Self Care Pharmacy Blog

 

Exercise to Save Your Knees

December 2nd, 2013

by Jeniffer George, PharmD student

An estimated 27 million adults in the United States suffer from osteoarthritis of the knee or hip which is commonly seen in patients 65 and older.1 Osteoarthritis is the breakdown in cartilage that covers the ends of the bone to where they meet and form a joint to allow movement.1 As of today, researchers have not found a set cure for arthritis, however, mild pain relief can be found from the use of NSAIDS, acetaminophen and combination products such as glucosamine and chondroitin. In addition, with the increase in obesity in the United States, exercise can relieve stress that is placed on the knees for patients with osteoarthritis. A survey conducted by the Centers for Disease Control and Prevention showed 53% of patients with arthritis didn’t walk at all for exercise, and 23% meet the current recommendation for activity—walking for at least 150 minutes a week.2 So the question I pose is: as future pharmacists, should we recommend glucosamine and chondroitin or exercise to patients with osteoarthritis?

For almost 20 years, the nutritional supplement glucosamine and chondroitin has been marketed to the public for joint health. Glucosamine is an amino sugar that can help renew cartilage while chondroitin is thought to be a complex carbohydrate that helps cartilage retain water.3 Glucosamine and chondroitin are found as natural substances in and around the cells of cartilage.3

NPR recently released an article that presented a study published by the New England Journal of Medicine (NEJM) and another study by the Journal of American Medical Association (JAMA). The study found in NEJM, involved 1,583 randomly selected patients receiving glucosamine and chondroitin with placebo.4 They found that glucosamine/chondroitin, in comparison with placebo seemed to show no effect on patients with osteoarthritis, however, a smaller subgroup characterized with moderate to severe pain showed a significant reduction of knee pain after the use of glucosamine. The study was conducted well, however, patients measured at baseline reported having mild knee pain, as compared with that in classic studies of osteoarthritis, in which a criterion for entry was a disease flare after the discontinuation of NSAIDs.4 In general, the evidence on glucosamine/chondroitin is varied, leaving it difficult to answer if the use of supplements are proven to be effective.

The second study presented in JAMA, included 399 participants that are overweight and presented with knee osteoarthritis. Participants in the study endured 18 months of combined intense diet and exercise modifications to see if there would be an increase in knee function and reduction in pain. Participants in the diet and exercise and diet groups had greater reductions in Interleukin 6 (used to measure inflammation) levels than those in the exercise group; those in the diet group had greater reductions in knee compressive force than those in the exercise group.5 The article does a great job on emphasizing the importance of exercise, however, patients with moderate to severe osteoarthritis, who may have difficulty exercising were excluded from the study.

I agree with most of the content in the article and seem to agree with the studies associated with the material. As a future pharmacist, I would recommend using glucosamine and chondroitin in conjunction with exercise while living a healthy dietary lifestyle to help patients with osteoarthritis. It is human nature to avoid doing things when you are in pain. Patients with osteoarthritis may avoid exercise when a hip, knee, or other joints hurt. As shown in the NEJM study, patients with moderate-to-severe pain saw a reduction in pain after using glucosamine and chondroitin. Recommending glucosamine and chondroitin can help patients have temporary relief in pain, which can enable them to engage in low impact activities, get the heart rate up and burn calories. If exercise is not an option for the patient, guiding the patient in dietary modifications can help in weight reduction. Other treatment options include: rest which helps reduce stress and tension that is put on the knees, hot and cold therapy to help increase blood flow and reduce inflammation near the joint area, and to avoid standing in one position for an extended time.

With studies like these, would you suggest glucosamine and chondroitin as a form of therapy? How can you advise a patient that is adamant on not losing weight due to the pain they are experiencing?

 

References

 

  1. National Center for Complementary and Alternative Medicine. http://nccam.nih.gov/research/results/gait/qa.htm. Published May 2002. Updated October 2008. Accessed November 1, 2013.
  2. Skerrett PJ. Exercise is good, not bad, for arthritis. Harvard Health Publication Web site. http://www.health.harvard.edu/blog/exercise-is-good-not-bad-for-arthritis-201305086202. Published May 8,2013. Accessed November 21, 2013.
  3. Patti Neighmond. National Public Radio. National Public Radio Website. http://www.npr.org/blogs/health/2013/10/14/231451187/exercise-may-help-knees-more-than-glucosamine-and-chondroitin?utm_content=socialflow&utm_campaign=nprfacebook&utm_source=npr&utm_medium=facebook. Published October 14, 2013. Accessed November 1, 2013
  4. Clegg DO, Reda DJ, Harris CL, et al. Glucosamine, Chondroitin Sulfate, and the Two in Combination for Painful Knee Osteoarthritis. N Engl J Med. 2006;354(8):795-808.
  5. Messier SP, Mihalko SL, Legault C, et al. Effects of Intensive Diet and Exercise on Knee Joint Loads, Inflammation, and Clinical Outcomes Among Overweight and Obese Adults With Knee Osteoarthritis: The IDEA Randomized Clinical Trial. JAMA. 2013;310(12):1263-1273. doi:10.1001/jama.2013.277669.Accessed November 1, 2013.

 

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4 Responses to “Exercise to Save Your Knees”

  1. Ashley Peterson Says:

    That last paragraph of the NPR article talked about that patients that hurt are not willing to exercise as much as others. I agree with your thoughts that more exercise would seem to help joint flexibility and subsequent pain as well. Trying to help patients that are overweight lose weight could mean suggesting that they continue or start on glucosamine/chondroitin supplementation to see if that helps the pain enough to allow them to start exercising. More importantly, assessing how will a patient is to lose weight is the start to this whole conversation. These supplements may not work for some people but I think if patients are willing to try and see if they work despite the side effects then they may be beneficial; especially to patients who need to loose weight by exercising.

  2. Yeseul Kim Says:

    Obesity can be one of the cause for osteoarthritis with older age and I agree that loosing weight will help to improve the symptom of osteoarthritis. I would recommend a patient, who does not want to exercise, to try less painful and easier exercise, such as swimming. Moving inside of water will not have as much effect to the joint as other exercises, like running. I will also ask patients whether they want to take glucosamine/chondroitin supplement for pain relief. If a patient ever want to do any kinds of physical activity, I will recommend to start with changing diet. Regular eating habit and intake of foods that are helpful to osteoarthritis like milk, egg, or cheese will be my recommendation to patient.

  3. Zachary A Wallace Says:

    Improving patient adherence is a challenge medical professionals will always face. This can be seen specifically in osteoarthritis, where as discussed, exercising among patients is rather low because of the pain they experience. As a future pharmacist, I feel that any resources that may (even if only to a small extent) improve patient adherence are worth analysis and possible recommendation. As mentioned, glucosamine and chondroitin have been studied more so than many dietary supplements. This results in a fairly good understanding of contraindications and interactions of the two with other drugs and certain disease states. Additionally, I would agree that literature supports use of them for moderate-severe OA pain- in my opinion, this level of pain is likely to be more closely related to the non-adherence. In addition to losing weight by other means (such as caloric restriction), adding glucosamine/chondroitin to the diet may be worth recommendation to patients simply because risk factors are well known and unlikely to do much harm unless specific contraindication exists. The key to recommending supplementation like this rests in asking the patient to keep a log of benefits/detriments. Doing so will make it obvious if the supplementation is working.

  4. Jordan Long Says:

    The relationship that obesity and osteoarthritis has in the health of the cartilage in the knee. The more weight you gain, the more pressure put on the knees, which in turn makes it hard to exercise and lose that weight. Glucosamine/chondroitin is a good selection for reducing that pain and getting someone to become more active. I think it is important to counsel a patient on the importance of exercise in the process though. Without the actual physical activity to keep the leg loose and to lose the weight, you are not really fully benefitting from the decreased pain from the combination supplement. I think that it crucial to have them document everything while on the supplement. Eating pattern, sleeping pattern, exercise habits, and pain level documentation could help us counsel the patient on what they doing wrong and right…and check to see if it is actually working!

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