Prescribing an Osteoarthritis (OA) Exercise Program

Osteoarthritis Re-assessment (5 mins)

A brief osteoarthritis re-assessment should be performed. This should primarily involve “checking in” with the patient about the following:

• changes in knee pain
• how they have managed with their strengthening exercises
• comments/questions arising from discussion topics in the first consultation.

Osteoarthritis (OA) Strengthening Exercise Program (10 mins)

Review patient progress with the prescribed strengthening program from session 1:

• Review the patient’s “Knee Plan and Log Book” (if the patient has used it to record adherence to the program).
• If the patient has been adherent, congratulate them and reinforce any strategies they used to help them adhere.
• Discuss any reasons for non-adherence, and identify any challenges/barriers encountered with completing the exercise program as prescribed, and discuss with the patient ideas for overcoming these challenges/barriers in the future.
• Some prompts you may wish to use……

• “Did you feel like you were working at a hard to very hard intensity when performing your sets of exercises?”
• “Did you have any problems during the exercises and were you able to overcome them?”
• “Did you feel any pain in the knee during or after the exercises?”

• Two quadriceps exercises
• One hip abduction/gluteal exercise
• One hamstring/gluteal exercise
• One calf exercise
• One optional extra (of any of the exercises in the Exercise Booklet)

• watch the patient perform each exercise themselves. Correct their technique if necessary. Ideally, you should watch the patient complete one set of each exercise (see dosage below).
• prescribe a dosage for each exercise. The strengthening exercise program should, ideally, be performed 3 times each week by the patient. However, the number of sets and repetitions to be performed is at your discretion, and this may vary across each exercise prescribed. The exercises, and the level of intensity should be chosen on the basis of the assessment, and what you observe as the patient performs a set of the exercises during the consultation. Ideally, each exercise should feel “hard” to “very hard” to perform.
• instruct the patient to complete the “Knee Plan & Log Book” during your consultation, so they have a written record of what you have advised them to do.
• Encourage patients to record their exercise performance in the log book section of the “Knee Plan and Log Book” until your next consultation so you can review their progress.

Osteoarthritis (OA) Exercise Progression

• changing the starting level of the exercise (listed as variations under exercise in the Exercise Booklet)
• changing the colour of the resistance band used
• changing the sets/repetitions
• ceasing some exercises and replacing them with harder exercises

• If the patient is not able to perform the task with what they/you think is the correct exercise technique. They should remain on that level. Spend time instructing them to use correct technique during the consultation. If this is still not possible, an easier exercise may be required.
• If the patient is experiencing increased pain and swelling lasting more than one day after their exercises, they should go back to a lower level, do fewer repetitions of their current level, or try an alternative exercise.

Osteoarthritis Education (5 mins)

• Physical activity (pg 6 OA Info Book)
• Activity pacing (pg 9 OA Info Book)

Osteoarthritis Exercise Program (10 mins)

• Review the patient’s baseline physical activity (which you asked them to monitor over the previous week)- this may include a daily step count based on an activity tracker (if they own one) and/or a discussion of the types/amounts of physical activity the patient has engaged in over the prior week.
• If appropriate, set a daily step goal on the basis of this information and discussion with the patient, ensuring it is realistic and achievable. It is OK if the goal is to MAINTAIN daily steps (eg in the case of someone already taking >10,000 steps/day). In most cases however, you will want to aim to increase the daily step count. Note that a threshold of 6,000 steps/day seems to best discriminate between people with knee OA who do and do not develop functional limitations 2 years later, so this could be a useful goal for some patients.
• For all patients, agree on a personal (daily or weekly) physical activity plan, that will help them achieve the step goal and/or help them to increase the amount/intensity of physical activity they regularly undertake. Again, it is OK to set a plan that MAINTAINS physical activity levels if the patient is already sufficiently physically active.

• Encourage the patient to complete the physical activity plan template in the “Knee Plan and Log Book” – so they know exactly WHAT they should do, WHEN and for HOW long.
• Encourage patients with a step goal to record their progress in the “Knee Plan and Log Book” each week, until the next consultation.
• Ask your patient to think about potential barriers to their physical activity plan, and think of potential strategies for overcoming barriers (discuss some ideas contained on pg 7-8 OA Booklet)- people are much better at dealing with set-backs if they plan ahead and have some clear strategies to help overcome them in the first place!

Recommendations for Knee Osteoarthritis (OA) Exercise Program

• Doing any physical activity is better than doing none. If you currently do no physical activity, start by doing some, and gradually build up to the recommended amount.
• Be active on most, preferably all, days every week.
• Accumulate 150 to 300 minutes (2 ½ to 5 hours) of moderate intensity physical activity or 75 to 150 minutes (1 ¼ to 2 ½ hours) of vigorous intensity physical activity, or an equivalent combination of both moderate and vigorous activities, each week.
• Do muscle strengthening activities on at least 2 days each week.

• Minimise the amount of time spent in prolonged sitting
• Break up long periods of sitting as often as possible Australia’s Physical Activity & Sedentary Behaviour Guidelines for Older Australians (65 years and older) (www.health.gov.au)[https://www1.health.gov.au/internet/main/publishing.nsf/Content/health-pubhlth-strateg-phys-act-guidelines#npa%2065]:

There are 5 physical activity recommendations for older Australians:

1. Do some physical activity, no matter age, weight, health or abilities
2. Be active every day in as many ways as possible, doing a range of physical activities that incorporate fitness, strength, balance and flexibility
3. Accumulate at least 30 mins of moderate intensity physical activity on most, preferably >all, days
4. If you have stopped physical activity, or are starting a new physical activity, start at a >level that is easily manageable & gradually build up to recommended amount, type & >frequency
5. Those who have enjoyed a lifetime of vigorous physical activity should carry on doing >so in a manner suited to capability in later life, provided recommended safety >procedures and guidelines are adhered to.

How intense does the activity need to be? For good health, people should spend some time on most days being physically active at moderate intensity. However, if this is too difficult for your patient at first, health benefits can still be gained by doing more light physical activity and less sedentary activity. Therefore, the focus should be on increasing the amount of general physical activity you do, regardless of the intensity.

Gauging intensity of physical activity– One way is to get the patient to think about how hard they are breathing. If they are breathing harder than normal but still able to speak in sentences, then they are working at a moderate intensity. If they are out of breath and can speak only one word at a time, then their intensity is probably vigorous! If they don’t even have to breathe deeper or faster, then they are probably working at a light level.

Benefits of a regular and ongoing physical activity plan- will help patients manage their symptoms, lose weight, feel better and, of course, has all the other added general health, well-being and disease prevention benefits. Physical activity plans will be highly varied and individualised in terms of content, frequency, timing and intensity. Below are some general principles with which to guide your conversations about physical activity plans:

• Anything is better than nothing. Everyone can benefit from doing more physical activity (apart from some extremes). However, people who go from doing nothing to a little bit of activity gain more benefit than people who go from doing a lot of physical activity to doing a little bit more. That means any small increase is worth it, particularly if they are already doing very little.
• Don’t set them up to fail. Remember not to impose your own agenda onto the patient. Also make sure the patient is not being overly ambitious about what they can achieve. Start with easy goals so patients achieve success and then BUILD HABITS as well as skills in planning and problem-solving.
• Positive expectation of benefit. Your compassion and empathy as well as your optimism that they can do well will increase their likelihood of achieving success and positive outcomes. Reinforce that no harm is being done to their painful joint(s) even if they feel some pain, and that joints will do better in the long term if they are used and loaded. Consider using stories of other people’s successes.
• Variety is the spice of life. People can do several different types of activity during any week, mix it up and change over time. Discuss a range of options they can consider now or in the future. Explain that all different types of activities can provide benefits (e.g. housework, playing with children, walking to shops).

Osteoarthritis (OA) Exercises to Consider

What types of general physical activity may be suitable? The table below lists some ideas you could consider in conjunction with your patient:

Tips for helping your patient increase general physical activity levels:

• Small changes to your daily routine can have a positive effect on your overall health as well as your knee osteoarthritis.
• Avoid long periods of inactivity in your day.
• More frequent short bouts of activity work best for people with knee osteoarthritis.
• Perform physical activities over realistic timeframes.
• Gradually increase your physical activity and/or make it harder.
• Vary your activity by changing the environment (eg walking in water or at the local park instead of around the block).
• Pace your activities- even on bad days.
• Time yourself to help you pace your activity and make sure you don’t over- or under-do it.
• Use the activity tracker provided by the study to record how many steps per day you take.
• Perform moderate intensity activity in bouts of at least 10 minutes. That means you are puffing for 10 minutes continuously.

If appropriate, encourage your patients to access local exercise facilities in their community e.g. the gym, local walking group, local pool. Help them locate the services and facilities they require by searching the Web for facilities/services in their area. During the COVID-19 pandemic, please make recommendations about appropriate home based activities

Concluding the Consultation:

• Book the next consultation with your patient.
• Ask the patient to do some pre-reading for next session (Barriers to exercise and physical activity pg 7-8 OA Book; Understanding & managing pain pg 13-19 OA Book).