Osteoarthritis & Movement: Facts vs. Fiction
by Special Guest Contributor Magnus Ringberg, MSc Sport Science, BSc Physiotherapy
A Note From Jenni:
I’m more than excited to present a brand-new, specially-commissioned article by my friend and colleague Magnus Ringberg on the important topic of osteoarthritis (OA), movement, and yoga!
Magnus, a physiotherapist and yoga teacher, will share essential, evidence-based information with our yoga community about OA.
Magnus wrote his master’s thesis about resistance training and OA and has a special interest in joint health. He has published research on ACL injury and return to sport, has worked as a research assistant in physiotherapy, and has been a PhD student in medical science.
According to Magnus, “There are many misconceptions about OA. We need to focus on what matters most and stop sharing inaccurate information that is causing a cascade of issues (e.g. fear of movement and avoidance behavior). We know that motion is lotion for our joints, it’s OK to have pain while you exercise, and lifestyle changes can reduce pain, increase function, and improve quality of life.”
In this article, Magnus will debunk the most common myths about OA. He will also cover what you as a yoga practitioner or yoga teacher can implement in practice with regard to OA.
If you find this article to be of value, please share it far and wide with your networks. We need to spread up-to-date, evidence-based information about OA – and especially the relationship between OA and movement!
Without further ado, here is Magnus’ article!
–Jenni
Osteoarthritis: Facts vs. Fiction
By Magnus Ringberg
What is Osteoarthritis (OA)?
Osteoarthritis is one of the world's most common diseases, and according to the World Health Organization (WHO), one of the ten most disabling diseases in developed countries.
Each year, an increasing number of people suffer from OA. Any joint in the body can be affected by OA, and it is also possible for several joints in the body to be affected at the same time.
Inside a joint, two or more bones meet and the bone surfaces are covered by a thin layer of cartilage. This layer of cartilage protects the bone, and between these cartilage-covered bone surfaces is synovial fluid that keeps the cartilage lubricated.
It’s common to hear OA described as a condition of “bone to bone”. But OA is not entirely about loss of cartilage; it's a disease that attacks the entire joint, affecting ligaments, bones, menisci, joint membranes, and muscles.
The degradation of articular cartilage in OA seems to be driven by a myriad of biological processes that alter the balance between anabolic and catabolic pathways. OA is a low-level inflammatory condition with many contributors to pain.
Traditional medical views are that OA is a degenerative disease that is progressive and ultimately requires surgical intervention.
Newer evidence, however, suggests that the reality of OA is more complex than we originally thought.
The WHO estimates that the prevalence of OA is between 10-15% in adults over the age of 60. It is difficult to give an exact number of how many people are affected by OA, as not everyone experiences symptoms or seeks medical care and diagnosis. We also tend to report data somewhat differently from country to country.
Seeking medical care and getting the right diagnosis in time to commence first-line treatment will increase the chances of living an active life with less pain and increased joint mobility.
How is Osteoarthritis Diagnosed?
OA is a clinical diagnosis, meaning that a diagnosis should be made through a clinical examination by a doctor or a physiotherapist.
Stiffness, pain, and swelling of the joint are the most common symptoms of OA. Almost everyone seeking medical care is primarily concerned with joint pain.
Specific symptoms can vary depending on which joint is affected. The disease most commonly affects the knees, hips, and small joints in the fingers, but it can also affect the spine, jaw, shoulders, and feet.
Sometimes OA is difficult to diagnose as symptoms such as pain, swelling and stiffness can vary over time.
In fact, many individuals with OA can go weeks or even months with little to no symptoms before a flare-up. It’s not uncommon for symptoms to improve, worsen, and then improve again, especially among patients with early stages of the joint disease.
Diagnostic Imaging and Osteoarthritis
The diagnosis of OA is not as straightforward as we once thought.
One common myth is that an X-ray is needed to diagnose OA. Radiological diagnostics in medical care can be fantastic, but images in OA can be misleading.
It’s important to remember that there can be radiological OA with no symptoms. For example, one study (with MRI) demonstrated that 43% of asymptomatic adults older than 40 had OA. On the other hand, sometimes the changes from OA that are visible on X-rays occur relatively late in the process.
Therefore, an X-ray picture is not always an accurate representation of the disease. (However, in certain cases, it can be used to exclude other diagnoses or to assess joint status in later stages of the disease.)
It is important that OA is treated as early as possible as it allows the individual more time to influence the course of the disease.
What Causes Osteoarthritis?
Is Osteoarthritis Caused by “Wear and Tear”?
For a long time, OA was considered a “wear and tear disease”, but today we know that that’s not the whole story.
If OA were simply a wear and tear issue, we would expect that athletes in repetitive movement patterns (e.g. runners) to develop a higher percentage of OA in the knee – but recreational runners have less knee OA compared with a sedentary control group!
OA seems to be more than an issue of high load or too much exercise.
OA is described as complex joint disease, and it's often difficult to know the exact cause for why some individuals develop the disease.
There are several risk factors that can contribute to the development of OA. Some risk factors are modifiable and can be changed (e.g. weight and activity levels) whereas others are non-modifiable (genetics, age and gender).
Genes play an important role in the development of OA. If OA runs in one’s family, the likelihood that one may develop the disease increases.
Congenital disorders and certain medical conditions can also increase the risk of developing OA later on in life.
Age as a Risk Factor for Osteoarthritis
The risk of developing OA increases with age. However, even young adults may develop the disease. (In most cases, OA in young people is due to a previous joint injury, a congenital disorder, or genetics.)
OA often debuts after the age of 45, as it can take years for the disease to develop.
Age as an OA risk factor can partly be due to the length of exposure one’s joints have experienced to other risk factors, such as being overweight or having previous joint trauma/injury.
Postmenopausal women are twice as likely to develop OA than men of the same age. It is still unclear why.
The Connection Between Weight and Osteoarthritis – It’s Not What You Think!
Weight matters when it comes to OA, but not the way that most people assume.
It is not extra body weight and its associated load on the joints that contributes to OA progression. Instead, it is central adiposity.
Research has shown that fat secretes inflammatory proteins in the body that result in a low grade systemic (i.e. body-wide) inflammation. This systemic inflammation negatively affects the OA joint and causes increased pain and loss of function.
An obese individual with a Body Mass Index (BMI) over 30 is up to 8 times at higher risk of developing knee OA compared to an individual with a normal BMI (between 18.5-24.9). OA of the hands (a non-weight-bearing joint) is also more common among overweight people.
Regardless of BMI, you are at risk of developing OA if you live an inactive, sedentary lifestyle for too long, as this can lead to the muscles around the joints weakening.
Previous Joint Injury and Osteoarthritis
A previous joint injury increases the risk of developing OA. This joint injury would need to be a relatively big trauma, though. An ankle sprain, for example, will not destine you for ankle OA.
The knee and hip joint have received a lot of interest in OA research and 50% of all individuals who injure the anterior cruciate ligament (ACL) in the knee develop knee OA within 15-20 years. Athletes in sports requiring pivoting footwork are at higher risk. Sports injury prevention is important for reducing the number of people who develop OA early in life.
Active vs. Sedentary Occupation and Osteoarthritis
Certain occupations that involve an increased amount of pressure on joints can increase the risk of developing OA later in life.
However, it is not only physically strenuous work that can increase the risk of joint problems. Jobs that require long periods of sitting may also create problems.
This is because our body requires movement, but too much and too little movement seems to be a bad thing.
Most people move too little. Very few people in today's society move too much.
How is Osteoarthritis Treated? (Motion is Lotion!)
The first-line treatment for OA is education and exercise.
Several studies on OA have shown that exercise can reduce pain, increase function and improve quality of life.
Education about the disease and learning self-care tips are important, as they empower the individual to increase their knowledge and understand more about the disease.
The Problem With “The Body as a Machine That Wears Away” Imagery
The belief that our bodies are like machines that “wear away” is the primary reason why many people with OA struggle to control the condition.
Reducing fear of movement and knowledge about joint pain is essential for improving OA symptoms.
Our bodies are in a constant state of “wear & repair”, and exercise therapy has been proven to reduce joint pain as effectively as painkillers, and possibly more.
Research shows that exercise will not make OA worse or progress faster. On the contrary, exercise will very likely cause the OA condition to improve.
Exercise is also protective against other chronic lifestyle illnesses. And for those with such illnesses, exercise can help to manage them.
Common Misconceptions About Osteoarthritis and Exercise
It is common for patients to believe exercise will further damage their joints and lead to increased pain, therefore resulting in preferences for other treatment approaches that could replace lost or damaged articular cartilage.
And when I started working as a physiotherapist 24 years ago, most patients were recommended aqua rehabilitation “to reduce joint load”.
Today, though, we know that exercise does not increase joint damage associated with OA. In fact, research has shown that even high intensity resistance training is not bad for the OA joint and will not damage the cartilage.
We also have to remember that for many people with OA, their cartilage in the joint is not gone. There might be a loss, but the joint surface still needs lubrication. Cartilage dosen´t have a blood supply. It is the synovial fluid that is responsible for supplying the articular cartilage with nutrients, and therefore it is crucial that the joint is both loaded and unloaded so that synovial fluid is both pushed out of the cartilage and absorbed again.
The articular cartilage is similar to a sponge. Cartilage loves loading and can adapt.
Which Type of Exercise is Best for OA?
We cannot say that one type of exercise is better than another. Global OA recommendations encourage both aerobic and resistance training.
The best exercise for OA is truly the one that an individual can stay consistent with over time.
Since OA is a chronic condition, the aim is to build a lifelong commitment to physical activity. Strive for mindful progressions and choose meaningful activities.
Avoid too much, too soon, too often, with too little recovery.
For example, if you like to run and are diagnosed with hip or knee OA, don’t stop running! But perhaps be open to redefining what running looks like for you. Instead of running 30K five times/week, you could adjust to 15K three times/week.
Redefining the activity and modulating intensity, duration and frequency can be necessary.
Exercise for More Than Just Osteoarthritis
Exercise is important for both physical and mental health, regardless of BMI.
Both healthy weight and overweight individuals with OA can easily end up in a vicious cycle, as joint pain may result in lack of exercise which in turn leads to increased pain, weight gain, fatigue, and reduced joint mobility.
The danger of this vicious cycle is not only that it worsens OA symptoms, but it also places an individual in a risk group for developing other health problems.
People with OA face an increased risk of developing comorbidities such as cardiovascular disease, depression, stroke, and diabetes.
How Do Exercise & Movement Help With the Symptoms of OA?
Local vs. Systemic Effects
The mechanisms through which exercise improves OA symptoms are probably mainly due to systemic effects (e.g. reducing chronic systemic inflammation) rather than local effects (e.g. specifically improving the condition of the OA joint).
For example, exercise-specific knee joint movement is not required to relieve knee OA symptoms. You can actually improve with a generic resistance training program!
Since no single exercise therapy program shows vastly superior benefit, patient preference and contextual factors should be central to the shared decision-making process when selecting and individualizing appropriate exercise therapy prescriptions.
My Academic Research on Resistance Training and Osteoarthritis
In my master’s thesis, I wanted to understand more about resistance training programs in individuals with OA. Since there are many studies investigating knee OA and resistance training, I decided to deepen my knowledge within this field.
The aim of the thesis was to conduct a systematic literature review comparing the composition of resistance training programs according to outcome measures for self-rated pain, self-rated function and capacity in physical function.
I only used study designs using randomized controlled trials in which both genders were given access. After selection, 10 articles remained. All programs lasted from 6 to 16 weeks and included equipment such as elastic bands, weights, and resistance exercise machines.
The majority of the interventions showed significant improvements for OA symptoms between baseline and the end of the intervention compared to the control group.
The number of exercises varied from 1 to 7, intensity could be both low and high, 1 to 10 sets and 2-15 reps.
My conclusion was that strength training programs of different designs may be successful and the application of training variables (e.g. type of resistance, number of exercises, intensity, set x reps) may vary.
Further, strength training can be performed in a home environment, or in a gym, with the support of a physiotherapist.
We do not need to exercise in a specific way. There seem to be many options.
I think it’s important to let the individual with OA decide what kind of program would be most interesting.
Other Considerations for Osteoarthritis Treatment
Besides exercise therapy for OA, it is also recommended to have a normal BMI. Weight loss is an important part of the treatment to alleviate symptoms of the disease. (But remember that weight loss as an intervention has more to do with systemic effects than localized, joint-based ones.)
What about diet? According to research, there is no diet which seems to be better than others for individuals with OA.
It’s commonly believed that everyone affected by OA will need surgery at some point in their life, but this is a myth. Most people with OA will not require surgery or a new joint (arthroplasty), but for a small number of patients who have not benefited from first-line treatment, surgery may be necessary. The vast majority of those with OA manage the condition without surgery.
Pain is OK When You Exercise!
It’s very common for OA patients to puzzle over the following conundrum:
If cartilage loves being loaded, why does it hurt when I move?
We know that exercise in general is a fantastic tool for the whole body, with positive effects on both our physical and mental health.
We also know that exercise has been proven to provide similar pain relief as many over-the-counter painkillers.
But in those with OA, exercise can feel worrisome, because moving the affected OA joint is sometimes painful.
This can be a scary experience, and many people with OA stop moving out of fear.
But a quick look at the nature of OA-associated pain can help to calm these fears.
Why Is Osteoarthritis Painful?
There are changes to the neuroimmune system in OA that mean the system is overprotective and the sensitivity system becomes very “alert”. It’s like a smoke detector alarm that normally only signals when there’s a smoke or fire, but now, in its highly “alert” state, it sounds its alarm when there’s a candle at the dinner table.
It’s a protective reaction, but the problem is that it happens when there’s no danger or harm.
An important part of the exercise plan in OA is to be informed about this overprotective “alert” system.
In this process, a physiotherapist can be an important support, providing a tailor-made exercise program and helping with pain management.
Many therapists use a scale (see Visual Analogue Scale (VAS) figure) from 0 to 10, where 0 is no pain and 10 is the worst pain ever. In several studies with exercise and OA-patients, it has been shown to be OK to have a maximum of 5-6 on the pain scale during one singular exercise session.
However, if the pain hasn’t returned to its original state within 24 hours, the exercise plan needs to be adjusted.
An important takeaway is that exercising with OA may involve short term (acute) increased painful sensations, but in the long term (chronic), exercise therapy can help to reduce these painful OA symptoms.
Quick Primer: The Visual Analog Scale (VAS) for Rating Pain
The Visual Analogue Scale (VAS) measures pain intensity. The VAS consists of a 10cm line, with two end points representing 0 ('no pain') and 10 ('pain as bad as it could possibly be'). The patient is asked to rate their current level of pain by placing a mark on the line. The most simple VAS is a straight horizontal line of fixed length, usually 100 mm. The ends are defined as the extreme limits of the parameter to be measured (symptom, pain, health) orientated from the left (worst) to the right (best). VAS sometimes have extra graphics and colour effects.
Physical therapy treatment and evaluation of OA should last at least 8-12 weeks. This allows for the symptoms of OA, which have natural ups and downs, to be observed and monitored over time.
“Pain comes and goes” and many factors (known and unknown) can be involved. It is normal to want to understand why the OA symptoms are worse or better, but most of the time it is very difficult to determine an exact cause.
But if the evaluation plan is over a longer time frame, it’s easier to detect and measure the overall difference in pain, function and quality of life.
A physiotherapist can support this process with OA questionnaires, which can be a great tool to include in the treatment plan.
No cure for OA is currently available. Therefore, treatment is primarily aimed at modulating symptoms and reducing functional decline.
Overall, physical therapy treatment for OA should establish a patient’s baseline and build capacity over time.
How Do We Prevent Osteoarthritis?
Is There a Magic Pill We Can Take?
There is no magic pill that to ensure that OA will not develop.
However, some risk factora for OA are modifiable, and therefore within our control to change.
It is possible to minimize the risk of developing the disease by influencing
improving our knowledge about the disease
moving your joints regularly
meeting the recommended levels of physical activity
and trying to maintain a healthy BMI.
Proactively addressing these factors can both help to potentially prevent OA and alleviate symptoms in those already affected.
In addition, it’s important to reduce the risk of serious injury in athletes, because previous joint injury is another known risk factor for OA.
Is Yoga an Effective Treatment for Osteoarthritis?
Yes and no.
There is no evidence that yoga would be superior or inferior to other types of movement techniques.
If someone has OA, they shouldn’t worry that practicing yoga will be harmful, but we cannot say that someone diagnosed with OA must practice yoga.
We also cannot say that any style of yoga is preferable to any other as an OA intervention. However, yoga that involves props (e.g. blocks, straps, blankets, bolsters) might be a good idea to support more individual adaptations for those with OA.
Yoga can be similar to other types of exercise (e.g. bodyweight movement) and is therefore an excellent choice of physical activity and recovery strategy.
But, depending on the type of yoga, some asanas (positions) might be difficult because of joint stiffness, weakness and joint pain.
Tips for Practicing Yoga With Osteoarthritis
In my experience as a yoga teacher and physiotherapist, it’s good to explore modifications. Since some pain is OK in exercise, we can modulate and adjust the yoga practice.
Do not assume that deloading the position is necessarily “better”. Sometimes adding more muscular activity (global muscles) can be a good idea.
This approach can be helpful for more than one reason. First, using more muscles engages and supports the body. And second, coordinating and collaborating more parts of the body in a position can also serve as a helpful distraction from joint-specific OA pain.
Try to pay attention to all joints in the body. Not only the OA-specific joint. Overprotecting a specific part of the body can cause fear of movement, and this is believed to increase pain sensitivity.
Instructions like “be careful with your osteoarthritic hip” are not helpful, and I recommend that yoga teachers be mindful of negative, micromanaging, nocebic, and fearful language when teaching yoga classes.
Minimize attention to limitations and instead, explore movement potential.
It’s very easy to tell someone that they “take it easy” or “rest if it hurts” in the yoga practice (whether they have OA or not!). Here, I recommend that you as a yoga teacher change your approach.
Let the student be in the driver’s seat. They can make their own decisions about what to do or not to do. If you make sure to always include and demonstrate options in the sequence you teach, students can decide and explore on their own. Again, this applies whether you have OA or not.
Never tell yoga students with osteoarthritis which exercises are “good for them” and which exercises are “harmful”.
OA is a complex disease, and specifically labelling certain movements as good or bad can send a yoga student down an unhelpful path.
Keep in mind that you as a yoga teacher aren’t responsible for your students’ medical statuses. Encourage students to seek medical care. There are many great OA-specific programs worldwide – both in person and online.
Most people with OA would like to be thought of as more than “the hip OA yoga student”. They already live with their condition 24/7, and attending a yoga class is many times a way to escape and focus on something else (besides cartilage and meds).
Remember that community and social interactions are so important for our wellbeing.
In a yoga practice we can also focus on relaxation and mindfulness that could be supportive for recovery, self-regulation and pain management.
Summary of Main Points: Osteoarthritis, Yoga, & Movement/Exercise
The “wear & tear” idea is outdated as an explanation model for OA. There is more to the story e.g. lifestyle, knowledge and activity levels.
Some risk factors can be changed (weight, activity levels and injury prevention), whereas others are inevitable (genetics, age and gender).
Stay active and support a healthy lifestyle with a normal BMI
Exercise doesn't harm or progress OA. When you stay active, the entire body receives multiple positive effects of exercise. Our tissue can also repair when we load it (“wear & repair”).
Keep up with activities that are meaningful for you. You do you!
Every movement counts.
Motion is lotion for our joints.
About the Author: Magnus Ringberg
Magnus is a physiotherapist (Bachelor of Science in Physiotherapy from the University of Lund in Sweden) with a master’s degree in Sports Science from the University of Linneus in Sweden, and experience as a PhD student in medical science
He’s also a yoga teacher and personal trainer who travels around the world teaching trainings, workshops, and classes.
Website: www.magnusringberg.com / IG: @magnusringberg
Other Articles by Magnus Ringberg:
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