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Three Part Question

In [adult patients with OA knee] Does [running] result in [worsening radiographic OA features].

Clinical Scenario

A 45 year old male patient was referred to community physiotherapy via his GP with a diagnosis of Grade 2 knee OA confirmed by x-ray. The patient is very fit and active and previously ran four times weekly. The patient is worried about worsening of his OA and asked whether continued running would cause disease progression of his OA.

Search Strategy

Amed 1985-2018, BNI 1992-2018, Cinahl 1937-2018, Cochrane library, Embase 1974-2018, Medline 1946-2018
[osteoarthritis OR oa OR arthritis OR "OSTEOARTHRITIS,KNEE"/] AND [knee* AND (joint* OR region*) OR KNEE/] AND [run* OR jog*OR RUNNING/ OR JOGGING/] AND [DISEASE PROGRESSION/ OR DISEASE EXACERBATION/ OR disease* progress*] AND [x-ray* OR radiographic image* OR diagnostic radiological exam* OR radiography OR "DIAGNOSTIC IMAGING"/ OR RADIOGRAPHY/] AND [reduce* function or reduce* physical activit* or pain or PAIN/]

Search Outcome

153 papers were found of which 151 were irrelevant or of insufficient quality for inclusion. The remaining 2 papers are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Bastick et al., 2015 The Netherlands	Schouten et al., (1992) N = 239 with radiological OA grade 2-4 (Kellgren) Lane et al., (1998) N = 55 (28 runners and 27 non-runners) with OA related changes on radiograph	Systematic review which included two studies that investigated the effects of running as a potential prognostic factor for radiographic progression of knee OA.	Joint Space Width (JSW)	Not clearly presented in results	This systematic review as a whole only included two studies on running which reduces the generalisability of these findings to the wider population. The two studies included were outdated; Schouten et al., (1992) and Lane et al., (1998) and they did not utilise an accurate outcome measure to record subjects running level or activity. Schouten et al., (1992) was a general population survey, which lacked control and did not even clearly present the results of the main outcome measure. There was also poor inter-rater reliability of the radiographs using the Kellgren Lawrence Scale and lateral radiographs were not actually taken at baseline so monitoring of disease progression was not able to take place effectively. Lane et al., (1998) was a 9 year longitudinal study but the small sample size of 55 decreases the generalisability of these results to the wider population and weakens the statistical power making a Type 2 error more likely. The study also had a high dropout rate.
			Joint Space Narrowing (JSN)	Runners (p = 0.06) Non-Runners (p = 0.01)
			Radiographic progression of knee osteophytes	Runners (p = 0.002) Non-Runners ( p = 0.05)
			Total Knee Score (TKS)	Runners ( p= 0.02) Non-Runners ( p = 0.02)
Lo et al., 2018 America	N = 1,203 (138 runners and 1065 non-runners) with radiographic evidence of knee OA in at least one knee at baseline	Observational nested cohort study	Prevalence of new knee pain	Runners 26.8% and Non-Runners 29%	This is an observational cohort study which is a lower quality of evidence and results are provided from logistic regression analysis using runner status as the predictor. The external validity of the study may be more applicable to men as a larger percentage of runners were male. Running status was only retrospectively recorded at the 96 month visit and not at the same time as the other outcome measures, which may lead to inaccuracies in subject recall of running frequency. There was poor recording of running status which did not establish distance, speed, and intensity and it is not certain whether knee OA predated running exposure because of the nature of the questions used to ascertain running status.
			Prevalence of improvement of knee pain	Runners 50% and Non-Runners 39.1%
			Prevalence of Kellgren Lawrence worsening	Runners 15.6% and Non-Runners 19.2%
			Prevalence of Medial Joint Space Narrowing Worsening	Runners 19.5% and Non-Runners 23.6%
			Adjusted odds ratio for running - new knee pain	0.9 (0.6-1.6)
			Adjusted odds ratio for running - improvement of knee pain	1.7 (1.0-2.8)
			Adjusted odds ratio for running - Kellgren Lawrence Worsening	0.9 (0.6-1.3)
			Adjusted odds ratio for running - Medial Joint Space Narrowing Worsening	0.8 (0.5-1.2)

Comment(s)

Only two studies were relevant to answer the three part question. Other studies were not used either because they were not relevant to the question and/or did not investigate subjects with pre-existing knee OA or within a running population. The first paper was a systematic review that looked at the prognostic factors for radiographic progression of knee OA. However only two studies within this review specifically looked at the effects of running in subjects with knee OA; Schouten et al., (1992) and Lane et al., (1998). Schouten et al., (1992) was a very poor and outdated study that did not clearly present the main outcome measure and therefore no clear conclusion can be drawn with regards to running and knee OA progression. Lane et al., (1998) was a higher quality study that compared members of a running club to non-running controls, finding that running did not result in significantly worsening of joint space narrowing or total knee scores. However, the high dropout rate, and small sample size reduces the generalisability of these findings to the wider population. Lo et al., (2018) was a large observational cohort study that specifically investigated the effects of running in subjects with pre-exisiting knee OA. However, the study design is of a lower quality of evidence and running status was poorly recorded. They performed knee based logistic regression analyses to predict prevalence of outcome for KL worsening, medial JSN worsening, new frequent knee pain, and improvement of frequent knee pain. Despite the large sample size of 1,203 only 138 were runners and 69.6% or runners were male which reduces the external validity of these results. There is a need for higher quality studies and better recording of running status in future studies.

Clinical Bottom Line

There is limited and low quality evidence to suggest that running does not result in worsening of radiographic OA features in persons with pre-existing knee OA.

References

1. Bastick, A.N, Belo, J.N., M.D., Runhaar, J., Bierma-Zeinstra, S.M.A What are the prognostic factors for radiographic progression of knee osteoarthritis? A meta-analysis Clinical Orthopaedics & Related Research 2015; 473: 2969-2989
2. Lo, G.H., Musa, S.M., Driban, J.B., Kriska, A.M., McAlindon, T.E., Souza, R.B., Peterson, N.J., Storti, K.L., Eaton, C.B., Hochberg, M.C., Jackson, R.D., Kwok, C.K., Nevitt, M.C., Suarez-Almazor, M.E. Running does not increase symptoms or structural progression in people with knee osteoarthritis: data from the osteoarthritis initiative Clinical Rheumatology 2018; 37: 2497-2504