Editorial Open Access
Osteoarthritis – Why Exercise?
Daniel J Leong1,2, Hui B Sun1,2*
1Departments of Orthopaedic Surgery, Albert Einstein College of Medicine, Bronx, NY 10461, USA
2Radiation Oncology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
*Corresponding author: Hui B. Sun, 1300 Morris Park Avenue, Golding 101, Bronx, NY 10461, USA, Tel: 718-430-4291; E-mail: @
Received: November 26, 2013; Accepted: December 27, 2013; Published: December 31, 2013
Citation: Leong DJ, Sun HB (2014) Osteoarthritis – Why Exercise?. J Exerc Sports Orthop, 1(1), 2. DOI: http://dx.doi.org/10.15226/2374-6904/1/1/00104
Osteoarthritis (OA) is a degenerative joint disease and a leading cause of adult disability. The etiology of OA is not clear, but common risk factors for developing OA include age, joint injury, mechanical overuse, and obesity. Exercise is the most common non-pharmacologic therapy prescribed to patients with osteoarthritis. The Arthritis Foundation promotes an exercise program involving low-impact physical activity, and participants have reported less pain and fatigue, and increased strength. Clinical trials of patients with OA report physical activities including aerobic exercise, stretching/flexibility, endurance training, aquatic exercise, and muscle strengthening lead to improvements in pain relief, body weight, and metabolic abnormalities [1]. Factors which are critical to successful outcomes of exercise programs include performing exercises at an appropriate intensity and duration, and long-term adherence to exercise programs. Individualized exercise programs are important to educate patients to avoid exercises which may be harmful to injured joints (e.g. high impact activities). Patient monitoring or prescription of exercises which the patients find enjoyable may promote long-term adherence to an exercise program.
In addition to the symptom-modifying effects of exercise, there is evidence of exercise exerting disease-modifying effects. For example, increased physical activity in the form of aerobic and weight-bearing exercises resulted in increased proteoglycan content, one of the major components of the cartilage extracellular matrix, in the cartilage of OA patients [2]. Strength training for 30 months, compared to range of motion exercises alone, resulted in a decreased mean rate of joint space narrowing [3].
Exercise at a moderate intensity is extremely important. Acute or chronic high-intensity loads, which often occur in athletes participating in high-impact sports such as soccer, football, and basketball, may increase risk of developing OA [4-6]. Inadequate loading also creates a degradative response within the articular cartilage [7,8]. Partial weight bearing for 7 weeks leads to cartilage thinning in the knee articular cartilage [9] and patients with spinal cord injury and subject to bed rest exhibit a rate of cartilage atrophy greater than that reported in age-associated osteoarthritis [10]. Exercise at moderate levels will also help avoid joint injuries. Traumatic joint injuries, such as anterior cruciate ligament (ACL) tears, result in degenerative changes in the articular joint such as chondral softening and fracture [11,12]. The definition of “moderate exercise” however, remains a challenge. It may be necessary to determine appropriate exercise intensities on an individual basis.
While degradation of the articular cartilage is considered a hallmark of OA, the pathogenesis of this disease includes pathologic changes to tissues of the entire joint, including altered bone remodeling, synovitis, and degeneration of the tendons and ligaments [13]. Targeting only one aspect of the disease process (e.g. suppressing bone turnover with risedronate [14]) has not been reported to slow progression of OA. Therefore, the design for future OA therapies should consider the influences of all joint tissues. Mechanical loading of an articular joint involves the participation of multiple joint components, including muscles, ligaments and tendons, bone and articular cartilage. The biological effects of mechanical stimuli on these and other joint tissues, such as the synovium, are dependent on the magnitude, duration, and mode of loading.
While the clinical benefit of dynamic moderate exercise is significant, mechanisms underlying the effects of physical activity on the joint are not well understood. Experimental studies in animal models of osteoarthritis and human cartilage tissues ex vivo suggest moderate exercise also leads to increased anti-catabolic, anti-inflammatory, and anabolic activity [15]. Dynamic stimulation of cartilage explants increases synthesis of cartilage matrix components and physiologic loading of animals with experimental osteoarthritis suppresses expression of inflammatory mediators (e.g. interleukin-1β and tumor necrosis factor-α) and enzymes which directly cleave the articular cartilage including (MMPs) matrix metalloproteinases and ADAMTS (A Disintegrin And Metalloproteinase with Thrombospondin Motifs) [15].
Exercise is beneficial for the maintenance of metabolic homeostasis. Excessive adipose tissue, as seen in obesity, not only increases mechanical stresses on weight-bearing joints, but also generates an imbalance in the secretory profile of adipokines, including leptin, adiponectin, visfatin, and resistin [16]. These conditions create an environment of low-grade inflammation, which in turn upregrulate expression of MMPs and ADAMTS, and eventually cartilage breakdown. A recent clinical trial studied the effect of an intensive 18-month diet and exercise program in 454 overweight and obese patients with osteoarthritis. The exercise program consisted of aerobic walking, strength training, a second aerobic phase, followed by a cool-down period. This diet and exercise regime led to significant decreases in weight, total fat mass, pain relief, and improvements in mobility. Diet and exercise also led to decreases in knee joint loading and plasma levels of inflammatory cytokine interleukin (IL)-6 [17]. These findings suggest exercise exerts anti-inflammatory and biomechanical beneficial effects on a systemic and local joint tissue level. Recently, moderate treadmill running has also been demonstrated to activate autophagy, a physiologic process of intracellular recycling, in skeletal muscle [18]. Interestingly, pharmacologic activation of autophagy in chondrocytes in surgical models of osteoarthritis prevents cartilage degradation [19], suggesting exercise may maintain chondrocyte function by activating autophagy.
Can we design an “exercise pill” to mimic the physiologic effects of exercise on joint tissues? Such treatments will be especially beneficial to astronauts, bed-ridden patients, and patients with very limited mobility due to degenerative joint diseases. Studies suggest proteins such as integrins and primary cilium, in response to moderate loading, sense mechanical signals and initiate anti-catabolic, anti-inflammatory, and other pathways involved in cartilage homeostasis. The elucidation of these mechanosensitive signaling pathways in joint tissues will reveal specific molecules which may be pharmacologically targeted for novel OA treatments.
In conclusion, dynamic moderate exercise in patients with OA exerts symptom-modifying effects, and may have the potential to exert OA disease-modifying effects. Exercise involves all tissues within the articular joint and may comprehensively target multiple aspects of osteoarthritis progression including the suppression of inflammation and catabolic activity, enhancing anabolic activity, and maintaining metabolic homeostasis. Elucidation of the mechanisms mediating these effects could lead to the development of pharmacologic mimics of exercise. These will be especially beneficial to patients with limited joint mobility and may also synergistically enhance the chondroprotective effects of moderate exercise.
We appreciate Dr. Paul Levin’s comments and suggestions during the writing of this manuscript. This work is supported in part by NIH R01AR050968 and the Arthritis Foundation.
  1. Uthman OA, van der Windt DA, Jordan JL, Dziedzic KS, Healey EL, et al., (2013) Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis.BMJ 347: f5555.
  2. Roos EM, Dahlberg L (2005) Positive effects of moderate exercise on glycosaminoglycan content in knee cartilage: a four-month, randomized, controlled trial in patients at risk of osteoarthritis.Arthritis Rheum 52: 3507-3514.
  3. Mikesky AE, Mazzuca SA, Brandt KD, Perkins SM, Damush T, et al. (2006) Effects of strength training on the incidence and progression of knee osteoarthritis. Arthritis Rheum,. 55: 690-699.
  4. Mandelbaum, B.R., et al. (1998) Articular cartilage lesions of the knee. Am J Sports Med 26: 853-861.
  5. Moti AW, Micheli LJ (2003) Meniscal and articular cartilage injury in the skeletally immature knee. Instr Course Lect 52: 683-690.
  6. Smith AD, Tao SS (1995) Knee injuries in young athletes. Clin Sports Med 14: 629-650.
  7. Jones MH, Amendola AS (2007) Acute treatment of inversion ankle sprains: immobilization versus functional treatment. Clin Orthop Relat Res  455: 169-172.
  8. McCarthy C, Oakley E (2002) Management of suspected cervical spine injuries--the paediatric perspective. Accid Emerg Nurs 10: 163-169.
  9. Hinterwimmer S, Krammer M, Krötz M, Glaser C, Baumgart R, et al. (2004) Cartilage atrophy in the knees of patients after seven weeks of partial load bearing. Arthritis Rheum 50: 2516-2520.
  10. Vanwanseele B, Eckstein F, Knecht H, Spaepen A, Stüssi E, et al. (2003) Longitudinal analysis of cartilage atrophy in the knees of patients with spinal cord injury. Arthritis Rheum 48: 3377-3381.
  11. Speer KP, Spritzer CE, Bassett FH 3rd, Feagin JA Jr, Garrett WE Jr (1992) Osseous injury associated with acute tears of the anterior cruciate ligament. Am J Sports Med 20: 382-389.
  12. Meyer EG, Baumer TG, Slade JM, Smith WE, Haut RC (2008) Tibiofemoral contact pressures and osteochondral microtrauma during anterior cruciate ligament rupture due to excessive compressive loading and internal torque of the human knee. Am J Sports Med 36: 1966-1977.
  13. Loeser RF, Goldring SR, Scanzello CR, Goldring MB (2012) Osteoarthritis: a disease of the joint as an organ. Arthritis Rheum 64: 1697-1707.
  14. Bingham CO 3rd, Buckland-Wright JC, Garnero P, Cohen SB, Dougados M, et al. (2006) Risedronate decreases biochemical markers of cartilage degradation but does not decrease symptoms or slow radiographic progression in patients with medial compartment osteoarthritis of the knee: results of the two-year multinational knee osteoarthritis structural arthritis study. Arthritis Rheum 54: 3494-507.
  15. Sun HB (2010) Mechanical loading, cartilage degradation, and arthritis. Ann N Y Acad Sci 1211: 37-50.
  16. Wluka AE, Lombard CB, Cicuttini FM (2013) Tackling obesity in knee osteoarthritis. Nat Rev Rheumatol 9: 225-235.
  17. Messier SP, Mihalko SL, Legault C, Miller GD, Nicklas BJ, et al. (2013) 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 310: 1263-1273.
  18. He C, Bassik MC, Moresi V, Sun K, Wei Y, et al. (2012) Exercise-induced BCL2-regulated autophagy is required for muscle glucose homeostasis. Nature 481: 511-515.
  19. Caramés B, Hasegawa A, Taniguchi N, Miyaki S, Blanco FJ, et al. (2012) Autophagy activation by rapamycin reduces severity of experimental osteoarthritis. Ann Rheum Dis 71: 575-581.
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