Physical Activity in Long Term Musculoskeletal Conditions

Original Editor - Caroline Hooper

Top Contributors - Wendy Walker, Kim Jackson, Lucinda hampton, Tony Lowe, Michelle Lee, Simisola Ajeyalemi, Vidya Acharya, Tarina van der Stockt, Rucha Gadgil and Lauren Lopez  

Introduction

In 2015, a study on the Global Burden of Disease and the worldwide impact of all diseases and risk factors included back and neck pain, osteoarthritis and other musculoskeletal disorders in the leading ten causes of adult global age-specific years lived with disability. When discussing disease-specific issues the report stated that “Musculoskeletal disorders continue to be a leading cause of disability worldwide”.  It advised that “a key component of healthy ageing is to maintain mobility, and a key public health intervention recommended for improving health outcomes for all chronic diseases is physical activity”.

The burden of musculoskeletal diseases will only increase with an increasing ageing population and an increased number of people not taking diet, lifestyle, health and physical activity seriously. A pragmatic multidisciplinary approach to treatment and prevention is needed to tackle these problems; including raising public awareness of risk factors and improving the understanding of these approaches within the medical and scientific community. Behaviour change and patient participation are absolutely crucial for success.

Musculoskeletal Health - A Public Health Approach

Versus Arthritis UK define musculoskeletal conditions as “disorders of the bones, joints, muscles and spine, as well as rarer autoimmune conditions such as lupus”.  They suggest considering three key categories:

1. The commonest group consists of painful musculoskeletal conditions such as osteoarthritis and back pain. Risk factors include physical inactivity, obesity and injury.
2. Osteoporosis and fragility fractures - 50% of women and 20% of men over the age of 50 will suffer at least one fragility fracture.
3. Inflammatory conditions such as rheumatoid arthritis.  The conditions in this category are much less common.

In 2013, Arthritis Research UK organized an expert workshop of epidemiologists, public health specialists and others in order to help shape a national agenda for musculoskeletal public health.

A key concept was that musculoskeletal health means more than the absence of a musculoskeletal condition and that it is possible to have poor musculoskeletal health without having a specific musculoskeletal condition. In order to have good musculoskeletal health the muscles, joints and bones must work well together without pain in order to carry out activities with ease and without discomfort.

At the core of this approach to musculoskeletal health was physical activity. It was emphasized that “remaining active is one of the best things anyone can do for their musculoskeletal health, to help strengthen muscles, keep bones healthy, reduce pain and prolong the life of joints”.  It was recommended that initiatives aimed at increasing physical activity should always explicitly refer to the musculoskeletal health benefits, that joint or back pain is not seen as a barrier to participation, and that these activities are making a difference to people who are living with a musculoskeletal condition. A cross-sectional study suggested that the older inpatient showed an increase in the intramuscular quadricep muscle adipose tissue approx 1.7 times that of the healthy older individuals. Also, the study observed increased intramuscular adipose tissue with older inpatients who were unable to walk independently as compared to older inpatients who were able to walk freely.

Recommendations

4 Key recommendations were made:

1. Assessment of Population Health When assessing local and national population health, musculoskeletal health must be included in the assessment.
2. Health Programme Design When designing, implementing and evaluating programmes targeting lifestyle factors such as obesity and physical inactivity, impact on musculoskeletal health should be explicitly included.
3. Health Promotion When developing health promotion messages, the benefits of physical activity to people with musculoskeletal conditions should be emphasised.
4. Health Data All this public health activity must be underpinned by high-quality data about musculoskeletal health.

Prevention and Management of Musculoskeletal Conditions with Physical Activity

Some specific benefits of physical activity on the musculoskeletal system include increased lean muscle and bone density, strong and supple joints, improved range of joint motion, and improved metabolic rate

The Arthritis Research Council divide prevention and management of musculoskeletal conditions  into two key areas:  reducing risk (physical activity as primary prevention),  and reducing impact (physical activity as secondary prevention) ( ARC 2013)

Physical activity improves musculoskeletal health. A wide range of physical activities have been shown to be beneficial in reducing the overall risk of musculoskeletal pain and disability. These include swimming, walking, cycling and running.( ARC 2013) . An evidence-based Public Health England blog “Preventing Musculoskeletal Disorders has Wider Impacts for Public Health” recommends regular physical activity and exercise at every stage of life (from pregnancy to old-age) to reduce the risk of many musculoskeletal conditions including low back and neck pain, osteoarthritis and falls.

The American College of Sports Medicine has produced several relevant evidence-based position stands relating to physical activity, and the use and prescription of exercise for health. They describe the types and quantity of exercise useful for different components of health. Three-position stands are of particular relevance to musculoskeletal health, they include apparently healthy adults, older adults and bone health.  They give precise recommendations for a comprehensive program of exercise including cardiorespiratory, resistance, flexibility, and neuromotor exercise for apparently healthy adults of all ages in order to improve multiple aspects of physical and mental health including musculoskeletal health. Weight-bearing endurance activities that involve jumping and resistance exercise that targets all muscle groups are recommended from childhood to older adults in order to improve bone health.  Balance exercises are recommended to help reduce the risk of falls for older adults. The position stands recommend reducing total time spent being sedentary by interspersing short bouts of physical activity and standing, and stipulate that for sedentary people some activity is better than none.  The recommendations on activity and dose are well recognised  and used in International and National  Physical Activity Guidance ( e.g. WHO 2010, Department of Health 2011)

Reducing the Risk - Physical Activity as Primary Prevention

Several studies have examined physical activity and exercise in relation to primary prevention of musculoskeletal problems. Higher levels of fitness may correlate with a lower incidence of musculoskeletal disorders including low back pain in working populations such as the navy and police force.  A dose-response relationship between regular physical activity have been associated with a reduced risk of developing painful osteoarthritis particularly in women.

Additionally, high levels of walking are associated with a reduced need for hip replacement surgery especially for women.

Two longitudinal studies indicated that participation in physical activity including running as an adult does not increase the risk of hip osteoarthritis, there doesn’t seem to be a threshold of increasing risk with increased training among walkers and runners. Interestingly running may provide a protective role, and reduce the risk of hip replacement

Increasing physical activity and optimising exercise (as recommended by Arthritis Research UK/Versus Arthritis and World Health Organisation (WHO)) is seen as an optimal way to improve musculoskeletal health. Only 36% of the adult population in the UK take part in moderate-intensity physical activity of about 30 min at least once a week. An increasing body of evidence is showing that even the effects of a sedentary lifestyle (for example, of those with a desk job) can be mitigated by a small amount of activity every day. A recent meta-analysis of the data from studies involving over 1 million individuals concluded that an hour of moderate-level activity per day eliminated the increased risk of death associated with 8 h of sitting.

Biological Mechanisms

A number of biological mechanisms have been demonstrated in studies. These include better nutrition and structure of cartilage and improved strength of the muscles surrounding joints providing stability. Importantly, physical activity is also important in bone strength and reducing the risk of fragility fracture. Bone mass peaks typically by the end of the second or early in the third decade of life. As in early life, high impact physical activity promotes strengthening of the bones. People who are physically active reach a higher peak bone strength in mid-adult life and reduce the subsequent speed of decline in bone strength. The benefits of this become apparent in later life with reduced risk of fragility fractures ( ARC 2013).

Reducing Impact - Physical Activity as Secondary Prevention

For people who have already developed a painful musculoskeletal condition, engaging in appropriate physical activity reduces pain intensity, improves quality of life and prevents further disability.( ARC 2013),

A recent high-quality systematic review investigated effective options for management of musculoskeletal pain in primary care. It included 10 Cochrane reviews and 3 policy documents, and examined the effects of different exercise modalities on back, neck, shoulder, knee and multi-site pain. The review summarised that “Current evidence shows significant positive effects in favour of exercise on pain, function, quality of life and work related outcomes in the short and long-term for all the musculoskeletal pain presentations (compared to no exercise or other control) but the evidence regarding optimal content or delivery of exercise in each case is inconclusive.” Functional exercises related to daily activities appeared to be more beneficial than non-functional exercises. These results concur with previously published studies, and evidence-based guidelines.

When considering secondary prevention for specific conditions, most robust evidence is available for the effectiveness of exercise interventions rather than physical activity for osteoarthritis, low back pain and chronic painful conditions. However, as will be seen, the evidence generally points to functional exercise programmes in line with physical activity guidance rather than specific exercise so it is worth considering.

Management of Osteoarthritis

Several robust systematic reviews are available for osteoarthritis of the hip and knee. Cochrane reviews of exercise for osteoarthritis of the hip,  and osteoarthritis of the knee,  considered exercise to be “ any activity that enhances or maintains muscle strength, physical fitness and overall health”. 

• The review considering exercise for hip osteoarthritis examined 10 RCTs.  Pooling the results of these demonstrated that land-based therapeutic exercise programmes can reduce pain and improve physical function among people with symptomatic hip OA,
• The review considering exercise for osteoarthritis of the knee analysed 44 studies. It concluded that there was good evidence that land-based therapeutic exercise has at least short term benefit in terms of reduced knee pain and improved physical function for people with knee OA. The magnitude of the treatment effect for these reviews would be considered small, but comparable to estimates reported for non-steroidal anti-inflammatory drugs.   
• A subsequent Cochrane review of aquatic exercise for hip and knee osteoarthritis provided moderate-quality evidence that among people with hip and knee osteoarthritis, aquatic exercise may reduce pain and disability, and increase quality of life immediately after the end of the programme of treatment,
• Other systematic reviews considering exercise for knee osteoarthritis support the latter, advocating a combination of lower limb strength and flexibility plus aerobic fitness exercises,

UK NICE Guidance on “Osteoarthritis Care and Management”,  advocates exercise as a core treatment irrespective of age, comorbidity, pain severity or disability. It supports the evidence base of local muscle strengthening and general aerobic fitness. Other guidelines such as the OsteoArthritis Society International (OARSI) “Guidelines for the non-surgical management of knee osteoarthritis”, and the Arthritis Research Council (ARC) “Osteoarthritis” guide support this.

Management of Low Back Pain

Low back pain is extremely common, it is the largest single cause of loss of disability adjusted life years, and the largest single cause of years lived with disability in England. Typical low back pain has a recurrent course with fluctuating symptoms. The majority of back pain patients will have experienced a previous episode and acute attacks often occur as exacerbations of chronic low back pain,    A report by the Health and Safety executive in the UK stated that in 2015/16 the prevalence rate was 660 cases per 100,000 people employed, and  working days lost due to work-related back disorders was 3,417,000 days with the average number of days lost per case of 15.9 days,

A systematic review and meta-analysis of 18 studies suggested that there was no correlation between disability and physical activity levels for acute and sub-acute low back pain. However, for chronic low back pain, it was revealed that people with higher levels of disability were likely to have lower levels of physical activity (Chung-Wei et al  2011),   Extensive research on low back pain is clear that chronic, disabling symptoms have complex biopsychosocial elements, with psychosocial dimensions increasing the risk of chronicity.  In view of this, it is difficult to evaluate the actual effect of physical activity and exercise, due to the complex inter-relationship of factors. Stratification of risk for chronic disabling symptoms using this model is advocated through the use of the STarT Back stratification tool in the UK  (Hill et al 2011)

Two Cochrane reviews looked at exercise for low back pain. Hayden et al (2005) analysed 16 RCTs. It was concluded that exercise was as effective as no treatment or other treatment for acute back pain. Graded activity programmes were moderately effective in improving absenteeism outcomes. Exercise therapy provided some reduction of pain and improved function in adults with chronic low-back pain, particularly in populations visiting a healthcare provider. Another review evaluated 9 studies, and reported moderate quality evidence that post-treatment exercises could reduce both the rate and the number of recurrences of back pain. However, the results of exercise treatment studies were conflicting

Recent UK NICE Guidance on Low back Pain and Sciatica in over 16s, supported by the National Low back Pain and Radicular Pain Pathway, advocate conservative management including group exercise programmes (with psychological support if required)  as a key management strategy for back pain with or without sciatica.

Management of Chronic Musculoskeletal Pain

The topic of pain management is complex and a topic in its own right.  An example of a chronic pain condition that manifests with musculokeletal symptoms, and where the effects of exercise have been systematically evaluated is fibromyalgia. This is a syndrome expressed by chronic widespread body pain associated with central sensitisation, decreased physical function and other co-morbidiies.

Busch et al published a Cochrane Review examining the effectiveness of exercise as a treatment for fibromyalgia syndrome in 2007. 34 studies were considered, and resulted in moderate quality evidence that aerobic exercise training in line with the WHO guidelines had positive effects on global well-being, physical function and possibly pain and tender points. It was recommended that strength and flexibility, plus long-term benefits are researched in the future.  The authors produced another report in 2011. They considered studies from 2009-2011 that investigated different types of exercise for fibromyalgia. Interestingly They emphasised the difficulties with potentially narrow windows of exercise dose for this population and concluded that individually tailored progressive programmes incorporating cognitive strategies, graded exercise and pacing were required in line with many other chronic diseases.

The International Association for the Study of Pain (IASP) promote exercise as “one of the best, most effective and long-lasting treatments for chronic pain”.  In 2010 they published a brief informative video explaining the multiple positive effects of exercise in order to increase physical activity and well-being for musculoskeletal pain:

The video supports the combination of enjoyable tailored programmes incorporating paced, graded strength, flexibility and aerobic exercise programmes.

The University of South Australia has an extremely active pain research group called Body in Mind. There are many studies on this site supporting the importance of physical activity and exercise in the management of chronic musculoskeletal pain conditions. Again, the importance of cognitive strategies together with individually tailored enjoyable physical activity and exercise programmes are emphasised, highlighting the importance of both physical and psychological components of the effects of activity for individuals.

Resources

Motivate to Move website, created by Wales Deanery has a very useful section on Musculoskeletal Health and exercise.