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Keep moving and then keep it up

Published on 07 January 2014
Source: Arthritis Today

‘Keep moving’ is our mantra: exercise is proven to be one of the best ways of managing osteoarthritis. Arthritis Today looks at two enterprising Arthritis Research UK-funded projects that aim to bring exercise to the masses – and keep people motivated.

Dr Nicki Walsh supervises an exercise session for people with osteoarthritis at Frenchay hospital in BristolIncreasingly, research tells us that exercise is good for people with osteoarthritis. It sounds like a simple and effective way to improve the quality of life for the enormous numbers of people affected by the painful joint condition. But many factors conspire to make it quite complicated.

In an ideal world, people with osteoarthritis would be able to take part in regular exercise classes held around the country and run by experts, resulting in less pain, and putting them more in control of their condition.

In reality the provision of exercise classes aimed at those people with joint pain is at best patchy and at worst non-existent.

Motivation is another big issue. It’s one thing to know that exercise can help your osteoarthritis and quite another to do something about it – how many people start to exercise and then quickly lose the will to carry on?

Another factor is the sheer numbers of people involved. More than eight million people in the UK are struggling with the painful symptoms of osteoarthritis today, and as the population ages and becomes more obese, that figure is set to rise. And that prompts the question: can there ever be enough exercise classes to satisfy demand?

Anyone who has ever tried to get a referral to see a physiotherapist for exercises for their osteoarthritis will know that they face a long wait. Exercise classes run by NHS physiotherapist in hospitals are thin on the ground. And classes provided by leisure centres and private gyms don’t necessarily cater for people with specific joint problems. So what’s to be done?

For the past few years these knotty problems have been occupying the minds of two leading academic physiotherapists working closely together in the musculoskeletal field: Dr Nicki Walsh, associate professor in musculoskeletal rehabilitation at the University of the West of England in Bristol, and Professor Mike Hurley, professor of rehabilitation sciences at St George’s University in London.

Dr Walsh is half way through an Arthritis Research UK career development fellowship that aims to develop a more effective – and cost-effective – way of making it easier for people with osteoarthritis of the knee, hip and back to get into the habit of exercising regularly in order to keep their pain at bay.

Dr Nicki WalshWith additional funding from the Chartered Society of Physiotherapy Charitable Trust, she has set up a series of community-based six-week-long exercise classes run by physiotherapists in a number of centres in the South West. The exercises are a combination of generic aerobic exercises such as using a bike and bouncer, plus a series of circuit-based exercises for each of the joints that patients can pick and choose from according to their needs. So far they are proving popular, with many people reporting reduced pain and greater ability to self-manage.

As part of her fellowship Dr Walsh is also interviewing patients and clinicians to find out what patients want and why they’re not currently getting it, and why people don’t continue with community-based exercises once they’ve started.

Lack of motivation is key, and because there are so few exercise classes for osteoarthritis patients, many people will have a short course of exercise with a physiotherapist and then be expected to carry on independently, at which point many of them give up.

These findings have led Dr Walsh to rethink the way that exercise classes are run for people with osteoarthritis, and to consider the possibility of moving classes out of NHS hospital settings into leisure centres and private gyms run by non-healthcare instructors.

Dr Walsh acknowledges this is a big step, and one which has made a number of physiotherapists uneasy, but she says: “There are simply too many people with osteoarthritis to be managed effectively within the current healthcare system: it can’t provide long-term exercise support for everyone, and there’s a place for more integration between the health and leisure/fitness sectors.”

There’s another possible barrier in the way of this step-change. Dr Walsh has also found that people value being taught by physiotherapists but have less confidence in ‘non-medical’ exercise instructors or less qualified support workers to manage their condition safely. Similarly, she found exercise instructors are not trained in this area, and so have less confidence in leading classes specifically for people with osteoarthritis. However, they have a massive appetite to gain expertise and qualifications in this area.

So Dr Walsh is now tackling this by working with Skills Active – the officially recognised and licensed organisation that sets standards for skills and training in the fitness sector – and has developed national occupational standards for arthritis, and a training course to help individuals meet those standards. 

“That means in future, exercise professionals such as fitness and gym instructors and support workers can achieve quality education and training in managing osteoarthritis, and patients can be more confident that they are receiving the best quality management for their condition,” she adds. “There’s a register of exercise professionals, so people with osteoarthritis can find out which instructors have this qualification and seek them out.”

The next stage in her fellowship will be to set up more community-based pilot exercise classes, this time using appropriately trained support workers rather than traditional physiotherapists, which will lead to a large-scale clinical trial.

Over the past few years, Dr Walsh has collaborated with Professor Hurley on another important piece of research also funded by Arthritis Research UK. They devised and tested the effectiveness of a six-week exercise programme of older people with knee pain. The study found that exercise, self-management and active coping strategies were effective, and that it also led to improvements in pain, general quality of life, anxiety and depression. Crucially it also corrected people’s entrenched – and incorrect – perceptions that exercise makes osteoarthritis worse.

The study, called ESCAPE, was picked up by several hospital physiotherapy departments, and following its successful adoption by Sevenoaks Hospital in Kent was used by the National Institute for Health and Clinical Excellence (NICE) as a case study of good practice.

However, Professor Hurley and Dr Walsh recognise that that this type of approach needs to reach larger numbers of people.

“Because of the large population of people with osteoarthritis, and of negative beliefs about the way it can be managed held by patients and healthcare professionals, few people get the advice they need to encourage them to start exercising to get those health benefits,” explains Professor Hurley.

”Even fewer people receive sufficient on-going support and motivation needed to sustain these benefits. Innovative ways are needed to reach the large and rapidly increasing number of people requiring help.”
The innovative way they have come up with is a user-friendly, online version of the ESCAPE programme. With a £42,000 12-month educational project grant from Arthritis Research UK they plan to ask people likely to use such a programme what they would like to see in the online package, and to then produce a prototype web version.

People with osteoarthritis are out through their paces at Dr Nicki Walsh's exercise classes at Frenchay Hospital in BristolWhat they are keen to avoid is a ‘high-tech but low impact’ online programme, aiming instead for simplicity and ease-of-use. “Once we’ve interviewed potential users to establish their needs and wants, we’ll work with web designers to incorporate these into a prototype online version of ESCAPE that people will find usable, useful accessible and effective,” adds Professor Hurley.

Says Dr Walsh: “We want the online version of ESCAPE to act as a kind of aide-memoire for people who’ve already done a hospital-based exercise class, but also for people who’ve never had the opportunity to get into the healthcare system, or don’t want to, and want to manage their condition themselves. 

“There’s so much unproven material on the internet, but this will give them an appropriate, evidence-based resource. We don’t just want it to be about information delivery as we know that doesn’t work – it’ll be an interactive site with chat rooms so that patients can discuss their coping strategies. And people will be able to measure their progress and have peer support, which is important.”

Professor Hurley and Dr Walsh are assembling a team, including experts in the development of ‘e-technologies’, and hope to have the prototype ready for testing within the next 18 months. 

Dr Walsh adds: “Exercise isn’t for everyone; some people with osteoarthritis will never want to exercise, no matter what. But the majority genuinely want to have control of their disease in the longer term and not to be constantly reliant on the healthcare system. And we want to help them do that.”

Case study

Holly Simon, aged 69, with Dr Nick Walsh Holly Simon, aged 69, attended Dr Walsh’s exercise classes in Trowbridge Hospital last year and credits her physiotherapist, Jackie, who led the class, for her renewed motivation and determination to keep going, despite the pain from the osteoarthritis in her spine.

Holly enjoys using a trampoline, exercise ball and bikes at the classes and bought herself a trampoline to use at home. Although she still suffers from aches and pain she feels she can now cope with the pain and the condition better since taking the classes.

“When you’re in pain it makes you feel very low and quite depressed at times: I found it difficult. It makes me feel old and I don’t like that,” says Holly.

“The strange thing is that when I’m really, really in pain I get on the bike and the pain goes. I sit on the ball and do various things and it goes, I jump up and down on the trampoline – doing exercise relieves the pain, and it’s far quicker than taking drugs. I’ve just come in from a half hour walk along the canal, and last year I couldn't walk as vigorously as I can today.“

Comments Professor Hurley: “People need to participate in an active exercise regimen with clear, unambiguous, specific advice about what to do, what to avoid doing, when, how, how much, how to progress and what to do when the pain is bad.”

Find out about the best types of exercise for people with arthritis in Arthritis Research UK’s Keep moving guide, available on 0800 389 6692 or

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