Appeal towards Convincing Exercise Recommendations for Patients with Osteoarthritis

Sport- and Exercise Therapy (SET) is one of the central elements of conservative therapy in gon- and coxarthrosis. An earlier article in the DZSM addressed the efficacy and application modalities of this form of therapy (11). The treating physician plays a major role in the indication for therapy, since he can exert essential influence on the initiation, maintenance and also the effect of SET.

Two points will be particularly emphasized in this Editorial: (a) convincing the patient to begin therapy and (b) the psychosocial context factors in the doctor-patient discussion, which may additionally strengthen the physiological effect of the active substance SET in the sense of a placebo effect. Concerning (a): the doctor’s recommendation of SET is the convincing motivation for many patients to take up regular training (14). Even if training should be the patient’s responsibility long-term, doctors and other caregivers play a decisive role, especially at the beginning. Not only in selecting and correctly dosing the exercises, but also in strengthening the patient’s resolve and relieving his anxiety concerning exercise and activity. Whereas the concrete managing of training falls primarily to sport, exercise or physiotherapists, convincing the patient is an important task for the doctor.

What conditions can be created in the doctor-patient discussion to form or strengthen the patient’s intention to undertake SET? Various factors have decisive influence on eliciting the willingness for physical activity. One important determinant is the expected consequence (15). It reflects the patient’s personal estimate of the consequences the behavioral change will have. The patient must therefore be or become convinced that SET will lead to a reduction in complaints. Explanation of possible side effects along with information about dealing with initial complaints can reduce the fear of negative consequences (11).
It is often easier for patients with arthrosis who are accustomed to sports and exercise to take up health-promoting activity. But it is the patient who is inexperienced in sports who requires support of others to change their lifestyles. This is particularly true of inactive, elderly patients whose arthrosis is more advanced or who suffer from other diseases as well (4). It is important that especially these people are informed of the benefits of SET and that their fear of exercise be relieved. Patients can be introduced to training initially under supervision, for example in outpatient rehabilitation measures or under the supervision of a physiotherapist as part of individual therapy or patient gymnastics using equipment. Sport and Exercise Therapy is recommended for all patients with hip or knee arthrosis, independent of age, severity of the disease or existing concomitant diseases (1, 7, 13). Of course, contraindications of existing concomitant diseases and the current complaint symptoms of the arthrosis must be taken into account in the selection and dosing of the exercises included. The patient’s wishes and preferences should also be included in designing the training program (1, 3, 4, 7, 11).

Point (b) refers to the influence of psychosocial context factors on the effectiveness of an intervention. SET is effective in arthrosis, also compared to a placebo intervention with bogus ultrasound (10). The therapy form thus works like an active substance. Placebo interventions in arthrosis also show relevant effects with effect strengths between 0.5 and 0.7. The motto here: the more invasive the procedure and the more expensive, the more effective (5). Invasive and expensive – two attributes that should not usually apply to sports therapy. Nonetheless, it can be assumed that the success of treatment depends, among other things, on the psychosocial context of the doctor-patient relationship. The term context effect is often used as a synonym for the term placebo and cited as a possible potentiator of the mechanism of action of a therapy (2, 5). This context, convincing the patient that training is effective and relieving the patient’s fear is described as extremely relevant in placebo research and can be applied 1:1 in sport and exercise therapy in arthrosis. To be precise, this means that the treatment is more effective when there is a friendly climate between the doctor and the patient, when a clear diagnosis has been named and a positive course is guaranteed. The doctor’s conviction that the therapy is effective with respect to pain reduction and improved function is central in this. The patient’s fear about pain caused by physical activity can, as described earlier, be completely relieved or reduced by the doctor. The basic statement that Sport and Exercise Therapy is an application with few side effects can also reassure the patient (5, 10, 11, 12).
For many doctors, a lack of knowledge about existing offers in the community is one barrier to approving and explicitly recommending self-management programs and lifestyle interventions like SET (6).

Knowledge of possible forms of sport therapy or providers who offer patient-oriented programs is thus an important factor for the promising successful recommendation for therapy. For this reason, literature references are pointed out here which provide detailed information on examples of training programs (1, 3, 8, 9) and possible providers of arthrosis-specific exercise groups (9, 12). I hope that, in the sense of interdisciplinary cooperation between doctors, therapists and patients, the present article may strengthen awareness of the important function of doctors in the prescription and supervision of SET.