Exercise therapy and comorbidity in osteoarthritis of the hip or knee: case series

Physical therapy has been proved to be an effective intervention for patients
with knee and/or hip osteoarthritis in reducing pain and improving physical
functioning. Physical therapy, e.g., exercise therapy, is recommended in
existing guidelines.
Comorbidity is highly prevalent in patients with knee and/or hip
osteoarthritis. As comorbidity is associated with physical and psychological
limitations it is important to adapt exercise therapy to the comorbidity. For
example, exercise therapy for a diabetis patient should be delayed when blood
glucosis levels are equal or below 5 mmol/l. Another example is the adaptation
of exercise therapy for a patient with chronic widespread pain by using
behavioural principles.
In existing guidelines patiens with comorbidity are often excluded and no
advice is given how exercise therapy should be adapted to comorbidity.

The aim of this explorative study is to develop and evaluate an exercise
protocol for patients with knee and/or hip osteoarthritis and comorbidity
(e.g., coronary heart diseases, heart failure, hypertension, diabetes type 2,
chronic obstructive pulmonary diseases (COPD), arthritis of the foot and hand,
low back pain, chronic pain, depression, visual/hearing impairments and
cystitis)

The present study is performed with case studies. At least 12 case studies
(with a minimum of 1 case study per comorbidity) will be performed, including
all relevant comorbidities.
Measurements for the evaluation of the treatmentprocess and the evaluation of
the treatment itself will be performed.
Evaluation of the treatment process: weekly measurements and a pre- and
posttreatment measurement.
Evaluation of the treatment itself: weekly measurements and three more
extensive measurements which will be planned at baseline, in week 12 and
immediately after the treament.

Prior to treatment, the goals for the treatment are established which have to
be relevant for the patient. Examples of frequently established goals are: (1)
increasing walking distance (2) improving stair climbing and (3) raising from a
chair with less effort.
The following training modalities are used: aerobic exercise, strength
training, training of coordination and stability, training of range of motion,
training of daily activities such as walking and stair climbing. The training
modalities have been advised in the guideline for knee an hip osteoarthritis
(KNGF).

During the treatment of the case studies the exercise therapy will be adapted
to the comorbidity in: intensity, duration and content of the therapy. This
depends on present restrictions in exercise therapy, identified by the
therapist during anamnesis and physical examination. A treatment protocol was
developed for each comorbidity. In addition to exercise therapy, education will
be given about the pathology and on how to cope with it. Therapy sessions will
be given once or twice a week, during half an hour or one hour, depending on
the complexity of the diseases. Treatment will be ended when the goals for
treatment have been reached or no more improvements towards these goals can be
expected.

This study will provide insight into how exercise therapy treatment can be
adapted in the presence of comorbidity, in patients with knee or hip
osteoarthritis. Patient burden is limited to the time and effort needed to
participate in the therapeutic and measurement sessions. there are no specific
risks associated with participation, as the patients will be exposed to a
treatment that is regularly provided to osteoarthritis patients within the jan
van Breemen Institute, with adaptations made specifically for the benefit of
patients with present comorbidity.