No pain, no gain for knee osteoarthritis

Photo by Andrew Campbell

Jamie O’Donnell participated in a study at Western’s Wolf Orthopaedic Biomechanics Laboratory (WOBL) that showed -- with persistence -- patients suffering from knee osteoarthritis were able to work harder while experiencing decreases in pain.

In the late 1970s, Jamie O’Donnell deked and dangled on the ice for the Mitchell Hawks. Big goals, big games: he has no trouble remembering his junior hockey glory days. But if he ever does, his knees won’t let him forget.

O’Donnell, now 62, is not alone in his pain. Osteoarthritis (OA) is the most common type of arthritis, affecting about five million Canadians, and it occurs when cartilage – the normally smooth, tough, elastic material that covers and protects the ends of bones – begins to wear away after prolonged use and damage. The knees of former hockey players like O’Donnell are a prime example. In severe cases, surgery may eventually be required to reduce the pain, but an important first step is exercise.

The problem is, exercise hurts. For some it hurts a lot.

But a new study from Western University shows that working through the pain pays off: exercise will hurt less over time, and the benefits will greatly outweigh any early discomfort. However, it’s important to be doing the right kind of exercise.

O’Donnell participated in a study testing a 12-week program at Western’s Wolf Orthopaedic Biomechanics Laboratory (WOBL) at the world-renowned Fowler Kennedy Sport Medicine Clinic. With persistence, the study found, patients suffering from OA were able to work harder while experiencing decreases in pain.

“I found that the more exercise I was doing, and the more I was strengthening, the pain did subside,” said O’Donnell. “I always knew the pain wasn’t so bad because the therapists wouldn’t have me doing it if it was, and I always thought I was reasonably strong. But when they started telling me different things to do, to actually work on specific muscles in my legs and my core, I did notice a significant difference. But the exercises got easier and the pain went away.”

Trevor Birmingham

Trevor Birmingham

No pain. No gain. It could be just that simple – within limits – said WOBL co-director and Western physical therapy professor Trevor Birmingham.

“You really shouldn’t be afraid of exercise. We know it can sometimes hurt when you move a joint with OA, but as long as you’re careful about it and take a break when you have substantial amounts of pain, it’s actually better for you to keep exercising,” said Birmingham, who is also Canada Research Chair in Musculoskeletal Rehabilitation.

The 12-week study was based on a neuromuscular exercise program for patients suffering from knee osteoarthritis. Participants were surveyed during supervised therapy sessions (pre-COVID) on their perceived exertion and, more importantly, their perceived pain.

Neuromuscular exercise – a signature rehabilitation strategy for therapists and clinicians at Western – is quite different than traditional strength or aerobic training. It is far more focused on postural control and balance.

“It’s not just the load that breaks you,” said Birmingham, a founding member of Western’s Bone and Joint Institute. “The way you carry yourself might actually be causing extra damage. Neuromuscular exercise is more focused, in this instance, on your knee position while you are doing these various exercises properly.”

Codie Primeau, a member of Western’s collaborative training specialization in the Musculoskeletal Health Research group, completed the study with his collaborators including Birmingham and Dr. Robert Giffin, an orthopaedic surgery professor at Western’s Schulich School of Medicine & Dentistry and WOBL co-director.

Codie Primeau

Codie Primeau

“We really wanted to look at how pain changed over time and also how the level of perceived exertion changed,” said Primeau. “Perceived exertion is a good indicator of overall intensity of an exercise, so we wanted to see whether patients were able to work harder while minimizing how pain was exacerbated through exercise.”

It was important for participants to understand that they would likely experience some pain at the start of the exercise program, but that it would go away with time and effort.

“If pain goes above a certain threshold then that’s when we need to pause and make modifications to the program,” said Primeau. “But as long as the pain is in a comfortable and acceptable range, then the participant is going to be okay.”

“Exercise should be your first line treatment for knee OA,” said Birmingham. “And most types of exercise improve pain as long as you stick with it: work harder, feel better. Having said that, as a physiotherapist I think probably the safest exercise, and perhaps where we see some of the biggest gains, is neuromuscular exercise.”

And neuromuscular exercise, like even a fine-tuned Formula One racing car, is all about proper alignment.

The findings were published in Osteoarthritis and Cartilage, the official journal of the Osteoarthritis Research Society International.

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The exercises in the Western study require good alignment of the leg. When performing the exercises, patients must think about keeping the position of the knee in line with toes. Keep the kneecap pointing straight ahead and minimize the leg turning inward or outward during the exercise. Emphasis must be placed on maintaining proper form during the exercises taught by the therapist.
Jamie O’Donnell participated in a study at Western’s Wolf Orthopaedic Biomechanics Laboratory (WOBL) that showed -- with persistence -- patients suffering from knee osteoarthritis were able to work harder while experiencing decreases in pain.

Trevor Birmingham
Trevor Birmingham
Codie Primeau
Codie Primeau