Clinical Concepts

Benefits of Physical Activity for Knee Osteoarthritis

A Brief Review
Beverly Anne Egan, BS; and Janet C. Mentes, PhD, APRN, BC

Abstract
Osteoarthritis (OA) is the second most
prevalent health condition in commu-
nity-dwelling adults 65 and older, with
27 million older Americans affected. Ap-
proximately half of community-dwelling
women (54%) and men (43%) older than
65 have OA, and the percentage with
symptomatic knee OA rises to more than
60% among older adults who are over-
weight. This article examines major risk
factors for knee OA and nursing interven-
tions to help older adults with knee OA
minimize disease symptoms. Significant
O steoarthritis (OA) is the
second most prevalent health
condition in community-dwelling
adults 65 and older (Federal Inter-
agency Forum on Aging-Related
Statistics, 2010), with 27 million
older Americans affected (Helmick
et al., 2008). Approximately half of
community-dwelling women (54%)
and men (43%) older than age 65
have OA, and the percentage with
symptomatic OA of the knee rises
to more than 60% among older
adults who are overweight (Murphy
et al., 2008). Although not fatal,
OA is associated with pain, stiff-

© 2010 iStockphoto.com/Eileen Hart

health benefits of physical activity for ness, decreased physical functioning,
the prevention of obesity, delay of onset incontinence, depression, and overall
of physical limitation, and importance to poorer quality of life for affected
normal joint health for older adults with older adults (Arthritis Foundation,
OA are emphasized. Nursing recommen- 2008). Often, coping with other
major health conditions, such as
dations for physical activity in older adults
congestive heart failure or chronic
with OA are detailed. Social and environ- Helmick, & Sacks, 2010). Nurses can
respiratory disease with an overlay of
mental barriers inhibiting older adults intervene at any point of the decline
OA precipitates a cascading decline
from achieving their weight loss and ex- to improve function and quality of
in function for older adults, result-
life. The purpose of this article is
ercise goals are discussed. Resources sup- ing in social isolation and depres-
to discuss the major risk factors for
porting physical activity in older adults sion (Fried, Storer, King, & Lodder,
knee OA and nursing interventions
with OA are provided. 1991; Theis, Murphy, Hootman,
to help older adults with knee OA
minimize disease symptoms.
ABOUT THE AUTHORS OA is a progressive and debilitat-
Ms. Egan is a nurse, Santa Monica UCLA Medical Center gerontology unit, and ing disease that commonly affects
Dr. Mentes is Associate Professor, University of California Los Angeles, School of
the hand, knee, hip, and spine joints
Nursing, Los Angeles, California.
The authors disclose that they have no significant financial interests in any product or (Goldring & Goldring, 2006).
class of products discussed directly or indirectly in this activity, including research support. Elements of joints, such as the
Address correspondence to Janet C. Mentes, PhD, APRN, BC, Associate Professor, synovial lining, periarticular bone,
University of California Los Angeles, School of Nursing, 5-262 Factor Building, PO and supportive connecting tissues,
Box 956919, Los Angeles, CA 90095-6919; e-mail: jmentes@sonnet.ucla.edu.
are adversely modified by OA with
Posted: August 23, 2010
doi:10.3928/00989134-20100730-03 structural changes including continu-

Journal of Gerontological Nursing • Vol. 36, No. 9, 2010 

ous loss of articular cartilage, forma-
tion of new bone at joint margins,
increased thickness of the subchon-
dral plate, and growth of subchondral
bone cysts. In addition, calcified
cartilage forms at the attachments of
the surrounding subchondral bone
and articular hyaline cartilage. These
structural alterations manifest in
symptoms of pain, stiffness, and loss
of mobility.
Several current studies of healthy
young and old adults who underwent
magnetic resonance imaging of their
joints revealed that joint changes man-
ifest earlier than thought (Ding, Jones,
Wluka, & Cicuttini, 2010). Early signs
of joint degeneration are associated
with smoking; vitamin D deficiency;
and increased levels of lipids, leptin,
and inflammation and are thought to
be potentially reversible at a younger
age (Ding et al., 2010). The investiga-
tors concluded that early intervention
could possibly avert or reverse some
of the joint deterioration that may
progress to OA (Ding et al., 2010).
Risk factors
Major risk factors for OA are older
age, overweight and obesity, physi-
cal inactivity, previous joint injury,
repeated overuse of certain joints, and
heredity (Ding et al., 2010). After age
50, women are more likely than men
to be affected by OA (Lawrence et al.,
1998). Of these factors, overweight
and obesity and physical inactivity are
two risks that can be minimized.
Overweight
Being overweight or obese is rec-
ognized as a major risk factor for OA,
particularly OA of the knee. Nation-
ally, 70.8% of adults older than 60 are
identified as overweight, and 32.9%
are identified as obese (Wang, Miller,
Messier, & Nicklas, 2007). Obesity,
defined as a body mass index (BMI)
>30 kg/m2, can cause severe health
implications, including increased
risk for additional chronic illnesses,
impaired quality of life, and increased
mortality (Villareal, Apovian, Kush-
ner, & Klein, 2005).
10
A recent study of older adults liv-
ing in rural North Carolina suggested
that adults have a 50% lifetime risk of
developing knee OA by age 85, and
for those who are overweight, the risk
rises to 67% (Murphy et al., 2008).
However, current opinions concerning
the link between obesity and knee OA
are evolving and suggest that BMI as
a measure of obesity/overweight only
reveals part of the relationship (Sowers
& Karvonen-Gutierrez, 2010). It has
been assumed that the shearing force
of additional weight is the mechanism
for deterioration of the knee joint;
however, the use of BMI to deter-
mine obesity is problematic because it
does not adequately characterize the
amount and strength of lean muscle
mass (Sowers & Karvonen-
Gutierrez, 2010). Since muscle
strength and increased muscle mass
are thought to be protective against
cartilage loss in middle-aged and older
adults, it is important to know the
overweight older adult’s fitness level.
An additional emerging opinion
concerning the link between obesity
and knee OA is that the metabolic
and inflammatory environment as-
sociated with obesity may contribute
to knee OA through direct joint
degradation or mediation of local
inflammatory processes (Sowers &
Karvonen-Gutierrez, 2010). This is a
compelling finding because OA had
previously been considered a disease
of “wear and tear” rather than influ-
enced by inflammatory processes.
Physical Inactivity
Another major risk factor for OA
is physical inactivity. According to the
National Health Interview Survey,
the percentage of people 45 and older
who reported engaging in regular
leisure time physical activity declines
with age (Federal Interagency Forum
on Aging-Related Statistics, 2010).
In 2007-2008, approximately 22% of
people 65 and older—25% of those
65 to 74, 21% of those 75 to 84, and
11% of those 85 and older—reported
engaging in regular physical activity
(Federal Interagency Forum on Ag-
ing-Related Statistics, 2010). Although
these statistics may not be representa-
tive of the general population with
arthritis, these data show that many
older adults are not including physical
activity in their daily lives.
The health benefits of physical
activity are well established, includ-
ing prevention of obesity, delay of
onset of physical limitation, and
importance to normal joint health
(Hootman, Macera, Ham, Helmick,
& Sniezek, 2003). Vigorous activ-
ity has been associated with better
joint health in people age 50 to 79
(Racunica et al., 2007), and Ding et
al. (2010) reported that women who
were regular walkers were less likely
to have early signs of joint abnormal-
ities, such as cartilage degeneration.
Although there are conflicting data
on the effect of quadriceps strength
on knee OA, older adults with a
higher muscle mass, presumably
from regular exercise, have decreased
cartilage loss, suggesting that in-
creased muscle mass and strength
protect joints from degenerative
changes (Ding et al., 2010).
The Vicious Cycle of Body Weight
and Physical Inactivity
Many overweight older adults with
OA choose not to exercise because
of joint pain and fear of exacerbating
their symptoms. Consequently, lack
of physical activity leads to continued
weight gain, which further stresses ar-
thritic joints and worsens symptoms.
Studies show that for every pound of
weight loss, there is a 4-pound reduc-
tion in load exerted on the knee, with
further reduction of pain with as little
as 15 pounds of weight loss (Messier,
Gutekunst, Davis, & DeVita, 2005).
Aerobic and resistance exercise have
been shown to reduce pain and dis-
ability among those with OA, while
increasing physical performance;
however, individuals with arthritis are
often wary of exercise because activity
can initially increase pain or because
they inaccurately believe physical
activity will worsen their arthritis
(Hootman et al., 2003). Furthermore,
Copyright © SLACK Incorporated
 Table
Activity Recommendations for Older Adults
Type of Exercise/
Activity Duration/Frequency Suggested Activities
Aerobic
Moderate 30 minutes, 5 or more days per week Dancing, swimming or water exercises, jogging, bik-
ing, brisk walking, household chores, gym workout at
an intensity of 5 to 6 on a 10-point scalea
Vigorous 20 minutes, 3 or more days per week Performing same activities as for moderate but at an
intensity of 7 to 8 on a 10-point scalea
Strengthening 2 to 3 days per week for 8 to 10 muscle groups Using household items (e.g., can of soup), light hand
weights, or weight machines to exercise major muscle
groups. Examples for home exercise include wall
push-ups, toe stands, and use of resistance bands. In-
tensity of 5 on a 10-point scale for 10 to 15 repetitions.
Flexibility At least 10 minutes, 2 or more days per week Stretching most joints (e.g., shoulder, hip, knee, back,
elbow, wrist, ankle); performing yoga.
Balance 3 or more days per week until exercises completed Standing on one foot; performing yoga and/or tai chi.

Sources. Nelson et al. (2007), Partners in Care Foundation (2000), and Resnick (2001).
a
Intensity is graded on a 10-point scale where 0 = sitting and 10 = all-out effort. Moderate activity produces noticeable increases in heart rate and
breathing, and vigorous activity produces large increases in heart rate and breathing.

older adults with OA may not be
counseled by their health providers
to lose weight or exercise, despite the
fact that such advice is the best predic-
tor of weight loss attempts (Fontaine,
Haaz, & Bartlett, 2007; Houston,
Nicklas, & Zizza, 2009). A summary
of a Cochrane review examining
exercise for OA of the knee discov-
ered small, statistically significant
benefit for exercise effects on pain and
self-reported physical function (Lin,
Taylor, Bierma-Zeinstra, & Mather,
2010). However, it is unclear how of-
ten exercise prescriptions are given to
older adults, and when recommended,
whether the type and duration of
exercise is well specified.
Social and Environmental
Barriers to Exercise and
Weight Loss
Understanding the factors affect-
ing physical activity and exercise
behavior is a necessary first step
toward identifying the needs of and
intervention strategies for people
with arthritis. Several social and
environmental barriers hamper older
adults from achieving their weight
loss and exercise goals, including low
motivation, lack of social support,
low self-efficacy, and unsafe environ-
ments in which to exercise. Howarth,
Inman, Lingard, McCaskie, and
Gerrand (2010) studied barriers faced
by obese individuals with OA of the
knee to achieve weight loss. Among
the 35 participants, 89% had at some
point attempted to lose weight, of
which 87.5% tried to lose weight
through diet alone. A majority (89%)
of participants reported that lack of
motivation was their greatest barrier
to achieving weight loss, with only
28% reporting knee pain to be their
greatest barrier to weight loss. Pa-
tients with higher BMIs (>40 kg/m2)
expressed a preference for a weight
loss support group (Howarth et al.,
2010).
This evidence highlights the im-
portance of the use of support groups
for exercise or weight reduction.
Older adults may become more mo-
tivated to lose weight if they have the
social support of a structured group
and are informed about ways to live
a more active lifestyle that promotes
weight loss. Other group programs,
such as People with Arthritis Can
Exercise (PACE), a community-
based exercise program developed
by the Arthritis Foundation, can be
implemented to promote physical
activity that prevents disease pro-
gression. Schoster, Callahan, Meier,
Mielenz, and DiMartino (2005) found
that individuals with OA reported re-
ceiving considerable support through
exercising with a group with other
people who have arthritis. Two key
motivational factors that helped them
continue attending the exercise classes
were confidence that they could safe-
ly perform different types of exercise
(i.e., self-efficacy) and flexibility to
exercise at their own pace during the
class (Schoster et al., 2005).
Glass, Rasmussen, and Schwartz
(2006) examined unsafe neighbor-
hood environments as a barrier for
weight reduction. A total of 1,140
community-dwelling men and wom-
en (ages 50 to 70) from 65 neighbor-
hoods in Baltimore, Maryland, were
randomly selected to participate in

Journal of Gerontological Nursing • Vol. 36, No. 9, 2010 11

the study. Results indicated that 38%
were obese and that despite indi-
vidual socioeconomic and behavioral
risk factors, participants who lived in
more dangerous neighborhoods were
two times as likely to be obese than
those living in the least dangerous
neighborhoods. The authors con-
cluded that patterns of obesity are
influenced by neighborhood condi-
tions. Through education, reducing
crime rates, and increasing public
safety, communities can reduce envi-
ronmental and sociological hazards
that impact the health of its residents
(Glass et al., 2006).
Although diet and weight reduction are important
aspects of a treatment plan for older adults with
osteoarthritis, increasing physical activity may be the
best first treatment intervention.
Crime and violence within com-
munities cause significant barri-
ers to physical activity for older
adults. Environments that have
high crime rates and limited safe
places for outdoor physical activity,
including sidewalks and streets for
walking and jogging, restrict older
adults from living active lifestyles.
Maslow’s hierarchy of needs can
further explain the barriers that
older adults face within their com-
munities that restrict them from
being physically active and place
them at greater risk for obesity and
arthritis (Alfonzo, 2005).
When a population is exposed
to stressors such as inadequate and
unsafe shelter and unhealthy food,
they are unable to partake in healthy
lifestyle choices that do not seem
vital to immediate survival. Com-
munity members who live in fear of
violence are less likely to participate
in exercise, which may seem like
a leisurely and expendable aspect
of their lifestyle. However, for all
12
age groups, participating in exer-
cise is crucial to preventing chronic
illness and improving quality of
life (Weight-control Information
Network, 2008). Therefore, com-
munity leaders need to develop
strategies to decrease environmental
barriers, such as crime and fear of
violence, that encourage inactivity,
obesity, and arthritis. To promote
physical activity, communities can
strive to improve access to places
where people can be active, such as
accessible walking trails and classes
at gyms or senior centers.
Nursing Interventions for
Osteoarthritis
As health care providers for older
adults, nurses are in a position to
promote physical activity and weight
loss among overweight and obese
patients with knee OA. Although
diet and weight reduction are im-
portant aspects of a treatment plan
for older adults with OA, increas-
ing physical activity may be the best
first treatment intervention, espe-
cially when implementing several
lifestyle changes concurrently may
be challenging for an older adult.
Current research demonstrates that
the relationship between obesity and
OA is more complicated than simply
the effect of excess weight on joints
(Sowers & Karvonen-Gutierrez,
2010). Muscle size and strength is an
important factor in protecting joints,
even in older adults. Findings that
early signs of joint deterioration can
be reversed in younger adults suggest
that prevention of OA may be pos-
sible if one becomes physically active
as a younger adult and maintains this
habit into older age (Ding et al., 2010).
Current American College of
Sports Medicine and American
Heart Association recommendations
for older adults with chronic condi-
tions or functional limitation, with
suggested activities, are listed in the
Table (Nelson et al., 2007). With
these recommendations in mind,
nurses can implement several simple
interventions to encourage older
adults to decrease the incidence or
manage the symptoms of OA.
Plant the Seed
Nurses should always evalu-
ate their patients’ physical activity
levels, regardless of their weight.
Discussions about weight and ex-
ercise are often value laden and dif-
ficult to initiate, but it is important
for nurses to have a discussion and
“plant the seed” for beginning a life-
time of physical activity at a point
when prevention may be possible.
Nurses should not assume that older
adults who are overweight or obese
have been counseled to exercise;
preventive strategies can be over-
looked because of providers’ beliefs
that older adults cannot change or
are “too old” to begin an exercise
regimen (Resnick, 2001).
Individualized Exercise Assessment
A standard recommendation
for increasing activity is to encour-
age older adults to walk. However,
without conducting a personalized
assessment, as recommended by
Resnick (2001) and Resnick et al.
(2008), the likelihood of an older
adult following through on any
recommendation to increase physi-
cal activity is low. Older adults with
specific health concerns related to
OA and comorbid conditions, such
as pain, low endurance, or fatigue,
require a preliminary health assess-
ment and an individualized activity
prescription. Ideally, the assessment
and prescription are carried out
within the context of an interdis-
ciplinary team (physician, nurse,
Copyright © SLACK Incorporated
physical or exercise therapist) with
a focus on identifying ways for the
older adult to exercise and not on
potential risks (Resnick et al., 2008).
Activity versus Exercise
Older adults can increase their
activity levels in many ways. If the
term exercise is used, some may not
believe themselves capable of an
exercise regimen, possibly because
they equate exercise with vigorous
activity at a gym. In fact, moderate
activity is recommended for people
with knee and hip OA, including
gardening, dancing, swimming,
walking, golfing, and bicycling
(Hootman et al., 2003). It is chal-
lenging to help individuals with OA
choose the best type of physical
activity that will be fun and sustain-
able, yet not place excessive strain
on their joints. In addition, if the
person has a sedentary lifestyle, ac-
tivity may need to be incorporated
gradually. Nurses need to assess
the level of exercise that can make
a difference for the patient’s OA
symptoms (Hootman et al., 2003).
Participating in everyday activities,
such as walking a little farther to the
car when in a parking lot, climb-
ing the stairs instead of using the
elevator (however, descending stairs
should be avoided), and walking to a
favorite store on a regular basis, can
be an easy way for older adults to
increase daily activity.
Gearing Up
Once the older adult has made a
commitment to begin increasing ac-
tivity, he or she should consider the
appropriate footwear, which can be
overwhelming given the number of
choices. Several tips can be helpful
for those with knee OA:
l Avoid shoes with elevated heels.
l Select shoes with sufficient
room for toes; the older adult
should be able to wiggle the
toes up and down freely.
l Wear shoes with thicker sole
material of moderate stiffness
for shock absorption.
Journal of Gerontological Nursing • Vol. 36, No. 9, 2010
l Replace shoes after walking ap-
proximately 500 miles.
In addition, people with medial
compartment knee OA should wear
flexible shoes with laterally wedged
insoles, and those with lateral
compartment knee OA should wear
supportive shoes with medially
wedged insoles (Gross, 2010). The
rocker-bottom style of shoes that
have been advertised to improve
exercise workouts are not the best
choice for older adults. The design
may cause anterior-to-posterior
instability, causing the person to fall
forward or backward when shift-
ing the center of gravity suddenly
(Gross, 2010).
Resources
Many print and electronic
resources are available for health
care providers to distribute or for
older adults to access. Depending
on the older adult’s technology
skills, written materials or vid-
eos demonstrating exercises can
be accessed and downloaded to
cell phones, netbooks, or iPods®.
The National Institute of Aging
(NIA) has developed exercise/ac-
tivity guidelines specifically for
older adults (http://www.nia.
nih.gov/HealthInformation/
Publications/ExerciseGuide), and
the U.S. Department of Health
and Human Services has published
adult physical activity guide-
lines (http://www.health.gov/
paguidelines/guidelines/default.
aspx). Additional resources related
to exercise and activity for older
adults can be found on the NIA
website (http://www.nia.nih.gov).
An evidence-based program for
frail older adults, Healthy Moves
for Aging Well, is available in seven
languages on the Partners in Care
Foundation website at http://www.
picf.org/landing_pages/22,3.html.
In recommending use of electronic
resources, nurses should caution
older adults to look for current
information on reliable websites.
Summary
By being more active, older
adults with knee OA may decrease
their pain and the risk of functional
impairment or disability. They can
safely achieve recommended levels
of physical activity by choosing
joint-friendly types of moderate
activity and making an activity
plan for themselves. Nurses can
help by counseling their adult and
older adult patients to increase
their activity and by recommend-
ing an individualized exercise
assessment and prescription that
includes activities the older adult
enjoys, are the right intensity, and
will hold their interest. Multiple
resources are available to support
older adults’ ongoing participation
in enjoyable physical activity.
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