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Ottawa Panel Evidence-Based ClinicalPractice Guidelines for TherapeuticExercises and Manual Therapy in theManagement of Osteoarthritis

Background and Purpose. Osteoarthritis (OA) affects a large and growingproportion of the population. The purpose of this project was to createguidelines for the use of therapeutic exercises and manual therapy in themanagement of adult patients (�18 years of age) with a diagnosis of OA.All stages of the disease were included in the analysis, and studies ofpatients who had recent surgery or other rheumatologic, musculoskeletal,or spinal problems or of subjects without known pathology or impair-ments were excluded. Methods. The Ottawa Methods Group usedCochrane Collaboration methods to find and synthesize evidence fromcomparative controlled trials and then asked stakeholder groups tonominate representatives to serve on a panel of experts. The Ottawa Panelagreed on criteria for grading the strength of the recommendations andtheir supporting evidence. Of the 609 potential articles on therapeuticexercises for OA that were identified, 113 were considered potentiallyrelevant, and 26 randomized controlled trials and controlled clinical trialswere ultimately used. Results. Sixteen positive recommendations of clinicalbenefit were developed for therapeutic exercises, especially strengtheningexercises and general physical activity, particularly for the management ofpain and improvement of functional status. Manual therapy combinedwith exercises also is recommended in the management of patients withOA. Discussion and Conclusion. The Ottawa Panel recommends the use oftherapeutic exercises alone, or combined with manual therapy, formanaging patients with OA. There were a total of 16 positive recommen-dations: 13 grade A and 3 grade C�. The Ottawa Panel recommends theuse of therapeutic exercises because of the strong evidence (grades A, B,and C�) in the literature. [Ottawa Panel Evidence-Based Clinical PracticeGuidelines for Therapeutic Exercises and Manual Therapy in the Man-agement of Osteoarthritis. Phys Ther. 2005;85:907–971.]

Key Words: Clinical practice guidelines, Epidemiology, Evidence-based practice, Osteoarthritis, Physical

rehabilitation, Rheumatology.

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IntroductionOsteoarthritis (OA) affects a large proportion of thepopulation. Its prevalence is increasing dramatically asthe populations of industrialized countries age and thebaby boomers enter older adulthood.1 It has beenestimated that the prevalence will increase in the UnitedStates from 43 million in 1997 to 60 million in 2020.2Similarly, in Canada, an increase from 2.9 in 1991 to 6.5million in 2033 (a 124% increase) is expected.3 Osteo-arthritis is recognized as a substantial source of disabilitywith significant social and financial costs due to surgicaland medical interventions and frequent absenteeismfrom work.1,4 In 1994, the total cost for arthritis andrheumatism in Canada was estimated to be betweenCan $4.3 billion and $7.3 billion,5 and the estimatedmedical expenses (excluding cost of time lost from paidor unpaid work) were estimated to be between Can $1.7billion and $2.5 billion.6

Efficiency and efficacy of rehabilitation interventions inOA management have an obvious bearing on the directand indirect costs of the disease. The development ofevidence-based clinical practice guidelines (EBCPGs)will assist patients and clinicians in maximizing theirrehabilitative efforts. Evidence-based clinical practiceguidelines are systematically developed statements tohelp practitioners and clients choose proper health carefor specific clinical circumstances7 and can improve botha patient’s health outcomes and the process of care.8 Arapid and exponential growth in evidence-based clinicalpractice guideline (EBCPG) development has beenobserved in the last decade and may have resulted inseveral occasions of conflicting guidelines on the sametopic.9,10 These inconsistencies are attributed to varia-tions in EBCPG development processes and quality.9,11,12

Several authors10,13,14 have recommended that all

Ottawa Panel Members:

Ottawa Methods Group:Lucie Brosseau, PhD, University Research Chair in Evidence-Based Practice in Rehabilitation, Physiotherapy Program, School of Rehabilitation

Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, CanadaGeorge A Wells, PhD, Department of Epidemiology and Community Medicine, University of OttawaPeter Tugwell, MD, MSc, Centre for Global Health, Institute of Population Health, University of OttawaMary Egan, PhD, Occupational Therapy Program, School of Rehabilitation Sciences, Faculty of Health Sciences, University of OttawaClaire-Jehanne Dubouloz, PhD, Occupational Therapy Program, School of Rehabilitation Sciences, Faculty of Health Sciences, University of OttawaLynn Casimiro, MA, Physiotherapy Program, School of Rehabilitation Sciences, Faculty of Health Sciences, University of OttawaVivian A Robinson, MSc, Centre for Global Health, Institute of Population HealthLucie Pelland, PhD, Physiotherapy Program, School of Rehabilitation Sciences, Queens’ University, Kingston, Ontario, CanadaJessie McGowan, MLIS, Director, Medical Library, Centre for Global Health, Institute of Population Health, University of OttawaMaria Judd, PT, MSc, Canadian Physiotherapy Association, Ottawa, Ontario, CanadaSarah Milne, PT, MSc, Department of Epidemiology and Community Medicine, University of Ottawa

External Experts:Mary Bell, MD (Rheumatologist), Sunnybrook and Women’s College Health Sciences Centre, Toronto, Ontario, CanadaHillel M Finestone, MD (Physiatrist), Sisters of Charity of Ottawa Health Service, Ottawa, Ontario, CanadaFrance Legare, MD (Evidence-Based Practice in Family Medicine), University of Laval, Quebec City, Quebec, CanadaCatherine Caron, MD (Family Physician), Sisters of Charity of Ottawa Health ServiceSydney Lineker, PT, MSc, The Arthritis Society, Ontario Division, Research Co-ordinator, Toronto, Ontario, CanadaAngela Haines-Wangda, PT, MSc, Ottawa Hospital, General Campus, Ottawa, Ontario, CanadaMarion Russell-Doreleyers, PT who practices acupuncture, MSc, Canadian Physiotherapy Association and Ottawa Arthritis Rehabilitation and

Education Program, Ottawa, Ontario, CanadaMartha Hall, OT, MPA, Canadian Association of Occupational Therapists and Ottawa Arthritis Rehabilitation and Education ProgramGerry Arts, person with osteoarthritis (named with her written permission)

Assistant Manuscript Writer:Marnie Lamb, MA, School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa

Address all correspondence and requests for reprints to: Lucie Brosseau, PhD, Physiotherapy Program, School of Rehabilitation Sciences, Facultyof Health Sciences, 451 Smyth Rd, University of Ottawa, Ottawa, Ontario, Canada K1H 8M5 ([email protected]).

This study was financially supported by The Arthritis Society (Canada) (Grant TAS-319); the Ontario Ministry of Health and Long-Term Care(Canada) (Grant HRPD-05225); the Career Scientist Salary Support Program (HRPD-05225), for Dr Brosseau; the University Research ChairProgram, for research staff salary support for Dr Brosseau; the Centre National de Formation en Sante/Health Canada; and the Ministry of HumanResources, Summer Students Program, Government of Canada.

Acknowledgments: The Ottawa Panel is indebted to Ms Catherine Lamothe, Ms Gabriele Wieschollek, Ms Judith Robitaille, Ms Lucie Lavigne, MrMichel Boudreau, Mr Guillaume Michaud, Ms Michelle Vaillant, Ms Chantal Lavoie, and Mr Guillaume Lemieux for their technical support andhelp in data extraction.

908 . Ottawa Panel Physical Therapy . Volume 85 . Number 9 . September 2005

EBCPGs be assessed in a systematic manner using astandardized appraisal tool.

The Ottawa Panel was convened to evaluate the strengthof the scientific evidence on the efficacy of therapeuticexercises (TE) for patients with OA. A previous andsimilar article, using the rigorous methodology,15 waswritten by the Ottawa Panel on rheumatoid arthritis(RA).16 The Ottawa Panel also is preparing EBCPGs onthe use of TE, electrotherapy, and thermotherapymodalities and on patient education and splinting andorthosis for patients with OA. In this article, the OttawaPanel considers various types of TE: specific strengthen-ing exercises, general physical activity, and manual ther-apy combined with exercises.

Several systematic reviews and meta-analyses on the effec-tiveness of TE for patients with OA have been published inthe scientific literature, demonstrating a strong interest inthis intervention. Two meta-analyses using Cochrane Col-laboration methods have been conducted for the manage-ment of patients with OA: the effectiveness of exercise formanaging patients with hip and knee OA17 and the idealintensity of exercise for OA management.18 Of 3 systematicreviews on the effectiveness of exercise for managingpatients with OA, one was published a few years ago in ascientific journal19 and 2 were completed more recentlyand focused on the efficacy of strengthening exercises20

and fitness exercises.21 Eight other reviews22–29 exist on TEfor arthritis. Several of these reviews need updating, werenot systematic, or were not specific to OA. Nevertheless, allof these reviews unanimously agreed that TE are beneficialfor patients with OA, depending on the type and applica-tion of exercises (eg, strengthening, fitness, or combina-tion of manual therapy and exercise), the outcomes, thespecific joint affected, and the stage of the disease. To ourknowledge, no reviews are available on manual therapy(alone or combined with exercises); only one randomizedcontrolled trial (RCT) has been published on this topic.30

Several EBCPGs are available for the management ofpatients with OA using TE.31–36 These EBCPGs havebeen developed mainly for medical and surgical inter-ventions and are often not precise regarding rehabilita-tion interventions. Only British Medical Journal 34 haspublished recommendations on exercise, but they werebased on existing systematic reviews that had not beenrecently updated (Appendix 1). All of the aforemen-tioned EBCPGs are generally flawed. The authors didnot use a systematic literature search to find the studiesthat ultimately formed the basis of the EBCPGs, andalthough the authors reviewed the scientific results ofeach study, they did not synthesize the studies. Theguidelines were developed for limited clinical practiceareas. Although the EBCPGs were based on the currentscientific literature, their authors used a nonstandard-

ized approach to combine the scientific results; thus, theevidence of intervention efficacy is confusing, particu-larly in the presence of contradictory results. Theauthors also did not use a rigorous grading system toassess the evidence. Finally, with one exception, none ofthe guidelines have been updated recently. The OttawaPanel is proposing more precise EBCPGs (involvingspecific joints, outcomes, periods of intervention, anddisease stages) based on a rigorous quantitative meth-od.15 We believe that various people could benefit fromusing our guidelines, including patients, physical thera-pists, rheumatologists, physiatrists, orthopedic surgeons,occupational therapists, and family physicians. Our aimin developing the guidelines was to advance the properuse of the interventions studied (in this article, TE andmanual therapy).

MethodsFor this project, we used the same methods15 as those ofa previous study conducted by the Ottawa Panel on TEfor patients with RA.16 Evidence from RCTs and obser-vational studies were identified and synthesized usingmethods defined by the Cochrane Collaboration thatminimize bias by using a systematic approach to litera-ture search, study selection, data extraction, and datasynthesis. At the start of our OA project, we defined an apriori protocol that was used for separate systematicreviews of trials relating to each intervention. Thestrength of evidence was graded as level I for RCTs orlevel II for nonrandomized studies. An expert paneldeveloped a set of criteria for grading the strength ofboth the evidence and the recommendation. TheOttawa Panel decided that evidence of clinically importantbenefit (defined as a difference of more than 15% relativeto a control based on panel expertise and empiricresults) in patient-important outcomes was required fora recommendation. Statistical significance also wasrequired but was insufficient alone. Patient-importantoutcomes were decided by consensus as being pain,functional status, patient global assessment (defined as“patient’s assessment of overall disease activity orimprovement”37), quality of life, and return to work,providing that these outcomes were assessed with avalidated scale that yields reliable data.15

Target PopulationStudies of adult patients (�18 years of age) with classicalor definite OA as defined by Klippel et al38 wereincluded in our literature search. Patients with OA thataffected peripheral joints were eligible to participate.Patients at different stages of the disease participated inthe included clinical trials; some trials involved patientswith both chronic and acute conditions. All stages of thedisease were included in our analysis. The recommen-dations state the disease stage for which the interventionis most appropriate. If, however, the trial on which the

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recommendation was based did not mention diseasestage, neither does our recommendation (Appendix 2).Most trials involved patients with chronic OA (�12years’ duration).

Various exclusion criteria were established:• Studies of patients with OA involving spinal prob-

lems (excluded due to the numerous associatedsigns and symptoms and because the PhiladelphiaPanel guidelines for low back pain39 and neckpain40 were recently developed by the same meth-odologists);

• Studies of patients who recently had surgery;• Patients with other rheumatologic or musculoskel-

etal problems (eg, fractures, tendinitis, or bursitis),clinically important medical problems, or psychiat-ric conditions that could hamper rehabilitation orreduce functional status;

• Studies of subjects without known pathology orimpairments; and

• Studies of subjects with mixed arthritic conditionssuch as the sample in a study by D’Lima et al.41

Table 1 lists the complete inclusion and exclusion criteria.

Study Inclusion/Exclusion CriteriaGenerally, comparisons of 2 active interventions (head-to-head studies) were excluded for the same reasonsexplained in the previous publication on the OttawaPanel EBCPGs on RA.16 Examples of head-to-head stud-ies include dynamic exercises versus isometric exercis-es,42 individual versus group exercises,43 home exercisesversus aquatics,44 walking versus patient education,45

sham electrical stimulation versus patient educationcombined with TE,46 aerobics (walking) versus strength-ening exercises,45,47 and walking versus jogging inwater.48 Some studies had several comparative groups,and only some of the group comparisons were eligible tobe included.

Other excluded interventions comprised surgery, drug,or psychosocial (nonphysical) interventions. Forinstance, the RCTs on exercises after a total hip replace-ment for severe hip OA were excluded; RCTs withfrequent use of continuous passive motion (CPM) fol-lowing a total knee arthroplasty for severe knee OA49–61

also were excluded. However, practitioners can refer to arecent meta-analysis on the efficacy of CPM combinedwith physical therapy versus physical therapy alone(n�799) following a total knee arthroplasty for kneeOA62 to find further recommendations on these postsur-gery interventions (grade A for flexion deformity andtime to achieve 90 degrees of flexion and grade C� foractive knee flexion range of motion [ROM], pain relatedto analgesic use, and number of patients needing post-operative manual therapy). Postsurgery intervention

studies usually allowed samples with varying proportionsof patients with OA and RA. Most of the RCTs on efficacyof postsurgery interventions such as CPM recruitedsubjects with mixed arthritic conditions, which is thereason they are excluded in this article.

Subjects who received placebo, were untreated, orreceived routine conventional therapeutic approacheswere acceptable control groups. If concurrent interven-tions (eg, electroanalgesia and medication) were pro-vided to the experimental and control groups, theseinterventions were included. However, interventionswhere the patient acts as his or her own control were notincluded. A priori, we did not include or exclude studiesbased on the quality of their methods. However, we didconsider quality when grading our recommendations.

The categories of interventions selected were approvedby the Ottawa Panel according to the study’s descriptionof the intervention. Category selection also was influ-enced by previous work performed by the Ottawa Meth-ods Group15 and by the Ottawa Panel on TE for patientswith RA.16

Results of Literature SearchThrough a literature search (Appendix 3), 609 potentialarticles on TE and manual therapy for OA were identi-fied. Based on the selection criteria checklist (Tab. 1),113 studies were potentially relevant; 26 of these studieswere ultimately included30,42,45,47,48,63–83 (Appendix 2).One of the 26 studies had a follow-up study, so we havecounted these 2 studies as one, using the number ofpatients in the original study when calculating patientnumbers (Appendix 2). The other trials were excludedfor various reasons (Tab. 2).19,32,41,43,44,46,49–61,84–153 Thesearch identified 31 articles on manual therapy, 3 ofwhich were initially seen as relevant.30,122,132 Only onearticle30 was included (Appendix 2).

It was not possible to pool data to develop the followingEBCPGs. Each statement of recommendation representsone trial for a specific intervention (in terms of session/treatment duration and frequency) for a specific clinicaloutcome and a specific period of time. The includedstudies were gathered into general (ie, strengthening,general physical activity, combination of exercises) andmore specific (eg, isometric, isotonic, isokinetic, eccen-tric, concentric, aerobic) types of TE according to thedescription by the trial investigators. The reader needsto refer to the tables of included studies to find moredetails about the characteristics of the therapeutic appli-cation of a specific TE included in the followingEBCPGs.


Table 1.Inclusion and Exclusion Criteria for the Osteoarthritis Projecta

Inclusion Exclusion

Study Designs Study Designs● Randomized controlled trial● Controlled clinical trial● Cohort study● Case-control study● English and French articles only

● Case series/case report● Uncontrolled cohort studies● Data (graphic) without a mean and SD● Sample size of fewer than 5 patients per treatment group● Studies with more than 20% dropout rate

Population Population● Outpatients/inpatients● OA of all human joints (including temporomandibular joint) except

vertebral column● Chronic and acute conditions● Age groups �18 y

● Cancer (and other oncologic conditions)● Cardiac conditions● Dermatologic conditions● No known pathology or impairments● Juvenile arthritis● Mixed population (other than OA and RA)● Multiple conditions● Neurologic conditions● Other rheumatologic or musculoskeletal conditions● Pediatric conditions (no juvenile arthritis)● Psychiatric conditions● Pulmonary conditions● Scoliosis

Intervention Intervention● Eligible control groups: placebo, untreated, sham, routine

conventional therapy, active physical therapy treatments, andeducational pamphlets (no surgery, drugs, or injections)

● Eligible interventions:1. Chiropractic interventions (manipulation, mobilization, manual

therapy)2. Intensity of rehabilitation3. Therapeutic exercises, including swimming pool exercise

● Bilateral interventions (if systemic effects)● Neck and back interventions● Multidisciplinary, functional restoration programs● Surgery of shoulder, knee, neck, or low back● Medication (eg, phonophoresis with medications)● Thermal biofeedback● Psychosocial interventions● Therapeutic exercises, including postsurgery and CPM

Outcomes Outcomes● Absenteeism, sick leave, return to work (if available)● Balance status● Cardiopulmonary functions● Coordination status● Costs (economics)● Disease activity● Edema● EMG activity● Functional status, activities of daily living (self-care activities)● Gait status● Girth, volume● Inflammation● Joint imaging● Medication intake (if reported)● Muscle force, endurance, and power● Pain● Patient satisfaction● Postural assessment● Quality of life● Range of motion, flexibility, mobility● Side effects (if reported)● Swelling● Weight loss

● Biochemical measures● Patient adherence to medication● Psychosocial measures (depression, home and community

activities, leisure, social roles, sexual functions)● Serum markers (except ESR)

a CPM�continuous passive motion, EMG�electromyographic, ESR�erythrocyte sedimentation rate, OA�osteoarthritis, RA�rheumatoid arthritis, SD�standarddeviation.


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Table 2.Excluded Studies for Therapeutic Exercises (N�89)a

Study Reason for Exclusion

AGS32 Not an RCTAhern et al84 No statistical data for control

groupAubriot et al85 No standard deviationBaker et al86 Head-to-head studyBalint and Szebenyi87 Not an RCTBasso and Knapp88 Not an RCTBeaupre et al89 Mixed populationBelza et al90 More than 20% dropout rateBeverley91 ReviewBoardman et al92 Mixed populationBunning and Materson93 ReviewBurke et al94 No control groupCallaghan et al46 Combined interventionsChamberlain et al95 No statistical dataChen et al51 CPMChiarello et al52 CPMColwell and Morris53 CPMDavis96 Not enough statistical dataD’Lima et al41 Larger proportion of patients

with RADougados and Ravaud97 OverviewEttinger et al98 More than 20% dropout rateEungpinichpong99 No statistical dataFisher et al100 More than 20% dropout rateFisher et al101 No control groupFrank et al43 Head-to-head studyFransen et al102 More than 20% dropout rateFrost et al103 More than 20% dropout rateGerber104 ReviewGoletz and Henry105 Not an RCTGose106 Not an RCTGreen et al44 Head-to-head studyHall et al107 No interventionHarms and Engstrom54 CPMHartman et al108 Majority spine OAHaug and Wood109 Combined electrical stimulationHoeksma et al110 Head-to-head studyHopman-Rock and Westhoff111 Education on exercise (wrong

intervention)Johnson112 Head-to-head studyJohnson and Eastwood113 No standard deviationKim and Moon114 Head-to-head studyKumar et al55 CPMLangeland115 No control groupLau and Chiu116 Number of patients in each

group missingLeivseth et al117 Biochemical dataLynch et al118 No standard deviationMacDonald et al50 CPMMaloney et al119 Mixed populationMangione et al120 Patients as their own controlMangione et al121 Wrong interventionMarks and Cantin122 No control groupMays et al123 Head-to-head studyMei-Hwa and Jin-Shin124 No time period for the

outcomesMerchan and de la Corte125 No statistical dataMessier et al126 Nutrition was the main

interventionMessier et al127 Subjects without known

pathology or impairments

Table 2.Continueda

Study Reason for Exclusion

Meyer and Hawley128 No time period for theoutcomes

McInnes et al56 CPMMinor et al129 No control groupMinor and Brown130 No statistical data for controlMontgomery and Eliasson57 CPMNielsen et al58 CPMNicolakis et al131 No control groupNicolakis et al132 No control groupNordesjo et al133 Subjects without known

pathology or impairmentsOdenbring et al134 Not subjects with TKAPenninx et al135 No statistical dataPetrella and Bartha136 ReviewPope et al59 CPMRao and Evans137 No significant dataRasti and Olsen138 Literature reviewRejeski et al139 Outcome was adherenceRejeski et al140 More than 20% dropout rateSashika et al49 PostsurgerySimkin et al141 Not enough statistical dataStenstrom142 ReviewSullivan et al143 More than 20% dropout rateSylvester144 Head-to-head studyTan et al145 Subjects without known

pathology or impairmentsThomas et al146 Not specific to OATork and Douglas147 No control groupvan Baar et al19 Systematic reviewVervereli et al148 Not an RCTVince et al60 CPMWalker et al61 CPMWasilewski et al149 Not an RCT (retrospective

study)Weiss et al150 Multiple conditionsWorland et al151 Both groups received CPMYashar et al152 Mixed populationYoung and Kroll153 Not enough statistical data

a AGS�American Geriatrics Society Panel on Exercise and Osteoarthritis,RCT�randomized controlled trial, CPM�continuous passive motion,RA�rheumatoid arthritis, OA�osteoarthritis, TKA�total knee arthroplasty.


Therapeutic Exercises

EBCPGs Related to Strengthening Exercises

Lower-extremity (LE) strengthening versus control, level 1(3 RCTs, n�103): grade A for pain getting up and downfrom floor and functional status (clinically important ben-efit); grade C� for pain during walking, pain whileclimbing and descending stairs, arthritis activity, functionaltasks, and quadriceps femoris muscle peak torque (clini-cally important benefit); grade C for stiffness, mobility,quadriceps femoris muscle force, muscle activation, andquality of life (no benefit). Patients with a diagnosis of OAof the knee.

Lower-extremity isometric strengthening versus control,level 1 (1 RCT, n�67): grade A for pain getting downto and up from floor (clinically important benefit);grade C� for pain getting down and up stairs andtimed functional tasks (clinical benefit); grade C forstiffness and functional status (no benefit). Patients witha diagnosis of OA of the knee.

Isotonic resistance training versus isotonic combined withisokinetic (Kinetron*) resistance training for quadricepsfemoris and hamstring muscles, level 1 (1 RCT, n�15):grade C for quadriceps femoris muscle peak torque (nobenefit). Patients with a primary diagnosis of OA of theknee.

Isotonic combined with isokinetic (Kinetron) resistancetraining for quadriceps femoris and hamstring musclesversus control, level 1 (1 RCT, n�18): grade C for muscleforce (no benefit). Patients with primary diagnosis of OAof the knee.

Eccentric resistance training (Cybex*) for quadriceps fem-oris and hamstring muscles versus control, level 1 (1 RCT,n�17): grade C for muscle force (no benefit). Patientswith primary diagnosis of OA of the knee.

Concentric resistance training for quadriceps femoris andhamstring muscles versus control, level 1 (1 RCT, n�15):grade A for pain at rest and during activities (clinicallyimportant benefit); grade C for global functional status(no benefit). Patients with knee OA bilaterally and gradeII or III OA.

Concentric-eccentric resistance training for quadriceps fem-oris and hamstring muscles versus control, level 1 (1 RCT,n�14): grade A for pain at rest and during specificfunctional activities: 15-m walk and stair climbing/de-scending time (clinically important benefit). Patients withknee OA bilaterally and grade II or III OA.

Home strengthening program for quadriceps femoris mus-cle versus control, level 1 (1 controlled clinical trial [CCT],n�53): grade A for pain, functional status, energy level,and ROM in flexion (clinically important benefit); grade Cfor physical mobility, muscle force, swelling, and exercise(no benefit). Patients with OA of the knee.

General LE exercise program (including muscle forceresistance, flexibility, and mobility/coordination) versuscontrol, level 1 (8 RCTs, n�876): grade A for pain atnight and ability on stairs (clinically important benefit);grade C for knee flexion ROM, muscle force, knee jointposition sense, kinesthesia, stance, gait, functional status,quality of life, muscle activation, stiffness, and physicalactivity (no benefit). Patients with a diagnosis of OA.

Progression versus no-progression LE strengthening exer-cises, level 1 (1 RCT, n�179): grade A for pain at restand ROM (clinically important benefit); grade C forstiffness and functional status (no benefit). Patients withradiographic evidence of OA in the tibiofemoral compart-ment.

Hand strengthening versus control, level 1 (1 RCT, n�40):grade A for pain and grip force (clinically importantbenefit). Patients who met the American College ofRheumatology criteria for hand OA.154

EBCPGs Related to General Physical Activity, IncludingFitness and Aerobic Exercises

Whole-body functional exercise versus control, level 1 (4RCTs, n�864): grade A for pain and functional status(mobility, walking, work, disability in activities of dailyliving [ADL]) (clinically important benefit); grade C forknee flexion ROM, quadriceps femoris muscle force,hamstring muscle force, gait, stair climbing time, climbingself-efficacy, and quality of life (no benefit). Patients withOA of the knee.

* Cybex International Inc, 10 Trotter Dr, Medway, MA 02053.


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Walking program versus control, level 1 (6 RCTs,n�711): grade A for pain, functional status, stride length,disability transferring from bed, disability bathing, aerobiccapacity, exercise endurance, energy level, physical activ-ity, and sleep (clinically important benefit); grade C� fordisability in ADL (clinical benefit); grade C for walkingspeed, disability toileting, disability dressing and stairs,morning stiffness, and quality of life (no benefit). Patientswith OA.

Jogging in water versus control, level 1 (1 RCT, n�79):grade A for physical activity (clinically important benefit);grade C for walking time, morning stiffness, pain, gripforce, trunk ROM, functional status, and exercise endur-ance (no benefit). Patients with current symptoms ofchronic pain and stiffness in involved weight-bearingjoints.

Water exercises versus control, level 1 (1 RCT, n�30):grade C for hip and shoulder abduction torque and ROM(no benefit). Patients with OA or RA diagnosed by arheumatologist or an orthopedic physician.

Yoga versus control, level 1 (1 RCT, n�30): grade A forpain during activity and ROM (clinically important bene-fit); grade C for tenderness, grip force, swelling, and handfunction (no benefit). Patients with OA of the distalinterphalangeal or proximal interphalangeal joints of thefingers.

EBCPGs Related to the Combination of Exercises

Manual therapy combined with exercise versus control,level 1 (1 RCT, n�83): grade A for pain (clinicallyimportant benefit); grade C for 6-minute walk distance(no benefit). Patients with a diagnosis of OA.

Summary of TrialsTwenty-nine trials (n�2,486 patients) evaluated differ-ent types of TE for managing OA-affected joints of theupper extremities and LEs. Most of the trials comparedthese exercises with a control, but the trials examineddifferent kinds of TE. The strengthening exercise trialswere as follows: LE strengthening (n�345),42,70,71,79 LEisometric strengthening (n�102),42 isotonic resistancetraining versus isotonic combined with isokinetic (Kin-etron) resistance training for the knee (n�32),70 iso-tonic combined with isokinetic (Kinetron) resistance

training for the knee (n�32),70 eccentric resistance train-ing (Cybex) for the knee (n�32),70 concentric resistancetraining for the knee (n�23),67 concentric-eccentric resis-tance training for the knee (n�23),67 home programstrengthening for the knee (n�81),47 general LE exerciseprogram (including muscle force, flexibility, and mobility/coordination) (n�490),64,65,68,77,78,82,83 progression in LEstrengthening exercises versus no progression (n�179),75

and home program hand strengthening (n�40).80

Several RCTs examined general physical activities,including fitness and aerobic exercises, such as whole-body functional exercises (n�864),45,63,72,73,76 walkingprogram (n�1,089),45,47,48,69,73,74,76 jogging in water(n�115),48 water exercise (n�30),81 and yoga (n�30).66

One trial was related to the combination of manualtherapy and exercises (n�83).30

Twenty-three included trials were RCTs42,45,47,48,63–67,69–

76,78,80–83 and 3 trials were CCTs47,68,77 (Appendix 2). Weused the Jadad scale to decide whether a study was anRCT or a CCT.15

The trials examined 2 basic types of exercises. The firsttype involved strengthening exercises, such as resistanceisometric, stretching, eccentric, and concentric exer-cises; these exercises were specific to different muscles.The other type focused on whole-body functionalstrengthening programs and included aerobic condi-tioning and general fitness. Program duration, treat-ment schedule for exercise intervention, and length ofexercise session varied from 4 weeks64 to 18 months45,73,76

for program duration, from once a week66 to 10 times aday80 (depending on the phase of the program) for treat-ment schedule, and from 5 minutes to longer per exercisesession (length of exercise session increased depending ontolerance)74 (Appendix 2).

Strengthening ExercisesLower-extremity strengthening versus control (4 RCTs,n�345),42,70,71,79 showed clinical benefits for pain duringwalking, pain ascending and descending the stairs, quad-riceps femoris muscle peak torque, and timed functionaltasks (Tab. 3). Statistically significant differences werefound for pain (Western Ontario and McMaster Univer-sities Osteoarthritis Index [WOMAC]; Fig. 1a), painwhile getting up from the floor (weighted mean differ-


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�0.

63(�

2.32

,1.0

6)C

ontro

lPa

in,g

oing

upsta

irs(0

–16)

354.

594.

66

Topp

etal

42

Exer

cise

Pain

,goi

ngdo

wn

stairs

(0–1

6)35

5.30

3.71

�1.

52�

31%

�0.

69(�

2.27

,0.8

9)C

ontro

lPa

in,g

oing

dow

nsta

irs(0

–16)

354.

474.

40

Topp

etal

42

Exer

cise

Pain

(WO

MA

C)

3512

.40

10.7

1�

1.71

�15

%�

0.06

(�1.

54,1

.42)

Con

trol

Pain

(WO

MA

C)

3510

.75

10.7

7

Topp

etal

42

Exer

cise

Tim

eto

getd

own

toflo

or(s

)35

4.72

3.89

�1.

18�

24%

�1.

44(�

3.15

,0.2

7)C

ontro

lTi

me

toge

tdow

nto

floor

(s)

354.

985.

33

Topp

etal

42

Exer

cise

Tim

eto

getu

pof

fflo

or(s

)35

7.16

5.71

�1.

57�

21%

�2.

45(�

5.32

,0.2

7)C

ontro

lTi

me

toge

tup

offf

loor

(s)

358.

048.

16

Topp

etal

42

Exer

cise

Tim

eto

goup

stairs

(s)

3518

.85

16.3

3�

1.2

�6%

�1.

2(�

4.5,

2.1)

Con

trol

Tim

eto

goup

stairs

(s)

3518

.85

17.5

3

Topp

etal

42

Exer

cise

Tim

eto

godo

wn

stairs

(s)

3519

.29

15.9

6�

1.63

�9%

�0.

38(�

3.57

,2.8

1)C

ontro

lTi

me

togo

dow

nsta

irs(s

)35

18.0

416

.34

Topp

etal

42

Exer

cise

Func

tiona

llim

itatio

n(W

OM

AC

)35

41.0

935

.30

�6.

62�

17%

�4.

4(�

9.47

,0.6

7)C

ontro

lFu

nctio

nall

imita

tion

(WO

MA

C)

3538

.87

39.7

0

Schi

lke

etal

79

Exer

cise

Peak

torq

ue,r

ight

knee

exte

nsor

s10

52.5

067

.40

14.5

33%

31.1

(6.4

,55.

8)C

ontro

lPe

akto

rque

,rig

htkn

eeex

tens

ors

1035

.90

36.3

0

Schi

lke

etal

79

Exer

cise

OA

SI–m

obili

ty10

11.3

07.

64�

3.24

4%�

5.14

(�7.

37,�

2.91

)C

ontro

lO

ASI

–mob

ility

109.

909.

48

aW

OM

AC

�W

este

rnO

nta

rio

and

McM

aste

rU

niv

ersi

ties

Ost

eoar

thri

tis

Inde

x,O

ASI

�O

steo

arth

riti

sSc

reen

ing

Inde

x,W

MD

�w

eigh

ted

mea

ndi

ffer

ence

,C

I�co

nfi

den

cein

terv

al.


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��

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Figures 1a–f.Lower-extremity strengthening versus control. AIMS�Arthritis Impact Measurement Scales, FU�follow-up, LE�lower extremity, OASI�OsteoarthritisScreening Index, WOMAC�Western Ontario and McMaster Universities Osteoarthritis Index.


ence [WMD]�–2.36, 95% confidence interval [CI]��4.22 to –0.50; Fig. 1a), and functional status (Tab. 3).However, other outcomes were not statistically signifi-cant. Outcomes were measured at the end of interven-tion (4 months for Topp et al42 and 8 weeks forKreindler et al70 and Schilke et al79) or at follow-up (6weeks for Kreindler et al70) (Figs. 1a–f).

For LE isometric strengthening versus control (1 RCT,n�102),42 clinical benefits were found for pain getting

down and up from the floor, pain while going up anddown stairs, and timed functional tasks but not forstiffness and functional status (Tab. 4). Statistically sig-nificant differences were found for pain while gettingdown to the floor (WMD�–2.05, 95% CI�–3.62 to–0.48) and up from the floor (WMD�–2.14, 95% CI��4.01 to –0.27). Stiffness, functional limitation, pain,time to get down to the floor and to get up, and time togo up and down the stairs were not considered to beclinically important benefits at 4 months (Figs. 2a–d).

Figures 2a–d.Lower-extremity isometric strengthening versus control. LE�lower extremity, WOMAC�Western Ontario and McMaster Universities OsteoarthritisIndex.


��

��

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��

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Table

4.

Clin

ical

Rele

vanc

e:Lo

wer

-Ext

rem

ityIso

met

ricSt

reng

then

ing

Vers

usC

ontro

la

Study

Trea

tmen

tG

roup

Outc

om

eN

o.of

Patien

tsBase

line

Mea

nEn

d-o

f-St

udy

Mea

nA

bso

lute

Ben

efit

Rel

ative

Dif

fere

nce

inChange

From

Base

line

WM

D(9

5%

CI)

Topp

etal

42

LEis

omet

ricstr

engt

heni

ngPa

in,g

ettin

gup

from

floor

(0–1

6)32

5.39

2.89

�3

�61

%�

2.14

(�4.

01,�

0.27

)C

ontro

lPa

in,g

ettin

gup

from

floor

(0–1

6)35

4.53

5.03

Topp

etal

42

LEis

omet

ricstr

engt

heni

ngPa

in,g

ettin

gdo

wn

toflo

or(0

–16)

324.

201.

84�

2.71

�70

%�

2.05

(�3.

62,�

0.48

)C

ontro

lPa

in,g

ettin

gdo

wn

toflo

or(0

–16)

353.

543.

89

Topp

etal

42

LEis

omet

ricstr

engt

heni

ngPa

in,g

oing

upsta

irs(0

–16)

325.

192.

98�

2.28

�47

%�

1.68

(�3.

41,0

.05)

Con

trol

Pain

,goi

ngup

stairs

(0–1

6)35

4.59

4.66

Topp

etal

42

LEis

omet

ricstr

engt

heni

ngPa

in,g

oing

dow

nsta

irs(0

–16)

324.

702.

78�

1.85

�40

%�

1.62

(�3.

24,0

)C

ontro

lPa

ingo

ing

dow

nsta

irs(0

–16)

354.

474.

40

Topp

etal

42

LEis

omet

ricstr

engt

heni

ngPa

in(W

OM

AC

)32

11.7

510

.38

�1.

39�

12%

�0.

39(�

1.91

,1.1

3)C

ontro

lPa

in(W

OM

AC

)35

10.7

510

.77

Topp

etal

42

LEis

omet

ricstr

engt

heni

ngTi

me

toge

tdow

nto

floor

(s)

325.

564.

31�

1.6

�30

%�

1.02

(�2.

75,0

.71)

Con

trol

Tim

eto

getd

own

toflo

or(s

)35

4.98

5.33

Topp

etal

42

LEis

omet

ricstr

engt

heni

ngTi

me

toge

tup

offf

loor

(s)

328.

266.

37�

2.01

�25

%�

1.79

(�4.

67,1

.09)

Con

trol

Tim

eto

getd

own

toflo

or(s

)35

8.04

8.16

Topp

etal

42

LEis

omet

ricstr

engt

heni

ngTi

me

togo

upsta

irs(s

)32

17.9

915

.15

�1.

52�

8%�

2.38

(�5.

75,0

.99)

Con

trol

Tim

eto

goup

stairs

(s)

3518

.85

17.5

3

Topp

etal

42

LEis

omet

ricstr

engt

heni

ngTi

me

togo

dow

nsta

irs(s

)32

16.8

613

.95

�1.

21�

7%�

2.39

(�5.

66,0

.88)

Con

trol

Tim

eto

godo

wn

stairs

(s)

3518

.04

16.3

4

Topp

etal

42

LEis

omet

ricstr

engt

heni

ngSt

iffne

ss(W

OM

AC

)32

5.13

5.03

�0.

37�

7%�

0.47

(�1.

22,0

.28)

Con

trol

Stiff

ness

(WO

MA

C)

355.

235.

50

Topp

etal

42

LEis

omet

ricstr

engt

heni

ngFu

nctio

nall

imita

tion

(WO

MA

C)

3238

.13

35.9

7�

2.99

�8%

�3.

73(�

8.91

,1.4

5)C

ontro

lFu

nctio

nall

imita

tion

(WO

MA

C)

3538

.87

39.7

0

aL

E�

low

erex

trem

ity,

WO

MA

C�

Wes

tern

On

tari

oan

dM

cMas

ter

Un

iver

siti

esO

steo

arth

riti

sIn

dex,

WM

D�

wei

ghte

dm

ean

diff

eren

ce,

CI�

con

fide

nce

inte

rval

.


One trial (RCT, n�32)70 showed no statistically signifi-cant difference or clinically important benefit for quad-riceps femoris muscle peak torque in patients with OAeither at the end of a 6-week intervention or at a 6-weekfollow-up. This trial compared isokinetic resistance train-ing versus isotonic and isokinetic (Kinetron) resistancetraining for the knee (Fig. 3), resistance training andKinetron versus control (Fig. 4), and eccentric resistancetraining (Cybex) for the knee versus control (Fig. 5).

Statistically significant differences favored concentricexercises over control (1 RCT, n�23)67 for pain(WMD�–17.7, 95% CI�–22.79 to –12.61) and func-tional status (WMD�–10.85, 95% CI�–21.34 to –0.36)at 8 weeks (Figs. 6 and 7). A clinically important benefit

was observed for pain (Tab. 5) but not for functionalstatus.

For concentric-eccentric versus control (1 RCT, n�23),67

clinically important benefits and statistically significantdifferences were observed for pain (WMD��11.40, 95%CI�–17.95 to –4.85) (Tab. 6, Fig. 8) and functional status(WMD�–12.15, 95% CI�–22.67 to –1.63) (Tab. 6) at 8weeks. Results for 15-m walk, stair-climbing time, andstair-descending time also were significant, as were results

Figure 3.Isokinetic resistance training versus isotonic plus isokinetic resistancetraining. FU�follow-up, LE�lower extremity.

Figure 4.Isotonic and isokinetic (Kinetron) versus control. FU�follow-up,LE�lower extremity.


��

��

��

��

��

for pain at night, pain sitting, pain rising from a chair, painstanding, and pain climbing stairs (Tab. 6).

One CCT examined home program strengthening forknee versus control (n�81)47 and showed clinicallyimportant benefits for pain, functional status, energylevel (Tab. 7), and ROM (results not shown) but notfor physical mobility (Tab. 7). Statistically significantdata were found for WOMAC–pain (WMD�3.00, 95%CI�1.58 to 4.42), visual analog scale (VAS)–pain(WMD�3.30, 95% CI�2.62 to 3.98), WOMAC physicalfunction index (WMD�9.90, 95% CI�8.08 to 11.72),Nottingham Health Profile (NHP)–pain (WMD�10.60,95% CI�8.90 to 12.30), NHP–energy (WMD�15.90,95% CI�14.87 to 16.93), NHP–physical mobility

(WMD�7.10, 95% CI�4.14 to 10.06), NHP–sleep(WMD�3.40, 95% CI�0.89 to 5.91) (Figs. 9a–c, allat follow-up of 6 months), swelling (WMD�12.5, 95%CI�5.51 to 19.49), and ROM (WMD�19.5°, 95%CI�5.69° to 33.31°) (results not shown). However, nostatistically significant difference was observed for mus-cle force or exercise tolerance (results not shown). Noclinically important effects were found for muscle force,swelling, or exercise tolerance.

Several trials examined general LE exercise programs(including muscle force, flexibility, and mobility/coor-dination) versus control (7 RCTs, n�690).64,65,68,77,78,82,83

Important benefits were demonstrated for pain intensity

Figure 5.Eccentric resistance training (Cybex) versus control. FU�follow-up,LE�lower extremity.

Figure 6.Concentric versus control: pain.


Table

5.

Clin

ical

Rele

vanc

e:C

once

ntric

Vers

usC

ontro

la

Study

Trea

tmen

tG

roup

Outc

om

eN

o.of

Patien

tsBase

line

Mea

nEn

d-o

f-St

udy

Mea

nA

bso

lute

Ben

efit

Rel

ative

Dif

fere

nce

inChange

From

Base

line

WM

D(9

5%

CI)

Gur

etal

67

Con

cent

ricPa

inat

nigh

t(0–

10),

end

Tx:8

wk

94.

41.

4�

3.3

�84

%�

2.1

(�3.

64,�

0.56

)C

ontro

lPa

inat

nigh

t(0–

10),

end

Tx:8

wk

63.

23.

5G

uret

al6

7C

once

ntric

Pain

afte

rin

activ

ity(0

–10)

,end

Tx:8

wk

94.

11.

2�

2.9

�73

%�

2.6

(�3.

56,�

1.64

)C

ontro

lPa

inaf

ter

inac

tivity

(0–1

0),e

ndTx

:8w

k6

3.8

3.8

Gur

etal

67

Con

cent

ricPa

insi

tting

(0–1

0),e

ndTx

:8w

k9

3.4

0.9

�2.

7�

89%

�1.

8(�

2.51

,�1.

09)

Con

trol

Pain

sitti

ng(0

–10)

,end

Tx:8

wk

62.

52.

7G

uret

al6

7C

once

ntric

Pain

risin

gfro

mch

air,

end

Tx:8

wk

95.

22.

0�

3.2

�64

%�

2.7

(�3.

83,�

1.57

)C

ontro

lPa

inris

ing

from

chai

r,en

dTx

:8w

k6

4.7

4.7

Gur

etal

67

Con

cent

ricPa

insta

ndin

g,en

dTx

:8w

k9

4.0

1.4

�2.

6�

65%

�2.

6(�

3.46

,�1.

74)

Con

trol

Pain

stand

ing,

end

Tx:8

wk

64.

04.

0G

uret

al6

7C

once

ntric

Pain

clim

bing

stairs

,end

Tx:8

wk

95.

81.

7�

4.3

�80

%�

3.3

(�4.

17,�

2.43

)C

ontro

lPa

incl

imbi

ngsta

irs,e

ndTx

:8w

k6

4.8

5.0

Gur

etal

67

Con

cent

ricPa

inde

scen

ding

stairs

,end

Tx:8

wk

95.

81.

7�

4.1

�75

%�

3.3

(�4.

27,�

2.33

)C

ontro

lPa

inde

scen

ding

stairs

,end

Tx:8

wk

65.

05.

0G

uret

al6

7C

once

ntric

Pain

,tot

alsc

ore,

end

Tx:8

wk

933

.910

.3�

24.3

�78

%�

17.7

(�22

.79,

�12

.61)

Con

trol

Pain

,tot

alsc

ore,

end

Tx:8

wk

627

.328

.0

aT

x�tr

eatm

ent,

WM

D�

wei

ghte

dm

ean

diff

eren

ce,

CI�

con

fide

nce

inte

rval

.

Figure 7.Concentric versus control: functional status.


��

��

��

��

��

Table

6.

Clin

ical

Rele

vanc

e:C

once

ntric

-Ecc

entri

cVe

rsus

Con

trola

Study

Trea

tmen

tG

roup

Outc

om

eN

o.of

Patien

tsBase

line

Mea

nEn

d-o

f-St

udy

Mea

nA

bso

lute

Ben

efit

Rel

ative

Dif

fere

nce

inChange

From

Base

line

WM

D(9

5%

CI)

Gur

etal

67

Con

cent

ric-e

ccen

tric

Pain

atni

ght(

0–10

),en

dTx

:8w

k8

3.8

1.5

�2.

6�

73%

�2

(�3.

4,�

0.6)

Con

trol

Pain

atni

ght(

0–10

),en

dTx

:8w

k6

3.2

3.5

Gur

etal

67

Con

cent

ric-e

ccen

tric

Pain

sitti

ng(0

–10)

,end

Tx:8

wk

83.

51.

1�

2.6

�85

%�

1.6

(�2.

4,�

0.8)

Con

trol

Pain

sitti

ng(0

–10)

,end

Tx:8

wk

62.

52.

7

Gur

etal

67

Con

cent

ric-e

ccen

tric

Pain

risin

gfro

mch

air,

end

Tx:8

wk

85.

42.

5�

2.9

�57

%�

2.2

(�3.

43,�

0.97

)C

ontro

lPa

inris

ing

from

chai

r,en

dTx

:8w

k6

4.7

4.7

Gur

etal

67

Con

cent

ric-e

ccen

tric

Pain

stand

ing,

end

Tx:8

wk

83.

51.

6�

1.9

�51

%�

2.4

(�3.

54,�

1.26

)C

ontro

lPa

insta

ndin

g,en

dTx

:8w

k6

4.0

4.0

Gur

etal

67

Con

cent

ric-e

ccen

tric

Pain

clim

bing

stairs

,end

Tx:8

wk

86.

53.

5�

3.2

�55

%�

1.5

(�2.

78,�

0.22

)C

ontro

lPa

incl

imbi

ngsta

irs,e

ndTx

:8w

k6

4.8

5.0

Gur

etal

67

Con

cent

ric-e

ccen

tric

Pain

,tot

alsc

ore,

end

Tx:8

wk

835

.816

.6�

19.9

�62

%�

11.4

(�17

.95,

�4.

85)

Con

trol

Pain

,tot

alsc

ore,

end

Tx:8

wk

627

.328

.0

Gur

etal

67

Con

cent

ric-e

ccen

tric

15-m

wal

k(s

),en

dTx

:8w

k8

3.9

1.0

�2.

9�

78%

�0.

23(�

1.45

,0.9

9)C

ontro

l15

-mw

alk

(s),

end

Tx:8

wk

63.

53.

5

Gur

etal

67

Con

cent

ric-e

ccen

tric

Stai

r-clim

bing

time

(s),

end

Tx:8

wk

84.

61.

5�

4.1

�97

%�

0.07

(�0.

92,0

.78)

Con

trol

Stai

r-clim

bing

time

(s),

end

Tx:8

wk

63.

74.

7

Gur

etal

67

Con

cent

ric-e

ccen

tric

Stai

r-des

cend

ing

time

(s),

end

Tx:8

wk

85.

31.

8�

4.1

�81

%�

0.86

(�2.

52,0

.8)

Con

trol

Stai

r-des

cend

ing

time

(s),

end

Tx:8

wk

64.

75.

3

Gur

etal

67

Con

cent

ric-e

ccen

tric

Func

tion,

tota

lsco

re,e

ndTx

:8w

k8

19.1

6.0

�15

.6�

89%

�0.

86(�

2.52

,0.8

)C

ontro

lFu

nctio

n,to

tals

core

,end

Tx:8

wk

615

.518

.0

aT

x�tr

eatm

ent,

WM

D�

wei

ghte

dm

ean

diff

eren

ce,

CI�

con

fide

nce

inte

rval

.


Table

7.

Clin

ical

Rele

vanc

e:H

ome

Stre

ngth

enin

gPr

ogra

mVe

rsus

Con

trola

Study

Trea

tmen

tG

roup

Outc

om

eN

o.of

Patien

tsBase

line

Mea

nEn

d-o

f-St

udy

Mea

nA

bso

lute

Ben

efit

Rel

ative

Dif

fere

nce

inChange

From

Base

line

WM

D(9

5%

CI)

Evci

kan

dSo

nel4

7H

ome

stren

gthe

ning

WO

MA

C–p

hysi

calf

unct

ion

2725

.410

.8�

10.1

�40

%�

9.9

(�11

.72,

�8.

08)

Con

trol

WO

MA

C–p

hysi

calf

unct

ion

2625

.220

.7

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kan

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nel4

7H

ome

stren

gthe

ning

NH

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ysic

alm

obili

ty27

40.2

29.5

�3.

2�

8%�

7.1

(�10

.06,

�4.

14)

Con

trol

NH

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ysic

alm

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ty26

44.1

36.6

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kan

dSo

nel4

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ome

stren

gthe

ning

WO

MA

C–p

ain

276.

63.

0�

3�

45%

�3

(�4.

42,�

1.58

)C

ontro

lW

OM

AC

–pai

n26

6.6

6.0

Evci

kan

dSo

nel4

7H

ome

stren

gthe

ning

Pain

–VA

S27

7.2

3.5

�3.

5�

49%

�3.

3(�

3.98

,�2.

62)

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S26

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kan

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ome

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in27

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9)C

ontro

lN

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2640

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ergy

2753

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trol

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ergy

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este

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aste

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tis

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x,N

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tin

gham

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lth

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ile,

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ale,

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fide

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inte

rval

.

Figure 8.Concentric-eccentric versus control.


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Figures 9a–e.Home strengthening program versus control. FU�follow-up, NHP�Nottingham Health Profile, ROM�range of motion, VAS�visual analog scale,WOMAC�Western Ontario and McMaster Universities Osteoarthritis Index.


and ability to step down but not for ROM, muscle force,gait, functional status, quality of life (Tabs. 8 and 9),knee joint position at 6 weeks (Fig. 10f), or muscleactivation at 6 weeks (Fig. 10b). Statistically signifi-cant differences were found for the following out-comes:

• ROM in knee flexion, most affected knee at 10–12weeks (WMD�10.00°, 95% CI�5.91° to 14.09°)(Fig. 10a);

• ROM in knee flexion, least affected knee at 10–12weeks (WMD�10.00°, 95% CI�7.75° to 12.25°)(Fig. 10a);

• ROM in knee flexion, least affected knee at12-month follow-up (WMD�12.00°, 95% CI�7.06°to 16.94°) (results not shown);

• isometric quadriceps femoris muscle force at 6weeks (WMD�73 N, 95% CI�25.75 to 120.25 N)(Fig. 10b);

• quadriceps femoris muscle voluntary activation at6 weeks (WMD�14.0%, 95% CI�5.87% to 22.13%)(Fig. 10b);

• aggregate functional performance time at 6weeks (WMD��8.47, 95% CI��16.79 to �0.15)(Fig. 10d);

• functional status at 6 weeks (WMD��3.50, 95%CI��4.94 to �2.06) (Fig. 10d);

• mean change in physical function score at 3-monthfollow-up (WMD��3.54, 95% CI��6.04 to �1.04)(Fig. 10d);

• mean change in WOMAC–pain at 8 weeks (WMD��12.10, 95% CI��14.24 to �9.96) (Fig. 10e);

• mean change in pain at 10 to 12 weeks(WMD��17.10, 95% CI��29.99 to �4.21)(Fig. 10e);

• mean change in global pain score at 6-monthfollow-up (WMD��1.87, 95% CI��2.76 to �0.98)(Fig. 10e);

• mean change in pain (VAS), walking at 10 to 12weeks (WMD��7.07, 95% CI��13.90 to �0.24)(Fig. 10e);

• mean change in pain (VAS), stairs (WMD��10.42,95% CI��18.58 to �2.26) (results not shown);

• pain at night at 12-month follow-up (WMD��4.00,95% CI��5.94 to �2.06) (Fig. 10e);

• pain at rest at 10 to 12 weeks (WMD��1.50, 95%CI��2.80 to �0.20) (Fig. 10e);

• pain on weight bearing at 10 to 12 weeks (WMD��2.00, 95% CI��3.02 to �0.98) (Fig. 10e);

• mean change in isometric knee extensor muscleforce at 8 weeks (WMD�13.20 N, 95% CI�11.96 to14.44 N) (Fig. 10g);

• mean change in isometric knee flexor muscle forceat 8 weeks (WMD�9.00 N, 95% CI�8.04 to 9.96 N)(Fig. 10g);

• mean change in fast speed at 8 weeks (WMD�6.70cm/s, 95% CI�6.34 to 7.06 cm/s) (Fig. 10h);

• mean change in fast cadence at 8 weeks (WMD�1.60steps/min, 95% CI�1.40 to 1.80 steps/min)(Fig. 10h);

• mean change in fast stride length at 8 weeks(WMD�4.30 cm, 95% CI�3.99 to 4.61 cm)(Fig. 10h);

• quality of life measured with Medical OutcomesStudy 36-Item Short-Form Health Survey question-naire (SF-36) at 8 weeks (WMD�3.10, 95%CI�2.76 to 3.44) (Fig. 10i);

• mean change in WOMAC–function at 8 weeks(WMD��7.80, 95% CI��8.48 to �7.12) (Fig.10k);

• improvement in self-reported disability at 24-weekfollow-up (WMD��1.10, 95% CI��1.91 to �0.29)(Fig. 10k);

• mean change in left quadriceps femoris muscleforce at 6-week follow-up (WMD�10.86%, 95%CI�3.15% to 18.57%) (results not shown); and

• mean change in SF-36–physical function at 8 weeks(results not shown).


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Table

8.

Clin

ical

Rele

vanc

e:G

ener

alLo

wer

-Ext

rem

ityEx

erci

sePr

ogra

mVe

rsus

Con

trola

Study

Trea

tmen

tG

roup

Outc

om

eN

o.of

Patien

tsBase

line

Mea

nEn

d-o

f-St

udy

Mea

nA

bso

lute

Ben

efit

Rel

ative

Dif

fere

nce

inChange

From

Base

line

WM

D(9

5%

CI)

Rogi

ndet

al7

8Ex

erci

ses

ROM

inkn

eefle

xion

(°)(

mos

taffe

cted

knee

),en

dTx

:10–

12w

k12

130

135

32%

�10

(�14

.09,

�5.

91)

Con

trol

ROM

inkn

eefle

xion

(°)(

mos

taffe

cted

knee

),en

dTx

:10–

12w

k13

123

125

Rogi

ndet

al7

8Ex

erci

ses

ROM

inkn

eefle

xion

(°)(

leas

taffe

cted

knee

),en

dTx

:10–

12w

k12

132

135

43%

�10

(�12

.25,

�7.

75)

Con

trol

ROM

inkn

eefle

xion

(°)(

leas

taffe

cted

knee

),en

dTx

:10–

12w

k13

126

125

Rogi

ndet

al7

8Ex

erci

ses

ROM

inkn

eefle

xion

(°)(

leas

taffe

cted

knee

),FU

:12

mo

1213

213

36

5%�

12(�

16.9

4,�

7.06

)

Con

trol

ROM

inkn

eefle

xion

(°)(

leas

taffe

cted

knee

),FU

:12

mo

1312

612

1

van

Baar

etal

82

Exer

cise

sH

ipm

uscl

efo

rce,

chan

ge,F

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4w

k93

N/A

0.22

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0.18

�0.

18(�

0.34

,�0.

02)

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trol

Hip

mus

cle

forc

e,ch

ange

,FU

:24

wk

98N

/A0.

04

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sen

etal

65

Exer

cise

sW

OM

AC

–pai

n,ch

ange

(0–1

00),

end

Tx:

8w

k83

N/A

10.6

WM

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12.1

�12

.1(�

14.2

4,�

9.96

)

Con

trol

WO

MA

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ain,

chan

ge(0

–100

),en

dTx

:8

wk

43N

/A�

1.5

van

Baar

etal

82

Exer

cise

sPa

inpa

stw

eek–

VAS

(0–1

00),

chan

ge,e

ndTx

:10–

12w

k93

46.9

24.1

�17

.1�

38%

�17

.1(�

29.9

9,�

4.21

)

Con

trol

Pain

past

wee

k–VA

S(0

–100

),ch

ange

,end

Tx:1

0–12

wk

9843

.137

.4

van

Baar

etal

82

Exer

cise

sPa

in–V

AS

(0–1

00),

FU:2

4w

k93

34.0

23.5

�11

.2�

36%

�11

.2(�

18.5

9,�

3.81

)C

ontro

lPa

in–V

AS

(0–1

00),

FU:2

4w

k98

28.7

29.4

van

Baar

etal

83

Exer

cise

sPa

in–V

AS

(0–1

00),

FU:2

4w

k98

34.0

16.8

�11

.6�

37%

�11

.6(�

19.5

,�3.

7)C

ontro

lPa

in–V

AS

(0–1

00),

FU:2

4w

k10

228

.723

.1

Rogi

ndet

al7

8Ex

erci

ses

Pain

atni

ght(

0–10

),FU

:12

mo

124.

02.

0�

3�

66%

�4

(�5.

94,�

2.06

)C

ontro

lPa

inat

nigh

t(0–

10),

FU:1

2m

o13

5.0

6.0

Fran

sen

etal

65

Exer

cise

sM

uscl

efo

rce,

isom

etric

knee

exte

nsor

s(N

),en

dTx

:8w

k83

169.

4518

0.25

13.2

8%�

13.2

(�14

.44,

�11

.96)

Con

trol

Mus

cle

forc

e,is

omet

rickn

eeex

tens

ors

(N),

end

Tx:8

wk

4317

3.3

170.

9

Fran

sen

etal

65

Exer

cise

sM

uscl

efo

rce,

isom

etric

knee

flexo

rs(N

),en

dTx

:8w

k83

94.6

510

3.05

99%

�9

(�9.

96,�

8.04

)

Con

trol

Mus

cle

forc

e,is

omet

rickn

eefle

xors

(N),

end

Tx:8

wk

4310

0.1

99.5

Fran

sen

etal

65

Exer

cise

sFa

stsp

eed

(cm

/s),

end

Tx:8

wk

8312

8.6

135.

76.

75%

�6.

7(�

7.06

,�6.

34)

Con

trol

Fast

spee

d(c

m/s

),en

dTx

:8w

k43

127.

812

8.2

(Con

tinue

d)


Table

8.

Con

tinue

d

Study

Trea

tmen

tG

roup

Outc

om

eN

o.of

Patien

tsBase

line

Mea

nEn

d-o

f-St

udy

Mea

nA

bso

lute

Ben

efit

Rel

ative

Dif

fere

nce

inChange

From

Base

line

WM

D(9

5%

CI)

Fran

sen

etal

65

Exer

cise

sFa

stca

denc

e(s

teps

/min

),en

dTx

:8w

k83

119.

912

1.8

1.6

1%�

1.6

(�1.

8,�

1.4)

Con

trol

Fast

cade

nce

(ste

ps/m

in),

end

Tx:8

wk

4311

7.6

117.

9

Fran

sen

etal

65

Exer

cise

sFa

ststr

ide

leng

th(c

m),

end

Tx:8

wk

8312

8.2

132.

94.

33%

�4.

3(�

4.61

,�3.

99)

Con

trol

Fast

strid

ele

ngth

(cm

),en

dTx

:8w

k43

130.

313

0.7

Fran

sen

etal

65

Exer

cise

sW

OM

AC

–fun

ctio

n,ch

ange

(0–1

00),

end

Tx:

8w

k83

60.8

68.5

7.8

13%

�7.

8(�

8.48

,�7.

12)

Con

trol

WO

MA

C–f

unct

ion,

chan

ge(0

–100

),en

dTx

:8

wk

4360

.059

.9

van

Barr

etal

82

Exer

cise

sSe

lf-re

porte

ddi

sabi

lity

(IRLG

),FU

:24

wk

93�

20.0

�1.

1�

1.7

8%�

1.1

(�1.

91,�

0.29

)C

ontro

lSe

lf-re

porte

ddi

sabi

lity

(IRLG

),FU

:24

wk

98�

20.6

0.0

Fran

sen

etal

65

Exer

cise

sSF

-36

qual

ityof

life,

chan

ge,e

ndTx

:8w

k83

32.8

536

.45

3.1

9%�

3.1

(�3.

44,�

2.76

)C

ontro

lSF

-36

qual

ityof

life,

chan

ge,e

ndTx

:8w

k43

34.8

35.3

aFU

�fo

llow

-up,

N/A

�n

otav

aila

ble,

RO

M�

ran

geof

mot

ion

,T

x�T

reat

men

t,W

MD

�w

eigh

ted

mea

ndi

ffer

ence

,C

I�co

nfi

den

cein

terv

al,

VA

S�vi

sual

anal

ogsc

ale,

WO

MA

C�

Wes

tern

On

tari

oan

dM

cMas

ter

Un

iver

siti

esO

steo

arth

riti

sIn

dex,

IRL

G�

Infl

uen

ceof

Rh

eum

atic

Dis

ease

onG

ener

alH

ealt

han

dL

ifes

tyle

,SF

-36�

Med

ical

Out

com

esSt

udy

36-I

tem

Shor

t-For

mH

ealt

hSu

rvey

ques

tion

nai

re.

Table

9.

Clin

ical

Rele

vanc

e:Lo

wer

-Ext

rem

itySt

reng

then

ing

Exer

cise

Prog

ram

Vers

usC

ontro

la

Study

Gro

up

Outc

om

eN

o.

Impro

ved

NRis

kO

ccurr

ence

Ris

kD

iffe

rence

WM

D(9

5%

CI)

Borje

sson

etal

64

Exer

cise

sA

bilit

yto

step

dow

n13

3438

%26

%3.

25(1

.18,

8.97

)C

ontro

lA

bilit

yto

step

dow

n4

3412

%

aW

MD

�w

eigh

ted

mea

ndi

ffer

ence

,C

I�co

nfi

den

cein

terv

al.


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Figures 10a–o.General lower-extremity exercise program versus control. ADL�activities of daily living, AFI�Algofunctional Index, FU�follow-up, HSS�Health StatusSurvey, IRLG�Influence of Rheumatic Disease on General Health and Lifestyle, LE�lower extremity, MVC�maximal voluntary contraction, ROM�range ofmotion, VAS�visual analog scale, SF-36 PCS�Medical Outcomes Study 36-Item Short-Form Health Survey questionnaire Physical Component Summary,WOMAC�Western Ontario and McMaster Universities Osteoarthritis Index.


Figure 10.Continued.


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No statistically significant data were found for theremaining outcomes: ROM in knee extension and flex-ion (Fig. 10a); improvement in hip and knee ROM at24-week follow-up (Fig. 10a); improvement in knee orhip muscle force at 24-week follow-up (Fig. 10c); HealthStatus Survey (HSS) score (Fig. 10d); pain, pain duringwalking, and pain at night at 10 to 12 weeks (Fig. 10e);knee joint position sense at 6 weeks (Fig. 10f); peaktorque of the knee extensors and flexors at 10 to 12weeks (Fig. 10g); step frequency and stride length at 10to 12 weeks (Fig. 10h); stance at 10 to 12 weeks or at12-month follow-up for most affected and least affectedLEs (Fig. 10j); walking speed and stair-climbing time at10 to 12 weeks or at 12-month follow-up (Fig. 10l);Algofunctional Index–pain at 10 to 12 weeks or at12-month follow-up (Fig. 10m); improvement in physicalactivity at 10 to 12 weeks (Fig. 10n); and ability to stepdown (Fig. 10o).

For progression versus no-progression LE strengtheningexercises (one RCT, n�179),75 clinical benefits(Tab. 10) and statistically significant differences werefound for ROM in knee flexion (WMD�13°, 95%CI�11.55° to 14.45°) and pain at rest (WMD�–23 mm,95% CI�–24.03 to –21.97). No important differenceswere found for WOMAC–stiffness, WOMAC–pain, orpain after walk test. Outcomes were measured after 8weeks (Figs. 11a–c).

Hand strengthening versus control (one RCT, n�40)80

showed clinically important benefits for pain and gripforce at 3 months (Tabs. 11 and 12, Figs. 12a–b).Statistically significant differences were found for pain(WMD�7.43, 95% CI�1.78 to 31.04) and change in gripforce in the right hand (WMD�0.11, 95% CI�0.09 to0.13) and the left hand (WMD�0.10, 95% CI�0.09 to0.11) (Fig. 12b).

General Physical Activities, Including Fitness and AerobicExercisesFor whole-body functional exercise versus control (5RCTs, n�864),45,63,72,73,76 clinically important benefitswere found for pain and functional status (mobility,walking, work, and disability on ADL). Statistically signif-icant differences were found for numerous outcomes:

• pain frequency in transfer at 9 months (WMD�0.88, 95% CI�0.49 to 1.27) (Fig. 13a);

• pain intensity in transfer at 3 months (WMD��0.94, 95% CI��1.33 to �0.55), at 9 months(WMD��0.46, 95% CI��0.84 to �0.08), and at18 months (WMD��0.37, 95% CI��0.70 to�0.04) (Fig. 13a);

• pain (WMD��0.80, 95% CI��1.29 to �0.31)(Fig. 13b);

• functional status measured with the ArthritisImpact Measurement Scales (AIMS) (WMD�5.49,95% CI�3.92 to 7.06) (results not shown);

• functional status measured with the ArthritisImpact Measurement Scales 2 (AIMS2): arthritispain (WMD��0.85, 95% CI��1.52 to �0.18)(Fig. 13b);

• functional status measured with AIMS2: mobilitylevel at 12 weeks (WMD��0.50, 95% CI��0.93 to�0.07) favoring the control group (Fig. 13c);

• functional status measured with AIMS2: walkingand bending at 12 weeks (WMD��1.25, 95% CI��2.08 to �0.42) (Fig. 13c);

• functional status measured with AIMS2: level oftension at 12 weeks (WMD�2.58, 95% CI�1.88 to3.28) (Fig. 13c);

• hamstring muscle and low back flexibility at 12weeks (WMD�3.63 in, 95% CI�2.04 to 5.22 in)(Fig. 13d);

• 5-minute walk test at 12 weeks (WMD�42.19 m,95% CI�14.19 to 70.19 m) (Fig. 13e);

• hamstring muscle isometric torque at 30 degrees:most affected LE at 12 weeks (WMD�8.85 N�m,95% CI�1.91 to 15.79 N�m) (Fig. 13f);

• hamstring muscle isometric torque at 30 degrees:least affected LE at 12 weeks (WMD�10.51 N�m,95% CI�3.24 to 17.78 N�m) (Fig. 13f);

• quadriceps femoris muscle isometric torque at 60degrees: most affected LE at 12 weeks (WMD�19.80N�m, 95% CI�4.75 to 34.85 N�m) (Fig. 13f);

• quadriceps femoris muscle isometric torque at 60degrees: least affected LE at 12 weeks (WMD�17.03N�m, 95% CI�1.08 to 32.98 N�m) (Fig. 13f);

• hamstring muscle isometric torque at 60 degrees:most affected LE at 12 weeks (WMD�8.02 N�m,95% CI�0.88 to 15.16 N�m) (Fig. 13f);

• hamstring muscle isometric torque at 60 degrees:least affected LE at 12 weeks (WMD�10.99 N�m,95% CI�3.68 to 18.30 N�m) (Fig. 13f);

• hamstring muscle isokinetic torque at 30°/s: mostaffected LE at 12 weeks (WMD�10.98 N�m, 95%CI�0.38 to 21.58 N�m) (Fig. 13g);

• hamstring muscle isokinetic torque at 30°/s: leastaffected LE at 12 weeks (WMD�10.51 N�m, 95%CI�3.24 to 17.78 N�m) (Fig. 13g);

• hamstring muscle isokinetic torque at 90°/s: mostaffected LE at 12 weeks (WMD�9.73 N�m, 95%CI��1.40 to 20.86 N�m) (Fig. 13g);

• cadence at 3 months (WMD�0.87 steps/min, 95%CI�0.33 to 1.41 steps/min) (Fig. 13h), at 9 months(WMD�0.94 steps/min, 95% CI�0.37 to 1.51steps/min), and at 18 months (WMD�2.08 steps/min, 95% CI�1.56 to 2.60 steps/min) (results notshown);


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• stride length at 3 months (WMD�2.17 cm, 95%CI�1.18 to 3.16 cm), at 9 months (WMD�2.84 cm,95% CI�1.77 to 3.91 cm), and at 18 months(WMD�6.49 cm, 95% CI�5.49 to 7.49 cm)(Fig. 13i);

• walking speed at 3 months (WMD�3.77 cm/s, 95%CI�2.60 to 4.94 cm/s), at 9 months (WMD�4.37cm/s, 95% CI�3.12 to 5.62 cm/s), and at 18months (WMD�7.79 cm/s, 95% CI�6.60 to 8.98cm/s) (Fig. 13j);

• stance time at 3 months (WMD��0.01 s, 95%CI��0.01 to �0.01 s) and at 18 months(WMD��0.02 s, 95% CI��0.02 to �0.02 s)(Fig. 13k);

• percentage of swing at 3 months (WMD�0.39, 95%CI�0.18 to 0.60), at 9 months (WMD��0.36, 95%CI��0.59 to �0.13), and 18 months (WMD�0.54,95% CI�0.32 to 0.76) (Fig. 13k);

• stair-climbing time at 18 months (WMD��1.92 s,95% CI��2.01 to �1.83 s) (Fig. 13l);

• climbing self-efficacy score at 18 months(WMD�9.32, 95% CI�8.86 to 9.78) (Fig. 13m);

• quality of life (WMD�3.10, 95% CI�2.97 to 3.23)(results not shown); and

• disability in bathing (WMD�0.41, 95% CI�0.18 to0.91) (results not shown).

No clinically important benefits were found for quadri-ceps femoris and hamstring muscle force at 12 weeks(Figs. 13f–g), knee flexor ROM, gait, or quality of life(results not shown). No statistical data were found forpain intensity and frequency in ambulation at 3, 9, and18 months (Fig. 13a); pain frequency in transfer at 9 and18 months (Fig. 13a); AIMS2 hand and finger functionalstatus, arm functional status, self-care tasks, householdtasks, social activity, support from friends, work, or moodat 12 weeks (Fig. 13c); quadriceps femoris muscle iso-metric and isokinetic torque at 30 degrees (Figs. 13f–g),quadriceps femoris muscle isokinetic torque at 90degrees (Fig. 13g), or hamstring muscle isokinetictorque at 90 degrees (Fig. 13g), all at 12 weeks; stancetime at 9 months (Fig. 13k); or incidence of disability inADL, disability in transferring from a bed to a chair,disability in toileting, disability in dressing and eating, orquality of life measured by HSS score (results notshown).

Six RCTs and 1 CCT examined walking versus control(n�1,089),45,47,48,69,73,74,76 and trials discovered clinicalbenefits for pain, functional status, stride length, disabil-ity transferring from bed, disability bathing, disability inADL, energy level, medication use, aerobic capacity, andquality of life (Tabs. 13 and 14). No clinical benefitswere found for walking speed (Tab. 13), pain in ambu-lation (results not shown), disability toileting, or disabil-ity dressing (Fig. 13e, both at 18-month follow-up).

Table

10.

Clin

ical

Rele

vanc

e:Pr

ogre

ssio

nVe

rsus

No

Prog

ress

iona

Study

Trea

tmen

tG

roup

Outc

om

eN

o.of

Patien

tsBase

line

Mea

nEn

d-o

f-St

udy

Mea

nA

bso

lute

Ben

efit

WM

D(9

5%

CI)

Petre

lla7

5Ex

erci

ses

Pain

atre

st–VA

S(0

–100

),ch

ange

,en

dTx

:8w

k91

N/A

N/A

�23

WM

D�

23(�

24.0

3,�

21.9

7)

Con

trol

Pain

atre

st–VA

S(0

–100

),ch

ange

,en

dTx

:8w

k88

N/A

N/A

Petre

lla7

5Ex

erci

ses

Pain

afte

rste

pte

st–VA

S(0

–100

),ch

ange

,end

Tx:8

wk

91N

/AN

/A11

.3W

MD

�11

.3(�

12.0

4,�

10.5

6)

Con

trol

Pain

afte

rste

pte

st–VA

S(0

–100

),ch

ange

,end

Tx:8

wk

88N

/AN

/A

Petre

lla7

5Ex

erci

ses

ROM

inkn

eefle

xion

(°),

end

Tx:8

wk

91N

/AN

/A13

°�

13(�

14.4

5,�

11.5

5)C

ontro

lRO

Min

knee

flexi

on(°

),en

dTx

:8w

k88

N/A

N/A

aN

/A�

not

avai

labl

e,R

OM

�ra

nge

ofm

otio

n,

Tx�

trea

tmen

t,V

AS�

visu

alan

alog

scal

e,W

MD

�w

eigh

ted

mea

ndi

ffer

ence

,C

I�co

nfi

den

cein

terv

al.


Figures 11a–d.Progression versus no-progression lower-extremity exercises. LE�lower extremity, ROM�range of motion, VAS�visual analog scale,WOMAC�Western Ontario and McMaster Universities Osteoarthritis Index.


��

��

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Table 11.Clinical Relevance: Hand Strengthening Versus Controla

StudyTreatmentGroup Outcome

No. ofPatients

BaselineMean

End-of-StudyMean

AbsoluteBenefit

RelativeDifferencein ChangeFromBaseline WMD (95% CI)

Stamm et al80 Hand functionalstrengthening

Grip force, change,right, end Tx:3 mo

20 0.43 0.55 0.09 19% �0.11 (�0.13, �0.09)

Control Grip force, change,right, end Tx:3 mo

20 0.54 0.57


Grip force, change,left, end Tx: 3 mo

20 0.44 0.55 0.08 16% �0.1 (�0.11, �0.09)

Control Grip force, change,left, end Tx: 3 mo

20 0.53 0.56

a Tx�treatment, WMD�weighted mean difference, CI�confidence interval.

Table 12.Clinical Relevance: Hand Strengthening Versus Controla

Study Group OutcomeNo.Observed N

RiskOccurrence

RiskDifference WMD (95% CI)


Pain–VAS, no. improved, end Tx: 3 mo 13 20 65% 45% 3.25 (1.28, 8.27)

Control Pain–VAS, no. improved, end Tx: 3 mo 4 20 20%

a VAS�visual analog scale, Tx�treatment, WMD�weighted mean difference, CI�confidence interval.

Figures 12a and b.Hand strengthening versus control. VAS�visual analog scale.


Figures 13a–n.Whole-body functional exercises versus control. AIMS�Arthritis Impact Measurement Scales, AIMS2�Arthritis Impact Measurement Scales 2,FU�follow-up, HIKF�hamstring muscle isokinetic force, HIF�hamstring muscle isometric force, QIKF�quadriceps femoris muscle isokinetic force,QIF�quadriceps femoris muscle isometric force, VAS�visual analog scale.


��

��

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��

��

Statistically significant results were shown for the follow-ing outcomes:

• pain frequency in ambulation at 3 months (WMD��0.56, 95% CI��1.07 to �0.05) and in transfer(WMD��0.42, 95% CI��0.77 to �0.07) (resultsnot shown);

• pain intensity in transfer at 3 months (WMD��0.55,95% CI��1.02 to �0.08), at 9 months (WMD�

�0.46, 95% CI��0.84 to �0.08), and at 18 months(WMD��0.41, 95% CI��0.76 to �0.06) (results notshown);

• NHP–physical mobility, –pain, –energy, and –sleep(Tab. 13);

• WOMAC–physical function and –pain (Tab. 13);• VAS–pain (Tab. 13);• walking speed at 3 months (WMD�3.69 cm/s, 95%

CI�2.47 to 4.91 cm/s), at 9 months (WMD�10.29



cm/s, 95% CI�9.05 to 11.53 cm/s), and at 18 months(WMD�10.29 cm/s, 95% CI�9.07 to 11.51 cm/s)(Tab. 13);

• cadence at 3 months (WMD�3.56 steps/min, 95%CI�3.00 to 4.12 steps/min), at 9 months(WMD�3.69 steps/min, 95% CI�3.12 to 4.26steps/min), and at 18 months (WMD�3.77 steps/min, 95% CI�3.21 to 4.33 steps/min) (Tab. 13);

• stance time at 3 months (WMD��0.04 s, 95%CI�0.04 to �0.04 s), at 9 months (WMD��0.03 s,95% CI��0.03 to �0.03 s), and at 18 months(WMD��0.03 s, 95% CI��0.03 to �0.03 s)(results not shown);

• percentage of swing at 3 months (WMD�0.86, 95%CI�0.64 to 1.08) and at 18 months (WMD�0.54,95% CI�0.32 to 0.76) (Tab. 13);



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��

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Table

13.

Clin

ical

Rele

vanc

e:W

alki

ngPr

ogra

mVe

rsus

Con

trola

Study

Trea

tmen

tG

roup

Outc

om

eN

o.of

Patien

tsBase

line

Mea

nEn

d-o

f-St

udy

Mea

nA

bso

lute

Ben

efit

Rel

ative

Dif

fere

nce

inChange

From

Base

line

WM

D(9

5%

CI)

Reje

skie

tal7

6W

alki

ngpr

ogra

mSt

air-c

limbi

ngtim

e(s

),FU

:18

mo

357b

N/A

9.08

N/A

14%

�1.

41(�

1.51

,�1.

31)

Con

trol

Stai

r-clim

bing

time

(s),

FU:1

8m

o35

7bN

/A10

.49

Reje

skie

tal7

6W

alki

ngpr

ogra

mC

limbi

ngse

lf-ef

ficac

ysc

ore

(0–1

0),

FU:1

8m

o35

7bN

/A66

.06

N/A

13%

�8

(�8.

45,�

7.55

)

Con

trol

Clim

bing

self-

effic

acy

scor

e(0

–10)

,FU

:18

mo

357b

N/A

58.0

6

Reje

skie

tal7

6W

alki

ngpr

ogra

mG

ener

alhe

alth

statu

s(0

–100

),FU

:18

mo

357b

N/A

75.5

6N

/A5%

�3.

59(�

3.72

,3.4

6)

Con

trol

Gen

eral

heal

thsta

tus

(0–1

00),

FU:

18m

o35

7bN

/A71

.97

Kova

ret

al6

9W

alki

ngpr

ogra

m6-

min

wal

kte

st,en

dTx

:8w

k47

381

451

8724

%�

112

(�16

1.72

,�62

.28)

Con

trol

6-m

inw

alk

test,

end

Tx:8

wk

4535

633

9

Pete

rson

etal

74

Wal

king

prog

ram

6-m

inw

alk

test,

end

Tx:8

wk

4739

044

978

21%

�11

1(�

161.

02,�

60.9

8)C

ontro

l6-

min

wal

kte

st,en

dTx

:8w

k44

357

338

Pete

rson

etal

74

Wal

king

prog

ram

Free

spee

d(m

/min

),en

dTx

:8w

k47

5661

24%

�7

(�13

.66,

�0.

34)

Con

trol

Free

spee

d(m

/min

),en

dTx

:8w

k44

5154

Pete

rson

etal

74

Wal

king

prog

ram

Free

strid

e(m

),en

dTx

:8w

k47

1.1

1.2

0.2

18%

�0.

2(�

0.32

,�0.

08)

Con

trol

Free

strid

e(m

),en

dTx

:8w

k44

1.1

1.0

Pete

rson

etal

74

Wal

king

prog

ram

Fast

spee

d(m

/min

),en

dTx

:8w

k47

7683

912

%�

15(�

23.4

8,�

6.53

)C

ontro

lFa

stsp

eed

(m/m

in),

end

Tx:8

wk

4470

68

Pete

rson

etal

74

Wal

king

prog

ram

Fast

strid

e(m

),en

dTx

:8w

k47

1.2

1.4

0.2

17%

�0.

2(�

0.37

,�0.

03)

Con

trol

Fast

strid

e(m

),en

dTx

:8w

k44

1.2

1.2

Pete

rson

etal

74

Wal

king

prog

ram

AIM

S–ph

ysic

alac

tivity

(0–1

0),e

ndTx

:8w

k47

N/A

3.74

2.22

46%

�2.

22(�

3.25

,�1.

19)

Con

trol

AIM

S–ph

ysic

alac

tivity

(0–1

0),e

ndTx

:8w

k44

N/A

5.96

Min

oret

al4

8W

alki

ngpr

ogra

mA

IMS–

phys

ical

activ

ity(0

–10)

,end

Tx:1

2w

k36

N/A

3.6

1.3

31%

�1.

3(�

2.48

,�0.

12)

Con

trol

AIM

S–ph

ysic

alac

tivity

(0–1

0),e

ndTx

:12

wk

32N

/A4.

9

Evci

kan

dSo

nel4

7W

alki

ngpr

ogra

mN

HP–

phys

ical

mob

ility

(0–1

00),

FU:6

mo

2841

.38.

6�

25.2

�59

%�

28(�

30.7

7,�

25.2

3)

Con

trol

NH

P–ph

ysic

alm

obili

ty(0

–100

),FU

:6m

o26

44.1

36.6

(Con

tinue

d)


Table

13.

Con

tinue

d

Study

Trea

tmen

tG

roup

Outc

om

eN

o.of

Patien

tsBase

line

Mea

nEn

d-o

f-St

udy

Mea

nA

bso

lute

Ben

efit

Rel

ative

Dif

fere

nce

inChange

From

Base

line

WM

D(9

5%

CI)

Evci

kan

dSo

nel4

7W

alki

ngpr

ogra

mW

OM

AC

–phy

sica

lfun

ctio

n(0

–68)

,FU

:6m

o28

23.9

10.2

�9.

2�

38%

�10

.5(�

12.4

1,�

8.59

)

Con

trol

WO

MA

C–p

hysi

calf

unct

ion

(0–6

8),

FU:6

mo

2625

.220

.7

Pete

rson

etal

74

Wal

king

prog

ram

AIM

S–pa

in(0

–10)

,end

Tx:8

wk

47N

/A3.

77N

/A23

.5%

�1

(�1.

79,�

0.21

)C

ontro

lA

IMS–

pain

(0–1

0),e

ndTx

:8w

k44

N/A

4.77

Evci

kan

dSo

nel4

7W

alki

ngpr

ogra

mW

OM

AC

–pai

n(0

–10)

,FU

:6m

o28

6.9

3.4

�2.

9�

43%

�2.

6(�

3.96

,�1.

24)

Con

trol

WO

MA

C–p

ain

(0–1

0),F

U:6

mo

266.

66.

0

Evci

kan

dSo

nel4

7W

alki

ngpr

ogra

mPa

in–V

AS

(0–1

0),F

U:6

mo

287.

13.

6�

3.3

�47

%�

3.2

(�3.

84,�

2.56

)C

ontro

lPa

in–V

AS

(0–1

0),F

U:6

mo

267.

06.

8

Evci

kan

dSo

nel4

7W

alki

ngpr

ogra

mN

HP–

pain

(0–1

00),

FU:6

mo

2841

.39.

0�

11.8

�29

%�

11.4

(�13

.13,

�9.

67)

Con

trol

NH

P–pa

in(0

–100

),FU

:6m

o26

40.9

20.4

Evci

kan

dSo

nel4

7W

alki

ngpr

ogra

mN

HP–

ener

gy(0

–100

),FU

:6m

o28

50.7

14.6

�32

.5�

63%

�34

.7(�

35.5

1,�

33.8

9)C

ontro

lN

HP–

ener

gy(0

–100

),FU

:6m

o26

52.9

49.3

Evci

kan

dSo

nel4

7W

alki

ngpr

ogra

mN

HP–

sleep

(0–1

00),

FU:6

mo

2844

.919

.6�

15.6

�35

%�

15.7

(�17

.95,

�13

.45)

Con

trol

NH

P–sle

ep(0

–100

),FU

:6m

o26

45.0

35.3

Pete

rson

etal

74

Wal

king

prog

ram

AIM

S–m

edic

atio

nus

e(0

–6),

end

Tx:8

wk

47N

/A3.

64N

/A11

6%�

2.74

(�3.

55,�

1.93

)

Con

trol

AIM

S–m

edic

atio

nus

e(0

–6),

end

Tx:8

wk

44N

/A0.

9

Min

oret

al4

8W

alki

ngpr

ogra

m15

.2-m

(50-

ft)w

alki

ngtim

e(s

),en

dTx

:12

wk

369.

98.

7�

0.9

�9%

�2

(�2.

97,�

1.03

)

Con

trol

15.2

-m(5

0-ft)

wal

king

time

(s),

end

Tx:1

2w

k32

11.0

10.7

Min

oret

al4

8W

alki

ngpr

ogra

mA

erob

icca

paci

ty(m

L/kg

min

�1),

end

Tx:1

2w

k36

18.9

22.4

3.6

20%

�5.

1(�

7.32

,�2.

88)

Con

trol

Aer

obic

capa

city

(mL/

kgm

in�

1),

end

Tx:1

2w

k32

17.4

17.3

Min

oret

al4

8W

alki

ngpr

ogra

mEx

erci

seen

dura

nce

(min

),en

dTx

:12

wk

3611

.914

.81.

413

%�

3.3

(�5.

48,�

1.12

)

Con

trol

Exer

cise

endu

ranc

e(m

in),

end

Tx:

12w

k32

10.0

11.5

Min

oret

al4

8W

alki

ngpr

ogra

mEx

erci

sehe

artr

ate

(bpm

),en

dTx

:12

wk

3614

915

85

3%�

16(�

28.0

6,�

3.94

)

Con

trol

Exer

cise

hear

trat

e(b

pm),

end

Tx:

12w

k32

138

142

(Con

tinue

d)


��

��

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Table

13.

Con

tinue

d

Study

Trea

tmen

tG

roup

Outc

om

eN

o.of

Patien

tsBase

line

Mea

nEn

d-o

f-St

udy

Mea

nA

bso

lute

Ben

efit

Rel

ative

Dif

fere

nce

inChange

From

Base

line

WM

D(9

5%

CI)

Mes

sier

etal

45

Exer

cise

sW

alki

ngsp

eed

(cm

/s),

mid

-Tx:

3m

o34

109.

4211

4.64

3.77

3%�

3.69

(�4.

91,�

2.47

)

Con

trol

Wal

king

spee

d(c

m/s

),m

id-T

x:3

mo

3610

9.42

110.

87

Mes

sier

etal

45

Exer

cise

sW

alki

ngsp

eed

(cm

/s),

mid

-Tx:

9m

o34

109.

4211

6.30

4.37

4%�

10.2

9(�

11.5

3,�

9.05

)

Con

trol

Wal

king

spee

d(c

m/s

),m

id-T

x:9

mo

3610

9.42

111.

93

Mes

sier

etal

45

Exer

cise

sW

alki

ngsp

eed

(cm

/s),

FU:1

8m

o34

109.

4211

5.20

7.79

7%�

10.2

9(�

11.5

1,�

9.07

)C

ontro

lW

alki

ngsp

eed

(cm

/s),

FU:1

8m

o36

109.

4210

7.41

Mes

sier

etal

45

Exer

cise

sC

aden

ce(s

teps

/min

),m

id-T

x:3

mo

3410

6.45

109.

310.

871%

�3.

56(�

4.12

,�3)

Con

trol

Cad

ence

(ste

ps/m

in),

mid

-Tx:

3m

o36

106.

4510

8.44

Mes

sier

etal

45

Exer

cise

sC

aden

ce(s

teps

/min

),m

id-T

x:9

mo

3410

6.45

109.

420.

941%

�3.

69(�

4.26

,�3.

12)

Con

trol

Cad

ence

(ste

ps/m

in),

mid

-Tx:

3m

o36

106.

4510

8.48

Mes

sier

etal

45

Exer

cise

sC

aden

ce(s

teps

/min

),FU

:18

mo

3410

6.45

109.

312.

082%

�3.

77(�

4.33

,�3.

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• stride length at 9 months (WMD�7.53 cm, 95%CI�6.48 to 8.58 cm) and at 18 months (WMD�7.54cm, 95% CI�6.52 to 8.56 cm) (Tab. 13);

• climbing self-efficacy score at 18-month follow-up(WMD�8.00, 95% CI�7.55 to 8.45) (Fig. 14a);

• 6-minute walk test at 8 weeks (WMD�111.50 m,95% CI�76.24 to 146.77 m) (Fig. 14b);

• stair-climbing time at 18-month follow-up (WMD��1.41, 95% CI��1.51 to �1.31) (Fig. 14c);

• general health status at 18-month follow-up(WMD�3.59, 95% CI�3.46 to 3.72) (Fig. 14d);

• incidence of disability at 18-month follow-up(WMD�0.52, 95% CI�0.28 to 0.96) (Fig. 14e);

• disability in transferring from a bed to a chair at18-month follow-up (WMD�0.42, 95% CI�0.22 to0.79) (Fig. 14e);

• disability in bathing (WMD�0.38, 95% CI�0.17 to0.84) (Tab. 14) and in dressing at 18-month follow-up(WMD�0.28, 95% CI�0.10 to 0.83) (Fig. 14e);

• fast speed at 8 weeks (WMD�15.00 m/min, 95%CI�6.53 to 23.47 m/min) (Fig. 14f);

• fast stride at 8 weeks (WMD�0.20 m, 95% CI�0.03to 0.37 m) (Fig. 14f);

• free speed at 8 weeks (WMD�7.00 m/min, 95%CI�0.34 to 13.66 m/min) (Fig. 14g);

• free stride at 8 weeks (WMD�0.20 m, 95% CI�0.08to 0.32 m) (Fig. 14g);

• AIMS–pain at 8 weeks (WMD��1.00, 95%CI��1.79 to �0.21) (Fig. 14i);

• AIMS–physical activity at 8 weeks (WMD��2.22,95% CI��3.25 to �1.19) (Tab. 13) and at 12 weeks(WMD��1.30, 95% CI��2.48 to �0.12) (Tab. 14,Fig. 14j);

• AIMS–medication use (WMD�2.74, 95% CI�1.93to 3.55) (Tab. 13);

• 15.2-m (50-ft) walking time at 8 weeks (WMD��2.00 s, 95% CI��2.97 to �1.03 s) and at 12 weeks

(WMD��0.90 s, 95% CI��1.71 to �0.09 s) (Fig.14p for 12 weeks only);

• exercise heart rate at 12 weeks (WMD�16.00 bpm,95% CI�3.94 to 28.06 bpm) (Fig. 14q);

• aerobic capacity at 12 weeks (WMD�5.10 mL/kgmin�1 , 95% CI�2.88 to 7.32 mL/kg min�1)(Fig. 14s); and

• exercise endurance at 12 weeks (WMD�3.30 min,95% CI�1.12 to 5.48 min) (Fig. 14s).

No statistically significant data were found for the fol-lowing: pain intensity in ambulation (results not shown),pain frequency in ambulation at 9 and 18 months(results not shown), pain frequency in transfer at 9 and18 months (results not shown), stride length (Tab. 13),disability in toileting and in eating at 18-month follow-up(Fig. 14e), fast cadence at 8 weeks (Fig. 14f), freecadence at 8 weeks (Fig. 14g), NHP–physical mobilityand WOMAC–physical function at 6-month follow-up(Fig. 14h), AIMS–pain at 12 weeks and 9-monthfollow-up (Tab. 13, Fig. 14i), AIMS–physical activity at9-month follow-up (Fig. 14j), AIMS–arthritis impact at 8weeks (Fig. 14k), grip force at 12 weeks and 9-monthfollow-up (Fig. 14m), NHP–pain at 6-week follow-up(Fig. 14n), morning stiffness at 12 weeks and 9-monthfollow-up (Fig. 14o), 15.2-m (50-ft) walking time at9-month follow-up (Fig. 14p), resting systolic bloodpressure and resting diastolic blood pressure at 12 weeksand 9-month follow-up and exercise heart rate at9-month follow-up (Fig. 14q), trunk flexibility at 12weeks (Fig. 14r), and aerobic capacity and exerciseendurance at 9-month follow-up (Fig. 14s).

Physical activity and aerobic capacity yielded clinicallyimportant benefits favoring jogging in water versus con-trol (one RCT, n�115)48 (Tab. 15). However, no clinicalbenefits were shown for functional status (AIMS–physi-

Table 14.Walking Program Versus Controla

Study Group OutcomeNo.Observed N

RiskOccurrence

RiskDifference WMD (95% CI)

Penninx et al73 Walking program Incidence of disability in ADL,FU: 18 mo

32 88 36% �16% 0.69 (0.49, 0.98)

Control Incidence of disability in ADL,FU: 18 mo

42 80 53%

Penninx et al73 Walking program Disability in transferring frombed to chair, FU: 18 mo

26 88 30% �20% 0.59 (0.4, 0.87)

Control Disability in transferring frombed to chair, FU: 18 mo

40 80 50%

Penninx et al73 Walking program Disability in bathing, FU:18 mo

11 88 13% �15% 0.45 (0.24, 0.88)

Control Disability in bathing, FU:18 mo

22 80 28%

a ADL�activities of daily living, FU�follow-up, WMD�weighted mean difference, CI�confidence interval.


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Figures 14a–s.Walking program versus control. ADL�activities of daily living, AIMS�Arthritis Impact Measurement Scales, FU�follow-up, NHP�NottinghamHealth Profile, VAS�visual analog scale, WOMAC�Western Ontario and McMaster Universities Osteoarthritis Index.




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cal activity) at 12 weeks (Tab. 15), pain at 12 weeks and9-month follow-up (results not shown), morning stiffnessat 12 weeks and 9-month follow-up (results not shown),trunk ROM at 12 weeks and 9-month follow-up (resultsnot shown), exercise heart rate (Tab. 15), or exerciseendurance at 12 weeks (Tab. 15). Statistically significantdifferences were found for AIMS–physical activity at 12weeks (WMD��1.20, 95% CI��2.29 to �0.11)(Fig. 15a), 15.2-m (50-ft) walking time at 12 weeks(WMD��1.10 s, 95% CI��2.12 to �0.08 s) (Fig. 15e),exercise heart rate at 12 weeks (WMD�13.00 bpm, 95%CI�1.32 to 24.68 bpm) (Fig. 15f), exercise endurance at12 weeks (WMD�2.80 min, 95% CI�0.23 to 5.37 min)(Fig. 15h), and aerobic capacity (WMD�5.90 mL/kgmin�1 , 95% CI�3.30 to 8.50 mL/kg min�1) (results notshown). AIMS–pain, morning stiffness, grip force, trunkflexibility, and resting blood pressure offered no statisti-cally significant differences (results not shown for last).One RCT that compared water exercises with control(n�30)81 yielded no statistically significant differences

and no clinical benefits for torque or ROM at 6 weeks(Figs. 16a–b).

For yoga versus control (one RCT, n�30),66 clinicallyimportant benefits were found for ROM and painduring activity at 6 weeks (Figs. 17b– c) but not fortenderness, swelling, hand functional status, or gripforce at 6 weeks (Figs. 17a, d, e, and f). Statisticallysignificant data were found for mean change in ten-derness of right hand (WMD�1.80, 95% CI�0.99 to2.61) and left hand (WMD�1.73, 95% CI�0.63 to2.83), mean change in pain during activity (WMD�–3.29, 95% CI�–5.30 to –1.28), and mean change inROM of right hand (WMD�10.02, 95% CI�6.50 to13.54), all at 6 weeks (Figs. 17a– c). No statistical datawere found for mean change in hand pain at rest,mean change in ROM of left hand, mean change incircumference of the hands, mean change in handfunctional status, or mean change in grip force ofboth hands (Figs. 17b–f).



Manual Therapy Combined With Therapeutic ExercisesOne RCT (n�83)30 was found on manual therapycombined with exercises, and this RCT compared theintervention with a control. Important clin-ical benefits were demonstrated for pain but notfunctional status (Tab. 16). Statistically significantdata were found for all the outcomes: 6-minute walktest at 4 weeks (WMD�81.90 m, 95% CI�22.85 to140.95 m) and at 8 weeks (WMD�77.70 m, 95%CI�18.59 to 136.81 m) (Fig. 18a) and pain at 4 weeks(WMD��416.00, 95% CI��618.15 to �213.85) andat 8 weeks (WMD��471.90, 95% CI��732.81 to�210.99) (Fig. 18b).

Strength of Published Evidence Compared With OtherGuidelinesGood evidence (level I, RCT) shows that various kinds ofexercises and manual therapy are useful for patients withOA, with different outcomes occurring depending onthe intervention: strengthening exercises relieve pain atrest and during functional activities and improve kneeROM, quadriceps femoris muscle peak torque, grip force,level of energy, and functional status; general physicalactivities, including fitness and aerobic exercises, relievepain during functional activities and improve stride length,functional status, and aerobic capacity; and manual therapycombined with TE relieves pain.



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Three sources have considered the strength of evidence:The Philadelphia Panel,36 American Pain Society,33 andOntario Program for Optimal Therapeutics.35 All 3 sourcesreported good-quality evidence for TE, including strength-ening exercises and general physical activities (Appendix1). To our knowledge, the scientific literature offers noguidelines on manual therapy for patients with OA.

Clinical Recommendations Compared With OtherGuidelinesThe Ottawa Panel concluded that good evidence existssupporting the inclusion of all of the following maincategories of interventions in the management of patientswith OA: strengthening exercises (grade A for pain at restand during functional activities, ROM, grip force, level ofenergy, and functional status; grade C� for quadricepsfemoris muscle peak torque, specific functional activities,and timed functional activities); general physical activities,including fitness and aerobic exercises (grade A for painduring functional activities, stride length, functional status,energy level, aerobic capacity, and medication use;grade C� for disability in ADL); and manual therapycombined with exercises (grade A for pain). The recom-mendations related to strengthening exercises and generalphysical activities generally concur with all other existingguidelines.31–36

Practitioners’ Response to Ottawa Panel GuidelinesThe 5 practitioners who reviewed our guidelines agreedwith the recommendations. Four practitioners found therecommendations to be clear; 1 practitioner was uncer-tain which type of exercise was effective. The OttawaPanel explained that, depending on the specific out-come, interventions with grade A, B, or C� are benefi-cial. Guideline summaries (see evidence-based clinicalpractice guidelines in Appendix 4) were rewritten forbetter comprehension. A decision aid was created toclarify the application of the guidelines. This aid can befound on the University of Ottawa Web site(www.health.uottawa.ca/rehabguidelines).

DiscussionThe Ottawa Panel EBCPGs (grouped together in Appen-dix 4) were rigorously developed15,16 using an extensivesystematic review of TE (Figs. 1–18). Numerous grade A(n�13) and C� (n�3) recommendations have beendeveloped for TE for patients with OA. Various out-comes useful for rehabilitation practitioners andpatients with OA were considered, such as pain, func-tional status, and quality of life. However, more evidenceis needed to determine the efficacy of TE in the man-agement of patients with OA. Evidence on the effective-ness of the specific type of muscle contraction to be usedduring resistance training, on water exercises, and onhip strengthening is lacking, as is indicated by the grade

Table

15

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C recommendations for these interventions. No harmfulside effects were reported.

LimitationsEven though the Ottawa Panel EBCPGs on OA weredeveloped using a rigorous methodology,15 similarmethodological weaknesses were identified comparedwith the Ottawa Panel EBCPGs on RA.16 More precise

characteristics of the therapeutic application (eg, dos-age, type of exercise used, intensity, frequency) need tobe reported by investigators to reproduce the exerciseprograms (eg, quadriceps femoris and hamstringmuscle strengthening), especially when they wereproven effective.76,78

Figures 15a–i.Jogging in water versus control. FU�follow-up, ROM�range of motion, AIMS�Arthritis Impact Measurement Scales.


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Figures 16a and b.Water exercises versus control. ROM�range of motion.



The Ottawa Panel EBCPGs for the management ofpatients with OA, however, were in concordance withAppraisal of Guidelines Research and Evaluation(AGREE) criteria155 and yielded results identical tothose of the previous Ottawa Panel EBCPGs developedfor RA16 (see University of Ottawa Web site [www.health.uottawa.ca/rehabguidelines]). Furthermore, theOttawa Panel EBCPGs generally concur with previous

and relatively recent EBCPGs31–36 and systematic reviewsfor OA19–29,156 and fit entirely with the recommenda-tions from the Work Group on physical activity.157,158

Therapeutic ExercisesThe Ottawa Panel concluded that TE is beneficial forpatients with OA. Benefits are recognized for pain at restand during functional activities, knee ROM, quadriceps

Figures 17a–f.Yoga versus control. HAQ�Health Assessment Questionnaire, ROM�range of motion, VAS�visual analog scale.


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femoris muscle peak torque, grip force, stride length,level of energy, functional status, and aerobic capacity.Quality of life also was enhanced (statistical significanceonly) after an 8-week LE strengthening exercise pro-gram65 and 18 months after a walking program.76

Progressive exercises75 are promising prospects for OApatient management, but results were inconclusiveregarding the ideal intensity of the exercise program.18

Results for RA, however, were conclusive, with low-intensity exercises being recommended for patients withRA.16

All 3 main categories of exercises and physical activityare widely used and are effective for the management ofpatients with OA. The efficacy of exercises is mainlybased on the results of short-term RCTs, RCTs that arerelatively good quality, considering that exercise is aphysical intervention and thus blinding is an issue.159

Exercises and physical activity are promising interven-tions for reducing pain and improving functional status,aerobic capacity, and quality of life.47,48,67,79 They alsooffer the potential to reduce body weight160 and toprevent biomechanical problems161,162 and further jointdamage in patients with OA.163

Information on the long-term effect of the exercise pro-gram and specifications of the therapeutic application(intensity and dosage) are lacking. Researchers believe thatthe long-term efficacy of exercises for patients with OA(with or without other interventions) is influenced by avariety of factors, including physiological, biomechanical,psychosocial, and environmental factors.161,163,164 Thus,researchers157,158,162,165,166 have suggested multidimen-sional clinical management of patients with OA due to themultivariate nature of the disease.

Patients with OA tend to adopt sedentary lifestyles.167

The main challenge is to find effective strategies to helpthese patients adopt and sustain regular physical activityhabits so that they can benefit from the positive effectsand avoid the negative consequences and vicious cycle ofinactivity. Inactivity can lead to chronic comorbidityproblems (eg, obesity, cardiovascular conditions, diabe-tes) that affect joint health, functional status, and qualityof life in patients with OA.126,168,169 Change in lifestyleamong patients with OA is necessary to promote sus-tained physical activity.164,170 Fortunately, the level ofparticipation in regular aerobic physical activity can bemodified through behavioral interventions.171–173

The identification of predisposing, enabling, and rein-forcing factors174 for increasing the level of participationin regular physical activity and exercise is essential.Addressing these factors collectively may increase thelikelihood of intrapersonal, interpersonal, and environ-

Table

16.

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mental changes that are desirable for sustaining a newbehavior regarding TE and physical activity. Predisposingintrapersonal and interpersonal factors include psychologi-cal factors (eg, attitude, perceived behavioral control,self-efficacy, motivation, perceived health, expected ben-efits, depressive symptoms, fear of exercise and of expe-riencing pain, perceived stress and effort), biologicalfactors (eg, comorbidities, body mass index, smokingstatus, functional capacity), and demographic factors(eg, age, sex, education). These characteristics mayinteract with the format of the program and ultimatelywill determine the success of the physical activity inter-vention. Enabling factors are factors that affect behaviordirectly or indirectly through an environmental indica-tor163,175 and include the structure of the interventionprogram, the necessary physical activity skills and equip-ment, the format of the program (community-basedversus clinical setting), the type and frequency of expertsupervision and guidance provided, accessibility, time,weather, and the costs incurred by the participant.Reinforcing factors appear subsequent to the change inbehavior and provide continuing reward or incentive forthe new behavior to be maintained by the individual.Primary reinforcing factors include social support,health practitioner influence, peer influence, feedbackfrom significant others, vicarious reinforcement, incen-tives, mastery, self-monitoring activity, goal attainment,and enjoyment of the activity. Reinforcing factors willultimately determine whether the patient continues withthe physical activity program and thus will have animpact on the long-term quality of life.

Future studies examining the benefits of TE programs inthe management of patients with OA will need toidentify an effective physical activity program, enhance asustained physical activity program integrating behav-ioral interventions, be patient specific, develop a patienteducation program, and facilitate regular physical activ-ity in the community.163 The Work Group recommendsincreasing the awareness of EBCPGs on exercise andphysical activity programs among patients with arthritis,practitioners, health care administrators, educators, andpolicy makers.157

Manual TherapyOne study55 with an acceptable research design wasidentified. Yet, although the combination of manualtherapy and exercise reduces pain in patients with OA,the specific effect of manual therapy could not bedetermined in that study. Indeed, the reduction of painafter exercise is observed in patients with arthritis ingeneral.176–178 In the study by Deyle et al,30 exercise mayhave contributed to the reduction of pain, but themagnitude was not measured. A recent head-to-headRCT110 that compared the relative efficacy of manualtherapy compared with exercise therapy alone for hipOA showed that manual therapy was significantly moreeffective than TE for patient global assessment, pain,stiffness, functional status, and ROM after 5 weeks (9consecutive treatment sessions). Considering theserecent scientific results, further research is needed onthe individual effects of manual therapy for patients withOA.

Figures 18a and b.Manual therapy and exercise versus control. FU�follow-up, WOMAC�Western Ontario and McMaster Universities Osteoarthritis Index.


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Implications for PracticeThe Ottawa Panel has found evidence to recommendand support the use of TE (on their own or combinedwith manual therapy), especially strengthening exercisesand general physical activity, for patients with OA,particularly for the management of pain and improve-ment of functional status. These recommendations arelimited by methodological considerations, such as therelatively good quality, but generally poorly reporteddescription, of TE programs and the selection of out-comes of the included primary trials.

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164 Eyler AA. Correlates of physical activity: who’s active and who’snot? Arthritis Rheum. 2003;49:136–140.

165 Sniezek JE, Macera CA, Hootman JM, Eyler AA. Work GroupRecommendations: 2002 Exercise and Physical Activity Conference, StLouis, Missouri—Session II: the problem and challenge of inactivity.Arthritis Rheum. 2003;49:141.

166 Meenan R, Sharpe P, Boutaugh M, Brady T. Work Group Recom-mendations: 2002 Exercise and Physical Activity Conference, St Louis,Missouri—Session VI: population approaches to health promotion anddisability prevention through physical activity. Arthritis Rheum. 2003;49:477.

167 Hootman JM, Macera CA, Ham SA, et al. Physical activity levelsamong the general US adult population and in adults with and withoutarthritis. Arthritis Rheum. 2003;49:129–135.

168 Coggon D, Reading I, Croft P, et al. Knee osteoarthritis andobesity. Int J Obes Relat Metab Disord. 2001;25:622–627.

169 Huang M-H, Chen C-H, Chen T-W, et al. The effects of weightreduction on the rehabilitation of patients with knee osteoarthritis andobesity. Arthritis Care Res. 2000;13:398–405.

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171 Baranowski T, Anderson C, Carmack C. Mediating variable frame-work in physical activity interventions. How are we doing? How mightwe do better? Am J Prev Med. 1998;15:266–297.

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176 Jones CA, Rees JM, Dodds WN, Jayson MI. Changes in plasmaopioid concentrations after physiotherapeutic exercises for arthriticpatients. Neuropeptides. 1985;5:561–562.

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178 Kangilaski J. Beta-endorphin levels lower in arthritis patients.JAMA. 1981;246:203.


Appendix 1.Previous Evidence-Based Clinical Practice Guidelines for Therapeutic Exercises for Osteoarthritisa

Author/YearQuality of PublishedEvidence Clinical Recommendations

Philadelphia Panel,36 2001 Good scientific evidence (level 1)for therapeutic exercises

Good evidence (grade A) to include strengthening and stretchingexercises alone for knee OA

ACR,31 2000 N/R Exercise programs are recommended to maintain or improve joint ROMand periarticular muscle force

AGS,32 2001 N/R Exercise programs should be individualized. They are recommended forcontrolling pain, increasing flexibility, and improving muscle forceand endurance

APS,33 2002 Good-quality evidence Exercise—ROM, stretching, stengthening (isometric, dynamic), aerobicexercise, and physical activity—is recommended for pain relief

OPOT,35 2000 Good-quality evidence Exercise programs (stretching and quadriceps femoris musclestrengthening; aerobic exercise, including walking and swimming;and resistance exercises) are recommended to reduce pain and toimprove function in patients with OA of the knee

BMJ,34 2003 N/R Likely to be beneficial for pain relief and to improve function

a Interventions with no data are not exhibited. ACR�American College of Rheumatology Subcommittee on Osteoarthritis Guidelines, AGS�American GeriatricsSociety Panel on Exercise and Osteoarthritis, APS�American Pain Society, OPOT�Ontario Program for Optimal Therapeutics, BMJ�BMJ Books, N/R�notreported, OA�osteoarthritis, ROM�range of motion.


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notra

inin

gbu

tw

ere

teste

dtw

ice

thro

ugho

utth

e8-

wk

expe

rimen

tal

perio

d

Pain

atni

ght

Pain

afte

rin

activ

ityPa

insi

tting

Pain

risin

gfro

ma

chai

rPa

insta

ndin

gPa

incl

imbi

ngsta

irsPa

inde

scen

ding

stairs

Pain

tota

lsco

re(1

0-po

ints

cale

,0�

nopa

in)

15-m

wal

k(s

)Ti

me

risin

gfro

ma

chai

r(s

)Ti

me

clim

bing

stairs

(s)

Tim

ede

scen

ding

stairs

(s)

Tota

lsco

refu

nctio

nal

tests

(s)

For

Gr1

and

Gr2

,a

spec

trum

ofan

gula

rve

loci

ties

vary

ing

from

30°/

sto

180°

/sat

30°

inte

rval

s(3

0°,

60°,

90°,

etc)

bila

tera

llyw

asus

ed;a

2-m

inre

stw

asgi

ven

betw

een

knee

exte

nsor

and

flexo

rm

ovem

ents

inG

r2,a

nda

5-m

inre

stw

asgi

ven

betw

een

the

legs

inbo

thtra

inin

ggr

oups

3da

ysa

wee

kfo

r8

wk

N/A

1,0,

0

(Con

tinue

d)


Appen

dix

2.

Det

ails

ofIn

clud

edTr

ialsa

(con

tinue

d)

Auth

or/

Yea

rSa

mple

Size

Popula

tion

Det

ails

Sym

pto

mD

ura

tion

Age

(y)

Inte

rven

tion

Com

pari

son

Gro

up

Outc

om

esConcu

rren

tTh

erapy

Freq

uen

cyand

Dura

tion

Follo

w-u

pD

ura

tion

Qualit

y(R

,B,W

)

Hur

ley

and

Scot

t,68

1998

CC

TTo

tal:

60G

r1:4

4G

r2:1

6

Incl

usio

ncr

iteria

:pat

ient

sha

dto

fulfi

llth

eA

CR

crite

riafo

rkn

eeO

A;

the

pred

omin

ant

com

plai

ntof

all

patie

nts

was

knee

pain

;pat

ient

sw

hore

porte

dco

exis

tent

mild

sym

ptom

atic

OA

inot

her

join

tsw

ere

note

xclu

ded

from

the

trial

unle

ssth

epa

infro

mth

ese

othe

rjo

ints

inte

rfere

dw

ithth

epe

rform

ance

ofth

eas

sess

men

tpro

cedu

res

Gr1

:X�

51m

o,SD

�27

.75

mo

Gr2

:X�

54m

o,SD

�42

.75

mo

Gr1

:X�

62,

SD�

12.0

Gr2

:X�

61,

SD�

11.7

5

Gr1

:exe

rcis

epr

ogra

mfo

r5

wk,

2tim

esa

wee

kfo

r30

min

;24

isom

etric

quad

ricep

sfe

mor

ism

uscl

evo

lunt

ary

cont

ract

ions

(4�

6re

petit

ions

,he

ld4

s,2-

min

rest

betw

een

sets)

,2-m

insta

tiona

rybi

cycl

e,1-

min

isot

onic

knee

exte

nsio

n(c

once

ntric

quad

ricep

sfe

mor

ism

uscl

eco

ntra

ctio

ns)

and

flexi

on(e

ccen

tric

quad

ricep

sfe

mor

ism

uscl

eco

ntra

ctio

ns)

to90

°of

flexi

onus

ing

ther

apeu

ticre

sista

nce

band

s,3

func

tiona

lexe

rcise

s(si

t-sta

nd,s

tep-

ups,

step-

dow

ns),

and

3ba

lanc

e/co

ordi

natio

nex

erci

ses

(uni

late

ral

stanc

e,ba

lanc

ebo

ards

)tha

twer

eea

chpe

rform

edfo

r1

min

Gr2

:con

trol;

reha

bilit

atio

nw

asde

laye

d

Isom

etric

quad

ricep

sfe

mor

ism

uscl

efo

rce

(mus

cle

volu

ntar

yco

ntra

ctio

n)Q

uadr

icep

sfe

mor

ism

uscl

evo

lunt

ary

activ

atio

n(%

)Kn

eejo

intp

ositi

onse

nse

(°)

Agg

rega

tefu

nctio

nal

perfo

rman

cetim

e(s

)Le

ques

neIn

dex

(0–2

4)

N/A

2tim

esa

wee

kfo

r5

wk

6m

o0,

0,1

Kova

ret

al,6

9

1992

RCT

Tota

l:92

Gr1

:47

Gr2

:45

Incl

usio

ncr

iteria

:pat

ient

sw

how

ere

aged

�40

y;w

hoha

da

docu

men

ted

diag

nosis

ofch

roni

c,sta

ble,

prim

ary

OA

ofon

eor

both

knee

join

tsin

asso

ciat

ion

with

atle

ast

4-m

ohi

story

ofsy

mpt

omat

ickn

eepa

inoc

curri

ngdu

ring

wei

ght-b

earin

gac

tiviti

es(p

atie

nts

who

had

mul

tiple

join

tin

volv

emen

t,w

hoha

dun

derg

one

maj

orjo

int

surg

ery,

orw

hoha

da

low

erjo

intp

rosth

esis

also

wer

eel

igib

le);

who

had

radi

ogra

phic

evid

ence

ofpr

imar

yO

Aof

one

orbo

thkn

eejo

ints,

asde

mon

strat

edby

join

tsp

ace

narro

win

g,m

argi

nals

pur

form

atio

n,or

subc

hond

ralc

yst

form

atio

n;w

hous

edan

yof

the

vario

usco

mm

on,o

ver-t

he-

coun

terN

SAID

s�

2da

ysa

wee

k;an

dw

how

ere

notp

artic

ipat

ing

ina

regu

larp

rogr

amof

phys

ical

activ

ityat

the

time

ofen

rollm

ent

Gr1

:X�

12y,

SD�

12y

Gr2

:X�

11y,

SD�

11y

Gr1

: X�70

.38,

SD�

9.11

Gr2

: X�68

.48,

SD�

11.3

2

Gr1

:Exe

rcis

e.Tw

enty

-fo

ur90

-min

sess

ions

ofw

alki

ngan

ded

ucat

ion

desi

gned

and

led

bya

phys

ical

ther

apis

t.Lig

htstr

etch

ing

and

stren

gthe

ning

exer

cise

s;gu

est

spea

kers

onth

em

edic

alas

pect

sof

OA

and

exer

cise

;gr

oup

disc

ussi

onab

outb

arrie

rsan

dbe

nefit

sof

wal

king

;in

struc

tion

inpr

oper

wal

king

tech

niqu

esan

dth

em

aint

enan

ceof

aw

alki

ngpr

ogra

m;s

uppo

rtive

enco

urag

emen

t;an

dup

to30

min

ofw

alki

ng.

Gr2

:con

trol;

each

wee

k,th

epa

tient

sw

ere

cont

acte

dby

the

study

coor

dina

tor

via

tele

phon

eto

disc

uss

the

natu

reof

thei

rA

DL

6-m

inte

stof

wal

king

dista

nce

(m)

AIM

Ssu

bsca

les:

phys

ical

activ

ity(0

–10,

10�

grea

ter

disa

bilit

y),a

rthrit

isim

pact

(0–1

0,10

�po

orer

heal

thsta

tus)

Arth

ritis

pain

(0–1

0,10

�gr

eate

rpa

in),

med

icat

ion

use

(0–6

,6�

less

frequ

ent

med

icat

ion

use)

N/A

3tim

esa

wee

kfo

r8

wk

N/A

2,0,

1

(Con

tinue

d)


��

��

��

��

��

Appen

dix

2.

Det

ails

ofIn

clud

edTr

ialsa

(con

tinue

d)

Auth

or/

Yea

rSa

mple

Size

Popula

tion

Det

ails

Sym

pto

mD

ura

tion

Age

(y)

Inte

rven

tion

Com

pari

son

Gro

up

Outc

om

esConcu

rren

tTh

erapy

Freq

uen

cyand

Dura

tion

Follo

w-u

pD

ura

tion

Qualit

y(R

,B,W

)

Krei

ndle

ret

al,7

019

89RC

TTo

tal:

32G

r1:8

Gr2

:5G

r3:1

0G

r4:9

Incl

usio

ncr

iteria

:pat

ient

sw

ithpr

imar

ydi

agno

sis

ofO

Aof

the

knee

N/A

X�67

.42,

SD�

8.38

Gr2

:pro

gres

sive

exer

cise

prog

ram

cons

istin

gof

quad

ricep

sfe

mor

isan

dha

mstr

ing

mus

cle

stren

gthe

ning

exer

cise

s;ex

erci

ses

wer

ebe

gun

inse

ssio

n2,

mon

itore

d3

times

aw

eek,

and

prog

ress

edat

wee

kly

inte

rval

sfo

r6

cons

ecut

ive

wk

Gr3

:sam

eas

Gr1

,co

mbi

ned

with

prog

ress

ive

Kine

tron

prog

ram

;pat

ient

sex

erci

sed

atsp

eeds

that

regi

stere

dre

adin

gsof

100–

150

psi;

aspa

tient

spr

ogre

ssed

abov

eth

e10

0-to

150-

psil

evel

,th

eypr

ogre

ssed

toth

ene

xthi

gher

spee

d

Gr4

:10

quad

ricep

sfe

mor

ism

uscl

ese

tting

exer

cise

sfo

rw

arm

-up

befo

reex

erci

sing

onth

eC

ybex

;the

exer

cise

posi

tions

onth

eC

ybex

mat

ched

the

eval

uatio

npo

sitio

ns;2

-min

rest

perio

dsw

ere

gran

ted

betw

een

test

spee

dsG

r1:c

ontro

lgro

upw

asev

alua

ted

and

told

toco

ntin

ueno

rmal

activ

ities

and

retu

rnfo

rre

eval

uatio

nin

6w

k

Qua

dric

eps

fem

oris

mus

cle

forc

ere

lativ

eto

body

wei

ghta

t60°

,80

°,an

d12

0°/s

mea

sure

dw

ithth

eC

ybex

3tim

esa

wee

kfo

r6

wk

N/A

3tim

esa

wee

kfo

r6

wk

6w

k2,

0,0

Mes

sier

etal

,45

1997

RCT

Tota

l: 103

Gr1

:33

Gr2

:34

Gr3

:36

Incl

usio

ncr

iteria

:pat

ient

sw

ho(1

)wer

eag

ed�

60y,

(2)h

adpa

inon

mos

tday

sof

the

mon

thin

one

orbo

thkn

ees,

(3)s

how

edra

diog

raph

icev

iden

ceof

knee

OA

inth

etib

iofe

mor

alco

mpa

rtmen

tsof

the

pain

fulk

nee,

and

(4)

had

diffi

culty

with

atle

asto

neof

the

follo

win

gac

tiviti

esdu

eto

knee

pain

—w

alki

ng0.

4km

,clim

bing

stairs

,get

ting

inan

dou

tofa

car,

risin

gfro

ma

chai

r,lif

ting

and

carr

ying

groc

erie

s,ge

tting

out

ofbe

d,ge

tting

outo

fa

bath

tub,

shop

ping

,cl

eani

ng,o

rse

lf-ca

re

N/A

Gr1

: X�70

.3,

SD�

1.3

Gr2

: X�67

.2,

SD�

0.9

Gr3

: X�69

.2,

SD�

1.0

Gr1

:aer

obic

train

ing;

5-m

inw

arm

-up,

40-

min

wal

king

phas

eat

anin

tens

ityeq

ualt

o50

%–8

5%of

the

subj

ect’s

HR

rese

rve,

and

5-m

inco

ol-d

own

Gr2

:stre

ngth

enin

gtra

inin

g;w

arm

-up,

9up

per-

and

low

er-

body

exer

cise

sus

ing

dum

bbel

lsan

dcu

ffw

eigh

ts(le

gex

tens

ion,

leg

curl,

step-

up,h

eel-r

aise

,ch

estf

ly,u

prig

htro

w,

mili

tary

pres

s,bi

cep

curls

,and

pelv

ictil

t),an

dco

ol-d

own

phas

e;2

sets

of10

–12

repe

titio

nsw

ere

perfo

rmed

for

each

exer

cise

Gr3

:con

trol;

regu

larly

sche

dule

dco

ntac

tssi

mila

rto

thos

eof

the

2in

terv

entio

ngr

oups

;pat

ient

sw

ere

divi

ded

into

grou

psof

12–1

5to

parti

cipa

tein

mon

thly

on-si

tehe

alth

educ

atio

nse

ssio

nsdu

ring

mon

ths

1–3;

durin

gth

etra

nsiti

onph

ase

(4–6

mo)

,bi

wee

kly

tele

phon

eco

ntac

twas

mad

e;th

em

aint

enan

ceph

ase

(7–1

8m

o)co

nsis

ted

ofm

onth

lyte

leph

one

calls

Wal

king

spee

d(c

m/s

),ca

denc

e(s

teps

/min

),str

ide

leng

th(c

m),

stanc

etim

e(s

),%

swin

g

For

Gr1

and

Gr2

,18

-mo

perio

d;3-

mo

faci

lity-

base

dpr

ogra

mfo

llow

edby

15-m

oho

me-

base

dpr

ogra

m:(

1)3-

mo

trans

itory

phas

eof

cont

acts

once

ever

y2

wk

(4ho

me

visi

tsan

d6

tele

phon

eca

lls)a

nd(2

)12

-mo

mai

nten

ance

phas

eof

tele

phon

eco

ntac

tson

ceev

ery

3w

kdu

ring

the

first

3m

oan

dm

onth

lyco

ntac

tdu

ring

mo

9–18

3tim

esa

wee

kfo

r18

mo

N/A

2,0,

0

(Con

tinue

d)


Appen

dix

2.

Det

ails

ofIn

clud

edTr

ialsa

(con

tinue

d)

Auth

or/

Yea

rSa

mple

Size

Popula

tion

Det

ails

Sym

pto

mD

ura

tion

Age

(y)

Inte

rven

tion

Com

pari

son

Gro

up

Outc

om

esConcu

rren

tTh

erapy

Freq

uen

cyand

Dura

tion

Follo

w-u

pD

ura

tion

Qualit

y(R

,B,W

)

Min

oret

al,4

8

1989

RCT

Tota

l: 115

Gr1

:36

Gr2

:47

Gr3

:32

Incl

usio

ncr

iteria

:pat

ient

sw

ithcu

rren

tsym

ptom

sof

chro

nic

pain

and

stiffn

ess

inin

volv

edw

eigh

t-bea

ring

join

ts;ob

ject

ive

evid

ence

ofjo

intp

ain

and

crep

itatio

nw

ithPR

OM

;and

docu

men

ted

roen

tgen

ogra

phic

sign

sof

hype

rtrop

hic

chan

ges,

subc

hond

ral

scle

rosi

s,or

nonu

nifo

rmjo

ints

pace

narr

owin

gin

invo

lved

join

ts

N/A

N/M

Gr1

:wal

king

ona

leve

lco

urse

,pro

gres

sing

from

10to

30m

inat

exer

cise

HR

Gr2

:jog

ging

insh

allo

wan

dde

epw

ater

and

mod

ified

calis

then

ics

perfo

rmed

inch

est-

high

wat

er

Gr3

:con

trol;

gent

leA

ROM

and

isom

etric

stren

gthe

ning

and

rela

xatio

nex

erci

ses,

with

noae

robi

csti

mul

uspe

riod

Cha

nge

inA

IMS–

pain

(0–1

0)C

hang

ein

AIM

S–ph

ysic

al(0

–10)

Cha

nein

mor

ning

stiffn

ess

(h)

Cha

nge

ingr

ipfo

rce

(mm

Hg)

Cha

nge

intru

nkfle

xibi

lity

(cm

)C

hang

ein

15.2

-m(5

0-ft)

wal

king

time

(s)

Cha

nge

inae

robi

cca

paci

ty(m

L/kg

min

�1)

Cha

nge

inex

erci

seen

dura

nce

(min

)C

hang

ein

resti

ngbl

ood

pres

sure

:sy

stolic

and

dias

tolic

(mm

Hg)

Cha

nge

inex

erci

seH

R(b

pm)

Gr1

and

Gr2

:pa

tient

sw

ithex

erci

seH

Rth

atva

ried

60%

–80

%of

max

imal

HR

wer

eas

signe

din

divi

dual

lyto

parti

cipa

tein

aero

bic

exer

cise

s(p

ool

and

wal

kgr

oups

);cl

asse

sin

clud

eda

war

m-u

p,ge

nera

lfle

xibi

lity

and

isom

etric

stren

gthe

ning

ofpo

stura

lm

uscl

es,a

nae

robi

csti

mul

uspe

riod

prog

ress

ing

to30

min

ofco

ntin

uous

activ

ity,a

nda

cool

-dow

nof

10m

inof

ARO

Man

dstr

etch

ing

12w

k3,

9m

o1,

0,1

O’R

eilly

etal

,71

1999

RCT

Tota

l: 191

Gr1

: 113

Gr2

:78

Incl

usio

ncr

iteria

:pat

ient

sw

ith�

1m

oof

pain

inor

arou

ndth

ekn

eeon

mos

tday

san

dan

ypa

inin

the

past

year

N/A

Gr1

: X�61

.94,

SD�

10.0

1G

r2: X�

62.1

5,SD

�9.

73

Gr1

:Exe

rcis

epr

ogra

mco

nsis

ting

ofth

efo

llow

ing:

(1)

isom

etric

quad

ricep

sfe

mor

ism

uscl

eco

ntra

ctio

nin

full

exte

nsio

n,he

ldfo

r5

s;(2

)iso

toni

cqu

adric

eps

fem

oris

mus

cle

cont

ract

ion

inm

idfle

xion

;(3)

isot

onic

quad

ricep

sfe

mor

ism

uscl

eco

ntra

ctio

nin

full

flexi

on;(

4)is

oton

icqu

adric

eps

fem

oris

mus

cle

cont

ract

ion

infu

llex

tens

ion;

and

(5)

dyna

mic

stepp

ing

exer

cise

.Exe

rcis

esin

crea

sed

toa

max

imum

of20

repe

titio

nsan

dw

ere

perfo

rmed

atho

me

ona

daily

basi

s.Su

bjec

tsw

ere

visi

ted

atw

eeks

2an

d6

and

atm

onth

3.

Gr2

:con

trol;

noTx

WO

MA

C–p

ain

(0–

20,h

ighe

rsc

ore�

mor

epa

in)

WO

MA

C–f

unct

ion

(0–6

8,hi

gher

scor

e�m

ore

disa

bilit

y)Iso

met

ricqu

adric

eps

fem

oris

mus

cle

forc

eSe

lf-re

porte

dhe

alth

statu

s(S

F-36

,0–

100,

high

ersc

ore�

bette

rhe

alth

)

N/A

1tim

ea

day

for

6m

o

N/A

2,0,

1

(Con

tinue

d)


��

��

��

��

��

Appen

dix

2.

Det

ails

ofIn

clud

edTr

ialsa

(con

tinue

d)

Auth

or/

Yea

rSa

mple

Size

Popula

tion

Det

ails

Sym

pto

mD

ura

tion

Age

(y)

Inte

rven

tion

Com

pari

son

Gro

up

Outc

om

esConcu

rren

tTh

erapy

Freq

uen

cyand

Dura

tion

Follo

w-u

pD

ura

tion

Qualit

y(R

,B,W

)

Pelo

quin

etal

,72

1999

RCT

Tota

l: 124

Gr1

:59

Gr2

:65

Incl

usio

ncr

iteria

:pat

ient

sw

ho(1

)wer

eag

ed�

50y;

(2)h

adno

cont

rain

dica

tions

toex

erci

se;(

3)w

ere

not

abse

ntfro

mci

tyfo

rm

ore

than

2w

k;(4

)ha

dan

inde

pend

ent,

noni

nstit

utio

nal

lifes

tyle

;(5)

had

noin

tra-a

rticu

lar

stero

idor

visc

oela

stic

devi

cein

ject

ions

with

inth

epr

evio

us2

mo;

(6)

had

stabl

ere

gim

enus

ing

anal

gesi

csor

NSA

IDs

for

atle

ast2

wk

befo

reth

ebe

ginn

ing

ofth

estu

dy;(

7)ha

ddi

agno

sis

ofm

inim

alto

mod

erat

eid

iopa

thic

OA

of1

orbo

thkn

eejo

ints;

(8)h

ad�

15°

fixed

-flex

ion

defo

rmity

;(9

)had

�10

°of

genu

varu

mor

valg

um;a

nd(1

0)ha

dno

join

tbl

ocki

ng

Gr1

:X�

7.92

y,SD

�7.

90y

Gr2

:X�

6.38

y,SD

�6.

05y

Gr1

: X�65

.64,

SD�

7.41

Gr2

: X�66

.43,

SD�

6.39

Gr1

:3tim

esa

wee

k,1-

hex

erci

sese

ssio

n;5-

min

war

m-u

p,br

isk

wal

k,m

uscl

estr

engt

heni

ngw

ithTh

era-

Band

,c

resi

stanc

epr

ogra

m(is

omet

ricco

ntra

ctio

nsat

3di

ffere

ntan

gles

),5-

min

cool

-dow

n

Gr2

:con

trol;

1-h

educ

atio

n/in

form

atio

nse

ssio

ns2

times

aw

eek

AIM

S2(0

–10,

0�go

odhe

alth

statu

s)A

erob

icca

paci

ty(m

)H

amstr

ing

mus

cle

and

low

back

flexi

bilit

y(in

)Q

uadr

icep

sfe

mor

ism

uscl

eis

omet

ricfo

rce

(N�m

)H

amstr

ing

mus

cle

isom

etric

forc

e(N

�m)

Qua

dric

eps

fem

oris

and

ham

strin

gm

uscl

eis

okin

etic

forc

e(N

�m)

N/A

3tim

esa

wee

kfo

r3

mo

N/A

2,0,

1

Penn

inx

etal

,73

2001

RCT

Tota

l: 250

Gr1

:82

Gr2

:88

Gr3

:80

Incl

usio

ncr

iteria

:pat

ient

sw

ho(1

)wer

eag

ed�

60y;

(2)h

adpa

inin

the

knee

(s)o

nm

ost

days

ofth

em

onth

;(3)

had

diffi

culty

with

atle

asto

neof

the

follo

win

gbe

caus

eof

knee

pain

—w

alki

ng0.

4km

;clim

bing

stairs

;get

ting

inan

dou

tofa

car,

bath

,or

bed;

risin

gfro

ma

chai

r;or

perfo

rmin

gsh

oppi

ng,c

lean

ing,

orse

lf-ca

reac

tiviti

es;a

nd(4

)sho

wed

radi

ogra

phic

evid

ence

ofkn

eeO

A

N/A

Gr1

: X�68

.8,

SD�

5.2

Gr2

: X�69

.9,

SD�

5.8

Gr3

: X�68

.5,

SD�

5.4

Gr1

:Stre

ngth

enin

gtra

inin

g.Te

n-m

inw

arm

-up

and

cool

-do

wn

phas

ean

d40

-m

inph

ase

cons

istin

gof

2se

tsof

12re

petit

ions

of9

exer

cise

s:le

gex

tens

ion,

leg

curl,

step-

up,h

eel-r

aise

,ch

estf

ly,u

prig

htro

w,

mili

tary

pres

s,bi

cep

curls

,and

pelv

ictil

t.H

ome

prog

ram

.G

r2:A

erob

ictra

inin

g.Te

n-m

inw

arm

-up

and

cool

-dow

nan

d40

-m

inpe

riod

ofw

alki

ngat

anin

tens

ityof

50%

–70%

ofH

Rre

serv

e.D

urin

gm

onth

s4–

6,ex

erci

sele

ader

visi

ted

4tim

esan

dca

lled

6tim

esto

offe

ras

sista

nce

with

hom

epr

ogra

m.

Gr3

:Con

trol.

Dur

ing

the

first

3m

o,m

onth

lygr

oup

sess

ions

oned

ucat

ion

rela

ted

toar

thrit

ism

anag

emen

t,in

clud

ing

time

for

disc

ussi

ons

and

soci

alga

ther

ings

.La

ter,

parti

cipa

nts

wer

eca

lled

bim

onth

ly(m

onth

s4–

6)or

mon

thly

(mon

ths

7–18

)to

mai

ntai

nhe

alth

upda

tes

and

prov

ide

supp

ort.

Inci

denc

eof

disa

bilit

yin

AD

LD

isab

ility

intra

nsfe

rrin

gfro

ma

bed

toa

chai

rD

isab

ility

inba

thin

gD

isab

ility

into

iletin

gD

isab

ility

indr

essi

ngD

isab

ility

inea

ting

N/A

3tim

esa

wee

k,3-

msu

perv

ised

faci

lity-

base

dpr

ogra

man

d15

-mho

me-

base

dpr

ogra

m

N/A

1,0,

1

(Con

tinue

d)


Appen

dix

2.

Det

ails

ofIn

clud

edTr

ialsa

(con

tinue

d)

Auth

or/

Yea

rSa

mple

Size

Popula

tion

Det

ails

Sym

pto

mD

ura

tion

Age

(y)

Inte

rven

tion

Com

pari

son

Gro

up

Outc

om

esConcu

rren

tTh

erapy

Freq

uen

cyand

Dura

tion

Follo

w-u

pD

ura

tion

Qualit

y(R

,B,W

)

Pete

rson

etal

,74

1993

RCT

Tota

l:91

Gr1

:47

Gr2

:44

Incl

usio

ncr

iteria

:pat

ient

sw

ho(1

)had

atle

asta

4-m

ohi

story

ofsy

mpt

omat

ickn

eepa

indu

ring

wei

ght-b

earin

gac

tiviti

es;(

2)ha

dra

diog

raph

icev

iden

ceof

OA

ofth

ekn

eejo

int(s

),as

dem

onstr

ated

byjo

int

spac

ena

rrow

ing,

mar

gina

lspu

rfor

mat

ion,

orsu

bcho

ndra

lcys

tfo

rmat

ion;

and

(3)u

sed

NSA

IDs

2or

mor

eda

ysa

wee

kEx

clusio

ncr

iteria

:pat

ient

sw

how

ere

enro

lled

ina

regu

larp

rogr

amof

phys

ical

exer

cise

atth

etim

eof

the

pret

rial

inte

rvie

w

N/A

69.4

Gr1

:8w

k,ho

spita

l-ba

sed

educ

atio

nal

and

wal

king

prog

ram

.Th

ese

ssio

nsin

clud

edw

arm

-up,

stren

gthe

ning

,and

cool

-dow

nex

erci

ses.

The

cour

sebe

gan

with

easil

ym

aste

red

frequ

ency

and

inte

nsity

ofw

alki

ng.A

tfirs

t,su

bjec

tsw

alke

d3

times

aw

eek

for5

min

and

alw

ays

soth

atkn

eepa

inw

asno

tex

acer

bate

d.Ea

chw

alki

ngse

ssio

nw

asin

crea

sed

by2.

5m

ina

wee

k,if

tole

rate

d,un

tilth

esu

bjec

tw

alke

d4

times

aw

eek

for3

0m

inea

chse

ssio

n.

Gr2

:con

trol;

patie

nts

wer

ete

leph

oned

each

wee

kfo

ra

repo

rton

heal

than

dex

erci

seac

tiviti

es

Fast

and

free:

6-m

inw

alk

(m)

Free

spee

d(m

/min

)Fr

eeca

denc

e(s

teps

/m

in)

Free

strid

e(m

)Fa

stsp

eed

(m/m

in)

Fast

cade

nce

(ste

ps/

min

)Fa

ststr

ide

(m)

AIM

S–ph

ysic

alac

tivity

AIM

S–pa

inA

IMS–

med

icat

ion

use

N/A

8w

k8

wk

1,0,

1

Petre

lla,7

5

2000

RCT

Tota

l: 179

Gr1

:91

Gr2

:88

Incl

usio

ncr

iteria

:pat

ient

sw

how

ere

aged

�65

y,ha

dpa

inin

one

knee

onm

ostd

ays,

had

radi

ogra

phic

evid

ence

ofO

Ain

the

tibio

fem

oral

com

partm

ent,

and

had

diffi

culti

esin

perfo

rmin

gA

DL

N/A

Gr1

: X�72

.9,

SD�

4.5

Gr2

: X�74

.6,

SD�

5.2

Gr1

:Pro

gres

sive

exer

cise

prog

ram

cons

istin

gof

the

follo

win

gex

erci

ses:

(1)k

nee

unlo

adin

g(jo

intc

apsu

lestr

etch

)w

ithan

ankl

ew

eigh

tof

1–2

kg;(

2)RO

M(k

nee

exte

nsio

n)w

ithfo

otel

evat

ed,p

atie

nts

push

the

knee

tow

ard

the

floor

;(3)

open

kine

ticch

ain

resi

stanc

eex

erci

ses

(SLR

with

“T”

mot

ion)

3tim

es;a

nd(4

)cl

osed

kine

ticch

ain

resi

stanc

eex

erci

ses

(ecc

entri

cw

alls

lide

tokn

eefle

xion

of30

°,an

dpa

tient

spu

shof

fon

ato

wel

wra

pped

unde

rth

efo

ot,w

ithth

ekn

eebe

ntat

30°)

.All

exer

cise

sw

ithpr

ogre

ssio

n.

Gr2

:kne

eun

load

ing

(join

tca

psul

estr

etch

),RO

M(k

nee

exte

nsio

n),

with

out

prog

ress

ion

Mea

ndi

ffere

nce

inpa

inat

rest,

VAS

(0–1

0,0�

nopa

in)

Mea

ndi

ffere

nce

inpa

info

llow

ing

self-

pace

dste

pte

st,VA

S(0

–10,

0�no

pain

)M

ean

diffe

renc

ein

pain

follo

win

gse

lf-pa

ced

wal

kte

st,VA

S(0

–10,

0�no

pain

)M

ean

diffe

renc

ein

WO

MA

C–p

ain

(0–1

0,0�

nopa

in)

Mea

ndi

ffere

nce

inW

OM

AC

–stif

fnes

s(0

–10,

0�no

stiffn

ess)

Mea

ndi

ffere

nce

inW

OM

AC

–phy

sical

activ

ity(0

–10,

0�no

lack

offu

nctio

n)RO

Min

knee

flexi

on(°)

Mea

ndi

ffere

nce

inse

lf-pa

ced

step

test

(s)M

ean

diffe

renc

ein

self-

pace

dste

pte

st(m

etab

olic

equi

vale

ntun

its)

Mea

ndi

ffere

nce

inse

lf-pa

ced

wal

kte

st(s)

Mea

ndi

ffere

nce

inse

lf-pa

ced

wal

kte

st(m

etab

olic

equi

vale

ntun

its)

Oxa

proz

in1,

200

mg

oral

lyda

ilyG

r1:W

eeks

1–2:

3se

ssio

ns/

wk,

2re

ps/s

essio

nW

eeks

3–4:

3 sess

ions

/w

k;3

reps

/ses

sion

Wee

ks5–

6:3 se

ssio

ns/

wk;

3re

ps/s

essio

nW

eeks

7–8:

5 sess

ions

/w

k;5

reps

/ses

sion

Gr2

:3tim

esa

wee

kfo

r8w

k

N/A

2,1,

1

Mea

ndi

ffere

nce

inph

ysic

alac

tivity

scal

efo

rel

derly

peop

le(C

ontin

ued)


��

��

��

��

��

Appen

dix

2.

Det

ails

ofIn

clud

edTr

ialsa

(con

tinue

d)

Auth

or/

Yea

rSa

mple

Size

Popula

tion

Det

ails

Sym

pto

mD

ura

tion

Age

(y)

Inte

rven

tion

Com

pari

son

Gro

up

Outc

om

esConcu

rren

tTh

erapy

Freq

uen

cyand

Dura

tion

Follo

w-u

pD

ura

tion

Qualit

y(R

,B,W

)

Reje

skie

tal

,76

1998

RCT

Tota

l: 357

Incl

usio

ncr

iteria

:pat

ient

sw

ho(1

)wer

eag

ed�

60y,

(2)h

adpa

inon

mos

tday

sof

the

mon

thin

one

orbo

thkn

ees,

(3)h

addi

fficu

ltyw

ithat

leas

ton

eA

DL

(eg,

getti

ngin

and

outo

faca

r),an

d(4

)sho

wed

radi

ogra

phic

evid

ence

ofkn

eeO

A

N/A

X�68

.65,

SD�

5.50

Gr1

:Aer

obic

Txgr

oup.

Parti

cipa

nts

wal

ked

atan

inte

nsity

of50

%–

75%

ofH

Rre

serv

e.G

r2:R

esis

tanc

etra

inin

ggr

oup.

Parti

cipa

nts

perfo

rmed

9di

ffere

ntup

per-

and

low

er-

body

exer

cise

s:le

gex

tens

ions

,leg

curls

,ste

p-up

s,he

el-ra

ises

,ch

estf

lies,

uprig

htro

ws,

mili

tary

pres

ses,

bice

pcu

rls,

and

pelv

ictil

ts.Pa

rtici

pant

sco

mpl

eted

2se

tsof

each

exer

cise

ata

frequ

ency

of10

–12

repe

titio

ns.

Gr3

:Con

trol.

Parti

cipa

nts

wer

eco

nsol

idat

edin

grou

psof

10–

15.D

urin

gm

onth

s1–

3,th

eyre

ceiv

eda

mon

thly

educ

atio

nse

ssio

nth

atla

sted

1.5

h.Pa

tient

sin

this

cond

ition

wer

eco

ntac

ted

byte

leph

one

once

ever

y2

wk

for

mon

ths

4–6

and

then

mon

thly

for

the

rem

aind

erof

the

study

.

Stai

r-clim

bing

time

(s)

Clim

bing

self-

effic

acy

scor

e(0

�co

mpl

etel

yun

certa

in,

10�

com

plet

ely

certa

in)

Gen

eral

heal

thsta

tus

(0–1

00,0

�Ia

mas

heal

thy

asan

ybod

yIk

now

)

Gr1

and

Gr2

:3-

mo

faci

lity-

base

dex

erci

sefo

llow

edby

15-m

oho

me-

base

dph

ase.

3tim

esa

wee

k,10

-min

war

m-

up,4

0-m

insti

mul

usph

ase,

and

10-m

inco

ol-d

own.

Hom

e-ba

sed

phas

e:(1

)4ho

me

visit

san

d6

tele

phon

eco

ntac

tsdu

ring

the

first

3m

oan

d(2

)te

leph

one

calls

ever

y3

wk

for

the

seco

nd3

mo,

then

one

tele

phon

eca

llea

chm

onth

for

the

rem

aind

erof

the

study

.

3tim

esa

wee

kfo

rth

efir

st3

mo;

15-

mo

hom

e-ba

sed

prog

ram

N/A

1,0,

0

Rodg

ers

etal

,77

1998

CC

TTo

tal:

20G

r1:1

0G

r2:1

0

Incl

usio

ncr

iteria

:pat

ient

sw

ithun

ilate

ralp

rimar

yTK

Afo

rO

A

N/A

Gr1

:X�

70,

SD�

3.75

Gr2

:X�

65,

SD�

8.25

Gr1

:6w

kpr

eope

rativ

ePT

,3tim

esa

wee

k;pr

ogra

min

divi

dual

ized

acco

rdin

gto

base

line

phys

ical

capa

city

.St

retc

hing

and

war

m-

up,h

eel-s

lides

,is

omet

ricqu

adric

eps

fem

oris

mus

cle

sets

(qua

dse

ts),S

LR,

shor

t-arc

quad

sets,

stand

ing

squa

ts,ste

p-up

s,an

dsta

tiona

rybi

cycl

e.

Gr2

:con

curr

ent

ther

apy

only

ROM

(°)

Hos

pita

lfor

Spec

ial

Surg

ery

Knee

Ratin

gSc

ale

scor

e

Sam

ekn

eeim

plan

t;sa

me

posto

pera

tive

ther

apy,

incl

udin

gan

kle

pum

ps,q

uad

sets,

SLR,

shor

t-ar

cqu

adse

ts,he

el-sl

ides

,ha

mstr

ing

mus

cle-

stret

chin

g,ha

mstr

ing

mus

cle

sets,

hip

abdu

ctio

n,an

dhi

pad

duct

ion.

Patie

nts

starte

dga

ittra

inin

gon

the

first

posto

pera

tive

day.

They

wer

edi

scha

rged

depe

ndin

gon

thei

rpro

gres

san

dw

ere

instr

ucte

dto

begi

na

hom

ePT

prog

ram

.

3tim

esa

wee

kfo

r6

wk

6w

k,3

mo

0,0,

1

(Con

tinue

d)


Appen

dix

2.

Det

ails

ofIn

clud

edTr

ialsa

(con

tinue

d)

Auth

or/

Yea

rSa

mple

Size

Popula

tion

Det

ails

Sym

pto

mD

ura

tion

Age

(y)

Inte

rven

tion

Com

pari

son

Gro

up

Outc

om

esConcu

rren

tTh

erapy

Freq

uen

cyand

Dura

tion

Follo

w-u

pD

ura

tion

Qualit

y(R

,B,W

)

Rogi

ndet

al,7

819

98RC

TTo

tal:

25G

r1:1

2G

r2:1

3

Incl

usio

ncr

iteria

:pat

ient

sw

hom

etth

eA

CR

crite

riafo

rO

Ain

the

knee

that

they

repo

rted

asth

em

ost

affe

cted

knee

,with

the

radi

ogra

phof

this

knee

rate

dat

leas

t3on

the

Kellg

ren

scal

e,an

dw

how

ere

capa

ble

ofge

tting

dow

non

the

floor

and

upag

ain,

ofin

depe

nden

twal

king

and

trans

port,

and

ofta

king

one

fligh

tof

stairs

unas

siste

dto

reac

hth

etra

inin

gfa

cilit

ies

N/A

Gr1

: X�69

.3,

SD�

8.2

Gr2

: X�73

.0,

SD�

6.5

Gr1

:Mob

ility

train

ing

and

veno

usth

erap

ype

rform

edfro

msu

pine

posi

tion,

mov

ing

the

join

tsof

the

lum

bar

spin

e,hi

ps,k

nees

,ank

les,

shou

lder

s,an

del

bow

s.LE

and

trunc

alstr

engt

heni

ng:

repe

titiv

eex

erci

ses

for

quad

ricep

sfe

mor

is,h

ipad

duct

oran

dab

duct

or,

ham

strin

g,gl

uteu

sm

axim

us,e

rect

orsp

inae

,and

abdo

min

alm

uscl

es.

Stre

tchi

ng:c

alf,

quad

ricep

sfe

mor

is,

hip

addu

ctor

,ha

mstr

ing,

glut

eus

max

imus

,low

erba

ck,

and

pect

oral

ism

ajor

mus

cles

.Bal

ance

and

coor

dina

tion

exer

cise

s.

Gr2

:con

trol;

noTx

Pain

atni

ght(

0–10

,0�

nopa

in)

Pain

atre

st(0

–10,

0�no

pain

)Pa

inon

wei

ght

bear

ing

(0–1

0,0�

nopa

in)

ROM

inkn

eefle

xion

,m

osta

ffect

edkn

ee(°)

ROM

inkn

eefle

xion

,le

asta

ffect

edkn

ee(°)

Wal

king

spee

d(m

/s)

Stai

r-clim

bing

time

(s)St

ance

,mos

taffe

cted

LE(s)

Stan

ce,l

east

affe

cted

LE(s)

Alg

ofun

ctio

nalI

ndex

(0�

mild

,14

orhi

gher

�ex

trem

ely

seve

repa

in,

disc

omfo

rt,or

stiffn

ess

durin

gA

DL)

Postu

rogr

aphy

(cm

2),

stabl

epl

atfo

rm–

eyes

open

Postu

rogr

aphy

(cm

2),

stabl

epl

atfo

rm–

eyes

clos

edPo

sturo

grap

hy(c

m2),

mov

ing

plat

form

–ey

esop

enPo

sturo

grap

hy(c

m2),

mov

ing

plat

form

–ey

escl

osed

N/A

2tim

esa

wee

kfo

r3

mo

3,12

mo

2,0,

1

Schi

lke

etal

,79

1996

RCT

Tota

l:20

Gr1

:10

Gr2

:10

Incl

usio

ncr

iteria

:pat

ient

sw

hoha

dno

tpa

rtici

pate

din

astr

engt

h-tra

inin

gpr

ogra

mw

ithin

the

past

6m

o

�10

yG

r1: X�

64.5

,SD

�3.

75G

r2: X�

68.4

,SD

�8

Gr1

:Exe

rcis

e.W

arm

-up

of5

min

onsta

tiona

rybi

cycl

e,th

enis

okin

etic

exer

cise

at90

°/s

for

24se

ssio

ns.S

essi

on1,

1se

tof5

cont

ract

ions

;se

ssio

n2,

2�

5co

ntra

ctio

ns(1

-min

rest

betw

een

sets)

;se

ssio

n3,

3�

5co

ntra

ctio

ns(1

-min

rest

betw

een

sets)

;se

ssio

n4,

4�

5co

ntra

ctio

ns(1

-min

rest

betw

een

first

2se

ts,15

-min

rest

betw

een

sets

3an

d4)

;ses

sion

5,5

�5

cont

ract

ions

(1-m

inre

stbe

twee

nfir

st2

sets

and

betw

een

sets

4an

d5,

15-m

inre

stbe

twee

nse

ts3

and

4);a

ndse

ssio

ns6–

24,6

�5

cont

ract

ions

(1-m

inre

stbe

twee

nfir

st3

sets

and

last

3se

ts,15

-min

rest

betw

een

sets

3an

d4)

.

Gr2

:con

trol;

noTx

Oste

oarth

ritis

Scre

enin

gIn

dex–

pain

(10

cm,

0�no

pain

)O

steoa

rthrit

isSc

reen

ing

Inde

x–sti

ffnes

s(1

0cm

,0�

nosti

ffnes

s)O

steoa

rthrit

isSc

reen

ing

Inde

x–m

obili

ty(1

0cm

,0�

good

mob

ility

)A

IMS–

arth

ritis

activ

ity(0

�go

odhe

alth

statu

s)Pe

akto

rque

,rig

htkn

eeex

tens

ors

(ft�lb

)Pe

akto

rque

,rig

htkn

eefle

xors

(ft�lb

)Pe

akto

rque

,lef

tkn

eeex

tens

ors

(ft�lb

)Pe

akto

rque

,lef

tkn

eefle

xors

(ft�lb

)

N/A

3tim

esa

wee

kfo

r8

wk

N/A

2,0,

0

(Con

tinue

d)


��

��

��

��

��

Appen

dix

2.

Det

ails

ofIn

clud

edTr

ialsa

(con

tinue

d)

Auth

or/

Yea

rSa

mple

Size

Popula

tion

Det

ails

Sym

pto

mD

ura

tion

Age

(y)

Inte

rven

tion

Com

pari

son

Gro

up

Outc

om

esConcu

rren

tTh

erapy

Freq

uen

cyand

Dura

tion

Follo

w-u

pD

ura

tion

Qualit

y(R

,B,W

)

Stam

met

al,8

020

02RC

TTo

tal:

40G

r1:2

0G

r2:2

0

Incl

usio

ncr

iteria

:pat

ient

sw

hom

etth

eA

CR

crite

riafo

rha

ndO

A;

med

icat

ion

with

anal

gesi

csor

NSA

IDs

was

allo

wed

durin

gth

estu

dy,b

utha

dto

rem

ain

stabl

eat

leas

t1

mo

befo

rean

dth

roug

hout

the

study

N/A

Gr1

: X�60

.5,

SD�

8.33

Gr2

: X�60

.4,

SD�

8.43

Gr1

:Exe

rcis

e.Ea

chpa

tient

rece

ived

30m

inof

oral

and

writ

ten

instr

uctio

nsfo

rjo

intp

rote

ctio

nan

d15

min

oftra

inin

gin

hom

eex

erci

ses,

whi

chco

nsis

ted

of7

exer

cise

sto

perfo

rmw

ithbo

thha

nds

10tim

esa

day.

Gr2

:Con

trol.

Ora

lan

dw

ritte

nin

form

atio

nab

outh

and

OA

,joi

ntan

atom

y,an

dpa

thog

enes

isof

OA

.Pat

ient

sre

ceiv

eda

piec

eof

Dyc

emd

toop

enja

rsfo

rth

estu

dype

riod

of3

mo.

Cha

nge

ofgr

ipfo

rce

VAS

(no.

ofpa

tient

sim

prov

ed)

N/A

3m

oN

/A1,

0,0

Suom

iand

Linda

uer,8

1

1997

RCT

Tota

l:30

Gr1

:20

Gr2

:10

Incl

usio

ncr

iteria

:pat

ient

sw

how

ere

wom

enag

ed45

–70

y,ha

dbe

endi

agno

sed

with

RAor

OA

byei

ther

arh

eum

atol

ogis

tor

anor

thop

edic

phys

icia

n,ha

dcu

rren

tsym

ptom

sof

chro

nic

pain

and

stiffn

ess

inw

eigh

t-be

arin

gjo

ints,

scor

ed15

orle

sson

the

AIM

Skn

ee/h

ipsc

ales

,ha

dno

med

ical

cond

ition

prec

ludi

ngin

crea

sed

phys

ical

activ

ity,h

adno

tbee

nin

volv

edin

anor

gani

zed

exer

cise

prog

ram

for

the

past

3m

o,ha

da

stabl

em

edic

atio

nre

gim

enfo

rat

leas

t3m

obe

fore

ente

ring

the

study

,and

had

med

ical

clea

ranc

eth

roug

hth

eir

prim

ary

phys

icia

nto

parti

cipa

tein

the

Arth

ritis

Foun

datio

nA

quat

icPr

ogra

m

Gr1

:X�

21.3

y,SD

�6

yG

r2:X

�19

.0y,

SD�

4.5

y

Gr1

: X�59

.8,

SD�

5.5

Gr2

: X�54

.4,

SD�

4.75

Gr1

:Wat

erex

erci

ses

wer

epe

rform

edin

ath

erap

eutic

pool

with

aw

ater

tem

pera

ture

of85

°–87

°Fan

da

dept

hof

1.07

–1.5

2m

(3.5

–5.0

ft)fo

r45

min

,3tim

esa

wee

kfo

r6

wk,

follo

win

gA

rthrit

isFo

unda

tion

Aqu

atic

Prog

ram

guid

elin

es.

Gr2

:Con

trol.

Patie

nts

wer

eas

ked

tore

frain

from

enga

ging

inan

yor

gani

zed

phys

ical

activ

itypr

ogra

mor

begi

nnin

gan

yne

wph

ysic

alac

tivity

for

the

dura

tion

ofth

ein

vesti

gatio

n.

Peak

torq

ue(N

�m)

ROM

(°)

N/A

3tim

esa

wee

kfo

r6

wk

N/A

1,0,

0

(Con

tinue

d)


Appen

dix

2.

Det

ails

ofIn

clud

edTr

ialsa

(con

tinue

d)

Auth

or/

Yea

rSa

mple

Size

Popula

tion

Det

ails

Sym

pto

mD

ura

tion

Age

(y)

Inte

rven

tion

Com

pari

son

Gro

up

Outc

om

esConcu

rren

tTh

erapy

Freq

uen

cyand

Dura

tion

Follo

w-u

pD

ura

tion

Qualit

y(R

,B,W

)

Topp

etal

,42

2002

RCT

Tota

l: 102

Gr1

:35

Gr2

:32

Gr3

:35

Incl

usio

ncr

iteria

:pat

ient

sw

itha

diag

nosi

sof

knee

OA

and

asc

ore

of5

orm

ore

onth

eW

este

rnO

ntar

ioan

dM

cMas

ter

Uni

vers

ities

Oste

oarth

ritis

Inde

xpa

insu

bsca

le

N/A

Gr1

: X�60

.94,

SD�

10.7

7G

r2: X�

65.5

7,SD

�10

.77

Gr3

: X�63

.53,

SD�

10.7

5

Gr1

:dyn

amic

resi

stanc

ew

ithTh

era-

Band

elas

ticba

nds;

war

m-

up5

min

,stre

ngth

train

ing

30m

in,c

ool-

dow

n5

min

Gr2

:sta

ndar

dis

omet

rictra

inin

gte

chni

ques

;re

sista

nce

with

Ther

a-Ba

ndel

astic

band

sth

atpa

tient

sw

ere

unab

leto

stret

chG

r1an

dG

r2:m

uscl

esw

ere

ankl

epl

anta

rfle

xors

and

dors

iflex

ors,

knee

exte

nsor

san

dfle

xors

,an

dhi

pex

tens

ors

and

flexo

rs

Gr3

:no

inte

rven

tion

WO

MA

C–s

tiffn

ess

WO

MA

C–f

unct

iona

llim

itatio

nW

OM

AC

–pai

nTi

me

toge

tdow

nto

floor

(s)

Tim

eto

getu

pfro

mflo

or(s

)Ti

me

togo

upsta

irs(s

)Ti

me

togo

dow

nsta

irs(s

)Pa

inw

hile

getti

ngdo

wn

toflo

orPa

inw

hile

getti

ngup

from

floor

Pain

whi

lego

ing

upsta

irsPa

inw

hile

goin

gdo

wn

stairs

Non

e3

times

aw

eek

(twic

eat

hom

ean

don

ceun

der

supe

rvis

ion)

Non

e1,

0,1

van

Baar

etal

,82

1998

RCT

Tota

l: 191

Gr1

:93

Gr2

:98

Incl

usio

ncr

iteria

:pat

ient

sw

ithO

Aof

the

hip

orkn

eeac

cord

ing

toth

ecl

inic

alcr

iteria

ofth

eA

CR

N/A

Gr1

: X�68

.3,

SD�

8.4

Gr2

: X�67

.7,

SD�

9.2

Gr1

:Exe

rcis

esfo

rm

uscl

efu

nctio

ns(fo

rce

and

leng

th),

mob

ility

,and

coor

dina

tion

and

exer

cise

sfo

rel

emen

tary

mov

emen

tab

ilitie

san

dlo

com

otio

nab

ilitie

s.In

struc

tions

for

the

adap

tatio

nof

AD

Lan

dho

me

exer

cise

sw

ere

give

n.C

ombi

ned

with

conc

urre

ntth

erap

y.

Gr2

:con

curr

ent

ther

apy

only

Impr

ovem

enti

npa

inat

asse

ssm

ent,

VAS

(0–1

00,

0�no

pain

)C

hang

ein

pain

inpa

stw

eek

Impr

ovem

enti

npa

inin

past

mon

th,

VAS

(0–1

00,

0�no

pain

)Im

prov

emen

tin

hip

ROM

Impr

ovem

enti

nkn

eeRO

MIm

prov

emen

tin

hip

mus

cle

forc

eIm

prov

emen

tin

knee

mus

cle

forc

eIm

prov

emen

tin

self-

repo

rted

disa

bilit

y,In

fluen

ceof

Rheu

mat

icD

isea

seon

Gen

eral

Hea

lthan

dLif

esty

leIm

prov

emen

tin

phys

cial

activ

ity

Txby

the

gene

ral

prac

titio

ner:

pres

crip

tion

ofm

edic

atio

n(p

atie

nts

wer

ein

struc

ted

tous

eas

little

aspo

ssib

le)a

ndpa

tient

educ

atio

nth

roug

hbr

ochu

reto

pics

,in

clud

ing

diag

nosi

s,pr

ogno

sis,

advi

ceco

ncer

ning

rest,

daily

activ

ities

and

diet

,use

ofai

ds,a

ndm

edic

alTx

Gr1

:1-3

times

aw

eek,

depe

ndin

gon

pain

leve

l,fo

r12

wk

Gr2

: patie

nts

cons

ulte

dth

eir

gene

ral

prac

titio

ner

atle

ast

twic

e,at

wee

ks0

and

12,

and

whe

nne

eded

24w

k2,

0,1

(Con

tinue

d)


��

��

��

��

��

Appen

dix

2.

Det

ails

ofIn

clud

edTr

ialsa

(con

tinue

d)

Auth

or/

Yea

rSa

mple

Size

Popula

tion

Det

ails

Sym

pto

mD

ura

tion

Age

(y)

Inte

rven

tion

Com

pari

son

Gro

up

Outc

om

esConcu

rren

tTh

erapy

Freq

uen

cyand

Dura

tion

Follo

w-u

pD

ura

tion

Qualit

y(R

,B,W

)

van

Baar

etal

,83

2001

RCT

Tota

l: 200

Gr1

:98

Gr2

: 102

Incl

usio

ncr

iteria

:pat

ient

sw

ithO

Aof

the

hip

orkn

eeac

cord

ing

toth

ecl

inic

alcr

iteria

ofth

eA

CR

N/A

Gr1

: X�68

.3,

SD�

8.4

Gr2

: X�67

.7,

SD�

9.2

Gr1

:Exe

rcis

esfo

rm

uscl

efu

nctio

ns(fo

rce

and

leng

th),

mob

ility

,and

coor

dina

tion

and

exer

cise

sfo

rel

emen

tary

mov

emen

tab

ilitie

san

dlo

com

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Appendix 3.Literature Search Strategy (Part of a GlobalSearch)a

The literature search strategy used was asfollows:

1 exp osteoarthritis/2 osteoarthritis.tw.3 osteoarthrosis.tw.4 degenerative arthritis.tw.5 exp arthritis, rheumatoid/6 rheumatoid arthritis.tw.7 rheumatism.tw.8 arthritis, juvenile rheumatoid/9 caplan’s syndrome.tw.

10 felty’s syndrome.tw.11 rheumatoid.tw.12 ankylosing spondylitis.tw.13 arthrosis.tw.14 sjogren$.tw.15 or/1–1416 heat/tu17 (heat or hot or ice).tw.18 cryotherapy.sh,tw.19 (vapocoolant or phonophoresis).tw.20 exp hyperthermia, induced/21 (hypertherm$ or thermotherapy).tw.22 (fluidotherapy or compression).tw.23 15 and 2224 clinical trial.pt.25 randomized controlled trial.pt.26 tu.fs.27 dt.fs.28 random$.tw.29 placebo$.tw.30 ((sing$ or doubl$ or tripl$) adj (masked

or blind$)).tw.31 sham.tw.32 or/24–3133 23 and 32

a Reprinted with permission of the American PhysicalTherapy Association from: Ottawa Panel Evidence-Based Clinical Practice Guidelines for TherapeuticExercises in the Management of Rheumatoid Arthritisin Adults. Phys.Ther. 2004;84:934–972.


Appendix 4.Evidence-Based Clinical Practice Guidelinesa

Strengthening ExercisesLower-extremity strengthening versus control, level 1 (RCT, n�345): grade A for pain getting up from floor and functional status (clinically

important benefit); grade C� for pain during walking, pain while climbing stairs, functional tasks, and quadriceps femoris muscle peaktorque (clinical benefit); grade C for stiffness, mobility, quadriceps femoris muscle force, muscle activation, and quality of life (no benefit).Patients with a diagnosis of OA of the knee.

Lower-extremity isometric strengthening versus control, level 1 (RCT, n�102): grade A for pain getting down to and up from floor (clinicallyimportant benefit); grade C� for pain getting down and up stairs and timed functional tasks (clinical benefit); grade C for stiffness andfunctional status (no benefit). Patients with a diagnosis of OA of the knee.

Isotonic resistance training versus isotonic combined with isokinetic (Kinetron*) resistance training for knee, level 1 (RCT, n�32): grade C forquadriceps femoris muscle peak torque (no benefit). Patients with a primary diagnosis of OA of the knee.

Isotonic combined with isokinetic (Kinetron) resistance training for knee versus control, level 1 (RCT, n�32): grade C for muscle force (nobenefit). Patients with primary diagnosis of OA of the knee.

Eccentric resistance training (Cybex*) for knee versus control, level 1 (RCT, n�32): grade C for muscle force (no benefit). Patients withprimary diagnosis of OA of the knee.

Concentric resistance training for knee versus control, level 1 (RCT, n�23): grade A for pain at rest and during activities (clinically importantbenefit); grade C for global functional status (no benefit). Patients with knee OA bilaterally and grade II or III OA.

Concentric-eccentric resistance training for knee versus control, level 1 (RCT, n�23): grade A for pain at rest and during specific functionalactivities: 15-m walk and stair climbing/descending time (clinically important benefit). Patients with knee OA bilaterally and grade II or IIIOA.

Home program strengthening for knee versus control, level 1 (CCT, n�81): grade A for pain, functional status, energy level, and ROM inflexion (clinically important benefit); grade C for physical mobility, muscle force, swelling, and exercise (no benefit). Patients with OA ofthe knee.

General LE exercise program (including muscle force, flexibility, and mobility/coordination) versus control, level 1 (RCT, n�490): grade Afor pain at night and ability on stairs (clinically important benefit); grade C for knee flexion ROM, muscle force, knee joint position, gait,functional status, quality of life, muscle activation, stiffness, and physical activity (no benefit). Patients with a diagnosis of OA.

Progression versus no-progression LE strengthening exercises, level 1 (RCT, n�179): grade A for pain at rest and ROM (clinically importantbenefit); grade C for stiffness and functional status (no benefit). Patients with radiographic evidence of OA in the tibiofemoralcompartment.

Hand strengthening versus control, level 1 (RCT, n�40): grade A for pain and grip force (clinically important benefit). Patients who met theAmerican College of Rheumatology criteria for hand OA.154

***General Physical Activity, Including Fitness and Aerobic ExercisesWhole-body functional exercise versus control, level 1 (RCT, n�864): grade A for pain and functional status (mobility, walking, work,

disability in ADL) (clinically important benefit); grade C for knee flexor ROM, quadriceps femoris muscle force, hamstring muscle force,gait, and quality of life (no benefit). Patients with OA of the knee.

Walking program versus control, level 1 (RCT, n�1,089): grade A for pain, functional status, stride length, disability transferring from bed,disability bathing, aerobic capacity, energy level, and medication use (clinically important benefit); grade C� for disability in ADL (clinicalbenefit); grade C for walking speed, disability toileting, disability dressing, blood pressure, morning stiffness, and quality of life (nobenefit). Patients with OA.

Jogging in water versus control, level 1 (RCT, n�115): grade A for physical activity and aerobic capacity (clinically important benefit);grade C for morning stiffness, pain, grip force, trunk ROM, functional status, and exercise endurance (no benefit). Patients with currentsymptoms of chronic pain and stiffness in involved weight-bearing joints.

Water exercises versus control, level 1 (RCT, n�30): grade C for torque and ROM (no benefit). Patients with OA or RA diagnosed by arheumatologist or an orthopedic physician.

Yoga versus control, level 1 (RCT, n�30): grade A for pain during activity and ROM (clinically important benefit); grade C for tenderness,muscle force, swelling, and hand function (no benefit). Patients with OA of the distal interphalangeal or proximal interphalangeal joints ofthe fingers.

***Combination of ExercisesManual therapy combined with exercise versus control, level 1 (RCT, n�83): grade A for pain (clinically important benefit); grade C for

functional status (no benefit). Patients with a diagnosis of OA.

a RCT�randomized controlled trial, OA�osteoarthritis, CCT�controlled clinical trial, ROM�range of motion, ADL�activities of daily living, RA�rheumatoidarthritis, LE�lower extremity.* Cybex International Inc, 10 Trotter Dr, Medway, MA 02053.


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