attention. Indeed, a possible consequence of a pragmatic approach with little or no participant contact is low adherence. The use of multiple communication techniques with participants is critical to achieving compliance and high retention rates. The WE-CAN trial has hired interventionists from the communities and is working with participants to make sure communication is strong and conducted in the manner most acceptable to the participant.

 

Future directions

To meet the chronic disease burden in our nation the Centers for Disease Control and Prevention has launched several strategic initiatives of which one is to establish community-based programs that support healthy behaviors.12 One of these strategic methods is the development of a Physical Activity Implementation Guide from the Osteoarthritis Action Alliance (OAAA), a coalition of more than 90 organizations committed to elevating OA as a national health priority. OAAA works to increase access to community-based programs through their resource library, newsletters, and mini-grant program that funds community organizations to deliver evidence-based physical activity interventions such as the Arthritis Foundation’s Walk With Ease program.

One dilemma for physicians is the lack of practical means to implement and sustain a diet and exercise program in a community-based environment. WE-CAN is designed to test the effectiveness of a community program that can be implemented in various settings and develop guidelines and protocols for the scalability of a weight loss and exercise program designed to reduce knee pain, as well as improve other clinical outcomes in overweight and obese adults with knee OA. We envision a national implementation of this systematic program that will serve as a model for healthcare professionals on implementing platforms that are accessible to consumers and clinicians, and would be of value to insurers because it can be sustained long-term and at a reasonable cost.


For the latest in Osteoarthritis research subscribe to the Osteoarthritis Action Alliance Research Round-up. The Osteoarthritis Action Alliance serves as an excellent resource that can help physicians, researchers and patients stay up-to-date with OA research, treatment and prevention.


References
  1. Arden, N., & Nevitt, M.C.Epidemiology. In Oxford Textbook of Osteoarthritis and Crystal Arthropathy, 2016. 3rd ed., pp. 81-90. Oxford, UK: Oxford University Press.

  2. Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2163-96. doi: S0140-6736(12)61729-2 [pii];10.1016/S0140-6736(12)61729-2 [doi].

  3. Nelson, Amanda E. et al. A systematic review of recommendations and guidelines for the management of osteoarthritis: The Chronic Osteoarthritis Management Initiative of the U.S. Bone and Joint Initiative: Seminars in Arthritis and Rheumatism, Volume 43, Issue 6 , 701 – 712.

  4. Messier SP, Mihalko SL, Legault C, Miller GD, Nicklas BJ, Devita P, et al. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial. JAMA. 2013;310(12):1263-73. doi: 1741824 [pii];10.1001/jama.2013.277669 [doi].

  5. Messier SP, Loeser RF, Miller GD, Morgan TM, Rejeski WJ, Sevick MA, et al. Exercise and dietary weight loss in overweight and obese older adults with knee osteoarthritis: the Arthritis, Diet, and Activity Promotion Trial. Arthritis Rheum. 2004;50(5):1501-10.

  6. Pamuk ER, Williamson DF, Madans J, Serdula MK, Kleinman JC, Byers T. Weight loss and mortality in a national cohort of adults, 1971-1987. AmJ Epidemiol. 1992;136(6):686-97.

  7. Harrington M, Gibson S, Cottrell RC. A review and meta-analysis of the effect of weight loss on all-cause mortality risk. NutrResRev. 2009;22(1):93-108. doi: S0954422409990035 [pii];10.1017/S0954422409990035 [doi].

  8. Chodzko-Zajko WJ, Proctor DN, Fiatarone Singh MA, Minson CT, Nigg CR, Salem GJ, et al. American College of Sports Medicine position stand. Exercise and physical activity for older adults. MedSciSports Exerc. 2009;41(7):1510-30. doi: 10.1249/MSS.0b013e3181a0c95c [doi].

  9. Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008;16(2):137-62.

  10. Brand CA, Ackerman IN, Bohensky MA, Bennell KL. Chronic disease management: a review of current performance across quality of care domains and opportunities for improving osteoarthritis care. Rheum Dis Clin North Am. 2013;39(1):123-43. Epub 2013/01/15. doi: 10.1016/j.rdc.2012.10.005. PubMed PMID: 23312413.

  11. Brownell KD. The humbling experience of treating obesity: Should we persist or desist? BehavResTher. 2010;48(8):717-9. doi: S0005-7967(10)00114-2 [pii];10.1016/j.brat.2010.05.018 [doi].
  12. National Center for Chronic Disease Prevention and Health Promotion CfDCaP. Preventing chronic disease: eliminating the leading preventable causes of premature death and disabiity in the United States 2015. Available from: https://www.cdc.gov/chronicdisease/pdf/preventing-chronic-disease-508.pdf.


Leigh F. Callahan, PhD and Stephen P. Messier, PhD
Dr. Leigh Callahan is the Director of the Osteoarthritis Action Alliance (OAAA). She is also an epidemiologist and outcomes researcher who, for more than 30 years, has worked in musculoskeletal outcomes research. Her research has focused on predictors of outcomes and quality of life in individuals with osteoarthritis (OA) and rheumatoid arthritis (RA), patient-reported outcomes and measurement, physical activity and arthritis, social determinants and health outcomes, health literacy, and complementary and alternative medicine use in rheumatic diseases. She is also Director for Community and Outcomes Research at Thurston Arthritis Research Center, as well as Director of its Multidisciplinary Clinical Research Center, titled “Mitigating the Public Health Impact of OA”. Dr. Stephen Messier is Professor and Director of the J.B Snow Biomechanics Laboratory at Wake Forest University. He has 26 years of experience in clinical trials research specifically related to knee osteoarthritis. He and his OA research team are well known for their work on the effects of exercise and weight loss on gait, strength, function, and pain in knee OA. Dr. Messier is on the Board of Directors for the Osteoarthritis Research Society International (OARSI), the leading scientific organization devoted exclusively to osteoarthritis. He has also received the Career Achievement Award from the Biomechanics Interest Group of the American College of Sports Medicine. Additionally, Steve is the vice chair for the Osteoarthritis Action Alliance OA Prevention Working Group that focuses on efforts to prevent OA through weight management strategies.

2 COMMENTS

  1. Designing a diet in rheumatology and in orthopedy is not only reducing calories. Yes, the weight is increasing the knee pain for physical obvious reasons. I have observed overweight patients without crucial pain, without local inflamation. These patients were eating a vegetable base diet, they were eating too much healthy food. Reducing the calories was working well to reduce their weight and to gain a better mobility. When the blood test revealed inflamation and a disturbed mineral balance, my first goal is to change the quality of food before reducing the calories.

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