Exercise for the musculoskeletal system

Hello, and welcome to this presentation, which we’ll examine the role of exercise in managing musculoskeletal diseases. My name is Dr Fiona Wilson, and I’m an assistant professor in the discipline of physiotherapy. Musculoskeletal diseases are disorders of the musculoskeletal system, which include bones, joints, muscles, and ligaments, and other soft tissues. They are among the most common disorders of the vast majority of the population, particularly adult, with sustained, or have an ongoing musculoskeletal disorder. The most prevalent of these disorders are osteoarthritis, rheumatoid arthritis, osteoporosis, and low back pain. The disorder that causes the most disability, which is measured by things like being unable to work, is low back pain.

Due to the considerable public expense managing these disorders, recent research has focused on non-drug or surgical methods of management. In other words, exercise approaches for both, prevention, and treatment. Osteoarthritis, or OA, is the most common disease, and almost everyone over the age of 60 will have signs of OA in at least one joint. It causes changes in bones and joints, and leads to muscle wasting, pain, and stiffness, which leads to reduced function. There have been a number of studies which have evaluated the effect of exercise on OA, showing strong evidence there is significant benefit from exercise interventions. Exercise relieves pain and improves function. And individually tailored and to delivered programmes appear to have the greatest benefits.

An approach which combines exercise to improve strength, range of motion, and aerobic capacity is best. Exercise can’t cause OA. Even those exercising at high volumes and intensity. Rheumatoid arthritis, or RA, is a chronic autoimmune inflammatory disease that occurs in about 1% of the population. It usually presents with symptoms that are bilateral. For example, both hands are equally affected. This makes it different to OA. There’s presently no cure, but drug therapy and exercise combine the best approaches to management. Symptoms are joint stiffness, fatigue, muscle wasting, and eventually joint deformities. Patients with RA have a 50% higher risk of developing cardiovascular disease. There’s limited research in the effects of exercising RA compared to OA, but the body of evidence is growing.

In this patient group, aerobic and resistance training programmes improve aerobic capacity, muscle strength, and ability to function normally. Importantly, we now know that exercise did not make RA worse. So it’s a very safe management tool. Osteoporosis is a disease which causes decreased bone mass, causing a reduction in bone strength, which leads to a risk of bone fracture, or breakage. Often, the first time an individual knows they have osteoporosis, is when they have a bone fracture. Smoking, early menopause, a lack of physical activity, particularly during childhood and adolescence, all increase risk of developing osteoporosis. Weight bearing physical activity is crucial for prevention. Particularly up to about age 25. Aerobic exercise is very effective at increasing bone mineral density, or bone strength.

A combination of balance and strength training prevents the risk of falls, and less fractures, and help elderly people. Weight bearing exercise in childhood helps prevent osteoporosis. Low back pain is one of the most common musculoskeletal disorders and most individuals are expected to have at least one episode in their lifetime. It presents as pain, fatigue or discomfort in the lower region of the back, sometimes radiating to the legs. Modern thinking has moved away from an over emphasis on diagnosing a particular structure, such as a disc or a ligament. It’s more of a recognition that it’s a syndrome rather than a disease.

Much of the evidence related to the benefits of exercise for low back pain are less clear than for other musculoskeletal disorders. The disorder is also greatly influenced by psychological and social factors, which can influence how individuals respond to treatment. Despite this, the balance of evidence is in favour of exercise as an intervention for managing low back pain. There is good evidence that being physically active will help manage low back pain. Of interest, popular core stability training does not seem to be any better when compared to other types of exercise. It is not fully established how exercise improves signs and symptoms of musculoskeletal disorders but there are some emerging ideas.

In OA and RA, exercise appears to lower inflammation, and it has been shown that joint surfaces respond well to appropriate loading. Exercise has a positive effect on impairments associated with a disease, such as decreased range of motion and muscle wasting. The evidence for the role of exercise in osteoporosis is demonstrated very structurally with an increase in bone density. Like OA, exercise in osteoporosis reduces the impairments associated with the disease, but more importantly reduces the risk of falls and less fractures.

There are a few simple things to consider when prescribing exercise for someone with an MSK, musculoskeletal disorder. Prescribing an appropriate aerobic exercise programme may be a challenge for someone who has pain in the lower limbs. For example, walking may cause knee pain. The first choice of activity should then be non-weight bearing, such as cycling or swimming. However, research shows us that loading joints normally, even in those with OA or RA, can help reduce pain. And so an effort should be made to progress to some weight bearing activity. Comfortable, supportive, not expensive shoes really help. Strengthening exercise used to be avoided in RA, as it was thought that the loading may encourage joints to be more unstable.

We now know that is really important, and it’s a crucial part of the programme in all MSK conditions. An emphasis should be put on choosing lower load weights, with quite a high number of repetitions, depending on what is tolerable. Building up slowly is important. Range of motion exercise, or flexibility, is really important for all MSK disorders, as they all cause a reduced joint motion. Again, a conservative approach is good initially, with an emphasis on active movements of all major joints, rather than long, slow, sustained stretches. Programmes such as yoga, or tai-chi are really helpful, as they encourage smooth and controlled movement through many joints. Of interest, it’s not particularly necessary to concentrate exercise programmes on specific painful or stiff joints.

Becoming generally fitter has been shown to have great benefit of many of the signs and symptoms of most MSK disorders. For example, a simple walking programme, to improve aerobic fitness and increase physical activity, has been shown to be really effective in improving back pain with no special exercises targeted at the lower back, Exercise is generally very safe in common MSK diseases and disorders, other than an undiagnosed or unmanaged fracture, or other red flags. Red flags will include serious pain or other symptoms which are not clearly explained. These individuals should be referred for appropriate investigation before exercise should be considered. Normal pre-exercise screening tools, such as the PAR-Q, are appropriate to check if an MSK patient is ready for exercise.

The take home message is that exercise is very safe, and very effective in the management of all MSK diseases and disorders. Becoming more physically active, more aerobically fit, and improving muscle and joint strength and range of motion, has showed tremendous benefit to managing signs and symptoms, as well as living successfully with these chronic disorders.