October 2012

Out on a limb: Fit vs quit

Jordana Bieze Foster, Editor

If you treat overweight patients with hip or knee osteoarthritis, you’ve undoubtedly counseled them about the benefits of exercise and maintaining a healthy weight. They’ve probably told you how much they really would like to exercise, if only the pain weren’t so bad.

Don’t believe it.

A recent systematic review of 12 studies found no evidence that patients lose weight after total joint arthroplasty despite significant symptomatic improvement (see “Weighty issues after TJA”). In fact, many patients in the studies analyzed actually gained weight within three years after surgery—as many as 75% of patients in one study and 61% in another.

And a Dutch study published earlier this year in the Journal of Physiotherapy suggests those extra pounds didn’t come from added muscle mass. Researchers from the University of Groningen in the Netherlands analyzed 830 patients who had undergone total knee arthroplasty (TKA) one to six years earlier and found that only about half were adhering to the American College of Sports Medicine’s (ACSM) health and fitness recommendations for older adults.

The health recommendation calls for moderate-intensity physical activity for at least 30 minutes, five days a week; 51% of TKA patients in the Dutch study reported compliance. The fitness recommendation calls for vigorous aerobic activity for at least 20 minutes, three days a week; 53% of the Dutch TKA patients said they achieved that level of activity. Only 46% of patients complied with both recommendations, while 42% complied with neither.

And the Dutch are much more inclined to exercise than Americans: Government statistics from each country estimate that 62% of the general population in the Netherlands and just 49% of the US population comply with both of the ACSM recommendations. So when Dutch researchers find that 42% of TKA patients aren’t exercising, we can probably assume one could say the same about at least half of their American counterparts.

I’m sure many total joint patients have every intention of exercising. But I also suspect that years and years of joint pain lead to some sedentary habits that don’t magically disappear just because a patient’s symptoms have improved.

These patients need your help. They need you to educate them about the consequences of poor physical fitness after TKA: Not only does excess body mass contribute to osteoarthritis progression in other joints, but osteoporosis can lead to implant loosening, and decreased strength and balance can lead to falls, which in turn can damage or dislocate a prosthetic joint. Not to mention the obvious cardiovascular and metabolic effects.

Your patients need you to warn them that it won’t be easy. They need you to caution them to keep their expectations in check even as their activity levels rapidly increase in the first six months after surgery, because research suggests that improvement will inevitably plateau. They need to know that within six years of surgery, most patients are not exercising regularly.

And they need to know that’s not ok.

2 Responses to Out on a limb: Fit vs quit

  1. Without a history of trauma I would suggest that the knee and hip osteoarthritis in over weight individuals is frequently a result of kinetic chain imbalances starting at the feet. Without correcting the kinetic chain the individuals are still fighting their congenital angles and rotations of their legs that still make it uncomfortable to exercise. Just because they replaced the primary breakdown site does not mean they corrected the forces leading to that breakdown. Therefore exercise may still be difficult for them.

  2. Great article. I do believe as stated in a previous reply that the underlying issue must be addressed. The dysfunction must be corrected.

    Great info,

    Brian

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