20.03.2014 What are the benefits of physical activity? Oslo University Hospital Norwegian School Sport Sciences NIMI Coronary hear disease & Stroke Exercises and Musculoskeletal Health Diabetes Obesity Physical activity & Health Linköping, Mars 2014 Musculo skeletal Professor and physical therapist May Arna Risberg Norwegian Research Center Active Rehabilitation (NAR) Mental well‐ beingl Cancer Norwegian School of Sport Sciences, NIMI, and Oslo University Hospital, Norway www.active‐rehab.no Fysioterapeuten nr 3 2014 The new life style disease – musculoskeletal disorders ‐ Musculoskeletal injury and disorders • Musculoskeletal injury and disorders are common – – – – • • • • • most common cause of severe long‐term pain and disability 20‐30% of adults are affected at one time 25% of the total cost of illness in Sweden Most common cause of health problem limiting work ability Prevalence of symptomatic OA >50 years ‐ between 7‐15 % Increase with age and related to negative lifestyle factors as obesity, smoking and physical inactivity 2013 “Plager flest og Tendon koster mest” – 30% to 50% due to overuse injuries in sport Shoulder: – 16% of general population suffers from shoulder pain – 21% in the elderly population Articular cartilage lesions – 60‐63% had cartilage lesions found in 31.516 knee arthroscopy Woolf AD et al 2004, Picavet HS et al 2003, Jaconson & Lindgren 1996, National Board of Health and welfare, Sweden 2001 , MST Rapport, Oslo , Norway 2013, Rees JD et al 2009, Curl WW et al 1997, Hjelle K et al 2002, Robi K et al The Physiology of Sports Injuries and repair processes (Chapter 2). In: Current Issues in Sports and Exercise Medicine, 2013 Knee injuries Posttraumatic knee OA Musculoskeletal injury and disorders • • 40‐50 % of patients with knee OA come from previous injury – onset of the OA disease process • ACL injuries (combined): 21‐48% with symptomatic and radiological knee OA • • Full thickness cartilage defects in 36% of athletes • Cartilage defect associated with decreased knee cartilage volume and increased rate of cartilage loss • • • Mithoefer 2012, Øiestad 2009, 2010, Flanigan 2010,Brophy 2010, Walczak 2008, Widuchowski 2007, Eckstein 2006, Ding C 2005, Piasecki 2003, Årøen 2004 Musculoskeletal injury or disorders are common Musculoskeletal injury and disorders are common in all – most common cause of severe long‐term pain and disability age groups, sport, leisure time and work disorders, and – 20‐30% of adults are affected at one time high costs for society – 25% of the total cost of illness in Sweden – Most common cause of health problem limiting work ability Increase with age and related to negative lifestyle factors as obesity, smoking and physical inactivity Tendon: 30% to 50% due to overuse injuries in sport Shoulder: Studies from primary care show that 16% of general population suffers from shoulder pain ‐ 21% in the elderly population Articular cartilage lesions: 60‐63% had cartilage lesions found in 31.516 knee arthroscopy Woolf AD et al 2004, Picavet HS et al 2003, Jaconson & Lindgren 1996, National Board of Health and welfare, Sweden 2001 , MST Rapport, Oslo , Norway 2013, Rees JD et al 2009, Curl WW et al 1997, Hjelle K et al 2002, Robi K et al The Physiology of Sports Injuries and repair processes (Chapter 2). In: Current Issues in Sports and Exercise Medicine, 2013 1 20.03.2014 Musculoskeletal injury and disorders Musculoskeletal injury and disorders Why are we not more successful in treatment? Why are we not more successful in treatment? 1. A heterogeneous group > 200 different clinical health problems 1. A heterogeneous group > 200 different clinical health problems Clinical health problem Clinical health problem Clinical diagnosis Heterogeneous Clinical manifestation Mechanisms/ Biology Unclear Yes Not known 1. Many of the 200 European League Against Rheumatism 2012: http://www.eular.org, Hagen KB et al 2012 Clinical diagnosis Heterogeneous Clinical manifestation Mechanisms/ Biology 1. Many of the 200 Unclear Yes Not known 2. Fibromyalgia Unclear Yes Not known Partly known 3. Osteoarthritis Yes Yes 4. Rheumatoid Arthritis Yes Yes Well known 5. Osteoporosis Yes Yes Well known 2. Understanding biology (molecular level) is crucial and the only way to appropriate therapies 3. Exercise therapy programs need to be improved Dose‐response Progression of exercises European League Against Rheumatism 2012: Patient education http://www.eular.org, Hagen KB et al 2012 Dagens praksis ? Exercises and Musculoskeletal Health Muskel‐ og skjelettskader ”gå hjem og ta det med ro et par uker” • For decades, inactivity and bed rest were the main treatment strategies for patients with musculoskeletal injury and disorders Kunnskapsbasert ? Nei Er dette beste behandling ? Nei Påføres pasientene funksjonsproblemer? Ja • A paradigm has evolved – physical activity and exercises are beneficial to health, not only for traditionally life style diseases, but also for musculoskeletal injury and disorders – The negative effects of immobilization on musculoskeletal tissue are well known • How do we treat patients with musculoskeletal injury? Evidence‐Based Medicine (EBM) Immobilization and rehabilitation ‐changes in quadriceps lean mass‐ Muscles, ligaments, tendons, cartilage, bone Behandling av muskelskjelettskader 3 x immobilization period! Immob. Exercise ‐ Rehabilitation 2 weeks 2 weeks MAFbx Calpain 3 6 weeks 24 h Calpain 1,2 Calpastatin Myostatin MAFbx 6 weeks Calpain 1 Myostatin Jones et al Physiology, 2004 2 20.03.2014 How to exercise for musculoskeletal health? What is “exercise”? Terminology • Physical activity – all energy expended by movement • Bodily movement produced by skeletal muscles that results in energy expenditure • Physical Fitness – Set of attributes that determine capacity for physical activity • Exercises – Planned, structured and repetitive: to improve fitness and health • Exercise therapy – Prescription of a program that involves specific exercises to target symptoms, improving function, and improving, retaining or slowing deterioration of health Aktiv rehabilitering: Målrettet treningsprogram basert på optimalt dosert øvelsesprogram for å gjenvinne, bevare og utvikle funksjonsevnen From Exercise therapy to return to physical activities/Sport (Health) Musculo skeletal injury/ disorder Målrettet basert på: optimalt dosert øvelsesprogram for å gjenvinne, bevare og utvikle funksjonsevnen Exercise therapy Planned, structured and repetitive: to improve fitness and health Exercises All energy expended by movement: Everyday activities that involve moving the body Physical activity Evidence Exercise and Exercise therapy Adherence to exercises? Exercise for musculoskeletal conditions Cochrane Musculoskeletal Group 2012 • Osteoarthritis Exercise and physical activity is beneficial for the most • Osteoporosis common types of chronic musculoskeletal pain. • Rheumatoid arthritis, ankylosing spondylitis, fibromyalgia, juvenile arthritis However, poor adherence to exercise and physical activity may • Regional musculoskeletal conditions limit long‐term effectiveness. – Knee, low back, neck, shoulder, chronic musculoskeletal pain 3 20.03.2014 Exercise therapy and pain Exercise therapy and physical function 0.30 0.15 0.40 0.37 0.33 0.10 0.53 0.40 0.49 0.12 Hagen et al 2012 Exercise therapy for bone and muscle health: an overview of systematic review • Evidence supporting the continued use of exercise therapy for musculoskeletal conditions • The effect of exercise on disease pathogenesis – Lack knowledge on (except for osteoporosis ): disease pathogenesis , the magnitude of the positive effects, clinical relevance and the cost effectiveness Few adverse effects – safe and well tolerated • • How to exercise for musculoskeletal health? Dose? Type? Prescription of exercise programs with optimal health benefits for the individual patient, more knowledge is needed on which particular elements and modes of exercise therapy, as well as the dose and frequency of delivery Prescriptions – dose? Exercise therapy Physical activity • Healing tissue and restoring/remodeling tissue • Red flags checked • Life style changes • • • • Muscle Tendon and Ligament Cartilage Bone Dose‐response Medicine Physical activity Physical capacity (VO2) Muscle strength and endurance Neuromuscular power Exercises • Muscle strength in rehabilitation Exercise therapy Dose matters! Musculo skeletal injury/ disorder – Max strength, endurance and power • Neuromuscular training in rehabilitation? • Loading response ? Bone – Tendon and ligaments – Cartilage Lack knowledge 4 20.03.2014 Dose‐response Dose‐response – Physical activity – Exercises – Exercise therapy – Physical activity – Exercises – Exercise therapy • injury or dysfunctions • Rehabilitation: injury or disorders “Lagom” Dose‐response Dose‐response Muscle strength training • Guidelines for healthy adults – Physical activity – Exercises – Exercise therapy • Rehabilitation: injury or disorders • Patient group – Muscle – Tendon and ligaments – Cartilage – Bone – High load, low rep when tolerable – Variations in loads and exercises to avoid stagnation – Progressive overload Progression is need to improve muscle strength • Healing tissue and restoring/remodeling tissue AMERICAN COLLEGE OF SPORTS MEDICINE POSITION STAND “SCIENTIFIC STUDIES OF STRENGTH TRAINING PRINCIPLES AND METHODS USED BY ATHLETES SHOULD FORM THE BASIS OF REHABILITATION EXERCISE PROTOCOLS” Augustsson KSSTA 2012 • Resistance training can be used successfully as a therapeutic modality in several musculoskeletal conditions, especially those of a chronic variety • Resistance training proven effective in a healthy population, can also be successfully applied in a rehabilitation context Progression is need to improve muscle strength Raymond MJ et al 2013 5 20.03.2014 Neuromuscular training The effect of balance or instability training on force output, functional performance, balance Behn & Colado 2012 • Supplementing traditional strength training to improve function and mitigate abnormal movement patterns *Di Stasi & Snyder‐Mackler, Clin Biomech 2012, Logerstedt et al JOSPT 2010, Fitzgerald et al Phys Ther 2000 Behn & Colado 2012 Behn & Colado 2012 The effect of instability training on force The effect of balance or instability training on functional measures Behn & Colado 2012 Resistance exercises using unstable surfaces The effect of balance or instability training on balance and stability • Sport specificity • Increase stress on the neuromuscular system to a greater extent than the traditional strength training • In rehab: increase muscle activation, but reduce forces across a joint • Dose ‐ response? Progression is need to improve neuromuscular function 6 20.03.2014 Dose‐response Dose‐response Tendon and ligament Cartilage ‐ joints Loading – Optimal stress – strain curve to maintain healthy 1. Mechonotransduction of physical force to biochemical actions 2. Metabolically tenocytes age 3. Repetitive loading • mechanically alters the shape of the fibroblast cells in tendons • Needs recovery 4. High load ‐ overload • Needs recovery • Cartilage • Biomechanics • Muscles • Immobilization has a more rapid effect on mechanical properties than increased load from exercise Evidence for exercises for tendinopathy: Eccentric training and high intensity progressive resistance training Eckstein F et al 2006, Sun HB 2010, Leong DJ et al 2011 Nordin M et al 2001 The right dose in the prescription of exercises Hart & Scott 2013 • • • • Understanding some basic science will help us as clinicians to approach acute and chronic connective tissue conditions Mechanical loading and unloading follows key biological principles Connective tissues of the musculoskeletal system are diverse, but share some common features – Matrix‐rich tissues with relatively few cells ‐ respond to mechanical active but different environments – Mechanical loading – Compressive forces: cartilage, menisci and bone – shear forces: bone – tensile loading : muscle, tendons and ligaments Cells respond to different – mechanical cues (mechanotransduction) – biological cues from the endocrine system The right dose in the prescription of exercises Hart & Scott 2013 • • • • Understanding some basic science will help us as clinicians to approach acute and chronic connective tissue conditions Mechanical loading and unloading follows key biological principles Connective tissues of the musculoskeletal system are diverse, but share some common features – Matrix‐rich tissues with relatively few cells ‐ respond to mechanical active but different environments – Mechanical loading – Compressive forces: cartilage, menisci and bone – shear forces: bone – tensile loading: muscle, tendons and ligaments Cells respond to different Mechano‐ – mechanical cues (mechanotransduction) transduction – biological cues from the endocrine system The right dose in the prescription of exercises Hart & Scott 2013 • • • • Understanding some basic science will help us as clinicians to approach acute and chronic connective tissue conditions Mechanical loading and unloading follows key biological principles Connective tissues of the musculoskeletal system are diverse, but share some common features – Matrix‐rich tissues with relatively few cells ‐ respond to mechanical active but different environments – Mechanical loading – Compressive forces: cartilage, menisci and bone – Shear forces: bone – Tensile loading: muscle, tendons and ligaments Cells respond to different – mechanical cues (mechanotransduction) – biological cues from the endocrine system Mechanotransduction • Mechanotransduction is the process of converting physical forces into intracellular biochemical responses • The combination of mechanical and biological cues contributes to the anabolic/catabolic balance in the various tissue • In most tissue these processes seem to be regulated by the individual cell, but not in bone • Bone – the processes appear to be regulated by two different effector cells, the osteoblast and the osteoclast • Articular cartilage – mechanical loads are absorbed by the cartilage extracellular matrix (ECM) and transmitted to chondrocytes Yubing Sun & Jianping Fu: "Mechanobiology: A new frontier for human pluripotent stem cells," Integrative Biology, vol. 5, pp. 450‐457, 2013 7 20.03.2014 Knee injury and osteoarthritis Treatment focus? • • Trauma • • Dynamic mechano‐responsive tissue Joints in motion – the greates potential for improving the lives of people with OA Exercise promote tissue healing The effect of exercise type and dose Osteoarthritis Early OA Secondary prevention Severe OA Tertiary prevention Joint failure • Turning movement into tissue healing , Khan &Scott 2009 Wall ME et al 2005, Cheema U et al 2005, Banes AJ et al 2007, Khan &Scott 2009, Alfredson & Cook 2007, Jonsson P et al 2008 Mechanical loading should be used therapeutically to stimulate tissue repair and remodeling Evidence Exercise therapy ‐ knee OA Modality Effect size‐ Pain Effect size – Physical function Aerobics 0.52 0.46 0.32 0.32 Strengthening OARSI recommendations ‐ Part III. Zhang et al 2010 There is level 1a evidence that exercise therapy has at least short term effect on pain and function (illness) in people with knee OA Bennell et al 2013 ‐ the role of muscle in the management of knee OA‐ Evidence 2012– 2013 Exercises and knee OA ‐ 2012 and 2013 • Symptoms and dysfunctions (illness) – Tanaka et al 2013 – systematic review and meta‐analysis – Loew et al 2012 – meta‐analysis: walking programs SMD Tanaka et al 2013 Modality Pain – Wang et al 2012 – systematic review: different PT interventions – Hiyama et al 2012 – RCT: walking program Weigh‐bearing strengthening exercises 0.70 – Kim et al 2012 – RCT: aquarobic exercises Non‐weight‐bearing strengthening exercises 1.42 – Ebnezar et al 2012 – RCT: yoga therapy – Fernandes et al 2013 EULAR recommendations Aerobic exercises 0.45 – Abbott JH et al 2013 – RCT: manual therapy and multi‐modal exercises Total (95% CI) 0.94 (1.31‐0.57) – Alpayci M et al 2013 – RCT: joint traction • Structural changes (disease) – Hunt MA et al 2013 – RCT: strengthening exercises: loading and uCTX‐II – Beckwee D et al 2013 – why does it work? Adherence is important for exercise efficacy Lower risk of disability in high adherence subgroups • Interventions affecting muscle dysfunctions – Strengthening exercises • ‐11 % ‐ 50 % – Neuromuscular exercises – muscle activation • 5‐14% • changes in voluntary activation predicted 47% of changes in quadriceps strength – NEMS • Exercise prescriptions for muscle rehabilitation in knee OA – Guidelines AGS and ACSM – 40‐60% 1 RM 8‐12 reps 2‐3 t/w • Patient adherence – Supervised – group based and home based – Tailored – Patient education Bennell KL et al 2013, Wang S‐Y et al 2012 Pietrosimone & Saliba 2012, Scopaz et al 2009, Lange AK et al 2008, O’Reilly SC et al 1999, Hurley MV et al 1998 8 20.03.2014 Why does exercise improve symptoms and dysfunctions? How to exercise for musculoskeletal health? • Muscular and neuromuscular components Loading – – – – Muscles Proprioception, balance and motor learning Energy absorbing capacity Stability The neuromuscular system Dose? Type? Knee OA • Peri‐articular and intra‐articular components Loading – – – – Connective tissue and bone Cartilage Inflammation Joint fluid • General fitness and health components Loading – Weight loss, aerobic fitness • Psychosocial components – well being, self‐efficacy, depression, placebo – Gait control mechanisms or Central release of endorphines • • • • • • Beckwée D et al 2013 Standardized mean difference RCTs exercise versus non-exercise ACR criteria for OA Knee OA (and hip OA if separate analysis) Pain and disability 48 trials with 4,028 patients 64 years, 75% women, BMI:29 Exercise type: Pain Disability Aerobic 0.67 0.56 Resistance 0.62 0.60 Performance 0.48 0.56 Knee injury and osteoarthritis Day 1, 2 Early OA Primary prevention Secondary prevention Osteoarthritis Severe OA Joint failure Conclusion: • Optimal exercise program should have one aim/focus (at a time) • Patients with poor aerobic capacity, perform strength and aerobic exercises on different days • Should be supervised program 3 times weekly for at least 12 sessions Trauma Treatment focus? Day 3 Progression is need to improve function 9 20.03.2014 Evidence Exercise therapy ‐ focal cartilage defects How to exercise for musculoskeletal health? Dose? Type? Cartilage lesions There are no RCTs evaluating the effect of exercises versus surgery or exercises alone A few RTCs evaluating the effect of postopertive weightbearing on cartilage repair Ebert J et al 2008, 2012, 2013, Wondrasch et al 2009 The effect of exercises on articular cartilage The effect of exercises on articular cartilage 1. Specific exercises and short term changes in healthy 1. Exercises and short term changes in healthy • Single‐leg lunges • Bilateral knee bending exercises • Drop landing exercises • Walking Deformation ranges from 2.2% to 40% – 2.8% to 23 % • Cycling Deformational patterns depend on – 4.5 % ROM, load, frequency and intensity as well as properties of patellar, tibial and femoral • Running cartilage plates – 2.2‐40% Deformation ranges from 1.8% to 30% Recovery time dependent on deformation Greater deformation after static bending compared to dynamic‐ 90minutes recovery after 100 bilateral knee bending Niehoff 2011, Bingham 2008, Eckstein 1998, 1999, 2000, 2006, Hudelmaier 2001 Hosseini 2010, Liu 2010, Eckstein 2005, Mayerhoefer 2010, Nag 2004, Niehoff 2011, Boocock 2009, Kersting 2005, Mosher 2005, 2010, Subburaj 2010, Kessler 2006, 2008, Krampla 2001, 2008 The effect of exercises on articular cartilage The effect of exercises on articular cartilage 1. Exercises and short term changes in patients 2. Long term changes in healthy and patients • Static compression – OA patients increased deformation and contact areas • Single –leg lunge – ACL and ACLR: increased contact‐deformation Deformational patterns in patients showed responses that may subject the subchondral bone to higher impact stress OA patients Static compression have shown increased deformation and increased contact areas compared to healthy Cotofana S et al 2011, Shin CS et al 2011, Subburaj K et al al 2012 • Articular cartilage functional adaptive changes seem to depend upon – Age – Type and level of activity – Joint • Healthy • At risk • OA/pathology Ans Van Ginckel 2013 10 20.03.2014 The effect of weight‐bearing exercises on knee articular cartilage responses in patients with early knee OA Load modifying interventions Van Ginckel A et al 2013 • Dynamic weight‐bearing loading – 30 knee bending exercises Shorter exercise sessions but with higher frequency – Deformation similar between patients and controls (3.1‐ 3.9%) ‐ alternation between weight‐bearing and non‐weight‐bearing – Recovery tended to be slower in patients exercises ‐ • Requiring more than 15 minutes after exercise cessation for all cartilage plates to restitute to baseline volumes JOSPT 2013 The Oslo CARE Study • Load modifying interventions for knee OA – Exercise therapy – muscle function – Gait modifications – Braces – Insoles – Surgery – Weight reduction! • Load modifying interventions for focal cartilage defects – Exercise therapy – muscle function – Specific ROM – Weight reduction! Wondrasch et al JOSPT 2013 Eligible for cartilage repair n=50 Included n=48 3 months rehab Post‐testing Neuromuscular exercises ‐ progression is needed‐ Exercise therapy n=48 Continued no surgery OR Surgery Surgery n=17 No surgery n=31 65% Follow‐up 1 year Surgery n=17 No surgery n=31 65% Follow‐up 2 years Surgery n=21 No surgery n=27 56 % Slow progression for strength training 11 20.03.2014 Results – Wondrasch et al 2013 Results – Wondrasch et al 2013 Quadriceps strength + 29.9% + 2.5% p < 0.0001 **Danneskiold‐Samsøe et al 2009 How to exercise for musculoskeletal health? Dose? Type? Evidence The effect of exercise therapy after ACL injury • Cochrane review – Trees AH et al 2007 • Systematic reviews ACL rupture – – – – – – – – – Risberg et al 2004 Wright et al 2008 Zech et al 2009 van Grinsven et al 2010 Kim KM et al 2010 Howells et al 2011 Ardern et al 2011 Barber‐Westin & Noyes 2011 Imoto et al 2012 • RCTs – – – – – – – – – – – – – – – – – – – Beard et al 1994 Fitzgerald et al 2000 Mikkelsen et al 2000 Liu‐Ambrose 2003 Risberg et al 2007 Heijne et al 2007 Tagesson et al 2008 Hartigan et al 2009 Gerber et al 2009 Risberg et al 2009 Sekir U et al 2010 Feil et al 2011 Hohmann et al 2011 Lebon et al 2012 Ediz et al 2012 Beynnon et al 2012 Papandreou M et al 2013 Zaffagnini S et al 2013 Baltaci G et al 2013 Our ACL treatment algorithm Rehab • Phase 3 Post injury Rehab • Phase 1,2 • Preop rehab Tests / Screen •Milestones •Criteria Return to Sport • Tests Postop Rehab Return to Sport • Milestones • Criteria • Tests Eitzen I, Moksnes H, Snyder-Mackler L, Risberg MA J Orthop Sport Phys Ther Nov 2010 Neuromuscular and heavy resistance training ‐ progression is needed ‐ NIH grant # 2 RO1 HD 037985‐05. 12 20.03.2014 Røntgenologisk kneartrose – 15 år Knee injury and osteoarthritis Primary prevention Secondary prevention Severe OA Tertiary prevention Prosent Osteoarthritis Early OA Joint failure Trauma Treatment focus? 100 90 80 70 60 50 40 30 20 10 0 ACL rekonstruert kne 47% Motsatt sides kne 21% Artrose i motsatt kne som var uskadet: 15% 6% 0 1 2 3 4 Røntgenskår (K&L) 75 % tibiofemoral OA Oiestad et al 2010 Symptomatic TFOA and PFOA 20 years after ACL reconstruction How to exercise for musculoskeletal health? Dose? Type? Exercise therapy for musculoskeletal health in patients with hip OA Hip OA Hip function Active Rehabilitation THA Baseline testing Hip OA Screened n=220 Included n=109 Interventions Post‐testing SE+PE n=55 PE n=54 Follow‐up THA=4 Lost=4 THA=5 Lost=4 Follow‐up 16 months THA=6 Lost=7 THA=12 Lost=7 Follow‐up 29 months THA=10 Lost=4 THA=17 Lost=8 6 years survival analysis n=109 THA? THA? 10 months Fernandes et al 2010 Svege et al 2014 www.active‐rehab.no 13 20.03.2014 Fernandes et al 2010 Fernandes et al 2010 Progression is need to improve function Active rehabilitation program for patients with hip osteoarthritis Exercise therapy and patient education was significantly better in improving function compared to patient education alone in patients with mild to moderate hip OA. But not for pain. Summary – 1 Benefits of exercises for musculoskeletal health Svege et al 2014 Supervised exercise therapy p=0.03 Coronary Exercise and physical activity is beneficial for the most hear disease common types of chronic musculoskeletal pain. & Stroke However, poor adherence to exercise and physical activity may Diabetes Obesity limit long‐term effectiveness. Physical activity & Health Musculo skeletal Eitzen et al 2012 Mental well‐ beingl Cancer Summary – 2 Exercise therapy for musculoskeletal health • Musculoskeletal injury – Avoid immobilization after injury • Understanding the mechanisms of mechanical loading of musculoskeletal tissue will help us understanding type and dose of exercise interventions (Mechanotransduction) – Bone – Tendon and ligaments Mechanotherapy – Cartilage Significant for understanding understanding how exercises, loading and dose‐response affect structural changes and change patients symptoms/dysfunction Summary – 3 Exercise therapy for musculoskeletal health • Knee OA – Exercises improve function and reduce pain – Optimal exercise program should have one aim/focus (at a time): aerobic, strength, and performance exercises – Should be supervised program 3 times weekly for at least 12 sessions – Adherence is important! Adherence is needed • Knee articular cartilage – Shorter exercise sessions with longer recovery (weightbearing and non‐ weighbearing exercises) – Adaptive changes seem to depend upon: Age, type and level of activity and joint pathology Progression is need to improve function – Progress slowly – Muscle function can be improved! 14 20.03.2014 Summary – 4 Exercise therapy for musculoskeletal health Exercise therapy for musculoskeletal health Progression and Adherence Progression of exercises • ACL injury – Evidence for improving function but very little on secondary prevention of knee OA • More focus on articular cartilage degeneration early after injury for secondary prevention of OA Progression is need to improve function • Hip OA Adherence is needed – Same as knee OA ? probably not, but – Exercise therapy is effective for pain and disabilities and reduces the need for THA Take home messages Exercise therapy for musculoskeletal health • Mechanical loading should be used therapeutically to stimulate tissue repair and remodeling – significant for understanding dose‐response • We need to develop our exercise therapy program to improve – Muscular function Day 1 Day 2 Next step • Understanding loading of tendon, ligament and cartilage – Monitoring • Type and dose of exercises • Understanding patients perspectives The next step? • Muscle activation – to influence magnitude and rate of loading • Muscle strength – dose‐response – to influence magnitude and rate of loading – Tendon repair and cartilage remodeling Progression is need to improve muscle strength and neuromuscular function Thank you for your attention! The Norwegian Research Center for Active Rehabilitation Oslo, Norway 15
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