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Consider these exercises for chronic musculoskeletal conditions
Regular exercise confers several well-established benefits. In such conditions as coronary heart disease, stroke, heart failure, and diabetes, exercise has led to a reduction in mortality similar to that seen with pharmacotherapy.1 For patients with chronic musculoskeletal conditions, the benefits of exercise-based interventions are measurably reduced pain and improved daily function.2 However, prescribing of exercise is often neglected, with preference given to pharmacologic or surgical interventions.3 In part, the disregard of exercise as therapy results from unfamiliarity with appropriate exercise prescriptions,3 which include various forms of aerobic exercise, strength training, and stretching to increase flexibility (TABLE).
As is true of many therapeutic modalities, exercise must be tailored to the condition and to a patient’s preferences to optimize its benefits. In this review, we describe exercise regimens well suited for common musculoskeletal conditions, examine the effectiveness of exercise in each condition, and provide examples for use in treating patients.
Osteoarthritis of the hip and knee
Osteoarthritis (OA), one of the most common chronic joint diseases, erodes the articular cartilage and subchondral bone of a synovial joint, eventually leading to joint failure. Pain and diminished muscle strength restrict physical activity and can lead to decreased fitness and impaired muscle function. Exercise helps reduce pain and improve muscle function and quality of life in patients with hip or knee OA regardless of age, disease severity, or level of pain and dysfunction.2
Knee exercises. Activities suitable for patients with OA include muscle strengthening, aerobic conditioning, and range-of-motion (ROM) exercises.4-6 A 2015 Cochrane review of OA of the knee showed that exercise reduced pain and improved physical function and quality of life in patients who completed a treatment program, and that pain relief persisted up to 6 months after intervention.5
When designing an exercise prescription for patients with knee OA, consider quadriceps strengthening with an initial period of supervision, which may provide greater pain relief than nonspecific, unsupervised lower limb exercises.4 Enhanced strength of the lower limb may lessen force through the knee, thereby decreasing pain and improving overall physical function.7 Simple, teachable exercises include squats, step-ups, knee extension/flexion while sitting in a chair, and hip abduction/adduction while standing or lying down. Elastic bands, dumbbells, or cuff weights may be used to increase resistance.
Hip exercises. Exercise can significantly reduce pain and improve function for up to 6 months for patients with mild-to-moderate symptomatic hip OA.6 Types of exercise for hip OA include strength training of hip and core muscles, functional exercises that imitate movements in daily activities, and flexibility training. These exercises help reduce pain and increase ROM. Exercise should include resistance training and should not exceed the limit for acceptable pain.8
Aquatic therapy is also appropriate for exercise and strength training and can decrease pain and disability and improve quality of life.9 Supervised physical therapy, including strength training, manual therapy, and balance training, are important for reducing pain and improving function. Physical therapy can also enhance adherence to a prescribed exercise program.10
Continue to: Appropriate exercise prescriptions...
Appropriate exercise prescriptions for patients with knee or hip OA should focus on low-impact activities that can improve strength, flexibility, and function (FIGURE 1). A typical regimen would be 30 or more cumulative minutes daily of stationary cycling, water-based exercises, or strength training, 3 to 5 days per week. Individualize workout intensity for each patient, emphasizing that high-intensity, low-impact effort may yield greater strength gains and take less time to perform.11 A high-intensity exercise prescription focusing on quadriceps, hip, and core strengthening may consist of 3 sets of 8 repetitions with resistance set at 40% of the maximum resistance against which the patient can perform 1 repetition.7
Barriers to exercise in knee and hip OA include negative patient and provider perspectives on exercise and patients’ fear that increased activity may actually worsen OA.12 Depending on a patient’s personal preferences, ways to overcome these barriers and encourage adherence might be supervised exercises in an individual or group setting or audiotapes or videos of recommended exercises.10
Chronic low back pain
Chronic low back pain (LBP) is a large socioeconomic burden in the United States, with upward of $100 billion per year accounted for in health care costs and decreased worker productivity.13 The etiology of chronic LBP can be multifactorial and due to any of several conditions such as degenerative disc disease, spinal stenosis, spondylolisthesis, and facet arthropathy. Treatment is difficult, given that many common interventions—medications, massage, manipulation—have limited efficacy.14 However, for patients with nonspecific chronic LBP, exercise is an effective intervention for reducing pain and improving physical function.15
An effective approach is to design an exercise regimen for the individual by type, duration, and frequency of activity, administered under supervision to encourage adherence.16 Appropriate exercises emphasize resistance, strength training, and core stabilization, often focusing on whole body and trunk motion (FIGURE 2).17
Although yoga or Pilates classes may have a small effect on function, no high-quality evidence exists for their superiority to other forms of exercise.18,19 Back School, a therapeutic program that includes education on anatomy and biomechanics, optimal posture, ergonomics, and back exercises, has limited, low-quality evidence for treatment comparisons.20 Aerobic exercise, including treadmill, elliptical, or cycling exercises or walking outdoors can reduce pain and improve physical and psychologic functioning.21
Continue to: The most common reported adverse effect...
The most common reported adverse effect of exercise is a temporary exacerbation of back pain. However, having patients continue daily activities within the permitted limits of pain leads to more rapid recovery than rest or back-mobilizing exercises.15,22,23
Cautions. Exercise is contraindicated in patients with LBP arising from a serious medical condition, such as fracture, infection, cancer, or cauda equina syndrome.24 Importantly, exercise interventions recommended for acute LBP have not shown benefit for chronic LBP.
Chronic shoulder pain
With a prevalence ranging from 7% to 26% in the general population,25 chronic shoulder pain often interferes with essential activities of daily living. The etiology of chronic shoulder pain is broad and most commonly involves disorders of the rotator cuff, which functions in both motion and dynamic stabilization of the shoulder. The common term “rotator cuff pain syndrome” can cover such disorders as subacromial impingement syndrome, rotator cuff tendinopathy or tendinitis, partial or full thickness rotator cuff tears, calcific tendinitis, and subacromial bursitis. These pathologies may have overlapping presentations. Manual therapy and exercise, usually delivered as a component of structured physical therapy, focus on stretches and other exercises to increase ROM, stability, and strength of the rotator cuff musculature.26
A 2016 Cochrane review that evaluated manual therapy and exercise for chronic shoulder pain yielded limited high-quality evidence for effectiveness compared with placebo.27 Five trials found no important differences between manual therapy and exercise compared with glucocorticoid injection relative to overall pain, function, active shoulder abduction, and quality of life from 4 weeks up to 12 months.27 But compared with placebo, exercise has been more effective in reducing reported pain, especially in the context of strengthening regimens focused on flexion, extension, and internal and external rotation.28
For subacromial impingement syndrome, a 2017 meta-analysis found that a generalized exercise program relieves pain and improves function, ROM, and strength.29 A generalized shoulder-strengthening program includes exercises that focus on internal and external rotation, horizontal abduction, and shoulder stabilization (FIGURE 3). These exercises can be completed with 3 sets of 15 to 20 repetitions, which create a fatigue response that improves strength and targets local muscular endurance.30
Continue to: Achilles tendinopathy
Achilles tendinopathy
Achilles tendinopathy (also referred to as chronic Achilles tendinitis) is a degenerative condition of the Achilles tendon related to overuse that leads to pain, swelling, and impaired performance. It accounts for approximately 18% of injuries in runners and 4% of all patients presenting to sports medicine clinics.31 Eccentric muscle loading has become the dominant conservative intervention strategy for chronic Achilles tendinopathy.
For chronic tendinopathies, eccentric exercises subject greater force than concentric exercises through a controlled lengthening of a muscle-tendon unit, resulting in a greater remodeling stimulus of the tendon.32 Classically, the Alfredson protocol has been used to treat chronic Achilles tendinopathy. This program of eccentric heel-drop exercises recommends completion of 180 eccentric repetitions a day for up to 12 weeks (FIGURE 4).33 Exercises are performed slowly, and load can be increased when exercises are performed without pain or perhaps with mild nondisabling pain.
A variation of this protocol has allowed a gradual escalation of repetitions over a week up to the recommended 180 repetitions, and has shown improvements in pain reduction and function similar to that achieved with the primary protocol.34 Additionally, a 6-week “do as tolerated” program of eccentric exercises did not lead to lesser improvement for individuals with midportion Achilles tendinopathy.35
Several systematic reviews have supported the use of eccentric exercises for chronic Achilles tendinopathy,31,36,37 but no specific protocol or exercise regimen has demonstrated superiority. However, with the Alfredson protocol, improvement in pain and function in patients with chronic Achilles tendinopathy has persisted for up to 5 years.38
Lateral epicondylitis
Lateral epicondylitis (also called lateral epicondylosis or “tennis elbow”) is a disabling musculoskeletal condition that leads to pain and tenderness around the extensor mass of the lateral elbow. It is caused by microtrauma to the tendon, usually sustained through repetitive movement in a sporting activity, industrial work, or hobby. Affecting up to 3% of the US population, lateral epicondylitis is associated with pain and functional disability, as well as emotional and psychosocial consequences.39
Continue to: Proposed treatment and rehabilitation options...
Proposed treatment and rehabilitation options for patients with lateral epicondylitis have included massage, manipulation, taping, acupuncture, orthotic devices, ultrasound, activity modification, and rest. Exercise programs incorporating eccentric muscle activity are becoming increasingly popular for such conditions as Achilles and patellar tendinopathies, and they may translate well to other chronic tendinopathies, such as lateral epicondylitis.32
An eccentric exercise program for lateral epicondylitis, either in isolation or as an adjunct to other therapies, has decreased pain and improved function and grip strength from baseline measures.40 Compared with a standard exercise regimen without eccentric strength training, use of eccentric training improves such clinical measures as pain intensity and disability status, as it decreases tendon thickness and aids in recovering homogenous tendon structure.41
A sample exercise. The patient may sit in a chair and, with the forearm flexed and pronated over the edge of a table, grasp some form of resistance (bucket of water, training weight, resistance band) (FIGURE 5). The nonaffected hand can be used to help lift the affected wrist into full extension and then removed to allow lowering of the hand over several seconds into flexion. This activity can be performed in sets of 8 to 12 repetitions, 2 to 3 times a day, until the patient’s pain and function have improved.42
Overcoming barriers to exercise
A major concern across all studies assessing the therapeutic value of exercise is patient compliance and adherence to prescribed programs. Compliance and adherence are affected in part by psychosocial factors such as low literacy and poor social support. From a physician’s perspective, direct and indirect costs of treatment and rehabilitation of chronic musculoskeletal conditions may discourage the prescribing of supervised physical therapy.3
Steps to consider in overcoming these barriers would be advising an exercise regimen that requires only an initial period of supervision; educating patients about the benefits of an exercise program; exploring a patient’s expectations, beliefs, and fears; and developing strategies for long-term adherence.16 Supervision through physical therapy is often suggested. However, significant barriers may exist that impede a patient’s ability to attend or participate, in which case physician observation in the course of regularly scheduled clinical examinations could be considered.
Continue to: When prescribing exercises...
When prescribing exercises, be sure to address patient expectations regarding pain, duration, and limitations of exercise. It would be helpful for patients to know, for instance, that working through mild-to-moderate pain during exercise has been shown to shorten post-exercise recovery time and, in the short-term, improve relief from pain.43
Tailoring specific exercise prescriptions for a patient will make the regimen more satisfying for the individual and optimize adherence, which in turn will increase the potential for pain reduction and improved function. Secondary benefits would likely be weight loss and prevention (or regression) of cardiovascular disease. Continued evaluation by the physician or physical therapist should be part of ongoing management, as well as “refresher courses” to ensure understanding of, and adherence to, the exercise program. The potential benefits and limited risks of exercise, if done properly, make it a primary intervention for specific musculoskeletal conditions.
CORRESPONDENCE
Peter J. Carek, MD, MS, Department of Community Health and Family Medicine, College of Medicine, University of Florida, PO Box 100237, Gainesville, FL 32610-0237; [email protected].
1. Naci H, Ioannidis JP. Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study. BMJ. 2013;347:f5577.
2. Babatunde OO, Jordan JL, van der Windt DA, et al. Effective treatment options for musculoskeletal pain in primary care: a systematic overview of current evidence. PLoS One. 2017;12:e0178621.
3. Persson G, Brorsson A, Ekvall Hansson E, et al. Physical activity on prescription (PAP) from the general practitioner’s perspective - a qualitative study. BMC Fam Pract. 2013;14:128.
4. Juhl C, Christensen R, Roos EM, et al. Impact of exercise type and dose on pain and disability in knee osteoarthritis: a systematic review and meta-regression analysis of randomized controlled trials. Arthritis Rheumatol. 2014;66:622-636.
5. Fransen M, McConnell S, Harmer AR, et al. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2015;1:CD004376.
6. Fransen M, McConnell S, Hernandez-Molina G, et al. Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev. 2014;(4):CD007912.
7. Vincent KR, Vincent HK. Resistance exercise for knee osteoarthritis. PM R. 2012;4(suppl 5):S45-S52.
8. Fernandes L, Storheim K, Nordsletten L, et al. Development of a therapeutic exercise program for patients with osteoarthritis of the hip. Phys Ther. 2010;90:592-601.
9. Bartels EM, Juhl CB, Christensen R, et al. Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database Syst Rev. 2016;(3):CD005523.
10. Jordan JL, Holden MA, Mason EE, et al. Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2010;(1):CD005956.
11. Baker KR, Nelson ME, Felson DT, et al. The efficacy of home based progressive strength training in older adults with knee osteoarthritis: a randomized controlled trial. J Rheumatol. 2001;28:1655-1665.
12. Brakke R, Singh J, Sullivan W. Physical therapy in persons with osteoarthritis. PM R. 2012;4:S53-S58.
13. Katz JN. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am. 2006;88(suppl 2):21-24.
14. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166:514-530.
15. Hayden JA, van Tulder MW, Malmivaara A, et al. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005;(3):CD000335.
16. Hayden JA, van Tulder MW, Tomlinson G. Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Ann Intern Med. 2005;142:776-785.
17. Searle A, Spink M, Ho A, et al. Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clin Rehabil. 2015;29:1155-1167.
18. Yamato TP, Maher CG, Saragiotto BT, et al. Pilates for low back pain. Cochrane Database Syst Rev. 2015;(7):CD010265.
19. Wieland LS, Skoetz N, Pilkington K, et al. Yoga treatment for chronic non-specific low back pain. Cochrane Database Syst Rev. 2017;(1):CD010671.
20. Parreira P, Heymans MW, van Tulder MW, et al. Back Schools for chronic non-specific low back pain. Cochrane Database Syst Rev. 2017;(8):CD011674.
21. Meng XG, Yue SW. Efficacy of aerobic exercise for treatment of chronic low back pain: a meta-analysis. Am J Phys Med Rehabil. 2015;94:358-365.
22. Malmivaara A, Häkkinen U, Aro T, et al. The treatment of acute low back pain--bed rest, exercises, or ordinary activity? N Engl J Med. 1995;332:351-355.
23. van Tulder M, Malmivaara A, Esmail R, Koes B. Exercise therapy for low back pain: a systematic review within the framework of the cochrane collaboration back review group. Spine (Phila Pa 1976). 2000;25:2784-2796.
24. Hoffmann TC, Maher CG, Briffa T, et al. Prescribing exercise interventions for patients with chronic conditions. CMAJ. 2016;188:510-518.
25. Luime JJ, Koes BW, Hendriksen IJ, et al. Prevalence and incidence of shoulder pain in the general population; a systematic review. Scand J Rheumatol. 2004;33:73-81.
26. Kuhn JE. Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol. J Shoulder Elbow Surg. 2009;18:138-160.
27. Page MJ, Green S, McBain B, et al. Manual therapy and exercise for rotator cuff disease. Cochrane Database Syst Rev. 2016;(6):CD012224.
28. van den Dolder PA, Ferreira PH, Refshauge KM. Effectiveness of soft tissue massage and exercise for the treatment of non-specific shoulder pain: a systematic review with meta-analysis. Br J Sports Med. 2014;48:1216-1226.
29. Shire AR, Stæhr TAB, Overby JB, et al. Specific or general exercise strategy for subacromial impingement syndrome-does it matter? A systematic literature review and meta analysis. BMC Musculoskelet Disord. 2017;18:158.
30. Ellenbecker TS, Cools A. Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: an evidence-based review. Br J Sports Med. 2010;44:319-327.
31. Magnussen RA, Dunn WR, Thomson AB. Nonoperative treatment of midportion Achilles tendinopathy: a systematic review. Clin J Sport Med. 2009;19:54-64.
32. Rees JD, Wolman RL, Wilson A. Eccentric exercises; why do they work, what are the problems and how can we improve them? Br J Sports Med. 2009;43:242-246.
33. Alfredson H, Pietilä T, Jonsson P, et al. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998;26:360-366.
34. Rompe JD, Nafe B, Furia JP, et al. Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial. Am J Sports Med. 2007;35:374-383.
35. Stevens M, Tan CW. Effectiveness of the Alfredson protocol compared with a lower repetition-volume protocol for midportion Achilles tendinopathy: a randomized controlled trial. J Orthop Sports Phys Ther. 2014;44:59-67.
36. Habets B, van Cingel RE. Eccentric exercise training in chronic mid-portion Achilles tendinopathy: a systematic review on different protocols. Scand J Med Sci Sports. 2015;25:3-15.
37. Malliaras P, Barton CJ, Reeves ND, et al. Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med. 2013;43:267-286.
38. van der Plas A, de Jonge S, de Vos RJ, et al. A 5-year follow-up study of Alfredson’s heel-drop exercise programme in chronic midportion Achilles tendinopathy. Br J Sports Med. 2012;46:214-218.
39. Alizadehkhaiyat O, Fisher AC, Kemp GJ, et al. Pain, functional disability, and psychologic status in tennis elbow. Clin J Pain. 2007;23:482-489.
40. Cullinane FL, Boocock MG, Trevelyan FC. Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Clin Rehabil. 2014;28:3-19.
41. Croisier JL, Foidart-Dessalle M, Tinant F, et al. An isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy. Br J Sports Med. 2007;41:269-275.
42. Söderberg J, Grooten WJ, Ang BO. Effects of eccentric training on hand strength in subjects with lateral epicondylalgia: a randomized-controlled trial. Scand J Med Sci Sports. 2012;22:797-803.
43. Smith BE, Hendrick P, Smith TO, et al. Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. Br J Sports Med. 2017;51:1679-1687.
Regular exercise confers several well-established benefits. In such conditions as coronary heart disease, stroke, heart failure, and diabetes, exercise has led to a reduction in mortality similar to that seen with pharmacotherapy.1 For patients with chronic musculoskeletal conditions, the benefits of exercise-based interventions are measurably reduced pain and improved daily function.2 However, prescribing of exercise is often neglected, with preference given to pharmacologic or surgical interventions.3 In part, the disregard of exercise as therapy results from unfamiliarity with appropriate exercise prescriptions,3 which include various forms of aerobic exercise, strength training, and stretching to increase flexibility (TABLE).
As is true of many therapeutic modalities, exercise must be tailored to the condition and to a patient’s preferences to optimize its benefits. In this review, we describe exercise regimens well suited for common musculoskeletal conditions, examine the effectiveness of exercise in each condition, and provide examples for use in treating patients.
Osteoarthritis of the hip and knee
Osteoarthritis (OA), one of the most common chronic joint diseases, erodes the articular cartilage and subchondral bone of a synovial joint, eventually leading to joint failure. Pain and diminished muscle strength restrict physical activity and can lead to decreased fitness and impaired muscle function. Exercise helps reduce pain and improve muscle function and quality of life in patients with hip or knee OA regardless of age, disease severity, or level of pain and dysfunction.2
Knee exercises. Activities suitable for patients with OA include muscle strengthening, aerobic conditioning, and range-of-motion (ROM) exercises.4-6 A 2015 Cochrane review of OA of the knee showed that exercise reduced pain and improved physical function and quality of life in patients who completed a treatment program, and that pain relief persisted up to 6 months after intervention.5
When designing an exercise prescription for patients with knee OA, consider quadriceps strengthening with an initial period of supervision, which may provide greater pain relief than nonspecific, unsupervised lower limb exercises.4 Enhanced strength of the lower limb may lessen force through the knee, thereby decreasing pain and improving overall physical function.7 Simple, teachable exercises include squats, step-ups, knee extension/flexion while sitting in a chair, and hip abduction/adduction while standing or lying down. Elastic bands, dumbbells, or cuff weights may be used to increase resistance.
Hip exercises. Exercise can significantly reduce pain and improve function for up to 6 months for patients with mild-to-moderate symptomatic hip OA.6 Types of exercise for hip OA include strength training of hip and core muscles, functional exercises that imitate movements in daily activities, and flexibility training. These exercises help reduce pain and increase ROM. Exercise should include resistance training and should not exceed the limit for acceptable pain.8
Aquatic therapy is also appropriate for exercise and strength training and can decrease pain and disability and improve quality of life.9 Supervised physical therapy, including strength training, manual therapy, and balance training, are important for reducing pain and improving function. Physical therapy can also enhance adherence to a prescribed exercise program.10
Continue to: Appropriate exercise prescriptions...
Appropriate exercise prescriptions for patients with knee or hip OA should focus on low-impact activities that can improve strength, flexibility, and function (FIGURE 1). A typical regimen would be 30 or more cumulative minutes daily of stationary cycling, water-based exercises, or strength training, 3 to 5 days per week. Individualize workout intensity for each patient, emphasizing that high-intensity, low-impact effort may yield greater strength gains and take less time to perform.11 A high-intensity exercise prescription focusing on quadriceps, hip, and core strengthening may consist of 3 sets of 8 repetitions with resistance set at 40% of the maximum resistance against which the patient can perform 1 repetition.7
Barriers to exercise in knee and hip OA include negative patient and provider perspectives on exercise and patients’ fear that increased activity may actually worsen OA.12 Depending on a patient’s personal preferences, ways to overcome these barriers and encourage adherence might be supervised exercises in an individual or group setting or audiotapes or videos of recommended exercises.10
Chronic low back pain
Chronic low back pain (LBP) is a large socioeconomic burden in the United States, with upward of $100 billion per year accounted for in health care costs and decreased worker productivity.13 The etiology of chronic LBP can be multifactorial and due to any of several conditions such as degenerative disc disease, spinal stenosis, spondylolisthesis, and facet arthropathy. Treatment is difficult, given that many common interventions—medications, massage, manipulation—have limited efficacy.14 However, for patients with nonspecific chronic LBP, exercise is an effective intervention for reducing pain and improving physical function.15
An effective approach is to design an exercise regimen for the individual by type, duration, and frequency of activity, administered under supervision to encourage adherence.16 Appropriate exercises emphasize resistance, strength training, and core stabilization, often focusing on whole body and trunk motion (FIGURE 2).17
Although yoga or Pilates classes may have a small effect on function, no high-quality evidence exists for their superiority to other forms of exercise.18,19 Back School, a therapeutic program that includes education on anatomy and biomechanics, optimal posture, ergonomics, and back exercises, has limited, low-quality evidence for treatment comparisons.20 Aerobic exercise, including treadmill, elliptical, or cycling exercises or walking outdoors can reduce pain and improve physical and psychologic functioning.21
Continue to: The most common reported adverse effect...
The most common reported adverse effect of exercise is a temporary exacerbation of back pain. However, having patients continue daily activities within the permitted limits of pain leads to more rapid recovery than rest or back-mobilizing exercises.15,22,23
Cautions. Exercise is contraindicated in patients with LBP arising from a serious medical condition, such as fracture, infection, cancer, or cauda equina syndrome.24 Importantly, exercise interventions recommended for acute LBP have not shown benefit for chronic LBP.
Chronic shoulder pain
With a prevalence ranging from 7% to 26% in the general population,25 chronic shoulder pain often interferes with essential activities of daily living. The etiology of chronic shoulder pain is broad and most commonly involves disorders of the rotator cuff, which functions in both motion and dynamic stabilization of the shoulder. The common term “rotator cuff pain syndrome” can cover such disorders as subacromial impingement syndrome, rotator cuff tendinopathy or tendinitis, partial or full thickness rotator cuff tears, calcific tendinitis, and subacromial bursitis. These pathologies may have overlapping presentations. Manual therapy and exercise, usually delivered as a component of structured physical therapy, focus on stretches and other exercises to increase ROM, stability, and strength of the rotator cuff musculature.26
A 2016 Cochrane review that evaluated manual therapy and exercise for chronic shoulder pain yielded limited high-quality evidence for effectiveness compared with placebo.27 Five trials found no important differences between manual therapy and exercise compared with glucocorticoid injection relative to overall pain, function, active shoulder abduction, and quality of life from 4 weeks up to 12 months.27 But compared with placebo, exercise has been more effective in reducing reported pain, especially in the context of strengthening regimens focused on flexion, extension, and internal and external rotation.28
For subacromial impingement syndrome, a 2017 meta-analysis found that a generalized exercise program relieves pain and improves function, ROM, and strength.29 A generalized shoulder-strengthening program includes exercises that focus on internal and external rotation, horizontal abduction, and shoulder stabilization (FIGURE 3). These exercises can be completed with 3 sets of 15 to 20 repetitions, which create a fatigue response that improves strength and targets local muscular endurance.30
Continue to: Achilles tendinopathy
Achilles tendinopathy
Achilles tendinopathy (also referred to as chronic Achilles tendinitis) is a degenerative condition of the Achilles tendon related to overuse that leads to pain, swelling, and impaired performance. It accounts for approximately 18% of injuries in runners and 4% of all patients presenting to sports medicine clinics.31 Eccentric muscle loading has become the dominant conservative intervention strategy for chronic Achilles tendinopathy.
For chronic tendinopathies, eccentric exercises subject greater force than concentric exercises through a controlled lengthening of a muscle-tendon unit, resulting in a greater remodeling stimulus of the tendon.32 Classically, the Alfredson protocol has been used to treat chronic Achilles tendinopathy. This program of eccentric heel-drop exercises recommends completion of 180 eccentric repetitions a day for up to 12 weeks (FIGURE 4).33 Exercises are performed slowly, and load can be increased when exercises are performed without pain or perhaps with mild nondisabling pain.
A variation of this protocol has allowed a gradual escalation of repetitions over a week up to the recommended 180 repetitions, and has shown improvements in pain reduction and function similar to that achieved with the primary protocol.34 Additionally, a 6-week “do as tolerated” program of eccentric exercises did not lead to lesser improvement for individuals with midportion Achilles tendinopathy.35
Several systematic reviews have supported the use of eccentric exercises for chronic Achilles tendinopathy,31,36,37 but no specific protocol or exercise regimen has demonstrated superiority. However, with the Alfredson protocol, improvement in pain and function in patients with chronic Achilles tendinopathy has persisted for up to 5 years.38
Lateral epicondylitis
Lateral epicondylitis (also called lateral epicondylosis or “tennis elbow”) is a disabling musculoskeletal condition that leads to pain and tenderness around the extensor mass of the lateral elbow. It is caused by microtrauma to the tendon, usually sustained through repetitive movement in a sporting activity, industrial work, or hobby. Affecting up to 3% of the US population, lateral epicondylitis is associated with pain and functional disability, as well as emotional and psychosocial consequences.39
Continue to: Proposed treatment and rehabilitation options...
Proposed treatment and rehabilitation options for patients with lateral epicondylitis have included massage, manipulation, taping, acupuncture, orthotic devices, ultrasound, activity modification, and rest. Exercise programs incorporating eccentric muscle activity are becoming increasingly popular for such conditions as Achilles and patellar tendinopathies, and they may translate well to other chronic tendinopathies, such as lateral epicondylitis.32
An eccentric exercise program for lateral epicondylitis, either in isolation or as an adjunct to other therapies, has decreased pain and improved function and grip strength from baseline measures.40 Compared with a standard exercise regimen without eccentric strength training, use of eccentric training improves such clinical measures as pain intensity and disability status, as it decreases tendon thickness and aids in recovering homogenous tendon structure.41
A sample exercise. The patient may sit in a chair and, with the forearm flexed and pronated over the edge of a table, grasp some form of resistance (bucket of water, training weight, resistance band) (FIGURE 5). The nonaffected hand can be used to help lift the affected wrist into full extension and then removed to allow lowering of the hand over several seconds into flexion. This activity can be performed in sets of 8 to 12 repetitions, 2 to 3 times a day, until the patient’s pain and function have improved.42
Overcoming barriers to exercise
A major concern across all studies assessing the therapeutic value of exercise is patient compliance and adherence to prescribed programs. Compliance and adherence are affected in part by psychosocial factors such as low literacy and poor social support. From a physician’s perspective, direct and indirect costs of treatment and rehabilitation of chronic musculoskeletal conditions may discourage the prescribing of supervised physical therapy.3
Steps to consider in overcoming these barriers would be advising an exercise regimen that requires only an initial period of supervision; educating patients about the benefits of an exercise program; exploring a patient’s expectations, beliefs, and fears; and developing strategies for long-term adherence.16 Supervision through physical therapy is often suggested. However, significant barriers may exist that impede a patient’s ability to attend or participate, in which case physician observation in the course of regularly scheduled clinical examinations could be considered.
Continue to: When prescribing exercises...
When prescribing exercises, be sure to address patient expectations regarding pain, duration, and limitations of exercise. It would be helpful for patients to know, for instance, that working through mild-to-moderate pain during exercise has been shown to shorten post-exercise recovery time and, in the short-term, improve relief from pain.43
Tailoring specific exercise prescriptions for a patient will make the regimen more satisfying for the individual and optimize adherence, which in turn will increase the potential for pain reduction and improved function. Secondary benefits would likely be weight loss and prevention (or regression) of cardiovascular disease. Continued evaluation by the physician or physical therapist should be part of ongoing management, as well as “refresher courses” to ensure understanding of, and adherence to, the exercise program. The potential benefits and limited risks of exercise, if done properly, make it a primary intervention for specific musculoskeletal conditions.
CORRESPONDENCE
Peter J. Carek, MD, MS, Department of Community Health and Family Medicine, College of Medicine, University of Florida, PO Box 100237, Gainesville, FL 32610-0237; [email protected].
Regular exercise confers several well-established benefits. In such conditions as coronary heart disease, stroke, heart failure, and diabetes, exercise has led to a reduction in mortality similar to that seen with pharmacotherapy.1 For patients with chronic musculoskeletal conditions, the benefits of exercise-based interventions are measurably reduced pain and improved daily function.2 However, prescribing of exercise is often neglected, with preference given to pharmacologic or surgical interventions.3 In part, the disregard of exercise as therapy results from unfamiliarity with appropriate exercise prescriptions,3 which include various forms of aerobic exercise, strength training, and stretching to increase flexibility (TABLE).
As is true of many therapeutic modalities, exercise must be tailored to the condition and to a patient’s preferences to optimize its benefits. In this review, we describe exercise regimens well suited for common musculoskeletal conditions, examine the effectiveness of exercise in each condition, and provide examples for use in treating patients.
Osteoarthritis of the hip and knee
Osteoarthritis (OA), one of the most common chronic joint diseases, erodes the articular cartilage and subchondral bone of a synovial joint, eventually leading to joint failure. Pain and diminished muscle strength restrict physical activity and can lead to decreased fitness and impaired muscle function. Exercise helps reduce pain and improve muscle function and quality of life in patients with hip or knee OA regardless of age, disease severity, or level of pain and dysfunction.2
Knee exercises. Activities suitable for patients with OA include muscle strengthening, aerobic conditioning, and range-of-motion (ROM) exercises.4-6 A 2015 Cochrane review of OA of the knee showed that exercise reduced pain and improved physical function and quality of life in patients who completed a treatment program, and that pain relief persisted up to 6 months after intervention.5
When designing an exercise prescription for patients with knee OA, consider quadriceps strengthening with an initial period of supervision, which may provide greater pain relief than nonspecific, unsupervised lower limb exercises.4 Enhanced strength of the lower limb may lessen force through the knee, thereby decreasing pain and improving overall physical function.7 Simple, teachable exercises include squats, step-ups, knee extension/flexion while sitting in a chair, and hip abduction/adduction while standing or lying down. Elastic bands, dumbbells, or cuff weights may be used to increase resistance.
Hip exercises. Exercise can significantly reduce pain and improve function for up to 6 months for patients with mild-to-moderate symptomatic hip OA.6 Types of exercise for hip OA include strength training of hip and core muscles, functional exercises that imitate movements in daily activities, and flexibility training. These exercises help reduce pain and increase ROM. Exercise should include resistance training and should not exceed the limit for acceptable pain.8
Aquatic therapy is also appropriate for exercise and strength training and can decrease pain and disability and improve quality of life.9 Supervised physical therapy, including strength training, manual therapy, and balance training, are important for reducing pain and improving function. Physical therapy can also enhance adherence to a prescribed exercise program.10
Continue to: Appropriate exercise prescriptions...
Appropriate exercise prescriptions for patients with knee or hip OA should focus on low-impact activities that can improve strength, flexibility, and function (FIGURE 1). A typical regimen would be 30 or more cumulative minutes daily of stationary cycling, water-based exercises, or strength training, 3 to 5 days per week. Individualize workout intensity for each patient, emphasizing that high-intensity, low-impact effort may yield greater strength gains and take less time to perform.11 A high-intensity exercise prescription focusing on quadriceps, hip, and core strengthening may consist of 3 sets of 8 repetitions with resistance set at 40% of the maximum resistance against which the patient can perform 1 repetition.7
Barriers to exercise in knee and hip OA include negative patient and provider perspectives on exercise and patients’ fear that increased activity may actually worsen OA.12 Depending on a patient’s personal preferences, ways to overcome these barriers and encourage adherence might be supervised exercises in an individual or group setting or audiotapes or videos of recommended exercises.10
Chronic low back pain
Chronic low back pain (LBP) is a large socioeconomic burden in the United States, with upward of $100 billion per year accounted for in health care costs and decreased worker productivity.13 The etiology of chronic LBP can be multifactorial and due to any of several conditions such as degenerative disc disease, spinal stenosis, spondylolisthesis, and facet arthropathy. Treatment is difficult, given that many common interventions—medications, massage, manipulation—have limited efficacy.14 However, for patients with nonspecific chronic LBP, exercise is an effective intervention for reducing pain and improving physical function.15
An effective approach is to design an exercise regimen for the individual by type, duration, and frequency of activity, administered under supervision to encourage adherence.16 Appropriate exercises emphasize resistance, strength training, and core stabilization, often focusing on whole body and trunk motion (FIGURE 2).17
Although yoga or Pilates classes may have a small effect on function, no high-quality evidence exists for their superiority to other forms of exercise.18,19 Back School, a therapeutic program that includes education on anatomy and biomechanics, optimal posture, ergonomics, and back exercises, has limited, low-quality evidence for treatment comparisons.20 Aerobic exercise, including treadmill, elliptical, or cycling exercises or walking outdoors can reduce pain and improve physical and psychologic functioning.21
Continue to: The most common reported adverse effect...
The most common reported adverse effect of exercise is a temporary exacerbation of back pain. However, having patients continue daily activities within the permitted limits of pain leads to more rapid recovery than rest or back-mobilizing exercises.15,22,23
Cautions. Exercise is contraindicated in patients with LBP arising from a serious medical condition, such as fracture, infection, cancer, or cauda equina syndrome.24 Importantly, exercise interventions recommended for acute LBP have not shown benefit for chronic LBP.
Chronic shoulder pain
With a prevalence ranging from 7% to 26% in the general population,25 chronic shoulder pain often interferes with essential activities of daily living. The etiology of chronic shoulder pain is broad and most commonly involves disorders of the rotator cuff, which functions in both motion and dynamic stabilization of the shoulder. The common term “rotator cuff pain syndrome” can cover such disorders as subacromial impingement syndrome, rotator cuff tendinopathy or tendinitis, partial or full thickness rotator cuff tears, calcific tendinitis, and subacromial bursitis. These pathologies may have overlapping presentations. Manual therapy and exercise, usually delivered as a component of structured physical therapy, focus on stretches and other exercises to increase ROM, stability, and strength of the rotator cuff musculature.26
A 2016 Cochrane review that evaluated manual therapy and exercise for chronic shoulder pain yielded limited high-quality evidence for effectiveness compared with placebo.27 Five trials found no important differences between manual therapy and exercise compared with glucocorticoid injection relative to overall pain, function, active shoulder abduction, and quality of life from 4 weeks up to 12 months.27 But compared with placebo, exercise has been more effective in reducing reported pain, especially in the context of strengthening regimens focused on flexion, extension, and internal and external rotation.28
For subacromial impingement syndrome, a 2017 meta-analysis found that a generalized exercise program relieves pain and improves function, ROM, and strength.29 A generalized shoulder-strengthening program includes exercises that focus on internal and external rotation, horizontal abduction, and shoulder stabilization (FIGURE 3). These exercises can be completed with 3 sets of 15 to 20 repetitions, which create a fatigue response that improves strength and targets local muscular endurance.30
Continue to: Achilles tendinopathy
Achilles tendinopathy
Achilles tendinopathy (also referred to as chronic Achilles tendinitis) is a degenerative condition of the Achilles tendon related to overuse that leads to pain, swelling, and impaired performance. It accounts for approximately 18% of injuries in runners and 4% of all patients presenting to sports medicine clinics.31 Eccentric muscle loading has become the dominant conservative intervention strategy for chronic Achilles tendinopathy.
For chronic tendinopathies, eccentric exercises subject greater force than concentric exercises through a controlled lengthening of a muscle-tendon unit, resulting in a greater remodeling stimulus of the tendon.32 Classically, the Alfredson protocol has been used to treat chronic Achilles tendinopathy. This program of eccentric heel-drop exercises recommends completion of 180 eccentric repetitions a day for up to 12 weeks (FIGURE 4).33 Exercises are performed slowly, and load can be increased when exercises are performed without pain or perhaps with mild nondisabling pain.
A variation of this protocol has allowed a gradual escalation of repetitions over a week up to the recommended 180 repetitions, and has shown improvements in pain reduction and function similar to that achieved with the primary protocol.34 Additionally, a 6-week “do as tolerated” program of eccentric exercises did not lead to lesser improvement for individuals with midportion Achilles tendinopathy.35
Several systematic reviews have supported the use of eccentric exercises for chronic Achilles tendinopathy,31,36,37 but no specific protocol or exercise regimen has demonstrated superiority. However, with the Alfredson protocol, improvement in pain and function in patients with chronic Achilles tendinopathy has persisted for up to 5 years.38
Lateral epicondylitis
Lateral epicondylitis (also called lateral epicondylosis or “tennis elbow”) is a disabling musculoskeletal condition that leads to pain and tenderness around the extensor mass of the lateral elbow. It is caused by microtrauma to the tendon, usually sustained through repetitive movement in a sporting activity, industrial work, or hobby. Affecting up to 3% of the US population, lateral epicondylitis is associated with pain and functional disability, as well as emotional and psychosocial consequences.39
Continue to: Proposed treatment and rehabilitation options...
Proposed treatment and rehabilitation options for patients with lateral epicondylitis have included massage, manipulation, taping, acupuncture, orthotic devices, ultrasound, activity modification, and rest. Exercise programs incorporating eccentric muscle activity are becoming increasingly popular for such conditions as Achilles and patellar tendinopathies, and they may translate well to other chronic tendinopathies, such as lateral epicondylitis.32
An eccentric exercise program for lateral epicondylitis, either in isolation or as an adjunct to other therapies, has decreased pain and improved function and grip strength from baseline measures.40 Compared with a standard exercise regimen without eccentric strength training, use of eccentric training improves such clinical measures as pain intensity and disability status, as it decreases tendon thickness and aids in recovering homogenous tendon structure.41
A sample exercise. The patient may sit in a chair and, with the forearm flexed and pronated over the edge of a table, grasp some form of resistance (bucket of water, training weight, resistance band) (FIGURE 5). The nonaffected hand can be used to help lift the affected wrist into full extension and then removed to allow lowering of the hand over several seconds into flexion. This activity can be performed in sets of 8 to 12 repetitions, 2 to 3 times a day, until the patient’s pain and function have improved.42
Overcoming barriers to exercise
A major concern across all studies assessing the therapeutic value of exercise is patient compliance and adherence to prescribed programs. Compliance and adherence are affected in part by psychosocial factors such as low literacy and poor social support. From a physician’s perspective, direct and indirect costs of treatment and rehabilitation of chronic musculoskeletal conditions may discourage the prescribing of supervised physical therapy.3
Steps to consider in overcoming these barriers would be advising an exercise regimen that requires only an initial period of supervision; educating patients about the benefits of an exercise program; exploring a patient’s expectations, beliefs, and fears; and developing strategies for long-term adherence.16 Supervision through physical therapy is often suggested. However, significant barriers may exist that impede a patient’s ability to attend or participate, in which case physician observation in the course of regularly scheduled clinical examinations could be considered.
Continue to: When prescribing exercises...
When prescribing exercises, be sure to address patient expectations regarding pain, duration, and limitations of exercise. It would be helpful for patients to know, for instance, that working through mild-to-moderate pain during exercise has been shown to shorten post-exercise recovery time and, in the short-term, improve relief from pain.43
Tailoring specific exercise prescriptions for a patient will make the regimen more satisfying for the individual and optimize adherence, which in turn will increase the potential for pain reduction and improved function. Secondary benefits would likely be weight loss and prevention (or regression) of cardiovascular disease. Continued evaluation by the physician or physical therapist should be part of ongoing management, as well as “refresher courses” to ensure understanding of, and adherence to, the exercise program. The potential benefits and limited risks of exercise, if done properly, make it a primary intervention for specific musculoskeletal conditions.
CORRESPONDENCE
Peter J. Carek, MD, MS, Department of Community Health and Family Medicine, College of Medicine, University of Florida, PO Box 100237, Gainesville, FL 32610-0237; [email protected].
1. Naci H, Ioannidis JP. Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study. BMJ. 2013;347:f5577.
2. Babatunde OO, Jordan JL, van der Windt DA, et al. Effective treatment options for musculoskeletal pain in primary care: a systematic overview of current evidence. PLoS One. 2017;12:e0178621.
3. Persson G, Brorsson A, Ekvall Hansson E, et al. Physical activity on prescription (PAP) from the general practitioner’s perspective - a qualitative study. BMC Fam Pract. 2013;14:128.
4. Juhl C, Christensen R, Roos EM, et al. Impact of exercise type and dose on pain and disability in knee osteoarthritis: a systematic review and meta-regression analysis of randomized controlled trials. Arthritis Rheumatol. 2014;66:622-636.
5. Fransen M, McConnell S, Harmer AR, et al. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2015;1:CD004376.
6. Fransen M, McConnell S, Hernandez-Molina G, et al. Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev. 2014;(4):CD007912.
7. Vincent KR, Vincent HK. Resistance exercise for knee osteoarthritis. PM R. 2012;4(suppl 5):S45-S52.
8. Fernandes L, Storheim K, Nordsletten L, et al. Development of a therapeutic exercise program for patients with osteoarthritis of the hip. Phys Ther. 2010;90:592-601.
9. Bartels EM, Juhl CB, Christensen R, et al. Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database Syst Rev. 2016;(3):CD005523.
10. Jordan JL, Holden MA, Mason EE, et al. Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2010;(1):CD005956.
11. Baker KR, Nelson ME, Felson DT, et al. The efficacy of home based progressive strength training in older adults with knee osteoarthritis: a randomized controlled trial. J Rheumatol. 2001;28:1655-1665.
12. Brakke R, Singh J, Sullivan W. Physical therapy in persons with osteoarthritis. PM R. 2012;4:S53-S58.
13. Katz JN. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am. 2006;88(suppl 2):21-24.
14. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166:514-530.
15. Hayden JA, van Tulder MW, Malmivaara A, et al. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005;(3):CD000335.
16. Hayden JA, van Tulder MW, Tomlinson G. Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Ann Intern Med. 2005;142:776-785.
17. Searle A, Spink M, Ho A, et al. Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clin Rehabil. 2015;29:1155-1167.
18. Yamato TP, Maher CG, Saragiotto BT, et al. Pilates for low back pain. Cochrane Database Syst Rev. 2015;(7):CD010265.
19. Wieland LS, Skoetz N, Pilkington K, et al. Yoga treatment for chronic non-specific low back pain. Cochrane Database Syst Rev. 2017;(1):CD010671.
20. Parreira P, Heymans MW, van Tulder MW, et al. Back Schools for chronic non-specific low back pain. Cochrane Database Syst Rev. 2017;(8):CD011674.
21. Meng XG, Yue SW. Efficacy of aerobic exercise for treatment of chronic low back pain: a meta-analysis. Am J Phys Med Rehabil. 2015;94:358-365.
22. Malmivaara A, Häkkinen U, Aro T, et al. The treatment of acute low back pain--bed rest, exercises, or ordinary activity? N Engl J Med. 1995;332:351-355.
23. van Tulder M, Malmivaara A, Esmail R, Koes B. Exercise therapy for low back pain: a systematic review within the framework of the cochrane collaboration back review group. Spine (Phila Pa 1976). 2000;25:2784-2796.
24. Hoffmann TC, Maher CG, Briffa T, et al. Prescribing exercise interventions for patients with chronic conditions. CMAJ. 2016;188:510-518.
25. Luime JJ, Koes BW, Hendriksen IJ, et al. Prevalence and incidence of shoulder pain in the general population; a systematic review. Scand J Rheumatol. 2004;33:73-81.
26. Kuhn JE. Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol. J Shoulder Elbow Surg. 2009;18:138-160.
27. Page MJ, Green S, McBain B, et al. Manual therapy and exercise for rotator cuff disease. Cochrane Database Syst Rev. 2016;(6):CD012224.
28. van den Dolder PA, Ferreira PH, Refshauge KM. Effectiveness of soft tissue massage and exercise for the treatment of non-specific shoulder pain: a systematic review with meta-analysis. Br J Sports Med. 2014;48:1216-1226.
29. Shire AR, Stæhr TAB, Overby JB, et al. Specific or general exercise strategy for subacromial impingement syndrome-does it matter? A systematic literature review and meta analysis. BMC Musculoskelet Disord. 2017;18:158.
30. Ellenbecker TS, Cools A. Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: an evidence-based review. Br J Sports Med. 2010;44:319-327.
31. Magnussen RA, Dunn WR, Thomson AB. Nonoperative treatment of midportion Achilles tendinopathy: a systematic review. Clin J Sport Med. 2009;19:54-64.
32. Rees JD, Wolman RL, Wilson A. Eccentric exercises; why do they work, what are the problems and how can we improve them? Br J Sports Med. 2009;43:242-246.
33. Alfredson H, Pietilä T, Jonsson P, et al. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998;26:360-366.
34. Rompe JD, Nafe B, Furia JP, et al. Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial. Am J Sports Med. 2007;35:374-383.
35. Stevens M, Tan CW. Effectiveness of the Alfredson protocol compared with a lower repetition-volume protocol for midportion Achilles tendinopathy: a randomized controlled trial. J Orthop Sports Phys Ther. 2014;44:59-67.
36. Habets B, van Cingel RE. Eccentric exercise training in chronic mid-portion Achilles tendinopathy: a systematic review on different protocols. Scand J Med Sci Sports. 2015;25:3-15.
37. Malliaras P, Barton CJ, Reeves ND, et al. Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med. 2013;43:267-286.
38. van der Plas A, de Jonge S, de Vos RJ, et al. A 5-year follow-up study of Alfredson’s heel-drop exercise programme in chronic midportion Achilles tendinopathy. Br J Sports Med. 2012;46:214-218.
39. Alizadehkhaiyat O, Fisher AC, Kemp GJ, et al. Pain, functional disability, and psychologic status in tennis elbow. Clin J Pain. 2007;23:482-489.
40. Cullinane FL, Boocock MG, Trevelyan FC. Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Clin Rehabil. 2014;28:3-19.
41. Croisier JL, Foidart-Dessalle M, Tinant F, et al. An isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy. Br J Sports Med. 2007;41:269-275.
42. Söderberg J, Grooten WJ, Ang BO. Effects of eccentric training on hand strength in subjects with lateral epicondylalgia: a randomized-controlled trial. Scand J Med Sci Sports. 2012;22:797-803.
43. Smith BE, Hendrick P, Smith TO, et al. Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. Br J Sports Med. 2017;51:1679-1687.
1. Naci H, Ioannidis JP. Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study. BMJ. 2013;347:f5577.
2. Babatunde OO, Jordan JL, van der Windt DA, et al. Effective treatment options for musculoskeletal pain in primary care: a systematic overview of current evidence. PLoS One. 2017;12:e0178621.
3. Persson G, Brorsson A, Ekvall Hansson E, et al. Physical activity on prescription (PAP) from the general practitioner’s perspective - a qualitative study. BMC Fam Pract. 2013;14:128.
4. Juhl C, Christensen R, Roos EM, et al. Impact of exercise type and dose on pain and disability in knee osteoarthritis: a systematic review and meta-regression analysis of randomized controlled trials. Arthritis Rheumatol. 2014;66:622-636.
5. Fransen M, McConnell S, Harmer AR, et al. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2015;1:CD004376.
6. Fransen M, McConnell S, Hernandez-Molina G, et al. Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev. 2014;(4):CD007912.
7. Vincent KR, Vincent HK. Resistance exercise for knee osteoarthritis. PM R. 2012;4(suppl 5):S45-S52.
8. Fernandes L, Storheim K, Nordsletten L, et al. Development of a therapeutic exercise program for patients with osteoarthritis of the hip. Phys Ther. 2010;90:592-601.
9. Bartels EM, Juhl CB, Christensen R, et al. Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database Syst Rev. 2016;(3):CD005523.
10. Jordan JL, Holden MA, Mason EE, et al. Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2010;(1):CD005956.
11. Baker KR, Nelson ME, Felson DT, et al. The efficacy of home based progressive strength training in older adults with knee osteoarthritis: a randomized controlled trial. J Rheumatol. 2001;28:1655-1665.
12. Brakke R, Singh J, Sullivan W. Physical therapy in persons with osteoarthritis. PM R. 2012;4:S53-S58.
13. Katz JN. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am. 2006;88(suppl 2):21-24.
14. Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166:514-530.
15. Hayden JA, van Tulder MW, Malmivaara A, et al. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005;(3):CD000335.
16. Hayden JA, van Tulder MW, Tomlinson G. Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Ann Intern Med. 2005;142:776-785.
17. Searle A, Spink M, Ho A, et al. Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clin Rehabil. 2015;29:1155-1167.
18. Yamato TP, Maher CG, Saragiotto BT, et al. Pilates for low back pain. Cochrane Database Syst Rev. 2015;(7):CD010265.
19. Wieland LS, Skoetz N, Pilkington K, et al. Yoga treatment for chronic non-specific low back pain. Cochrane Database Syst Rev. 2017;(1):CD010671.
20. Parreira P, Heymans MW, van Tulder MW, et al. Back Schools for chronic non-specific low back pain. Cochrane Database Syst Rev. 2017;(8):CD011674.
21. Meng XG, Yue SW. Efficacy of aerobic exercise for treatment of chronic low back pain: a meta-analysis. Am J Phys Med Rehabil. 2015;94:358-365.
22. Malmivaara A, Häkkinen U, Aro T, et al. The treatment of acute low back pain--bed rest, exercises, or ordinary activity? N Engl J Med. 1995;332:351-355.
23. van Tulder M, Malmivaara A, Esmail R, Koes B. Exercise therapy for low back pain: a systematic review within the framework of the cochrane collaboration back review group. Spine (Phila Pa 1976). 2000;25:2784-2796.
24. Hoffmann TC, Maher CG, Briffa T, et al. Prescribing exercise interventions for patients with chronic conditions. CMAJ. 2016;188:510-518.
25. Luime JJ, Koes BW, Hendriksen IJ, et al. Prevalence and incidence of shoulder pain in the general population; a systematic review. Scand J Rheumatol. 2004;33:73-81.
26. Kuhn JE. Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol. J Shoulder Elbow Surg. 2009;18:138-160.
27. Page MJ, Green S, McBain B, et al. Manual therapy and exercise for rotator cuff disease. Cochrane Database Syst Rev. 2016;(6):CD012224.
28. van den Dolder PA, Ferreira PH, Refshauge KM. Effectiveness of soft tissue massage and exercise for the treatment of non-specific shoulder pain: a systematic review with meta-analysis. Br J Sports Med. 2014;48:1216-1226.
29. Shire AR, Stæhr TAB, Overby JB, et al. Specific or general exercise strategy for subacromial impingement syndrome-does it matter? A systematic literature review and meta analysis. BMC Musculoskelet Disord. 2017;18:158.
30. Ellenbecker TS, Cools A. Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: an evidence-based review. Br J Sports Med. 2010;44:319-327.
31. Magnussen RA, Dunn WR, Thomson AB. Nonoperative treatment of midportion Achilles tendinopathy: a systematic review. Clin J Sport Med. 2009;19:54-64.
32. Rees JD, Wolman RL, Wilson A. Eccentric exercises; why do they work, what are the problems and how can we improve them? Br J Sports Med. 2009;43:242-246.
33. Alfredson H, Pietilä T, Jonsson P, et al. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998;26:360-366.
34. Rompe JD, Nafe B, Furia JP, et al. Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial. Am J Sports Med. 2007;35:374-383.
35. Stevens M, Tan CW. Effectiveness of the Alfredson protocol compared with a lower repetition-volume protocol for midportion Achilles tendinopathy: a randomized controlled trial. J Orthop Sports Phys Ther. 2014;44:59-67.
36. Habets B, van Cingel RE. Eccentric exercise training in chronic mid-portion Achilles tendinopathy: a systematic review on different protocols. Scand J Med Sci Sports. 2015;25:3-15.
37. Malliaras P, Barton CJ, Reeves ND, et al. Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med. 2013;43:267-286.
38. van der Plas A, de Jonge S, de Vos RJ, et al. A 5-year follow-up study of Alfredson’s heel-drop exercise programme in chronic midportion Achilles tendinopathy. Br J Sports Med. 2012;46:214-218.
39. Alizadehkhaiyat O, Fisher AC, Kemp GJ, et al. Pain, functional disability, and psychologic status in tennis elbow. Clin J Pain. 2007;23:482-489.
40. Cullinane FL, Boocock MG, Trevelyan FC. Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Clin Rehabil. 2014;28:3-19.
41. Croisier JL, Foidart-Dessalle M, Tinant F, et al. An isokinetic eccentric programme for the management of chronic lateral epicondylar tendinopathy. Br J Sports Med. 2007;41:269-275.
42. Söderberg J, Grooten WJ, Ang BO. Effects of eccentric training on hand strength in subjects with lateral epicondylalgia: a randomized-controlled trial. Scand J Med Sci Sports. 2012;22:797-803.
43. Smith BE, Hendrick P, Smith TO, et al. Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis. Br J Sports Med. 2017;51:1679-1687.
From The Journal of Family Practice | 2018;67(9):534-538,540-543.
PRACTICE RECOMMENDATIONS
› Consider quadriceps strengthening for knee osteoarthritis with an initial period of supervision, which can provide greater pain relief than nonspecific, unsupervised lower limb exercises. B
› Consider a generalized exercise program for subacromial impingement syndrome, to relieve shoulder pain and improve function, range of motion, and strength. A
› Bear in mind that the Alfredson protocol for Achilles tendinopathy has yielded improvement in pain and function for up to 5 years, although other exercise regimens have also proven initially effective. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
