Exercise and Disease II

1. Exercise and Disease II Urho Kujala Professor of Sports & Exercise Medicine Department of Health Sciences, University of Jyväskylä Urho.Kujala@sport.jyu.fi

2. Contents • Musculoskeletal disease • Neurologic disease • Renal disease –bladder problems • GI-tract • Cancer • Infections • + Pulmonary disease (separate presentation)

3. Exercise and musculoskeletal disease • Relations to other diseases • Relations to functioning and disability • Immobilization • Sports and exercise in the prevention • Exercise in the treatment and rehabilitation

4. Wang et al. www.plosbiology.org; Oct 2004;vol 2; Issue 10; e294(WT=wild typeTG=transgenic) The role of interspecies differences has to be taken into account when attempting to extend the results of animal experiments to humans!

5. Muscle fibre-type distribution, weight gain and concentric remodelling of left ventricle: a 19-year follow-up study(Karjalainen J, Tikkanen H, Hernelahti M, Kujala UM: BMC Cardiovascular Disorders 2006;6:2. doi:10.1186/1471-2261-6-2.)

6. Basics on functions of skeletal muscle • Movement, posture, stability • Communication • Heat production, cold tolerance • Important role in metabolism/energy balance • Endocrine organ; ”myokines”(IL-6, -8, -15) and myostatin partly control/regulate inflammation, energy expenditure, muscle growth and fat deposition. NOTE: Skeletal muscle is a major mass peripheral tissue (about 36% for females and 42% for males)

7. Functions of bone • Support • Production of cells to circulation • Calcium reserve/metabolism • Associations to fat etc. Metabolism • Endocrine functions

8. Sarcopenia • Decrease in muscle mass is an important age-related change • Degreases in number and size of muscle cells and infiltration of fat into muscle • Associated with increased risk of disability and death • Risk factors for sarcopenia; aging, nutrition, hormonal balance, different diseases • Physical activity is the best preventive means • Muscle is important not only for producing work but olso for metabolism, body temperature maintenance, and protein source • Muscle training among older people important for maintaining mobility

9. Disability 25 years later according to midlife grip strength tertiles among 6089 initially healthy men, HHP Difficulty in Grip strength tertiles Functional limitations % (Rantanen et al. JAMA 1999;281:558-560)

10. Biological Change Risk of Injury Benefit profile B Net health benefit Benefit profile A Risk of injury; profile A Risk of injury; profile B Light Medium High Intensity of Exercise

11. What kind of evidencedo we need? • Prevention; Observational studies to give general advice for healthy people? • Treatment of patients with chronic disease using resourches of health care; RCTs are needed? • Studies on the effects of exercise on the mechanisms of disease

12. Exercise recommendations and how to follow the recommendations • Recommendations for the prevention of disease • Recommendations in the treatment and rehabilitation of disease • Contraindications/safety rules

13. Reduction of maxVO2 during bed rest (Greenleaf et al. J Appl Physiol 1989;67:1820-1826.)

14. Effects of immobilization on musculoskeletal system • Bone • Cartilage • Muscle • Tendon (See: Bloomfield et al. Changes in musculoskeletal structure and function with prolonged bed rest. Med Sci Sports Exerc 1997; 29: 197-206)

15. Osteoarthritis and exercise • Osteoarthritis causes long-lasting physical activity limitations more than any other disease

16. Factors predisposing to osteoarthritis • Overweight • High work-related loading • Joint injuries (leisure/sports and work) • Genetic factors • Other diseases (diabetes etc.)

17. HERITABILITY: TWIN STUDIES • The genetic influence explains 39-65% of the variance in the occurrence of radiographic hand or knee OA in women • OA-score; MZ - r=0.64 vs. DZ - r=0.38 • (Spector et al. BMJ 1996;312:940-3)

18. Hospital discharge reports ICD 8 (1970-1985) ICD 9 (1986-1990) Kujala et al. British Medical Journal 1994;308:231-234.

19. Impairments due to hip joint problems in former elite athletes and controls (adjusted for age, SES and BMI)

20. Impairments due to knee joint problems in former elite athletes and controls(adjusted for age, SES and BMI)

21. Sports or physical activity in the prevention of osteoarthritis • Sports including high risk of joint injuries and very high impact loads increases the risk of osteoarthritis • Low to moderate leisure physical activity without joint injuries does not increase the risk • High work-related loading increases the risk of osteoarthritis • Physical activity maintains function

22. Randomised Controlled Trial (RCT) Measurement of outcomes so that assessors are blinded to treatment group, and all subjects are included into the ’intention-to-treat’ -analysis

23. KNEE OA & EXERCISE • Randomized 18 mo trial; aerobic exercise vs. resistance exercise vs. education • N = 439 subjects, age 60+ • Conclusion: Older disabled persons participating in aerobic or resistance exercise programs had modest improvements in measures of disability, performance and pain • (Ettinger et al. JAMA 1997;277:64-66)

24. Statistical methods of meta-analyses • Dichotomous (or binary) data; odds ratios (OR), relative risks (or relative effects), risk differences as well as absolute measures, such as the number needed to treat (NNT). • For continuous data; weighted mean difference (WMD) is preferable when outcomes measured in a standard way. In case continuous outcomes are conceptually the same but measured in different ways, standardized mean differences (SMD). • Heterogeneity between different studies; fixed effect vs. random effects analysis methods

25. Osteoarthritis – Contrast; ExerciseOutcome; Pain (Fransen et al.)

26. Osteoarthritis – Contrast; ExerciseOutcome; Physical function

27. Osteoarthritis • Based on RCTs, land-based therapeutic exercise (with manual therapy or balance training in some studies) improved self reported pain and self-reported physical function in patients with knee osteoarthritis (Fransen et al., 2007). • Both aerobic walking and home based quadriceps strengthening exercise reduce pain and disability but no difference between them was found on indirect comparison (Fransen et al. 2008, Roddy et al. 2005, Lange et al. 2008). • The effect size of exercise in alleviating pain in hip OA has been shown to be compareable to that in knee osteoarthritis (Hernandez-Molina et al. 2008).

28. Osteoarthritis • Aquatic exercise gives rather similar benefits as land-based exercise (Bartels et al. 2008). The effect of exercise on the progression of osteoarthritis is unclear. • On the basis of 11 RCT:s Pisters et al. (2007) have analyzed long-term effects of exercise therapy in hip or knee osteoarthritis patients. The analysis showed that there is no long-term effectiveness on pain and self-reported physical function 6+ months after the treatment ended. • Additional booster sessions seem to maintain some of the benefits and some benefit on patient global assessment of effectiveness may remain without booster sessions.

29. EXERCISE WITH OA:TRAINING PRINCIPLES • Individual programmes and group-based programmes are equally effective; long-term compliance is a key factor. Utilise local resources. • Remember: Movement, progressive muscle strengthening, ROM, aerobic training. • Avoid: Injuries, high impact loads.

30. TAKE-HOME MESSAGE:EXERCISE AND OA • Exercise associated injuries may lead to degenerative changes and OA • Different types of training may help in the prevention or treatment of disability • Can exercise help in the prevention of degenerative changes? No final evidence.

31. Yleinen liikuntasuositus • Alaraajojen nivelrikkoa potevalle sopivat hyvin esim. uinti, pyöräily (huom. erit. ylipainoiset; ei kehon paino kipeän nivelen päällä), kävely • Huonommin sopivat juoksu, pallopelit yms. • Yläraajojen nivelrikkoa poteville sopii myös juoksu ym. esim. mailapelit huonommin

32. Vasta-aiheet ja varoitukset • Yleensä kyseessä iäkkäät henkilöt, aina vähintään kardiovaskulaarianamneesi • Kysytään kipeytymisistä, muunnetaan ohjelmaa • Jos nivelen lukkiutumisia, pahenevaa nivelturvotusta ym. arvioidaan kliininen tilanne ja harjoituskelpoisuus uudelleen

33. Ryhmäohjelman toteutus • Aluksi esim. 3 x viikko x 1 tunti, myöhemmin käyntejä harventaen ja kotiohjelmaa opastaen • Nousujohteinen • Sisätö: Lämmittely (esim. kuntopyörä, kävely), venyttely, kuntopiiri 2 x (2x10 liikettä) sisältäen mm. polven ojentajien ja koukistajien harjoituksia + esim istumasta ylös nousu, verryttely/venyttely

34. Exercise and the prevention of rheumatoid arthritis • There is no clear evidence on that exercise pedisposes to or prevents from rheumatoid arthritis

35. Rheumatoid arthritis • On the basis of more than 10 RCTs exercise therapy seems to be effective at increasing aerobic capacity and muscle strength in patients with rheumatoid arthritis though good meta-analyses are lacking (Kettunen and Kujala 2004, Van den Ende et al., 2004, Metsios et al. 2008). • Also on the basis of 3 RCTs in patients with juvenile idiopathic arthritis under 18 years of age the functional ability tended to be better after exercise therapy (Takken et al. 2008). • No detrimental effects on disease activity and pain were observed in these trials. • The effects of dynamic exercise therapy on radiological progression and cardiovascular disease need further studies (Kettunen and Kujala 2004, Van den Ende et al., 2004, Metsios et al. 2008). • Disease activity?

36. EXERCISE WITH RA:TRAINING PRINCIPLES • Individual programmes and group-based programmes are equally effective; long-term compliance is a key factor. Utilise local resources. • Remember: Movement, progressive muscle strengthening, ROM, aerobic training. • Avoid: Injuries, high impact loads.

37. TAKE-HOME MESSAGE:EXERCISE AND RA • Different types of training may help in the prevention or treatment of disability • Aerobic exercise helps in maintaining cardiovascular function (remember co-morbid conditions) • Can exercise help in the prevention of degenerative changes? No final evidence.

38. Takken et al.: Exercise therapy in juvenile idiopathic arthritis

39. Exercise after total joint replacement • There is some evidence based on RCTs that perioperative (Gilbey et al. 2003) and postoperative (Maire et al. 2003) exercise therapy improves early functional recovery after total hip arthroplasty.

40. Exercise after total joint replacement • Consensus statements say that participation in no-impact or low-impact sports (swimming, cycling etc.) can be encouraged, but participation in high-impact sports (running, ball games, racquetball etc.) should be prohibited after TJR (McGrory et al. Mayo Clin Proc 1995;75:342-348). • There is some evidence of increased surface wear rate (Dubs et al. Arch Orthop Trauma Surg 1983;101:161-169) and of increased aseptic loosening rates (Kilgus et al. Clin Orthop 1991;269:25-31) in active patients.

41. Ankylosing spondylolitis • Four RCTs compared exercise program with no intervention and reported some increases in spinal mobility and physical function (Dagfinrud et al., Cochrane Review 2008). • Training of ROM and muscle strength are effective.

42. Low back pain

43. Exercise in the prevention of low back pain • Leisure physical activity does neither predispose to nor prevent from LBP • Good muscle function does neither predispose to nor prevent from LBP • High work-related loading predisposes to LBP • Traumatic sports predisposes to degenerative changes and pain episodes • Physically active have better function

44. Low back pain • Acute back pain – Exercise does not help (strong evidence); subacute back pain – no help • Chronic low back pain; effect on pain based on 8 RCTs -10.2 units (95% CI; -19.09, -1.31) on a scale from 0 to 100. • Effect on function is smaller (target group has an effect) • Exercise may be helpful for chronic LBP patients to increase return to normal daily activities and work. (Hayden et al. Cochrane Database Syst Rev)

45. LBP- Hayden et al. Updated review

46. EXERCISE WITH CHRONIC LBP:TRAINING PRINCIPLES • Non-traumatic exercise that helps in increasing ordinary activity.

47. Best exercise programme? • Indirect comparisons using Bayesian multivariable random-effects meta-regression (Hayden et al. Ann Intern Med 2005;142:776-786) • Compared to non-supervised home exercises the improvements were higher for: • Individually designed programs 5.4 points • Supervised home exercise 6.1 p. • Group and individually supervised program 5.9 p.

48. TAKE-HOME MESSAGE:EXERCISE AND LBP • Exercise associated injuries may lead to degenerative changes • Different types of training may help in the prevention or treatment of disability • Can exercise help in the prevention of degenerative changes? No final evidence.

49. Neck and shoulder pain

50. Chronic non-specific neck-shoulder pain syndrome • 5% of Finnish men and 7% of Finnish women (Mini-Finland health survey) • Patholic-anatomic causes can be determined in only a small proportion of cases; imaging methods focus on excluding severe underlying causes • Pain originates from muscles?, other soft tissues?, facet joints?, intervertbral discs?