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An older man exercises outdoors with various muscle stretches.adamkaz/iStockPhoto / Getty Images

The first thing to do if you’re diagnosed with osteoarthritis in your knees is, unfortunately, exactly what your knees are telling you not to do. Exercise is the first-line treatment—but it hurts.

This paradox creates all sorts of problems, because people worry the pain is a sign that they’re making their joints worse and hastening the progression of the disease, says Trevor Birmingham, a professor of physical therapy at University of Western Ontario and co-director of the Wolf Orthopaedic Biomechanics Lab. There’s even a name for the resulting reluctance to exercise: “kinesiophobia,” a fear of pain associated with movement.

That’s what makes a new study from Birmingham and his colleagues significant. They put a group of 59 osteoarthritis patients through a specially designed 12-week exercise program, pushing them hard. The results, which appear in the journal Osteoarthritis and Cartilage, should be heartening to kinesiophobes: as the intensity of the exercise program ramped up, the level of pain the patients experienced actually decreased.

It’s perfectly reasonable to be cautious about knee pain, of course. The traditional view of osteoarthritis is that it’s the result of wear and tear on the cartilage that cushions your joints, leaving the bones rubbing painfully against each other. Since cartilage has a very limited ability to repair itself, you don’t want to hasten its demise.

But there are several reasons to push through the pain. Newer research has suggested that cartilage isn’t as inert as once thought, and may become bigger and springier in response to regular stimulus from exercise. That’s probably one reason that long-term studies over many decades have consistently found that regular runners have an equal, or perhaps even lower, risk of developing osteoarthritis than non-runners.

Staying active can also help control weight, minimizing the load that your knees have to carry with each step. And stronger muscles can take some of the load off your knees and other joints. “We do know that inactivity, weakness, and obesity increase the risk of osteoarthritis progression,” Birmingham says.

The new Western study, which was led by graduate student Codie Primeau, prescribed a specific program of neuromuscular exercises designed to help subjects learn to move in ways that minimize stress on the joints, for example by keeping the knee aligned over the toes while getting out of a chair. They completed one session a week under the supervision of a therapist, plus three more sessions at home, doing two to three sets of 10 to 15 repetitions of exercises such as lunges, step ups and calf raises.

To get the most of this—or any—exercise program, you can’t just go through the motions. You have to challenge yourself, and as you get stronger you have to increase the difficulty of the exercises you’re doing—a concept known in exercise physiology as the overload principle.

Unfortunately, Birmingham points out, “kinesiophobia and the overload principle don’t mix well.” The response from incredulous patients, he says, is “You want me to do the things that hurt my knee, then work harder to do more?!”

To that end, the volunteers initially rated their subjective effort during the workouts as “somewhat hard,” and steadily increased the intensity until they were pushing “hard” or “very hard” by the final weeks of the study. Over the same period of time, despite the greater effort, the maximum pain they experienced during the workout dropped by an average of one point on a zero to 10 scale.

The takeaway, Birmingham says, is that people who have been diagnosed with knee osteoarthritis shouldn’t be put off by initial discomfort when they start an unfamiliar exercise program. He suggests they keep pain to five or below out of 10, and modify the workout if it goes higher. Over time, the workout-related pain shouldn’t worsen, and may even decrease.

And he has a message for policymakers. Neuromuscular exercise programs like the one used in the study are widely available, including a highly respected program called GLA:D Canada, which is now being offered virtually. They’ve been repeatedly demonstrated to decrease pain and increase quality of life, and are the recommended first-line treatment for osteoarthritis around the world.

“These programs should be better covered by our health care payers,” he says, “including publicly funded.”

Alex Hutchinson is the author of Endure: Mind, Body, and the Curiously Elastic Limits of Human Performance. Follow him on Twitter @sweatscience.

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