MSK and Physical Activity
Edited by: Luxshmi Nageswaran
Chronic Diseases Related to System and PA
Within developed countries, musculoskeletal conditions are the number one contributor to physical disability (26). These conditions have increased by 25% in the past 10 years (26). There are two important diseases associated with aging: sarcopenia, and osteoporosis. The former is depicted by the loss of type 2 muscle fibers and motor neurons, leading to muscle weakness. Osteoporosis leads to decreased bone strength and can cause an increase in fractures. Osteoporosis is characterized by fragility fractures, which can result in a further loss of physical function, as well as other complications including malnutrition, depression, poor quality of life and even death.11 Loss of muscle strength can be much more serious than we perceive. In seniors, decreased muscle strength is associated with an increased risk of not only a loss of independence, but also dementia and mortality (14). As mentioned earlier, this loss of strength can lead to frailty which can accumulate into many issues, one of which being falls (4). Within Canada, those over 50 who sustain a hip or spine fracture are at a significantly increased risk of early death (26). Osteoporotic fractures have almost doubled in the last ten years.26 There is cause for concern within Canada as death from musculoskeletal conditions dropped since the 1970s, but have increased sharply in the past twenty years.26 Osteoarthritis (OA) is a steadily advancing condition of joints that are generally weight-bearing in nature. Traditionally OA was thought to be related to deterioration caused by aging. Contemporarily it is being recognized as the body improperly repairing the joints that are injured from abnormal joint stress, joint injury, and obesity (28). OA is more common than any other type of arthritis. As the Canadian population ages, the prevalence of this condition is expected to increase (28). To contrast the two types of arthritis, rheumatoid arthritis (RA) is an autoimmune condition that is chronic in nature and characterized by often affecting many joints, often the same joints are affected on both sides of the body. It is a progressive inflammatory disease that can damage and destroy joints, leading to substantial disability (27).
How PA can be Preventative
Physical activity is likely to delay or even prevent many common musculoskeletal disorders including lower back pain, neck, and shoulder pain, osteoporosis, and resulting fractures. It has been hypothesized that contracting skeletal muscles may be able to reduce the harmful results of inactivity by releasing certain circulating myokines. According to this theory, exercising skeletal muscle can decrease the risk of developing metabolic syndrome, diabetes, and cardiovascular disease (14). To reduce the chances of being diagnosed with OA or delay its onset, it is crucial to maintain a healthy BMI and exercise to keep joints and muscle strong (28). Canadian data has demonstrated a slight increase in death in those diagnosed with OA in comparison to those who did not have the condition (28).
The available body of research dating back to the mid-1990s was strong enough to recommend routine physical activity in order to boost musculoskeletal health and function (1). The heart muscle can also change for the better with exercise. The Cardia study prospectively looked at almost five thousand Americans between the ages of 18 and 30 years beginning in 1985 and followed-up serially up to 25 years later. They found a strong association between fitness and change in heart muscle structure, including fitness early in an adult’s life and long-term longevity independent of weight (8). Physical fitness in this study was determined by endurance on participants on a treadmill (9). Lower heart muscle mass was associated with higher baseline fitness at 25 years after the start of the trial (8). Increased Cardiorespiratory fitness (CRF) identified in early adulthood as being associated with long lasting change in heart muscle structure is strong evidence of the enduring effect of CRF on heart disease (8).
Physical activity can assist in preventing osteopenia and osteoporosis. In terms of physical activity, resistance exercises seem to have the most significant effect on bone mineral density (BMD) (21). Strength from physical activity can be used to risk-stratify individuals at increased risk of falls by determining their maximal leg press push of force (14). Recognizing those with lower leg press push off force could help prevent falls by enabling those to reinforce a safer environment and increase strength. It can be argued that it is never “too late” to start exercising. The ENHANce trial is currently examining adults over 65 have been randomized into groups that included exercise, protein supplementation, and omega fatty acid interventions or a combination for 12 weeks. The exercise program utilized is called the modified Otago Exercise Program (OEP). The OEP is a well-known exercise program that can prevent falls by increasing strength, balance, and endurance in older adults that can be performed in the comfort of your home. The conclusions have yet to be published (4). but hopefully we will see improvements in the intervention groups. A systematic review in 2019 also found that lean muscle mass increase after supplementing protein and incorporating muscle strengthening exercises into a lifestyle routine increased strength and mobility in senior patients who are at a high risk of frailty or sarcopenia (10).
Motivation to be more active can go above and beyond preventing disease and chronic conditions. Physical activity studied at a metallurgy facility in Brazil looking at both production line workers and office workers found that regular physical activity can reduce absenteeism (5). Resistance training can decrease sports injuries by 33% and overuse injuries by close to half (14). When it comes to preventing sports injuries, strength training was found to be more preventative than stretching, proprioception training and multiple exposure programmes (14). Physical activity can improve musculoskeletal rehabilitation and decrease convalescence post-orthopedic surgery (1). A very relevant study from Turkey looked at physical activity, smartphone use, and musculoskeletal complaints. The study mentioned that smartphone use has been associated with an inactive lifestyle, leading to musculoskeletal problems (13). In this study, university students were given questionnaires to complete and it was found that 75% of those who completed the questionnaires had not been doing regular physical activity for the last month. Sixty-seven percent had been sitting more than 4 hours a day, and half had musculoskeletal pain complaints. The students who had pain complaints spent more time on their computers and smart devices than those who did not (13). This is in line with a study by Alabdulwahab et al. that found a correlation between the smartphone addiction and the neck disability. This correlation was found to be statistically significant (13).
How PA can be treatment
Physical activity increases both the strength and bone mineral density of our bones (7). It may seem counterintuitive, but our bones respond well to loads that induce high strains at a high frequency (14). Walking has shown little benefit in the spinal bone mineral density of postmenopausal women (14). In contrast. high intensity resistance and impact-training proved to be more beneficial to lower intensity training in postmenopausal women who had confirmed osteopenia or osteoporosis (14). Included in the high-intensity training were deadlifts, overhead press, squats and impact loading by completing jumping chin-ups with drop landings (14). The result of high intensity training was improved spinal BMD (14). In a meta-analysis of randomized controlled trials, bone reduction on a yearly basis of the lumbar spine and femoral neck in women were prevented or reversed by nearly 1% per year in women who completed exercise training programs (21). In an article by Maestroni et al., it was said “strong evidence suggests that an appropriately designed resistance training program for older adults should include an individualized and periodized approach working toward 2–3 sets of 1–2 multi-joint exercises per major muscle group, achieving intensities of 70–85% of 1RM, 2–3 times per week” (14). Generally meaningful improvement in muscle and bone tissue can be evident after only 8 to 12 weeks of resistance training when following guideline-specific recommendations, while some literature observed improvement in as little as 2 to 4 weeks (14). It seems even youth can benefit from physical activity, particularly resistance and loading exercises. A study demonstrated that pre-pubertal high performance female gymnasts had higher BMD compared to swimmers and other active peers. Overall available evidence demonstrated encouraging youth to include weight-bearing exercise and impact loading to encourage and preserve healthy bones over the course of their life.14
Thirty years of evidence has shown that physical activity, in particular aquatic activity, is beneficial for decreasing pain and disability in a multitude of musculoskeletal conditions (12). Aquatic activity can decrease the pressure on bones joints and muscles to allow for increased movement and can possibly stop pain nerve transmission by acting on heat and pressure receptors (12). Water has the added benefit of allowing a great range of motion by providing buoyancy and supporting our natural body weight (12). Current clinical evidence-based guidelines for OA recommend strength training. A systematic review and meta-analysis by Juhl et al. showed pain and disability decreased with certain quadricep-specific exercises in comparison to general lower limb exercises (14). In OA, the knee joint is able to take loads associated with strength training in a safe manner without damaging consequences to the articular cartilage, however the specific dose is not fully clear (14). Individuals who have rheumatoid arthritis often will avoid exercise because of fear of increased pain (29). Studies have supported this increased time being sedentary in rheumatoid arthritis patients (30). However, exercise is a fundamental treatment to decrease disability (29). Some research has demonstrated that exercise will not worsen your symptoms, but individuals with advanced diseases may want to opt for more low impact exercises (29). In fact, the opposite is true. Studies have demonstrated the association between higher levels of physical activity and lower disease activity, as well as decreased bodily inflammation (30).
How Specific SES groups are affected
Canadians with the lowest incomes tend to report the least amount of physical activity, as poverty acts as a significant barrier (31). Traditionally it was challenging to find the relationship between socioeconomic status, bone density, and fractures related to osteoporosis (33). However, a 2021 Spanish study found that poverty was linked to higher parathyroid hormone levels, increased BMI, decreased vitamin D levels, lower spinal BMD, and an increased rate of both vertebral and non-vertebral fractures. Interestingly, another 2021 study from Korea found that individuals with the lowest incomes had a 1.63 times increased risk of developing osteoporosis (32). In the American Third National Health and Nutrition Examination Survey (NHANES-III), those with hip and knee OA and were of a lower socioeconomic status had a higher incidence, increased prevalence, and more unfavourable outcomes due to OA (16). A 2021 American cohort study also found more unfavourable functional status and accelerated declines in functioning in patients with rheumatoid arthritis from a lower SES background (17). In this study, almost 84,000 individuals were analyzed by completing questionnaires on functioning (17). Izadi et al. found “functional status was significantly worse across each successively lower quintile of socioeconomic status (SES)” (17). A study from the US a year later found that both low levels of education and occupation status were associated with increased pain in rheumatoid arthritis (18). Obtaining proper supports such as physiotherapy could be a facilitator to increase physical activity, especially if an individual suffers from a chronic musculoskeletal condition. Unfortunately, a recent British systemic review with studies from 8 countries found that a majority of the articles identified described moderate strength of association for each social determinant of health and probability of attaining physical therapy use (19). Being female, non-Hispanic, white, having a higher education, living in a city, increased ability to access transportation, being employed, having a higher income, and private insurance were associated with greater probability of physical therapy utilization (19). With regards to the elderly population it seems that musculoskeletal fitness is very important for this population to maintain functional independence. The majority of activities or daily living depend more so on musculoskeletal fitness as opposed to aerobic output (21).
General Info on the System with some fun facts/ stats
There are 206 bones in the human body, except at birth where there are 300 bones. Many of these bones fuse. ¼ of the 206 adult bones are located in the foot and hand (2).
The adult skeleton is essentially replaced once every ten years (24). Every year 10% of our bones ends up being replaced (24)
The funny bone is in fact not actually a bone (24). The feeling we perceive comes from the ulnar nerve and not the bone itself (24).
There are over 600 muscles in the human body (25)
Loss of muscle mass and strength associated with aging is called sarcopenia. This is a component of frailty and can lead to disability, immobility, falls, broken bones and even death in older adults (4).
We may generally perceive that as we age it is natural for our bodies to functionally decline. However, a large contributor to this is not aging itself, but instead inadequate physical activity (1). From Lawrence University “the old saying- move it or lose it- is a very appropriate adage for musculoskeletal health” (6). When we do not use our muscles via regular physical activity, muscle mass is decreased, bones become weak, and we become prone to injury and disease (6). Worldwide recommendations recommend strength training be completed two or more days a week (14).
Musculoskeletal conditions are some of the most common presenting concerns when patients speak to their primary care provider (15). A 2015 article found evidence that exercise prescriptions could be used to treat at least 26 different chronic medical conditions affecting approximately 117 million individuals (12).
As of 2012, osteoarthritis was the most common musculoskeletal condition (12). In the younger Canadian population, injury is a leading contributor to death and disability. Approximately 50% of treated injuries from Canadian youth in grades 6-10 occurs during physical activity (23). Biking outside seems to be the activity that is the least risky in terms of sustaining a musculoskeletal injury, while weightlifting is the riskiest (22).
The WHO has said that physical inactivity is a global epidemic, affecting nearly 70% of world’s population (5). Physical inactivity is the 4th leading risk for death.3 If 10% of Canadians decreased their sedentary lifestyle and moved more, the following benefits could be elucidated:
Less workplace absenteeism
Additional 1.6 billion to the Canadian economy by 2040
$2.6 billion in reductions on chronic health care management (20)
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