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2005; 85:907-971.PHYS THER.

Gerry Arts and Marnie LambHaines-Wangda, Marion Russell-Doreleyers, Martha Hall,Légaré, Catherine Caron, Sydney Lineker, Angela

Sarah Milne, Mary Bell, Hillel M Finestone, FranceRobinson, Lucie Pelland, Jessie McGowan, Maria Judd,

AEgan, Claire-Jehanne Dubouloz, Lynn Casimiro, VivianLucie Brosseau, George A Wells, Peter Tugwell, MaryTherapy in the Management of OsteoarthritisGuidelines for Therapeutic Exercises and ManualOttawa Panel Evidence-Based Clinical Practice

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Ottawa Panel Evidence-Based Clinical

Practice Guidelines for TherapeuticExercises and Manual Therapy in the

Management 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 of patients 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 to

nominate 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 potentially

relevant, and 26 randomized controlled trials and controlled clinical trials were ultimately used. Results. Sixteen positive recommendations of clinicalbenefit were developed for therapeutic exercises, especially strengthening

exercises and general physical activity, particularly for the management of pain and improvement of functional status. Manual therapy combined

with exercises also is recommended in the management of patients withOA. Discussion and Conclusion. The Ottawa Panel recommends the use of

therapeutic 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 the

use 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 .

Physical Therapy . Volume 85 . Number 9 . September 2005 907

S p e c i a l I s s u e

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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 2020.2

Similarly, 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 disability with 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 direct and indirect costs of the disease. The development of evidence-based clinical practice guidelines (EBCPGs) will assist patients and clinicians in maximizing theirrehabilitative efforts. Evidence-based clinical practiceguidelines are systematically developed statements to

help practitioners and clients choose proper health carefor specific clinical circumstances7 and can improve botha patient’s health outcomes and the process of care.8 A rapid 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, Canada

George A Wells, PhD, Department of Epidemiology and Community Medicine, University of Ottawa

Peter Tugwell, MD, MSc, Centre for Global Health, Institute of Population Health, University of Ottawa

Mary Egan, PhD, Occupational Therapy Program, School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa

Claire-Jehanne Dubouloz, PhD, Occupational Therapy Program, School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa

Lynn Casimiro, MA, Physiotherapy Program, School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa

Vivian A Robinson, MSc, Centre for Global Health, Institute of Population Health

Lucie Pelland, PhD, Physiotherapy Program, School of Rehabilitation Sciences, Queens’ University, Kingston, Ontario, Canada

Jessie McGowan, MLIS, Director, Medical Library, Centre for Global Health, Institute of Population Health, University of Ottawa

Maria 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, Canada

Hillel M Finestone, MD (Physiatrist), Sisters of Charity of Ottawa Health Service, Ottawa, Ontario, Canada

France Legare, MD (Evidence-Based Practice in Family Medicine), University of Laval, Quebec City, Quebec, Canada

Catherine Caron, MD (Family Physician), Sisters of Charity of Ottawa Health Service

Sydney Lineker, PT, MSc, The Arthritis Society, Ontario Division, Research Co-ordinator, Toronto, Ontario, Canada

Angela Haines-Wangda, PT, MSc, Ottawa Hospital, General Campus, Ottawa, Ontario, Canada

Marion Russell-Doreleyers, PT who practices acupuncture, MSc, Canadian Physiotherapy Association and Ottawa Arthritis Rehabilitation and

Education Program, Ottawa, Ontario, Canada

Martha Hall, OT, MPA, Canadian Association of Occupational Therapists and Ottawa Arthritis Rehabilitation and Education Program

Gerry 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, Faculty

of 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 Chair

Program, for research staff salary support for Dr Brosseau; the Centre National de Formation en Sante/Health Canada; and the Ministry of Human

Resources, 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, Mr

Michel Boudreau, Mr Guillaume Michaud, Ms Michelle Vaillant, Ms Chantal Lavoie, and Mr Guillaume Lemieux for their technical support and

help in data extraction.

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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 was

written by the Ottawa Panel on rheumatoid arthritis(RA).16 The Ottawa Panel also is preparing EBCPGs onthe use of TE, electrotherapy, and thermotherapy modalities 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 OA 17 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 recently and 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 beneficial

for 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 of patients with OA using TE.31–36 These EBCPGs havebeen developed mainly for medical and surgical interventions 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 of each study, they did not synthesize the studies. Theguidelines were developed for limited clinical practiceareas. Although the EBCPGs were based on the current scientific 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 of the guidelines have been updated recently. The OttawaPanel is proposing more precise EBCPGs (involving

specific 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 of a previous study conducted by the Ottawa Panel on TE

for patients with RA.16 Evidence from RCTs and obser- vational studies were identified and synthesized usingmethods defined by the Cochrane Collaboration that minimize 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 of both the evidence and the recommendation. The

Ottawa Panel decided that evidence of clinically important benefit (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-important outcomes 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 a validated 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 that affected peripheral joints were eligible to participate.Patients at different stages of the disease participated inthe included clinical trials; some trials involved patients with 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

Physical Therapy . Volume 85 . Number 9 . September 2005 Ottawa Panel . 909









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

versus aquatics,44 walking versus patient education,45sham electrical stimulation versus patient educationcombined with TE,46 aerobics (walking) versus strength-ening exercises,45,47 and walking versus jogging in water.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 with

frequent use of continuous passive motion (CPM) fol-lowing a total knee arthroplasty for severe knee OA 49–61

also were excluded. However, practitioners can refer to arecent meta-analysis on the efficacy of CPM combined with physical therapy versus physical therapy alone(n799) following a total knee arthroplasty for kneeOA 62 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 efficacy of 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, or

received routine conventional therapeutic approaches were acceptable control groups. If concurrent interven-tions (eg, electroanalgesia and medication) were pro- vided to the experimental and control groups, theseinterventions were included. However, interventions where the patient acts as his or her own control were not included. 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 patients with 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 studies were 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 of

patients in the original study when calculating patient numbers (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 of which 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 included

studies 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 2.Excluded Studies for Therapeutic Exercises (N89)a

Study Reason for Exclusion

AGS32 Not an RCTAhern et al84 No statistical data for control

groupAubriot et al85 No standard deviation

Baker 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 study

Hall 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 Westhoff 111 Education on exercise (wrong

intervention) Johnson112 Head-to-head study Johnson 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 data

Lynch 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 group

Minor 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,

RCTrandomized controlled trial, CPMcontinuous 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, n103): grade A for pain getting up and downfrom floor and functional status (clinically important ben-efit); grade C for pain during walking, pain while

climbing 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, n67): 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 for stiffness 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, n15):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, n18): grade C for muscle

force (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,n17): 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, n15):grade A for pain at rest and during activities (clinically important 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,n14): 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],n53): 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, n876): grade A for pain at night and ability on stairs (clinically important benefit);grade C for knee flexion ROM, muscle force, knee joint position 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, n179): grade A for pain at rest and ROM (clinically important benefit); grade C for stiffness and functional status (no benefit). Patients withradiographic evidence of OA in the tibiofemoral compart-ment.

Hand strengthening versus control, level 1 (1 RCT, n40):grade A for pain and grip force (clinically important

benefit). Patients who met the American College of Rheumatology criteria for hand OA.154

EBCPGs Related to General Physical Activity, IncludingFitness and Aerobic Exercises

Whole-body functional exercise versus control, level 1 (4RCTs, n864): grade A for pain and functional status(mobility, walking, work, disability in activities of daily living [ADL]) (clinically important benefit); grade C for knee flexion ROM, quadriceps femoris muscle force,hamstring muscle force, gait, stair climbing time, climbing

self-efficacy, and quality of life (no benefit). Patients withOA of the knee.

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










Walking program versus control, level 1 (6 RCTs,n711): 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 for disability 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, n79):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 of chronic pain and stiffness in involved weight-bearingjoints.

Water exercises versus control, level 1 (1 RCT, n30):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, n30): grade A for pain 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, n83): grade A for pain (clinically important benefit); grade C for 6-minute walk distance(no benefit). Patients with a diagnosis of OA.

Summary of TrialsTwenty-nine trials (n2,486 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 trials were as follows: LE strengthening (n345),42,70,71,79 LE

isometric strengthening (n

102),42

isotonic resistancetraining versus isotonic combined with isokinetic (Kin-etron) resistance training for the knee (n32),70 iso-tonic combined with isokinetic (Kinetron) resistance

training for the knee (n32),70 eccentric resistance train-ing (Cybex) for the knee (n32),70 concentric resistancetraining for the knee (n23),67 concentric-eccentric resis-tance training for the knee (n23),67 home programstrengthening for the knee (n81),47 general LE exerciseprogram (including muscle force, flexibility, and mobility/coordination) (n490),64,65,68,77,78,82,83 progression in LE

strengthening exercises versus no progression (n

179),75

and home program hand strengthening (n40).80

Several RCTs examined general physical activities,including fitness and aerobic exercises, such as whole-body functional exercises (n864),45,63,72,73,76 walkingprogram (n1,089),45,47,48,69,73,74,76 jogging in water(n115),48 water exercise (n30),81 and yoga (n30).66

One trial was related to the combination of manualtherapy and exercises (n83).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). We

used the Jadad scale to decide whether a study was anRCT or a CCT.15

The trials examined 2 basic types of exercises. The first type 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 of exercise session varied from 4 weeks64 to 18 months45,73,76

for program duration, from once a week66 to 10 times aday 80 (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,n345),42,70,71,79 showed clinical benefits for pain during walking, pain ascending and descending the stairs, quad-riceps femoris muscle peak torque, and timed functionaltasks (Tab. 3). Statistically significant differences were

found for pain (Western Ontario and McMaster Univer-sities Osteoarthritis Index [WOMAC]; Fig. 1a), pain while getting up from the floor (weighted mean differ-







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T o p p e t a l 4 2

E x e r c i s e

P a i n , g o i n g u p s t a i r s ( 0 – 1 6 )

3 5

5 . 6 1

4 . 0 3

1 . 6 5

3 2 %

0 . 6 3 ( 2 . 3 2 , 1 . 0 6 )

C o n t r o l


3 5

4 . 5 9

4 . 6 6

T o p p e t a l 4 2

E x e r c i s e

P a i n , g o i n g d o w n s t a i r s ( 0 – 1 6 )

3 5

5 . 3 0

3 . 7 1

1 . 5 2

3 1 %

0 . 6 9 ( 2 . 2 7 , 0 . 8 9 )

C o n t r o l


3 5

4 . 4 7

4 . 4 0

T o p p e t a l 4 2

E x e r c i s e

P a i n ( W O M A C )

3 5

1 2 . 4 0

1 0 . 7 1

1 . 7 1

1 5 %

0 . 0 6 ( 1 . 5 4 , 1 . 4 2 )

C o n t r o l


3 5

1 0 . 7 5

1 0 . 7 7

T o p p e t a l 4 2

E x e r c i s e

T i m

e t o g e t d o w n t o f l o o r ( s )

3 5

4 . 7 2

3 . 8 9

1 . 1 8

2 4 %

1 . 4 4 ( 3 . 1 5 , 0 . 2 7 )

C o n t r o l

T i m

e t o g e t d o w n t o f l o o r ( s )

3 5

4 . 9 8

5 . 3 3

T o p p e t a l 4 2

E x e r c i s e

T i m

e t o g e t u p o f f f l o o r ( s )

3 5

7 . 1 6

5 . 7 1

1 . 5 7

2 1 %

2 . 4 5 ( 5 . 3 2 , 0 . 2 7 )

C o n t r o l

T i m

e t o g e t u p o f f f l o o r ( s )

3 5

8 . 0 4

8 . 1 6

T o p p e t a l 4 2

E x e r c i s e

T i m

e t o g o u p s t a i r s ( s )

3 5

1 8 . 8 5

1 6 . 3 3

1 . 2

6 %

1 . 2 ( 4 . 5 , 2 . 1 )

C o n t r o l

T i m

e t o g o u p s t a i r s ( s )

3 5

1 8 . 8 5

1 7 . 5 3

T o p p e t a l 4 2

E x e r c i s e

T i m

e t o g o d o w n s t a i r s ( s )

3 5

1 9 . 2 9

1 5 . 9 6

1 . 6 3

9 %

0 . 3 8 ( 3 . 5 7 , 2 . 8 1 )

C o n t r o l

T i m

e t o g o d o w n s t a i r s ( s )

3 5

1 8 . 0 4

1 6 . 3 4

T o p p e t a l 4 2

E x e r c i s e

F u n

c t i o n a l l i m i t a t i o n ( W O M A C )

3 5

4 1 . 0 9

3 5 . 3 0

6 . 6 2

1 7 %

4 . 4 ( 9 . 4 7 , 0 . 6 7 )

C o n t r o l

F u n

c t i o n a l l i m i t a t i o n ( W O M A C )

3 5

3 8 . 8 7

3 9 . 7 0

S c h i l k e e t a l 7 9

E x e r c i s e

P e a

k t o r q u e , r i g h t k n e e e x t e n s o r s

1 0

5 2 . 5 0

6 7 . 4 0

1 4 . 5

3 3 %

3 1 . 1 ( 6 . 4 , 5 5 . 8 )

C o n t r o l

P e a

k t o r q u e , r i g h t k n e e e x t e n s o r s

1 0

3 5 . 9 0

3 6 . 3 0

S c h i l k e e t a l 7 9

E x e r c i s e

O A

S I – m o b i l i t y

1 0

1 1 . 3 0

7 . 6 4

3 . 2 4

4 %

5 . 1 4 ( 7 . 3 7 , 2 . 9 1 )

C o n t r o l

O A

S I – m o b i l i t y

1 0

9 . 9 0

9 . 4 8

a

W O M A C W e s t e r n O n t a r i o a n d M c M a s t e r U

n i v e r s i t i e s O s t e o a r t h r i t i s I n d e x , O A S I O s t e o a r t h r i t i s S c r e e n i n g I n d e x , W M D w e i g h t e d m e a n d i f f e r e n c e , C I c o n f i d e n c e i n t e r v a l .










Figures 1a–f.Lower-extremity strengthening versus control. AIMSArthritis Impact Measurement Scales, FUfollow-up, LElower extremity, OASIOsteoarthritisScreening Index, WOMACWestern 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 (6 weeks for Kreindler et al70) (Figs. 1a–f).

For LE isometric strengthening versus control (1 RCT,n102),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% CI4.01 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. LElower extremity, WOMACWestern Ontario and McMaster Universities OsteoarthritisIndex.










T a b l e 4 .

C l i n i c a l R e l e v a n c e : L o w e r - E x t r e m i t y I s o m e t r i c S t r e n g t h e n i n g V e r s u s C o n t r o l a

S t u d y

T r e a t m e n t G r o u p

O u t c o m e

N o . o f

P a t i e n t s

B a s e l i n e

M e a n


M e a n

A b s o l u t e

B e n e f i t



B a s e l i n e

W M D ( 9 5 % C I )

T o p p e t a l 4 2

L E i s o m e t r i c s t r e n g t h e n i n g


3 2

5 . 3 9

2 . 8 9

3

6 1 %

2 . 1 4 ( 4 . 0 1 , 0 . 2 7 )

C o n t r o l


3 5

4 . 5 3

5 . 0 3

T o p p e t a l 4 2



3 2

4 . 2 0

1 . 8 4

2 . 7 1

7 0 %

2 . 0 5 ( 3 . 6 2 , 0 . 4 8 )

C o n t r o l


3 5

3 . 5 4

3 . 8 9

T o p p e t a l 4 2



3 2

5 . 1 9

2 . 9 8

2 . 2 8

4 7 %

1 . 6 8 ( 3 . 4 1 , 0 . 0 5 )

C o n t r o l


3 5

4 . 5 9

4 . 6 6

T o p p e t a l 4 2



3 2

4 . 7 0

2 . 7 8

1 . 8 5

4 0 %

1 . 6 2 ( 3 . 2 4 , 0 )

C o n t r o l

P a i n g o i n g d o w n s t a i r s ( 0 – 1 6 )

3 5

4 . 4 7

4 . 4 0

T o p p e t a l 4 2



3 2

1 1 . 7 5

1 0 . 3 8

1 . 3 9

1 2 %

0 . 3 9 ( 1 . 9 1 , 1 . 1 3 )

C o n t r o l


3 5

1 0 . 7 5

1 0 . 7 7

T o p p e t a l 4 2


T i m e t o g e t d o w n t o f l o o r ( s )

3 2

5 . 5 6

4 . 3 1

1 . 6

3 0 %

1 . 0 2 ( 2 . 7 5 , 0 . 7 1 )

C o n t r o l


3 5

4 . 9 8

5 . 3 3

T o p p e t a l 4 2


T i m e t o g e t u p o f f f l o o r ( s )

3 2

8 . 2 6

6 . 3 7

2 . 0 1

2 5 %

1 . 7 9 ( 4 . 6 7 , 1 . 0 9 )

C o n t r o l


3 5

8 . 0 4

8 . 1 6

T o p p e t a l 4 2


T i m e t o g o u p s t a i r s ( s )

3 2

1 7 . 9 9

1 5 . 1 5

1 . 5 2

8 %

2 . 3 8 ( 5 . 7 5 , 0 . 9 9 )

C o n t r o l

T i m e t o g o u p s t a i r s ( s )

3 5

1 8 . 8 5

1 7 . 5 3

T o p p e t a l 4 2


T i m e t o g o d o w n s t a i r s ( s )

3 2

1 6 . 8 6

1 3 . 9 5

1 . 2 1

7 %

2 . 3 9 ( 5 . 6 6 , 0 . 8 8 )

C o n t r o l

T i m e t o g o d o w n s t a i r s ( s )

3 5

1 8 . 0 4

1 6 . 3 4

T o p p e t a l 4 2


S t i f f n e s s ( W O M A C )

3 2

5 . 1 3

5 . 0 3

0 . 3 7

7 %

0 . 4 7 ( 1 . 2 2 , 0 . 2 8 )

C o n t r o l

S t i f f n e s s ( W O M A C )

3 5

5 . 2 3

5 . 5 0

T o p p e t a l 4 2


F u n c t i o n a l l i m i t a t i o n ( W O M A C )

3 2

3 8 . 1 3

3 5 . 9 7

2 . 9 9

8 %

3 . 7 3 ( 8 . 9 1 , 1 . 4 5 )

C o n t r o l

F u n c t i o n a l l i m i t a t i o n ( W O M A C )

3 5

3 8 . 8 7

3 9 . 7 0

a

L E l o w e r e x t r e m i t y , W O M A C W e s t e r n O n t a r i o a n d M c M a s t e r U n i v e r s i t i e s O s t e o a r t h r i t i s I n d e x , W M D w e i g h t e d m e a n d i f f e r e n c e , C I c o n f i d e n c e i n t e r v a l .







One trial (RCT, n32)70 showed no statistically signifi-cant difference or clinically important benefit for quad-riceps femoris muscle peak torque in patients with OA either 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, n23)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, n23),67

clinically important benefits and statistically significant

differences were observed for pain (WMD11.40, 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 8 weeks. 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. FUfollow-up, LElower extremity.

Figure 4.Isotonic and isokinetic (Kinetron) versus control. FUfollow-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 (n81)47 and showed clinically

important benefits for pain, functional status, energy level (Tab. 7), and ROM (results not shown) but not for physical mobility (Tab. 7). Statistically significant data were found for WOMAC–pain (WMD3.00, 95%CI1.58 to 4.42), visual analog scale (VAS)–pain(WMD3.30, 95% CI2.62 to 3.98), WOMAC physicalfunction index (WMD9.90, 95% CI8.08 to 11.72),Nottingham Health Profile (NHP)–pain (WMD10.60,95% CI8.90 to 12.30), NHP–energy (WMD15.90,95% CI14.87 to 16.93), NHP–physical mobility

(WMD7.10, 95% CI4.14 to 10.06), NHP–sleep(WMD3.40, 95% CI0.89 to 5.91) (Figs. 9a– c, allat follow-up of 6 months), swelling (WMD12.5, 95%CI5.51 to 19.49), and ROM (WMD19.5°, 95%CI5.69° to 33.31°) (results not shown). However, no

statistically 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, n690).64,65,68,77,78,82,83

Important benefits were demonstrated for pain intensity

Figure 5.Eccentric resistance training (Cybex) versus control. FUfollow-up,LElower extremity.

Figure 6.Concentric versus control: pain.







T a b l e 5 .

C l i n i c a l R e l e v a n c e : C o n c e n t r i c V e r s u s C o

n t r o l a

S t u d y

T r e a t m e n t

G r o u p

O u t c o m e

N o . o f

P a t i e n t s

B a s e l i n e

M e a n


M e a n

A b s o l u t e

B e n e f i t

R e l a t i v e D i f f e r e n c e i n

C h a n g e F r o m B a s e l i n e

W M

D ( 9 5 % C I )

G u r e t a l 6 7

C o n c e n t r i c

P a i n a t n i g h t ( 0 – 1 0 ) , e n d T x : 8 w k

9

4 . 4

1 . 4

3 . 3

8 4 %

2 . 1 ( 3 . 6 4 , 0 . 5 6 )

C o n t r o l


6

3 . 2

3 . 5

G u r e t a l 6 7

C o n c e n t r i c

P a i n a f t e r

i n a c t i v i t y ( 0 – 1 0 ) , e n d T x : 8 w k

9

4 . 1

1 . 2

2 . 9

7 3 %

2 . 6 ( 3 . 5 6 , 1 . 6 4 )

C o n t r o l

P a i n a f t e r

i n a c t i v i t y ( 0 – 1 0 ) , e n d T x : 8 w k

6

3 . 8

3 . 8

G u r e t a l 6 7

C o n c e n t r i c

P a i n s i t t i n g ( 0 – 1 0 ) , e n d T x : 8 w k

9

3 . 4

0 . 9

2 . 7

8 9 %

1 . 8 ( 2 . 5 1 , 1 . 0 9 )

C o n t r o l


6

2 . 5

2 . 7

G u r e t a l 6 7

C o n c e n t r i c

P a i n r i s i n g

f r o m c h a i r , e n d T x : 8 w k

9

5 . 2

2 . 0

3 . 2

6 4 %

2 . 7 ( 3 . 8 3 , 1 . 5 7 )

C o n t r o l

P a i n r i s i n g

f r o m c h a i r , e n d T x : 8 w k

6

4 . 7

4 . 7

G u r e t a l 6 7

C o n c e n t r i c

P a i n s t a n d

i n g , e n d T x : 8 w k

9

4 . 0

1 . 4

2 . 6

6 5 %

2 . 6 ( 3 . 4 6 , 1 . 7 4 )

C o n t r o l

P a i n s t a n d

i n g , e n d T x : 8 w k

6

4 . 0

4 . 0

G u r e t a l 6 7

C o n c e n t r i c

P a i n c l i m b

i n g s t a i r s , e n d T x : 8 w k

9

5 . 8

1 . 7

4 . 3

8 0 %

3 . 3 ( 4 . 1 7 , 2 . 4 3 )

C o n t r o l

P a i n c l i m b

i n g s t a i r s , e n d T x : 8 w k

6

4 . 8

5 . 0

G u r e t a l 6 7

C o n c e n t r i c

P a i n d e s c e n d i n g s t a i r s , e n d T x : 8 w k

9

5 . 8

1 . 7

4 . 1

7 5 %

3 . 3 ( 4 . 2 7 , 2 . 3 3 )

C o n t r o l

P a i n d e s c e n d i n g s t a i r s , e n d T x : 8 w k

6

5 . 0

5 . 0

G u r e t a l 6 7

C o n c e n t r i c

P a i n , t o t a l s c o r e , e n d T x : 8 w k

9

3 3 . 9

1 0 . 3

2 4 . 3

7 8 %

1 7 . 7 ( 2 2 . 7 9 , 1 2 . 6 1 )

C o n t r o l


6

2 7 . 3

2 8 . 0

a

T x t r e a t m e n t , W M D w e i g h t e d m e a n d i f f e r

e n c e , C I c o n f i d e n c e i n t e r v a l .

Figure 7.Concentric versus control: functional status.










T a b l e 6 .

C l i n i c a l R e l e v a n c e : C o n c e n t r i c - E c c e n t r i c V e r s u s C o n t r o l a

S t u d y

T r e a t m e n t

G r o u p

O

u t c o m e

N

o . o f

P a t i e n t s

B a s e l i n e

M e a n


M e a n

A b s o l u t e

B e n e f i t



B a s e l i n e

W

M D ( 9 5 % C I )

G u r e t a l 6 7

C o n c e n t r i c - e c c e n t r i c P a i n a t n i g h t ( 0 – 1 0 ) , e n d T x : 8 w k

8

3 . 8

1 . 5

2 . 6

7 3 %

2 ( 3 . 4 , 0 . 6 )

C o n t r o l


6

3 . 2

3 . 5

G u r e t a l 6 7

C o n c e n t r i c - e c c e n t r i c P a i n s i t t i n g ( 0 – 1 0 ) , e n d T x : 8 w k

8

3 . 5

1 . 1

2 . 6

8 5 %

1 . 6 ( 2 . 4 , 0 . 8 )

C o n t r o l


6

2 . 5

2 . 7

G u r e t a l 6 7

C o n c e n t r i c - e c c e n t r i c P a i n r i s i n g f r o m c h a i r , e n d T x : 8 w k

8

5 . 4

2 . 5

2 . 9

5 7 %

2 . 2 ( 3 . 4 3 , 0 . 9 7 )

C o n t r o l

P a i n r i s i n g f r o m c h a i r , e n d T x : 8 w k

6

4 . 7

4 . 7

G u r e t a l 6 7

C o n c e n t r i c - e c c e n t r i c P a i n s t a n d i n g , e n d T x : 8 w k

8

3 . 5

1 . 6

1 . 9

5 1 %

2 . 4 ( 3 . 5 4 , 1 . 2 6 )

C o n t r o l

P a i n s t a n d i n g , e n d T x : 8 w k

6

4 . 0

4 . 0

G u r e t a l 6 7

C o n c e n t r i c - e c c e n t r i c P a i n c l i m b i n g s t a i r s , e n d T x : 8 w k

8

6 . 5

3 . 5

3 . 2

5 5 %

1 . 5 ( 2 . 7 8 , 0 . 2 2 )

C o n t r o l

P a i n c l i m b i n g s t a i r s , e n d T x : 8 w k

6

4 . 8

5 . 0

G u r e t a l 6 7

C o n c e n t r i c - e c c e n t r i c P a i n , t o t a l s c o r e , e n d T x : 8 w k

8

3 5 . 8

1 6 . 6

1 9 . 9

6 2 %

1 1 . 4 ( 1 7 . 9 5 , 4 . 8 5 )

C o n t r o l


6

2 7 . 3

2 8 . 0

G u r e t a l 6 7

C o n c e n t r i c - e c c e n t r i c 1

5 - m w a l k ( s ) , e n d T x : 8 w k

8

3 . 9

1 . 0

2 . 9

7 8 %

0 . 2 3 ( 1 . 4 5 , 0 . 9 9 )

C o n t r o l

1

5 - m w a l k ( s ) , e n d T x : 8 w k

6

3 . 5

3 . 5

G u r e t a l 6 7

C o n c e n t r i c - e c c e n t r i c S t a i r - c l i m b i n g t i m e ( s ) , e n d T x : 8 w k

8

4 . 6

1 . 5

4 . 1

9 7 %

0 . 0 7 ( 0 . 9 2 , 0 . 7 8 )

C o n t r o l

S t a i r - c l i m b i n g t i m e ( s ) , e n d T x : 8 w k

6

3 . 7

4 . 7

G u r e t a l 6 7

C o n c e n t r i c - e c c e n t r i c S t a i r - d e s c e n d i n g t i m e ( s ) , e n d T x : 8 w k 8

5 . 3

1 . 8

4 . 1

8 1 %

0 . 8 6 ( 2 . 5 2 , 0 . 8 )

C o n t r o l

S t a i r - d e s c e n d i n g t i m e ( s ) , e n d T x : 8 w k 6

4 . 7

5 . 3

G u r e t a l 6 7

C o n c e n t r i c - e c c e n t r i c F u n c t i o n , t o t a l s c o r e , e n d T x : 8 w k

8

1 9 . 1

6 . 0

1 5 . 6

8 9 %

0 . 8 6 ( 2 . 5 2 , 0 . 8 )

C o n t r o l

F u n c t i o n , t o t a l s c o r e , e n d T x : 8 w k

6

1 5 . 5

1 8 . 0

a

T x t r e a t m e n t , W M D w e i g h t e d m e a n d i f f e r

e n c e , C I c o n f i d e n c e i n t e r v a l .







T a b l e 7 .

C l i n i c a l R e l e v a n c e : H o m e S t r e n g t h e n i n g

P r o g r a m V e r s u s C o n t r o l a

S t u d y

T r e a t m e n t

G r o u p

O u t c o m e

N o .

o f

P a t i e n t s

B a s e l i n e

M e a n


M e a n

A

b s o l u t e

B

e n e f i t



B a s e l i n e

W M

D ( 9 5 % C I )

E v c i k a n d S o n e l 4 7

H o m e s t r e n g t h e n i n g

W O M A C – p h y s i c a l f u n c t i o n

2 7

2 5 . 4

1 0 . 8

1 0 . 1

4 0 %

9 . 9 ( 1 1 . 7 2 , 8 . 0 8 )

C o n t r o l

W O M A C – p h y s i c a l f u n c t i o n

2 6

2 5 . 2

2 0 . 7



N H P – p h y s i c a l m o b i l i t y

2 7

4 0 . 2

2 9 . 5

3 . 2

8 %

7 . 1 ( 1 0 . 0 6 , 4 . 1 4 )

C o n t r o l

N H P – p h y s i c a l m o b i l i t y

2 6

4 4 . 1

3 6 . 6



W O M A C – p a i n

2 7

6 . 6

3 . 0

3

4 5 %

3 ( 4 . 4 2 , 1 . 5 8 )

C o n t r o l


2 6

6 . 6

6 . 0



P a i n – V A S

2 7

7 . 2

3 . 5

3 . 5

4 9 %

3 . 3 ( 3 . 9 8 , 2 . 6 2 )

C o n t r o l

P a i n – V A S

2 6

7 . 0

6 . 8



N H P – p a i n

2 7

4 0 . 0

9 . 8

9 . 7

2 4 %

1 0 . 6 ( 1 2 . 3 , 8 . 9 )

C o n t r o l

N H P – p a i n

2 6

4 0 . 9

2 0 . 4



N H P – e n e r g y

2 7

5 3 . 2

3 3 . 4

1 6 . 2

3 1 %

1 5 . 9 ( 1 6 . 9 3 , 1 4 . 8 7 )

C o n t r o l

N H P – e n e r g y

2 6

5 2 . 9

4 9 . 3

a

W O M A C W e s t e r n O n t a r i o a n d M c M a s t e r U

n i v e r s i t i e s O s t e o a r t h r i t i s I n d e x , N H P N o t t i n g h

a m H e a l t h P r o f i l e , V A S v i s u a l a n a l o g s c a l e , W M

D w e i g h t e d m e a n d i f f e r e n c e , C I c o n f i d e n c e

i n t e r v a l .

Figure 8.Concentric-eccentric versus control.










Figures 9a–e.Home strengthening program versus control. FUfollow-up, NHPNottingham Health Profile, ROMrange of motion, VASvisual analog scale,WOMACWestern Ontario and McMaster Universities Osteoarthritis Index.







T a b l e 8 .

C l i n i c a l R e l e v a n c e : G e n e r a l L o w e r - E x t r e m

i t y E x e r c i s e P r o g r a m V e r s u s C o n t r o l a

S t u d y

T r e a t m e n t

G r o u p

O u t c o m e

N o . o f

P a t i e n t s

B a s e l i n e

M e a n


M e a n

A b s o l u t e

B e n e f i t



B a s e l i n e

W M

D ( 9 5 % C I )

R o g i n d e t a l 7 8

E x e r c i s e s

R O M

i n k n e e f l e x i o n ( ° ) ( m o s t a f f e c t e d k n e e ) ,

e n d

T x : 1 0 – 1 2 w k

1 2

1 3 0

1 3 5

3

2 %

1 0 ( 1 4 . 0 9 , 5 . 9 1 )

C o n t r o l

R O M

i n k n e e f l e x i o n ( ° ) ( m o s t a f f e c t e d k n e e ) ,

e n d

T x : 1 0 – 1 2 w k

1 3

1 2 3

1 2 5


E x e r c i s e s

R O M

i n k n e e f l e x i o n ( ° ) ( l e a s t a f f e c t e d k n e e ) ,

e n d

T x : 1 0 – 1 2 w k

1 2

1 3 2

1 3 5

4

3 %

1 0 ( 1 2 . 2 5 , 7 . 7 5 )

C o n t r o l

R O M


e n d

T x : 1 0 – 1 2 w k

1 3

1 2 6

1 2 5


E x e r c i s e s

R O M


F U : 1 2 m o

1 2

1 3 2

1 3 3

6

5 %

1 2 ( 1 6 . 9 4 , 7 . 0 6 )

C o n t r o l

R O M


F U : 1 2 m o

1 3

1 2 6

1 2 1

v a n B a a r e t a l 8 2

E x e r c i s e s

H i p m

u s c l e f o r c e , c h a n g e , F U : 2 4 w k

9 3

N / A

0 . 2 2

W M D 0 . 1 8

0 . 1 8 ( 0 . 3 4 , 0 . 0 2 )

C o n t r o l

H i p m

u s c l e f o r c e , c h a n g e , F U : 2 4 w k

9 8

N / A

0 . 0 4

F r a n s e n e t a l 6 5

E x e r c i s e s

W O M

A C – p a i n , c h a n g e ( 0 – 1 0 0 ) , e n d T x :

8 w

k

8 3

N / A

1 0 . 6

W M D 1 2 . 1

1 2 . 1 ( 1 4 . 2 4 , 9 . 9 6 )

C o n t r o l

W O M

A C – p a i n , c h a n g e ( 0 – 1 0 0 ) , e n d T x :

8 w

k

4 3

N / A

1 . 5


E x e r c i s e s

P a i n p a s t w e e k – V A S ( 0 – 1 0 0 ) , c h a n g e , e n d

T x :

1 0 – 1 2 w k

9 3

4 6 . 9

2 4 . 1

1 7 . 1

3 8 %

1 7 . 1 ( 2 9 . 9 9 , 4 . 2 1 )

C o n t r o l

P a i n p a s t w e e k – V A S ( 0 – 1 0 0 ) , c h a n g e , e n d

T x :

1 0 – 1 2 w k

9 8

4 3 . 1

3 7 . 4


E x e r c i s e s

P a i n – V A S ( 0 – 1 0 0 ) , F U : 2 4 w k

9 3

3 4 . 0

2 3 . 5

1 1 . 2

3 6 %

1 1 . 2 ( 1 8 . 5 9 , 3 . 8 1 )

C o n t r o l

P a i n – V A S ( 0 – 1 0 0 ) , F U : 2 4 w k

9 8

2 8 . 7

2 9 . 4


E x e r c i s e s

P a i n – V A S ( 0 – 1 0 0 ) , F U : 2 4 w k

9 8

3 4 . 0

1 6 . 8

1 1 . 6

3 7 %

1 1 . 6 ( 1 9 . 5 , 3 . 7 )

C o n t r o l

P a i n – V A S ( 0 – 1 0 0 ) , F U : 2 4 w k

1 0 2

2 8 . 7

2 3 . 1


E x e r c i s e s

P a i n a t n i g h t ( 0 – 1 0 ) , F U : 1 2 m o

1 2

4 . 0

2 . 0

3

6 6 %

4 ( 5 . 9 4 , 2 . 0 6 )

C o n t r o l

P a i n a t n i g h t ( 0 – 1 0 ) , F U : 1 2 m o

1 3

5 . 0

6 . 0


E x e r c i s e s

M u s c l e f o r c e , i s o m e t r i c k n e e e x t e n s o r s ( N ) ,

e n d

T x : 8 w k

8 3

1 6 9 . 4 5

1 8 0 . 2 5

1 3 . 2

8 %

1 3 . 2 ( 1 4 . 4 4 , 1 1 . 9 6 )

C o n t r o l

M u s c l e f o r c e , i s o m e t r i c k n e e e x t e n s o r s ( N ) ,

e n d

T x : 8 w k

4 3

1 7 3 . 3

1 7 0 . 9


E x e r c i s e s

M u s c l e f o r c e , i s o m e t r i c k n e e f l e x o r s ( N ) , e n d

T x :

8 w k

8 3

9 4 . 6 5

1 0 3 . 0 5

9

9 %

9 ( 9 . 9 6 , 8 . 0 4 )

C o n t r o l

M u s c l e f o r c e , i s o m e t r i c k n e e f l e x o r s ( N ) , e n d

T x :

8 w k

4 3

1 0 0 . 1

9 9 . 5


E x e r c i s e s

F a s t s p e e d ( c m / s ) , e n d T x : 8 w k

8 3

1 2 8 . 6

1 3 5 . 7

6 . 7

5 %

6 . 7 ( 7 . 0 6 , 6 . 3 4 )

C o n t r o l

F a s t s p e e d ( c m / s ) , e n d T x : 8 w k

4 3

1 2 7 . 8

1 2 8 . 2

( C o n t i n u e d )







T a b l e 8 .

C o n t i n u e d

S t u d y

T r e a t m e n t

G r o u p

O u t c

o m e

N o . o f

P a t i e n t s

B a s e l i n e

M e a n


M e a n

A b s o l u t e

B e n e f i t



B a s e l i n e

W

M D ( 9 5 % C I )


E x e r c i s e s

F a s t c a d e n c e ( s t e p s / m i n ) , e n d T x : 8 w k

8 3

1 1 9 . 9

1 2 1 . 8

1 . 6

1 %

1 . 6 ( 1 . 8 , 1 . 4 )

C o n t r o l

F a s t c a d e n c e ( s t e p s / m i n ) , e n d T x : 8 w k

4 3

1 1 7 . 6

1 1 7 . 9


E x e r c i s e s

F a s t s t r i d e l e n g t h ( c m ) , e n d T x : 8 w k

8 3

1 2 8 . 2

1 3 2 . 9

4 . 3

3 %

4 . 3 ( 4 . 6 1 , 3 . 9 9 )

C o n t r o l

F a s t s t r i d e l e n g t h ( c m ) , e n d T x : 8 w k

4 3

1 3 0 . 3

1 3 0 . 7


E x e r c i s e s

W O M

A C – f u n c t i o n , c h a n g e ( 0 – 1 0 0 ) , e n d T x :

8 w

k

8 3

6 0 . 8

6 8 . 5

7 . 8

1 3 %

7 . 8 ( 8 . 4 8 , 7 . 1 2 )

C o n t r o l

W O M

A C – f u n c t i o n , c h a n g e ( 0 – 1 0 0 ) , e n d T x :

8 w

k

4 3

6 0 . 0

5 9 . 9

v a n B a r r e t a l 8 2

E x e r c i s e s

S e l f - r e p o r t e d d i s a b i l i t y ( I R L G ) , F U : 2 4 w k

9 3

2 0 . 0

1 . 1

1 . 7

8 %

1 . 1 ( 1 . 9 1 , 0 . 2 9 )

C o n t r o l

S e l f - r e p o r t e d d i s a b i l i t y ( I R L G ) , F U : 2 4 w k

9 8

2 0 . 6

0 . 0


E x e r c i s e s

S F - 3 6

q u a l i t y o f l i f e , c h a n g e , e n d T x : 8 w k

8 3

3 2 . 8 5

3 6 . 4 5

3 . 1

9 %

3 . 1 ( 3 . 4 4 , 2 . 7 6 )

C o n t r o l

S F - 3 6

q u a l i t y o f l i f e , c h a n g e , e n d T x : 8 w k

4 3

3 4 . 8

3 5 . 3

a

F U f o l l o w - u p , N / A n o t a v a i l a b l e , R O M r a

n g e o f m o t i o n , T x T r e a t m e n t , W M D w e i g h t e d m e a n d i f f e r e n c e , C I c o n f i d e n c e i n t e r v a l , V A S

v i s u a l a n a l o g s c a l e , W O M A C W e s t e r n O n t a r i o a n d M c M a s t e r U n i v e r s i t i e s

O s t e o a r t h r i t i s I n d e x , I R L G I n f l u e n c e o f R h e u m a t i c D i s e a s e o n G e n e r a l H e a l t h a n d L i f e s t y l e , S F - 3 6 M e d i c a l O u t c o m e s S t u d y 3 6 - I t e m S h o r t - F o r m H e a l t h S u r v e y q u e s t i o n n a i r e .

T a b l e 9 .

C l i n i c a l R e l e v a n c e : L o w e r - E x t r e m i t y S t r e n

g t h e n i n g E x e r c i s e P r o g r a m V e r s u s C o n t r o l a

S t u d y

G r o u p

O u t c o m e

N o .

I m p r o v e d

N

R i s k

O c c u r r e n c e

R i s k

D i f f e r e n c e

W M D ( 9 5 % C I )

B o ¨ r j e s s o n e t a l 6 4

E x e r c i s e s

A b i l i t y t o s t e p d o w n

1 3

3 4

3 8

%

2 6 %

3 . 2 5 ( 1 . 1 8 , 8 . 9 7 )

C o n t r o l

A b i l i t y t o s t e p d o w n

4

3 4

1 2

%

a

W M D w e i g h t e d m e a n d i f f e r e n c e , C I c o n f i d e n c e i n t e r v a l .










Figures 10a–o.General lower-extremity exercise program versus control. ADLactivities of daily living, AFIAlgofunctional Index, FUfollow-up, HSSHealth StatusSurvey, IRLGInfluence of Rheumatic Disease on General Health and Lifestyle, LElower extremity, MVCmaximal voluntary contraction, ROMrange of motion, VASvisual analog scale, SF-36 PCSMedical Outcomes Study 36-Item Short-Form Health Survey questionnaire Physical Component Summary,

WOMACWestern Ontario and McMaster Universities Osteoarthritis Index.







Figure 10.Continued.










No statistically significant data were found for theremaining outcomes: ROM in knee extension and flex-ion (Fig. 10a); improvement in hip and knee ROM at 24-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 during walking, 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 12 weeks (Fig. 10g); step frequency and stride length at 10to 12 weeks (Fig. 10h); stance at 10 to 12 weeks or at 12-month follow-up for most affected and least affectedLEs (Fig. 10j); walking speed and stair-climbing time at 10 to 12 weeks or at 12-month follow-up (Fig. 10l); Algofunctional Index–pain at 10 to 12 weeks or at 12-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, n179),75 clinical benefits(Tab. 10) and statistically significant differences werefound for ROM in knee flexion (WMD13°, 95%CI11.55° to 14.45°) and pain at rest (WMD–23 mm,95% CI–24.03 to –21.97). No important differences were found for WOMAC–stiffness, WOMAC–pain, orpain after walk test. Outcomes were measured after 8 weeks (Figs. 11a– c).

Hand strengthening versus control (one RCT, n40)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(WMD7.43, 95% CI1.78 to 31.04) and change in gripforce in the right hand (WMD0.11, 95% CI0.09 to0.13) and the left hand (WMD0.10, 95% CI0.09 to0.11) (Fig. 12b).

General Physical Activities, Including Fitness and Aerobic ExercisesFor whole-body functional exercise versus control (5RCTs, n864),45,63,72,73,76 clinically important benefits were 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 (WMD0.88, 95% CI0.49 to 1.27) (Fig. 13a);

• pain intensity in transfer at 3 months (WMD0.94, 95% CI1.33 to 0.55), at 9 months(WMD0.46, 95% CI0.84 to 0.08), and at 18 months (WMD0.37, 95% CI0.70 to0.04) (Fig. 13a);

• pain (WMD0.80, 95% CI1.29 to 0.31)(Fig. 13b);

• functional status measured with the ArthritisImpact Measurement Scales (AIMS) (WMD5.49,95% CI3.92 to 7.06) (results not shown);

• functional status measured with the ArthritisImpact Measurement Scales 2 (AIMS2): arthritis

pain (WMD

0.85, 95% CI

1.52 to

0.18)(Fig. 13b);• functional status measured with AIMS2: mobility

level at 12 weeks (WMD0.50, 95% CI0.93 to0.07) favoring the control group (Fig. 13c);

• functional status measured with AIMS2: walkingand bending at 12 weeks (WMD1.25, 95% CI2.08 to 0.42) (Fig. 13c);

• functional status measured with AIMS2: level of tension at 12 weeks (WMD2.58, 95% CI1.88 to3.28) (Fig. 13c);

• hamstring muscle and low back flexibility at 12 weeks (WMD3.63 in, 95% CI2.04 to 5.22 in)

(Fig. 13d);• 5-minute walk test at 12 weeks (WMD42.19 m,

95% CI14.19 to 70.19 m) (Fig. 13e);• hamstring muscle isometric torque at 30 degrees:

most affected LE at 12 weeks (WMD8.85 Nm,95% CI1.91 to 15.79 Nm) (Fig. 13f);

• hamstring muscle isometric torque at 30 degrees:least affected LE at 12 weeks (WMD10.51 Nm,95% CI3.24 to 17.78 Nm) (Fig. 13f);

• quadriceps femoris muscle isometric torque at 60degrees: most affected LE at 12 weeks (WMD19.80Nm, 95% CI4.75 to 34.85 Nm) (Fig. 13f);

• quadriceps femoris muscle isometric torque at 60degrees: least affected LE at 12 weeks (WMD17.03Nm, 95% CI1.08 to 32.98 Nm) (Fig. 13f);

• hamstring muscle isometric torque at 60 degrees:most affected LE at 12 weeks (WMD8.02 Nm,95% CI0.88 to 15.16 Nm) (Fig. 13f);

• hamstring muscle isometric torque at 60 degrees:least affected LE at 12 weeks (WMD10.99 Nm,95% CI3.68 to 18.30 Nm) (Fig. 13f);

• hamstring muscle isokinetic torque at 30°/s: most affected LE at 12 weeks (WMD10.98 Nm, 95%CI0.38 to 21.58 Nm) (Fig. 13g);

•

hamstring muscle isokinetic torque at 30°/s: least affected LE at 12 weeks (WMD10.51 Nm, 95%CI3.24 to 17.78 Nm) (Fig. 13g);

• hamstring muscle isokinetic torque at 90°/s: most affected LE at 12 weeks (WMD9.73 Nm, 95%CI1.40 to 20.86 Nm) (Fig. 13g);

• cadence at 3 months (WMD0.87 steps/min, 95%CI0.33 to 1.41 steps/min) (Fig. 13h), at 9 months(WMD0.94 steps/min, 95% CI0.37 to 1.51steps/min), and at 18 months (WMD2.08 steps/min, 95% CI1.56 to 2.60 steps/min) (results not shown);










• stride length at 3 months (WMD2.17 cm, 95%CI1.18 to 3.16 cm), at 9 months (WMD2.84 cm,95% CI1.77 to 3.91 cm), and at 18 months(WMD6.49 cm, 95% CI5.49 to 7.49 cm)(Fig. 13i);

• walking speed at 3 months (WMD3.77 cm/s, 95%CI2.60 to 4.94 cm/s), at 9 months (WMD4.37

cm/s, 95% CI

3.12 to 5.62 cm/s), and at 18months (WMD7.79 cm/s, 95% CI6.60 to 8.98cm/s) (Fig. 13j);

• stance time at 3 months (WMD0.01 s, 95%CI0.01 to 0.01 s) and at 18 months(WMD0.02 s, 95% CI0.02 to 0.02 s)(Fig. 13k);

• percentage of swing at 3 months (WMD0.39, 95%CI0.18 to 0.60), at 9 months (WMD0.36, 95%CI0.59 to 0.13), and 18 months (WMD0.54,95% CI0.32 to 0.76) (Fig. 13k);

• stair-climbing time at 18 months (WMD1.92 s,95% CI2.01 to 1.83 s) (Fig. 13l);

• climbing self-efficacy score at 18 months(WMD9.32, 95% CI8.86 to 9.78) (Fig. 13m);

• quality of life (WMD3.10, 95% CI2.97 to 3.23)(results not shown); and

• disability in bathing (WMD0.41, 95% CI0.18 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, and

18 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 in ADL, disability in transferring from a bed to a chair,disability in toileting, disability in dressing and eating, or

quality of life measured by HSS score (results not shown).

Six RCTs and 1 CCT examined walking versus control(n1,089),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 in ADL, energy level, medication use, aerobic capacity, andquality of life (Tabs. 13 and 14). No clinical benefits were 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).

T a b l e 1 0 .

C l i n i c a l R e l e v a n c e : P r o g r e s s i o n V e r s u s N

o P r o g r e s s i o n a

S t u d y

T r e a t m e n t

G r o u p

O

u t c o m e

N o . o f

P a t i e n t s

B a s e l i n e

M e a n


M e a n

A b s o l u t e

B e n e f i t

W M

D ( 9 5 % C I )

P e t r e l l a 7 5

E x e r c i s e s

P a

i n a t r e s t – V A S ( 0 – 1 0 0 ) , c h a n g e ,

e n d T x : 8 w k

9 1

N / A

N / A

2 3 W M D

2 3 ( 2 4 . 0 3 , 2 1 . 9 7 )

C o n t r o l

P a

i n a t r e s t – V A S ( 0 – 1 0 0 ) , c h a n g e ,

e n d T x : 8 w k

8 8

N / A

N / A

P e t r e l l a 7 5

E x e r c i s e s

P a

i n a f t e r s t e p t e s t – V A S ( 0 – 1 0 0 ) ,

c h a n g e , e n d T x : 8 w k

9 1

N / A

N / A

1 1 . 3 W M D

1 1 . 3 ( 1 2 . 0 4 , 1 0 . 5 6 )

C o n t r o l

P a

i n a f t e r s t e p t e s t – V A S ( 0 – 1 0 0 ) ,

c h a n g e , e n d T x : 8 w k

8 8

N / A

N / A

P e t r e l l a 7 5

E x e r c i s e s

R O

M i n k n e e f l e x i o n ( ° ) , e n d T x : 8 w k

9 1

N / A

N / A

1 3 °

1 3 ( 1 4 . 4 5 , 1 1 . 5 5 )

C o n t r o l

R O

M i n k n e e f l e x i o n ( ° ) , e n d T x : 8 w k

8 8

N / A

N / A

a

N / A n o t a v a i l a b l e , R O M r a n g e o f m o t i o n , T x t r e a t m e n t , V A S v i s u a l a n a l o g s c a l e , W M D w e i g h t e d m e a n d i f f e r e n c e , C I c o n f i d e n c e i n t e r v a l .







Figures 11a–d.Progression versus no-progression lower-extremity exercises. LElower extremity, ROMrange of motion, VASvisual analog scale,WOMACWestern Ontario and McMaster Universities Osteoarthritis Index.










Table 11.Clinical Relevance: Hand Strengthening Versus Controla

Study TreatmentGroup Outcome

No. ofPatients

BaselineMean

End-of-Study Mean

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 Txtreatment, WMD weighted mean difference, CIconfidence interval.

Table 12.

Clinical Relevance: Hand Strengthening Versus Controla

Study Group OutcomeNo.Observed N

Risk Occurrence

Risk Difference 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, Txtreatment, WMD weighted mean difference, CIconfidence interval.

Figures 12a and b.Hand strengthening versus control. VASvisual analog scale.







Figures 13a–n.Whole-body functional exercises versus control. AIMSArthritis Impact Measurement Scales, AIMS2Arthritis Impact Measurement Scales 2,FUfollow-up, HIKFhamstring muscle isokinetic force, HIFhamstring muscle isometric force, QIKFquadriceps femoris muscle isokinetic force,QIFquadriceps femoris muscle isometric force, VASvisual analog scale.










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

• pain frequency in ambulation at 3 months (WMD0.56, 95% CI1.07 to 0.05) and in transfer(WMD0.42, 95% CI0.77 to 0.07) (resultsnot shown);

• pain intensity in transfer at 3 months (WMD0.55,95% CI1.02 to 0.08), at 9 months (WMD

0.46, 95% CI0.84 to 0.08), and at 18 months(WMD0.41, 95% CI0.76 to0.06) (results not shown);

• 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 (WMD3.69 cm/s, 95%

CI2.47 to 4.91 cm/s), at 9 months (WMD10.29








cm/s, 95% CI9.05 to 11.53 cm/s), and at 18 months(WMD10.29 cm/s, 95% CI9.07 to 11.51 cm/s)(Tab. 13);

• cadence at 3 months (WMD3.56 steps/min, 95%CI3.00 to 4.12 steps/min), at 9 months(WMD3.69 steps/min, 95% CI3.12 to 4.26steps/min), and at 18 months (WMD3.77 steps/min, 95% CI3.21 to 4.33 steps/min) (Tab. 13);

• stance time at 3 months (WMD0.04 s, 95%CI0.04 to 0.04 s), at 9 months (WMD0.03 s,95% CI0.03 to 0.03 s), and at 18 months(WMD0.03 s, 95% CI0.03 to 0.03 s)(results not shown);

• percentage of swing at 3 months (WMD0.86, 95%CI0.64 to 1.08) and at 18 months (WMD0.54,95% CI0.32 to 0.76) (Tab. 13);











T a b l e 1 3 .

C l i n i c a l R e l e v a n c e : W a l k i n g P r o g r a m V e

r s u s C o n t r o l a

S t u d y

T r e a t m e n t

G r o u p

O u t c o m e

N

o . o f

P

a t i e n t s

B a s e l i n e

M e a n


M e a n

A b s o l u t e

B e n e f i t



B a s e l i n e

W M

D ( 9 5 % C I )

R e j e s k i e t a l 7 6

W a l k i n g p r o g r a m

S t a i r - c l i m b i n g t i m e ( s ) , F U : 1 8 m o

3

5 7 b

N / A

9 . 0 8

N / A

1 4 %

1 . 4 1 ( 1 . 5 1 , 1 . 3 1 )

C o n t r o l

S t a i r - c l i m b i n g t i m e ( s ) , F U : 1 8 m o

3

5 7 b

N / A

1 0 . 4 9



C l i m b i n g s e l f - e f f i c a c y s c o r e ( 0 – 1 0 ) ,

F U : 1 8 m o

3

5 7 b

N / A

6 6 . 0 6

N / A

1 3 %

8 ( 8 . 4 5 , 7 . 5 5 )

C o n t r o l

C l i m b i n g s e l f - e f f i c a c y s c o r e ( 0 – 1 0 ) ,

F U : 1 8 m o

3

5 7 b

N / A

5 8 . 0 6



G e n e r a l h e a l t h s t a t u s ( 0 – 1 0 0 ) , F U :

1 8 m o

3

5 7 b

N / A

7 5 . 5 6

N / A

5 %

3 . 5 9 ( 3 . 7 2 , 3 . 4 6 )

C o n t r o l

G e n e r a l h e a l t h s t a t u s ( 0 – 1 0 0 ) , F U :

1 8 m o

3

5 7 b

N / A

7 1 . 9 7

K o v a r e t a l 6 9


6 - m i n w a l k t e s t , e n d T x : 8 w k

4 7

3 8 1

4 5 1

8 7

2 4 %

1 1

2 ( 1 6 1 . 7 2 , 6 2 . 2 8 )

C o n t r o l


4 5

3 5 6

3 3 9

P e t e r s o n e t a l 7 4



4 7

3 9 0

4 4 9

7 8

2 1 %

1 1

1 ( 1 6 1 . 0 2 , 6 0 . 9 8 )

C o n t r o l


4 4

3 5 7

3 3 8



F r e e s p e e d ( m / m i n ) , e n d T x : 8 w k

4 7

5 6

6 1

2

4 %

7 ( 1 3 . 6 6 , 0 . 3 4 )

C o n t r o l

F r e e s p e e d ( m / m i n ) , e n d T x : 8 w k

4 4

5 1

5 4



F r e e s t r i d e ( m ) , e n d T x : 8 w k

4 7

1 . 1

1 . 2

0 . 2

1 8 %

0 . 2 ( 0 . 3 2 , 0 . 0 8 )

C o n t r o l

F r e e s t r i d e ( m ) , e n d T x : 8 w k

4 4

1 . 1

1 . 0



F a s t s p e e d ( m / m i n ) , e n d T x : 8 w k

4 7

7 6

8 3

9

1 2 %

1

5 ( 2 3 . 4 8 , 6 . 5 3 )

C o n t r o l

F a s t s p e e d ( m / m i n ) , e n d T x : 8 w k

4 4

7 0

6 8



F a s t s t r i d e ( m ) , e n d T x : 8 w k

4 7

1 . 2

1 . 4

0 . 2

1 7 %

0 . 2 ( 0 . 3 7 , 0 . 0 3 )

C o n t r o l

F a s t s t r i d e ( m ) , e n d T x : 8 w k

4 4

1 . 2

1 . 2



A I M S – p h y s i c a l a c t i v i t y ( 0 – 1 0 ) , e n d

T x : 8 w k

4 7

N / A

3 . 7 4

2 . 2 2

4 6 %

2 . 2 2 ( 3 . 2 5 , 1 . 1 9 )

C o n t r o l


T x : 8 w k

4 4

N / A

5 . 9 6

M i n o r e t a l 4 8



T x : 1 2 w k

3 6

N / A

3 . 6

1 . 3

3 1 %

1 . 3 ( 2 . 4 8 , 0 . 1 2 )

C o n t r o l


T x : 1 2 w k

3 2

N / A

4 . 9



N H P – p h y s i c a l m o b i l i t y ( 0 – 1 0 0 ) ,

F U : 6 m o

2 8

4 1 . 3

8 . 6

2 5 . 2

5 9 %

2

8 ( 3 0 . 7 7 , 2 5 . 2 3 )

C o n t r o l

N H P – p h y s i c a l m o b i l i t y ( 0 – 1 0 0 ) ,

F U : 6 m o

2 6

4 4 . 1

3 6 . 6








T a b l e 1 3 .

C o n t i n u e d

S t u d y

T r e a t m e n t

G r o u p

O u t c o m e

N

o . o f

P

a t i e n t s

B a s e l i n e

M e a n


M e a n

A b s o l u t e

B e n e f i t



B a s e l i n e

W M

D ( 9 5 % C I )



W O M A C – p h y s i c a l f u n c t i o n ( 0 – 6 8 ) ,

F U : 6 m o

2

8

2 3 . 9

1 0 . 2

9 . 2

3 8 %

1 0

. 5 ( 1 2 . 4 1 , 8 . 5 9 )

C o n t r o l

W O M A C – p h y s i c a l f u n c t i o n ( 0 – 6 8 ) ,

F U : 6 m o

2

6

2 5 . 2

2 0 . 7



A I M S – p a i n ( 0 – 1 0 ) , e n d T x : 8 w k

4

7

N / A

3 . 7 7

N / A

2 3 . 5 %

1

( 1 . 7 9 , 0 . 2 1 )

C o n t r o l

A I M S – p a i n ( 0 – 1 0 ) , e n d T x : 8 w k

4

4

N / A

4 . 7 7



W O M A C – p a i n ( 0 – 1 0 ) , F U : 6 m o

2

8

6 . 9

3 . 4

2 . 9

4 3 %

2

. 6 ( 3 . 9 6 , 1 . 2 4 )

C o n t r o l

W O M A C – p a i n ( 0 – 1 0 ) , F U : 6 m o

2

6

6 . 6

6 . 0



P a i n – V A S ( 0 – 1 0 ) , F U : 6 m o

2

8

7 . 1

3 . 6

3 . 3

4 7 %

3

. 2 ( 3 . 8 4 , 2 . 5 6 )

C o n t r o l

P a i n – V A S ( 0 – 1 0 ) , F U : 6 m o

2

6

7 . 0

6 . 8



N H P – p a i n ( 0 – 1 0 0 ) , F U : 6 m o

2

8

4 1 . 3

9 . 0

1 1 . 8

2 9 %

1 1

. 4 ( 1 3 . 1 3 , 9 . 6 7 )

C o n t r o l

N H P – p a i n ( 0 – 1 0 0 ) , F U : 6 m o

2

6

4 0 . 9

2 0 . 4



N H P – e n e r g y ( 0 – 1 0 0 ) , F U : 6 m o

2

8

5 0 . 7

1 4 . 6

3 2 . 5

6 3 %

3 4

. 7 ( 3 5 . 5 1 , 3 3 . 8 9 )

C o n t r o l

N H P – e n e r g y ( 0 – 1 0 0 ) , F U : 6 m o

2

6

5 2 . 9

4 9 . 3



N H P – s l e e p ( 0 – 1 0 0 ) , F U : 6 m o

2

8

4 4 . 9

1 9 . 6

1 5 . 6

3 5 %

1 5

. 7 ( 1 7 . 9 5 , 1 3 . 4 5 )

C o n t r o l

N H P – s l e e p ( 0 – 1 0 0 ) , F U : 6 m o

2

6

4 5 . 0

3 5 . 3



A I M S – m e d i c a t i o n u s e ( 0 – 6 ) , e n d

T x : 8 w k

4

7

N / A

3 . 6 4

N / A

1 1 6 %

2

. 7 4 ( 3 . 5 5 , 1 . 9 3 )

C o n t r o l

A I M S – m e d i c a t i o n u s e ( 0 – 6 ) , e n d

T x : 8 w k

4

4

N / A

0 . 9



1 5 . 2 - m ( 5 0 - f t ) w a l k i n g t i m e ( s ) , e n d

T x : 1 2 w k

3

6

9 . 9

8 . 7

0 . 9

9 %

2

( 2 . 9 7 , 1 . 0 3 )

C o n t r o l

1 5 . 2 - m ( 5 0 - f t ) w a l k i n g t i m e ( s ) , e n d

T x : 1 2 w k

3

2

1 1 . 0

1 0 . 7



A e r o b i c c a p a c i t y ( m L / k g m i n

1

) ,

e n d T x : 1 2 w k

3

6

1 8 . 9

2 2 . 4

3 . 6

2 0 %

5

. 1 ( 7 . 3 2 , 2 . 8 8 )

C o n t r o l

A e r o b i c c a p a c i t y ( m L / k g m i n 1 ) ,

e n d T x : 1 2 w k

3

2

1 7 . 4

1 7 . 3



E x e r c i s e e n d u r a n c e ( m i n ) , e n d T x :

1 2 w k

3

6

1 1 . 9

1 4 . 8

1 . 4

1 3 %

3

. 3 ( 5 . 4 8 , 1 . 1 2 )

C o n t r o l

E x e r c i s e e n d u r a n c e ( m i n ) , e n d T x :

1 2 w k

3

2

1 0 . 0

1 1 . 5



E x e r c i s e h e a r t r a t e ( b p m ) , e n d T x :

1 2 w k

3

6

1 4 9

1 5 8

5

3 %

1 6

( 2 8 . 0 6 , 3 . 9 4 )

C o n t r o l

E x e r c i s e h e a r t r a t e ( b p m ) , e n d T x :

1 2 w k

3

2

1 3 8

1 4 2











T a b l e 1 3 .

C o n t i n u e d

S t u d y

T r e a t m e n t

G r o u p

O u t c o m e

N

o . o f

P

a t i e n t s

B a s e l i n e

M e a n


M e a n

A b s o l u t e

B e n e f i t



B a s e l i n e

W M

D ( 9 5 % C I )

M e s s i e r e t a l 4 5

E x e r c i s e s

W a l k i n g s p e e d ( c m / s ) , m i d - T x :

3 m o

3

4

1 0 9 . 4 2

1 1 4 . 6 4

3 . 7 7

3 %

3

. 6 9 ( 4 . 9 1 , 2 . 4 7 )

C o n t r o l


3 m o

3

6

1 0 9 . 4 2

1 1 0 . 8 7


E x e r c i s e s


9 m o

3

4

1 0 9 . 4 2

1 1 6 . 3 0

4 . 3 7

4 %

1 0

. 2 9 ( 1 1 . 5 3 , 9 . 0 5 )

C o n t r o l


9 m o

3

6

1 0 9 . 4 2

1 1 1 . 9 3


E x e r c i s e s

W a l k i n g s p e e d ( c m / s ) , F U : 1 8 m o 3

4

1 0 9 . 4 2

1 1 5 . 2 0

7 . 7 9

7 %

1 0

. 2 9 ( 1 1 . 5 1 , 9 . 0 7 )

C o n t r o l

W a l k i n g s p e e d ( c m / s ) , F U : 1 8 m o 3

6

1 0 9 . 4 2

1 0 7 . 4 1


E x e r c i s e s

C a d e n c e ( s t e p s / m i n ) , m i d - T x : 3 m o 3

4

1 0 6 . 4 5

1 0 9 . 3 1

0 . 8 7

1 %

3

. 5 6 ( 4 . 1 2 , 3 )

C o n t r o l


6

1 0 6 . 4 5

1 0 8 . 4 4


E x e r c i s e s


4

1 0 6 . 4 5

1 0 9 . 4 2

0 . 9 4

1 %

3

. 6 9 ( 4 . 2 6 , 3 . 1 2 )

C o n t r o l


6

1 0 6 . 4 5

1 0 8 . 4 8


E x e r c i s e s

C a d e n c e ( s t e p s / m i n ) , F U : 1 8 m o

3

4

1 0 6 . 4 5

1 0 9 . 3 1

2 . 0 8

2 %

3

. 7 7 ( 4 . 3 3 , 3 . 2 1 )

C o n t r o l

C a d e n c e ( s t e p s / m i n ) , F U : 1 8 m o

3

6

1 0 6 . 4 5

1 0 7 . 2 3


E x e r c i s e s

S t r i d e l e n g t h ( c m ) , m i d - T x : 3 m o

3

4

1 2 0 . 1 9

1 2 2 . 7 6

2 . 1 7

2 %

0

. 3 2 ( 0 . 7 1 , 1 . 3 5 )

C o n t r o l


3

6

1 2 0 . 1 9

1 2 0 . 5 9


E x e r c i s e s


3

4

1 2 0 . 1 9

1 2 3 . 5 4

2 . 8 4

2 %

7

. 5 3 ( 8 . 5 8 , 6 . 4 8 )

C o n t r o l


3

6

1 2 0 . 1 9

1 2 0 . 7 0


E x e r c i s e s

S t r i d e l e n g t h ( c m ) , F U : 1 8 m o

3

4

1 2 0 . 1 9

1 2 3 . 9 2

6 . 4 9

5 %

7

. 5 4 ( 8 . 5 6 , 6 . 5 2 )

C o n t r o l

S t r i d e l e n g t h ( c m ) , F U : 1 8 m o

3

6

1 2 0 . 1 9

1 1 7 . 4 3


E x e r c i s e s

% s w i n g , m i d - T x : 3 m o

3

4

3 4 . 3 6

3 3 . 8 5

0 . 3 9

1 %

0

. 8 6 ( 1 . 0 8 , 0 . 6 4 )

C o n t r o l

% s w i n g , m i d - T x : 3 m o

3

6

3 4 . 3 6

3 3 . 4 6


E x e r c i s e s

% s w i n g , m i d - T x : 9 m o

3

4

3 4 . 3 6

3 3 . 6 7

0 . 3 6

1 %

0

. 3 7 ( 1 . 7 , 0 . 9 6 )

C o n t r o l

% s w i n g , m i d - T x : 9 m o

3

6

3 4 . 3 6

3 4 . 0 3


E x e r c i s e s

% s w i n g , F U : 1 8 m o

3

4

3 4 . 3 6

3 5 . 6 3

0 . 5 4

2 %

0

. 5 4 ( 0 . 7 6 , 0 . 3 2 )

C o n t r o l

% s w i n g , F U : 1 8 m o

3

6

3 4 . 3 6

3 5 . 0 9

a

F U f o l l o w - u p , N / A n o t a v a i l a b l e , N H P N o t t i n g h a m H e a l t h P r o f i l e , T x t r e a t m e n t , V A S v i s u a l a n a l o g s c a l e , W M D w e i g h t e d m e a n d i f f e r e n c e , C I c o n f i d e n c e i n t e r v a l , W O M A C W e s t e r n O n t a r i o a n d M c M a s t e r

U n i v e r s i t i e s O s t e o a r t h r i t i s I n d e x , A I M S A r t h r i t i s I m p a c t M e a s u r e m e n t S c a l e s .

b

T o t a l n u m b e r o f p a t i e n t s i n t h e s t u d y . S t u d y

d i d n o t s p e c i f y n u m b e r o f p a t i e n t s p e r g r o u p .







•

stride length at 9 months (WMD

7.53 cm, 95%CI6.48 to 8.58 cm) and at 18 months (WMD7.54cm, 95% CI6.52 to 8.56 cm) (Tab. 13);

• climbing self-efficacy score at 18-month follow-up(WMD8.00, 95% CI7.55 to 8.45) (Fig. 14a);

• 6-minute walk test at 8 weeks (WMD111.50 m,95% CI76.24 to 146.77 m) (Fig. 14b);

• stair-climbing time at 18-month follow-up (WMD1.41, 95% CI1.51 to 1.31) (Fig. 14c);

• general health status at 18-month follow-up(WMD3.59, 95% CI3.46 to 3.72) (Fig. 14d);

• incidence of disability at 18-month follow-up(WMD0.52, 95% CI0.28 to 0.96) (Fig. 14e);

• disability in transferring from a bed to a chair at 18-month follow-up (WMD0.42, 95% CI0.22 to0.79) (Fig. 14e);

• disability in bathing (WMD0.38, 95% CI0.17 to0.84) (Tab. 14) and in dressing at 18-month follow-up(WMD0.28, 95% CI0.10 to 0.83) (Fig. 14e);

• fast speed at 8 weeks (WMD15.00 m/min, 95%CI6.53 to 23.47 m/min) (Fig. 14f);

• fast stride at 8 weeks (WMD0.20 m, 95% CI0.03to 0.37 m) (Fig. 14f);

• free speed at 8 weeks (WMD7.00 m/min, 95%CI0.34 to 13.66 m/min) (Fig. 14g);

• free stride at 8 weeks (WMD0.20 m, 95% CI0.08to 0.32 m) (Fig. 14g);

• AIMS–pain at 8 weeks (WMD1.00, 95%CI1.79 to 0.21) (Fig. 14i);

• AIMS–physical activity at 8 weeks (WMD2.22,95% CI3.25 to1.19) (Tab. 13) and at 12 weeks(WMD1.30, 95% CI2.48 to 0.12) (Tab. 14,Fig. 14j);

• AIMS–medication use (WMD2.74, 95% CI1.93to 3.55) (Tab. 13);

• 15.2-m (50-ft) walking time at 8 weeks (WMD2.00 s, 95% CI2.97 to1.03 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 (WMD16.00 bpm,

95% CI3.94 to 28.06 bpm) (Fig. 14q);• aerobic capacity at 12 weeks (WMD5.10 mL/kg

min1 , 95% CI2.88 to 7.32 mL/kg min1)(Fig. 14s); and

• exercise endurance at 12 weeks (WMD3.30 min,95% CI1.12 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 mobility and 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 at 9-month follow-up (Fig. 14j), AIMS–arthritis impact at 8 weeks (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-month

follow-up (Fig. 14o), 15.2-m (50-ft) walking time at 9-month follow-up (Fig. 14p), resting systolic bloodpressure and resting diastolic blood pressure at 12 weeksand 9-month follow-up and exercise heart rate at 9-month follow-up (Fig. 14q), trunk flexibility at 12 weeks (Fig. 14r), and aerobic capacity and exerciseendurance at 9-month follow-up (Fig. 14s).

Physical activity and aerobic capacity yielded clinically important benefits favoring jogging in water versus con-trol (one RCT, n115)48 (Tab. 15). However, no clinicalbenefits were shown for functional status (AIMS–physi-

Table 14.Walking Program Versus Controla

Study Group OutcomeNo.Observed N

Risk Occurrence

Risk Difference 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 ADLactivities of daily living, FUfollow-up, WMD weighted mean difference, CIconfidence interval.










Figures 14a–s.Walking program versus control. ADLactivities of daily living, AIMSArthritis Impact Measurement Scales, FUfollow-up, NHPNottinghamHealth Profile, VASvisual analog scale, WOMACWestern Ontario and McMaster Universities Osteoarthritis Index.







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 significant differences were found for AIMS–physical activity at 12 weeks (WMD1.20, 95% CI2.29 to 0.11)(Fig. 15a), 15.2-m (50-ft) walking time at 12 weeks(WMD1.10 s, 95% CI2.12 to 0.08 s) (Fig. 15e),exercise heart rate at 12 weeks (WMD13.00 bpm, 95%CI1.32 to 24.68 bpm) (Fig. 15f), exercise endurance at 12 weeks (WMD2.80 min, 95% CI0.23 to 5.37 min)(Fig. 15h), and aerobic capacity (WMD5.90 mL/kgmin1 , 95% CI3.30 to 8.50 mL/kg min1) (results not shown). 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(n30)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, n30),66 clinically important 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). Statistically significant data were found for mean change in ten-derness of right hand (WMD1.80, 95% CI0.99 to2.61) and left hand (WMD1.73, 95% CI0.63 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 (WMD10.02, 95% CI6.50 to13.54), all at 6 weeks (Figs. 17a– c). No statistical data were 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 of both hands (Figs. 17b–f).

Figure 14.

Continued.







Manual Therapy Combined With Therapeutic ExercisesOne RCT (n83)30 was found on manual therapy combined with exercises, and this RCT compared the

intervention with a control. Important clin-ical benefits were demonstrated for pain but not functional status (Tab. 16). Statistically significant data were found for all the outcomes: 6-minute walktest at 4 weeks (WMD81.90 m, 95% CI22.85 to140.95 m) and at 8 weeks (WMD77.70 m, 95%CI18.59 to 136.81 m) (Fig. 18a) and pain at 4 weeks(WMD416.00, 95% CI618.15 to 213.85) andat 8 weeks (WMD471.90, 95% CI732.81 to210.99) (Fig. 18b).

Strength of Published Evidence Compared With Other GuidelinesGood evidence (level I, RCT) shows that various kinds of

exercises and manual therapy are useful for patients withOA, with different outcomes occurring depending onthe intervention: strengthening exercises relieve pain at rest 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 therapy combined with TE relieves pain.











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 Other GuidelinesThe Ottawa Panel concluded that good evidence existssupporting the inclusion of all of the following maincategories of interventions in the management of patients with OA: strengthening exercises (grade A for pain at rest and during functional activities, ROM, grip force, level of energy, 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 therapy combined 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 agreed with the recommendations. Four practitioners found therecommendations to be clear; 1 practitioner was uncer-tain which type of exercise was effective. The Ottawa

Panel 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 extensive

systematic review of TE (Figs. 1–18). Numerous grade A (n13) and C (n3) 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

T a b l e 1 5 .

C l i n i c a l R e l e v a n c e : J o g g i n g i n W a t e r V e r s u s C o n t r o l a

S t u d y

T r e a t m e n t

G r o u p

O u t c o m e

N o . o f

P a t i e n t s

B a s e l i n e

M e a n


M e a n

A b s o l u t e

B e n e f i t



B a s e l i n e

W M D ( 9 5 % C I )


J o g g i n g i n w a t e r A I M S – p h y s i c a l a c t i v i t y ( 0 – 1 0 ) , e n d T x :

1 2 w k

4 7

4 . 9

3 . 7

2 . 1

4 6 %

1 . 2 ( 2 . 2 9 , 0 . 1 1 )

C o n t r o l

A I M S – p h y s i c a l a c t i v i t y ( 0 - – 1 0 ) , e n d T x :

1 2 w k

3 2

4 . 0

4 . 9


J o g g i n g i n w a t e r 1 5

. 2 - m ( 5 0 - f t ) w a l k i n g t i m e ( s ) , e n d T x :

1 2 w k

4 7

1 0 . 9

9 . 6

1 . 0

9 %

1 . 1 ( 2 . 1 2 , 0 . 0 8 )

C o n t r o l

1 5

. 2 - m ( 5 0 - f t ) w a l k i n g t i m e ( s ) , e n d T x :

1 2 w k

3 2

1 1 . 0

1 0 . 7


J o g g i n g i n w a t e r E x e r c i s e e n d u r a n c e ( m i n ) , e n d T x : 1 2 w k

4 7

1 1 . 5

1 4 . 3

1 . 3

1 2 %

2 . 8 ( 5 . 3 7 , 0 . 2 3 )

C o n t r o l

E x e r c i s e e n d u r a n c e ( m i n ) , e n d T x : 1 2 w k

3 2

1 0 . 0

1 1 . 5


J o g g i n g i n w a t e r E x e r c i s e h e a r t r a t e ( b p m ) , e n d T x : 1 2 w k

4 7

1 4 5

1 5 5

6

4 %

1 3 ( 2 4 . 6 8 , 1 . 3 2 )

C o n t r o l

E x e r c i s e h e a r t r a t e ( b p m ) , e n d T x : 1 2 w k

3 2

1 3 8

1 4 2

a

A I M S A r t h r i t i s I m p a c t M e a s u r e m e n t S c a l e s , T x t r e a t m e n t , W M D w e i g h t e d m e a n d i f f e r e n

c e , C I c o n f i d e n c e i n t e r v a l .







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 compared with 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. FUfollow-up, ROMrange of motion, AIMSArthritis Impact Measurement Scales.










Figures 16a and b.Water exercises versus control. ROMrange of motion.








The Ottawa Panel EBCPGs for the management of patients with OA, however, were in concordance with Appraisal of Guidelines Research and Evaluation(AGREE) criteria155 and yielded results identical tothose of the previous Ottawa Panel EBCPGs developedfor RA 16 (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 OA 19–29,156 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 rest and during functional activities, knee ROM, quadriceps

Figures 17a–f.Yoga versus control. HAQHealth Assessment Questionnaire, ROMrange of motion, VASvisual analog scale.










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 OA

patient 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 activity are widely used and are effective for the management of patients with OA. The efficacy of exercises is mainly based 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 weight 160 and toprevent biomechanical problems161,162 and further joint damage 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 that the long-term efficacy of exercises for patients with OA (with or without other interventions) is influenced by a variety 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 activity habits so that they can benefit from the positive effectsand avoid the negative consequences and vicious cycle of inactivity. Inactivity can lead to chronic comorbidity problems (eg, obesity, cardiovascular conditions, diabe-

tes) that affect joint health, functional status, and quality of 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 of participation 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-

T a b l e 1 6 .

C l i n i c a l R e l e v a n c e : M a n u a l T h e r a p y a n d

E x e r c i s e V e r s u s C o n t r o l a

S t u d y

T r e a t m e n t G r o u p

O u t c o m e

N o . o f

P a

t i e n t s

B a s e l i n e

M e a n


M e a n

A b

s o l u t e

B e

n e f i t



B a s e l i n e

W M D ( 9 5 % C I )

D e y l e e t a l 3 0

M a n u a l t h e r a p y a n d e x e r c i s e

W O M A C – p a i n , e n d T x : 4 w k 4 2

1 , 0 4 6 . 7

5 0 5 . 2

3

6 9 . 2

3 4 %

4 1 6 ( 6 1 8 . 1 5 , 2 1 3 . 8 5 )

S u b t h e r a p e u t i c u l t r a s o u n d

( p l a c e b o )


1 , 0 9 3 . 5

9 2 1 . 2




1 , 0 4 6 . 7

4 6 2 . 4

4

2 5 . 1

4 0 %

4 7 1 . 9

( 7 3 2 . 7 4 , 2 1 1 . 0 6 )


( p l a c e b o )


1 , 0 9 3 . 5

9 3 4 . 3



6 - m i n w a l k t e s t , e n d T x : 4 w k 4 2

4 3 1 . 0

4 8 4 . 0

5 3 . 8

1 3 %

8 1 . 9

( 1 4 1 . 0 4 , 2 2 . 7 6 )


( p l a c e b o )

6 - m i n w a l k t e s t , e n d T x : 4 w k 4 1

4 0 2 . 9

4 0 2 . 1



6 - m i n w a l k t e s t , F U : 8 w k

4 2

4 3 1 . 0

4 8 7 . 4

4 9 . 6

1 2 %

7 7 . 7

( 1 3 6 . 8 1 , 1 8 . 5 9 )


( p l a c e b o )

6 - m i n w a l k t e s t , F U : 8 w k

4 1

4 0 2 . 9

4 0 9 . 7

a

F U f o l l o w - u p , W M D w e i g h t e d m e a n d i f f e r e n c e , C I c o n f i d e n c e i n t e r v a l , W O M A C W e s t e r

n O n t a r i o a n d M c M a s t e r U n i v e r s i t i e s O s t e o a r t h r i t i s I n d e x , T x t r e a t m e n t .







Implications for PracticeThe Ottawa Panel has found evidence to recommendand support the use of TE (on their own or combined with 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 are

limited 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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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 ROM

and periarticular muscle forceAGS,32 2001 N/R Exercise programs should be individualized. They are recommended for

controlling 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, AG S American Geriatrics

Society Panel on Exercise and Osteoarthritis, APS American Pain Society, OPOTOntario Program for Optimal Therapeutics, BMJBMJ Books, N/R not

reported, OA osteoarthritis, ROMrange of motion.










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s t r e n g t h e n i n g

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S u b t h e r a p e u t i c

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t i m e s a

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2 0 0 2

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G r 1 : 2 7

G r 2 : 2 8

G r 3 : 2 6


w i t h k n e e O A

E x c l u s i o n c r i t e r i a :

p a t i e n t s w h o h a d

t a k e n a q u a d r i c e p s


e x e r c i s e p r o g r a

m

d u r i n g t h e l a s t 6 m o

o r w h o h a d e f f u s i o n

o n k n e e s , p r e v i o u s

k n e e r e p l a c e m e n t ,

s e v e r e c a r d i o v a s c u l a r

d i s e a s e s , o r g r a d e 4

O A a c c o r d i n g

t o

K e l l g r e n a n d

L a w r e n c e c r i t e r

i a

N / A

G r 1 : X 5 6 . 3 ,

S D 6 . 1

G r 2 : 5 6 . 9 ,

S D 6 . 5

G r 3 : X 5 5 . 8 ,

S D 6 . 9

G r 1 :

h o m e e x e r c i s e

p r

o g r a m : i s o m e t r i c

s t r a i g h t l e g l i f t s ,

i s o m e t r i c q u a d r i c e p s


c o

n t r a c t i o n a n d

i s o t o n i c q u a d r i c e p s


c o

n t r a c t i o n e x e r c i s e s

p r

o g r e s s e d b y a d d i n g

w e i g h t f r o m 0 . 5 t o 5

k g

, 1 0 r e p e t i t i o n s

G r 2 :

r e g u l a r w a l k i n g

p r

o g r a m

G r 3 : c o n t r o l

( p h y s i c a l

t h e r a p i s t t o l d

p a t i e n t s t o

c o n t i n u e t h e i r

n o r m a l d a i l y

a c t i v i t i e s )

W O M A C – p a i n ( 0 –

1 0 )

V A S ( 0

– 1 0 )

W O M A C – p h y s i c a l

f u n c

t i o n ( 0 – 6 8 )

N H P – p

a i n

N H P – e

n e r g y

N H P – p

h y s i c a l

m o b

i l i t y

N H P – s

l e e p

N o n e

G r 1 : 2 t i m e s a

d a y f o r 3

m o

G r 2 : 1 0

m i n , 3

t i m e s a

w e e k f o r

3 m o ;

g r a d u a l l y

i n c r e a s e d

w a l k i n g

t i m e u p

t o 3 0 m i n

6 m o

0 , 0 , 1











A p p e n d i x 2 .



A u t h o r /

Y e a r

S a m p l e

S i z e


S y m p t o m

D u r a t i o n

A g e ( y )


C o m p a r i s o n

G r o u p

O u t c o

m e s

C o n c u r r e n t

T h e r a p y

F r e q u e n c y


F o l l o w - u p

D u r a t i o n

Q u a l i t y

( R ,

B ,

W )

M i n o r e t a l , 4 8

1 9 8 9

R C T T o t a l : 1 1 5

G r 1 : 3 6

G r 2 : 4 7

G r 3 : 3 2


w i t h c u r r e n t s y m p t o m s

o f c h r o n i c p a i n

a n d

s t i f f n e s s i n i n v o l v e d

w e i g h t - b e a r i n g

j o i n t s ;

o b j e c t i v e e v i d e n c e o f

j o i n t p a i n a n d

c r e p i t a t i o n w i t h

P R O M ; a n d

d o c u m e n t e d

r o e n t g e n o g r a p h i c

s i g n s o f h y p e r t r o p h i c

c h a n g e s , s u b c h

o n d r a l

s c l e r o s i s , o r

n o n u n i f o r m j o i n t s p a c e

n a r r o w i n g i n i n

v o l v e d

j o i n t s

N / A

N / M

G r 1 :

w a l k i n g o n a l e v e l

c o

u r s e , p r o g r e s s i n g

f r o m 1 0 t o 3 0 m i n a t

e x

e r c i s e H R

G r 2 :

j o g g i n g i n s h a l l o w

a n

d d e e p w a t e r a n d

m o d i f i e d c a l i s t h e n i c s

p e

r f o r m e d i n c h e s t -

h i g h w a t e r

G r 3 : c o n t r o l ;

g e n t l e A R O M

a n d i s o m e t r i c

s t r e n g t h e n i n g

a n d r e l a x a t i o n

e x e r c i s e s , w i t h

n o a e r o b i c

s t i m u l u s p e r i o d

C h a n g

e i n A I M S –

p a i n ( 0 – 1 0 )

C h a n g

e i n A I M S –

p h y s i c a l ( 0 – 1 0 )

C h a n e

i n m o r n i n g

s t i f f n e s s ( h )

C h a n g

e i n g r i p f o r c e

( m m

H g )

C h a n g

e i n t r u n k

f l e x i b i l i t y ( c m )

C h a n g

e i n 1 5 . 2 - m

( 5 0 - f t ) w a l k i n g

t i m e

( s )

C h a n g

e i n a e r o b i c

c a p a c i t y ( m L / k g

m i n 1 )

C h a n g

e i n e x e r c i s e

e n d u r a n c e ( m i n )

C h a n g

e i n r e s t i n g

b l o o

d p r e s s u r e :

s y s t o l i c a n d

d i a s t o l i c ( m m H g )

C h a n g

e i n e x e r c i s e

H R ( b p m )

G r 1 a n d G r 2 :

p a t i e n t s w i t h

e x e r c i s e H R t h a t

v a r i e d 6 0 % –

8 0 % o f

m a x i m a l H R

w e r e a s s i g n e d

i n d i v i d u a l l y t o

p a r t i c i p a t e i n

a e r o b i c

e x e r c i s e s ( p o o l

a n d w a l k

g r o u p s ) ; c l a s s e s

i n c l u d e d a

w a r m - u p ,

g e n e r a l

f l e x i b i l i t y a n d

i s o m e t r i c

s t r e n g t h e n i n g o f

p o s t u r a l

m u s c l e s , a n

a e r o b i c s t i m u l u s

p e r i o d

p r o g r e s s i n g t o

3 0 m i n o f

c o n t i n u o u s

a c t i v i t y , a n d a

c o o l - d o w n o f

1 0 m i n o f

A R O M a n d

s t r e t c h i n g

1 2 w k

3 , 9 m o

1 , 0 , 1

O ’ R e i l l y e t

a l , 7 1 1 9 9 9

R C T T o t a l : 1 9 1

G r 1 : 1 1 3

G r 2 : 7 8


w i t h 1 m o o f

p a i n i n

o r a r o u n d t h e k n e e o n

m o s t d a y s a n d

a n y

p a i n i n t h e p a s

t y e a r

N / A

G r 1 : X 6 1 . 9 4 ,

S D 1 0 . 0 1

G r 2 : X 6 2 . 1 5 ,

S D 9 . 7 3

G r 1 :

E x e r c i s e p r o g r a m

c o

n s i s t i n g o f t h e

f o l l o w i n g : ( 1 )



c o

n t r a c t i o n i n f u l l

e x

t e n s i o n , h e l d f o r 5

s ;

( 2 ) i s o t o n i c

q u

a d r i c e p s f e m o r i s

m u s c l e c o n t r a c t i o n i n

m i d f l e x i o n ; ( 3 )

i s o t o n i c q u a d r i c e p s


c o

n t r a c t i o n i n f u l l

f l e

x i o n ; ( 4 ) i s o t o n i c

q u

a d r i c e p s f e m o r i s

m u s c l e c o n t r a c t i o n i n

f u l l e x t e n s i o n ; a n d ( 5 )

d y

n a m i c s t e p p i n g

e x

e r c i s e . E x e r c i s e s

i n c r e a s e d t o a

m a x i m u m o f 2 0

r e p e t i t i o n s a n d w e r e

p e

r f o r m e d a t h o m e

o n

a d a i l y b a s i s .

S u

b j e c t s w e r e v i s i t e d

a t

w e e k s 2 a n d 6

a n

d a t m o n t h 3 .

G r 2 : c o n t r o l ; n o T x

W O M A C – p a i n ( 0 –

2 0 ,

h i g h e r

s c o r e m o r e p a i n )

W O M A C – f u n c t i o n

( 0 – 6 8 , h i g h e r

s c o r e m o r e

d i s a

b i l i t y )

I s o m e t r i c q u a d r i c e p s


f o r c e

S e l f - r e p o r t e d h e a l t h

s t a t u s ( S F - 3 6 , 0 –

1 0 0

, h i g h e r

s c o r e b e t t e r

h e a l t h )

N / A

1 t i m e a

d a y f o r 6

m o

N / A

2 , 0 , 1











A p p e n d i x 2 .



A u t h o r /

Y e a r

S a m p l e

S i z e


S y m p t o m

D u r a t i o n

A g e ( y )


C o m p a r i s o n

G r o u p

O u t c o

m e s

C o n c u r r e n t

T h e r a p y

F r e q u e n c y


F o l l o w - u p

D u r a t i o n

Q u a l i t y

( R ,

B ,

W )

R e j e s k i e t

a l , 7 6 1 9 9 8

R C T T o t a l : 3 5 7


w h o ( 1 ) w e r e a

g e d

6 0 y , ( 2 ) h a d

p a i n

o n m o s t d a y s o

f t h e

m o n t h i n o n e o

r b o t h

k n e e s , ( 3 ) h a d

d i f f i c u l t y w i t h a

t l e a s t

o n e A D L ( e g , g

e t t i n g

i n a n d o u t o f a

c a r ) ,

a n d ( 4 ) s h o w e d

r a d i o g r a p h i c e v i d e n c e

o f k n e e O A

N / A

X 6 8 . 6 5 ,

S D 5 . 5 0

G r 1 :

A e r o b i c T x g r o u p .

P a

r t i c i p a n t s w a l k e d a t

a n

i n t e n s i t y o f 5 0 % –

7 5 % o f H R r e s e r v e .

G r 2 :

R e s i s t a n c e t r a i n i n g

g r

o u p . P a r t i c i p a n t s

p e

r f o r m e d 9 d i f f e r e n t

u p

p e r - a n d l o w e r -

b o

d y e x e r c i s e s : l e g

e x

t e n s i o n s , l e g c u r l s ,

s t e p - u p s , h e e l - r a i s e s ,

c h

e s t f l i e s , u p r i g h t

r o

w s , m i l i t a r y

p r

e s s e s , b i c e p c u r l s ,

a n

d p e l v i c t i l t s .

P a

r t i c i p a n t s

c o

m p l e t e d 2 s e t s o f

e a

c h e x e r c i s e a t a

f r e q u e n c y o f 1 0 – 1 2

r e p e t i t i o n s .

G r 3 : C o n t r o l .

P a r t i c i p a n t s

w e r e

c o n s o l i d a t e d i n

g r o u p s o f 1 0 –

1 5 . D u r i n g

m o n t h s 1 – 3 ,

t h e y r e c e i v e d a

m o n t h l y

e d u c a t i o n

s e s s i o n t h a t

l a s t e d 1 . 5 h .

P a t i e n t s i n t h i s

c o n d i t i o n w e r e

c o n t a c t e d b y

t e l e p h o n e o n c e

e v e r y 2 w k f o r

m o n t h s 4 – 6 a n d

t h e n m o n t h l y f o r

t h e r e m a i n d e r

o f t h e s t u d y .

S t a i r - c l i m b i n g t i m e ( s )

C l i m b i n g s e l f - e f f i c a c y

s c o r e

( 0 c o m p l e t e l y

u n c e r t a i n ,

1 0 c o m p l e t e l y

c e r t a i n )

G e n e r a l h e a l t h s t a t u s

( 0 – 1 0 0 , 0 I a m

a s h

e a l t h y a s

a n y b o d y I k n o w )

G r 1 a n d G r 2 : 3 -

m o f a c i l i t y -

b a s e d e x e r c i s e

f o l l o w e d b y

1 5 - m o h o m e -

b a s e d p h a s e . 3

t i m e s a w e e k ,

1 0 - m i n w a r m -

u p , 4 0 - m i n

s t i m u l u s p h a s e ,

a n d 1 0 - m i n

c o o l - d o w n .

H o m e - b a s e d

p h a s e : ( 1 ) 4

h o m e v i s i t s a n d

6 t e l e p h o n e

c o n t a c t s d u r i n g

t h e f i r s t 3 m o

a n d ( 2 )

t e l e p h o n e c a l l s

e v e r y 3 w k f o r

t h e s e c o n d 3

m o , t h e n o n e

t e l e p h o n e c a l l

e a c h m o n t h f o r

t h e r e m a i n d e r

o f t h e s t u d y .

3 t i m e s a

w e e k f o r

t h e f i r s t 3

m o ; 1 5 -

m o h o m e -

b a s e d

p r o g r a m

N / A

1 , 0 , 0

R o d g e r s e t

a l , 7 7 1 9 9 8

C C T T o t a l : 2 0

G r 1 : 1 0

G r 2 : 1 0


w i t h u n i l a t e r a l p r i m a r y

T K A f o r O A

N / A

G r 1 : X 7 0 ,

S D 3 . 7 5

G r 2 : X 6 5 ,

S D 8 . 2 5

G r 1 :

6 w k p r e o p e r a t i v e

P T

, 3 t i m e s a w e e k ;

p r

o g r a m

i n d i v i d u a l i z e d

a c

c o r d i n g t o b a s e l i n e

p h

y s i c a l c a p a c i t y .

S t r e t c h i n g a n d w a r m -

u p

, h e e l - s l i d e s ,


f e m o r i s m u s c l e s e t s

( q u a d s e t s ) , S L R ,

s h

o r t - a r c q u a d s e t s ,

s t a n d i n g s q u a t s , s t e p -

u p

s , a n d s t a t i o n a r y

b i c y c l e .

G r 2 : c o n c u r r e n t

t h e r a p y o n l y

R O M ( ° )

H o s p i t a l f o r S p e c i a l

S u r g e r y K n e e

R a t i n g S c a l e s c o r e

S a m e k n e e

i m p l a n t ; s a m e

p o s t o p e r a t i v e

t h e r a p y ,

i n c l u d i n g a n k l e

p u m p s , q u a d

s e t s , S L R , s h o r t -

a r c q u a d s e t s ,

h e e l - s l i d e s ,

h a m s t r i n g

m u s c l e -

s t r e t c h i n g ,

h a m s t r i n g

m u s c l e s e t s , h i p

a b d u c t i o n , a n d

h i p a d d u c t i o n .

P a t i e n t s s t a r t e d

g a i t t r a i n i n g o n

t h e f i r s t

p o s t o p e r a t i v e

d a y . T h e y w e r e

d i s c h a r g e d

d e p e n d i n g o n

t h e i r p r o g r e s s

a n d w e r e

i n s t r u c t e d t o

b e g i n a h o m e

P T p r o g r a m .

3 t i m e s a

w e e k f o r

6 w k

6 w k , 3 m o

0 , 0 , 1








A p p e n d i x 2 .



A u t h o r /

Y e a r

S a m p l e

S i z e


S y m p t o m

D u r a t i o n

A g e ( y )


C o m p a r i s o n

G r o u p

O u t c o

m e s

C o n c u r r e n t

T h e r a p y

F r e q u e n c y


F o l l o w - u p

D u r a t i o n

Q u a l i t y

( R ,

B ,

W )

S t a m m e t

a l , 8 0 2 0 0 2

R C T T o t a l : 4 0

G r 1 : 2 0

G r 2 : 2 0


w h o m e t t h e A C R

c r i t e r i a f o r h a n d O A ;

m e d i c a t i o n w i t h

a n a l g e s i c s o r N

S A I D s

w a s a l l o w e d d u r i n g

t h e s t u d y , b u t h

a d t o

r e m a i n s t a b l e a

t l e a s t

1 m o b e f o r e a n d

t h r o u g h o u t t h e s t u d y

N / A

G r 1 : X 6 0 . 5 ,

S D 8 . 3 3

G r 2 : X 6 0 . 4 ,

S D 8 . 4 3

G r 1 :

E x e r c i s e . E a c h

p a

t i e n t r e c e i v e d 3 0

m i n o f o r a l a n d

w r i t t e n i n s t r u c t i o n s f o r

j o i n t p r o t e c t i o n a n d

1 5 m i n o f t r a i n i n g i n

h o

m e e x e r c i s e s ,

w h i c h c o n s i s t e d o f 7

e x

e r c i s e s t o p e r f o r m

w i t h b o t h h a n d s 1 0

t i m

e s a d a y .

G r 2 : C o n t r o l . O r a l

a n d w r i t t e n

i n f o r m a t i o n

a b o u t h a n d

O A , j o i n t

a n a t o m y , a n d

p a t h o g e n e s i s o f

O A . P a t i e n t s

r e c e i v e d a

p i e c e o f

D y c e m

d

t o o p e n

j a r s f o r t h e

s t u d y p e r i o d o f

3 m o .

C h a n g

e o f g r i p f o r c e

V A S ( n

o . o f p a t i e n t s

i m p r o v e d )

N / A

3 m o

N / A

1 , 0 , 0

S u o m i a n d

L i n d a u e r , 8 1

1 9 9 7

R C T T o t a l : 3 0

G r 1 : 2 0

G r 2 : 1 0


w h o w e r e w o m

e n

a g e d 4 5 – 7 0 y , h a d

b e e n d i a g n o s e d w i t h

R A o r O A b y e

i t h e r a

r h e u m a t o l o g i s t

o r a n

o r t h o p e d i c p h y

s i c i a n ,

h a d c u r r e n t s y m

p t o m s

o f c h r o n i c p a i n

a n d

s t i f f n e s s i n w e i g h t -

b e a r i n g j o i n t s ,

s c o r e d

1 5 o r l e s s o n t h e

A I M S k n e e / h i p

s c a l e s ,

h a d n o m e d i c a

l

c o n d i t i o n p r e c l u d i n g

i n c r e a s e d p h y s i c a l

a c t i v i t y , h a d n o

t b e e n

i n v o l v e d i n a n

o r g a n i z e d e x e r c i s e

p r o g r a m f o r t h e p a s t 3

m o , h a d a s t a b

l e

m e d i c a t i o n r e g i m e n

f o r a t l e a s t 3 m

o

b e f o r e e n t e r i n g

t h e

s t u d y , a n d h a d

m e d i c a l c l e a r a n c e

t h r o u g h t h e i r p r i m a r y

p h y s i c i a n t o

p a r t i c i p a t e i n t h e

A r t h r i t i s F o u n d a t i o n

A q u a t i c P r o g r a

m

G r 1 : X 2 1 . 3

y , S D 6 y

G r 2 : X 1 9 . 0

y , S D 4 . 5 y

G r 1 : X 5 9 . 8 ,

S D 5 . 5

G r 2 : X 5 4 . 4 ,

S D 4 . 7 5

G r 1 :

W a t e r e x e r c i s e s

w e r e p e r f o r m e d i n a

t h e r a p e u t i c p o o l w i t h

a

w a t e r t e m p e r a t u r e

o f

8 5 ° – 8 7 ° F a n d a

d e

p t h o f 1 . 0 7 – 1 . 5 2

m

( 3 . 5 – 5 . 0 f t ) f o r 4 5

m i n , 3 t i m e s a w e e k

f o r 6 w k , f o l l o w i n g

A r t h r i t i s F o u n d a t i o n

A q u a t i c P r o g r a m

g u

i d e l i n e s .

G r 2 : C o n t r o l .

P a t i e n t s w e r e

a s k e d t o r e f r a i n

f r o m e n g a g i n g

i n a n y

o r g a n i z e d

p h y s i c a l a c t i v i t y

p r o g r a m o r

b e g i n n i n g a n y

n e w p h y s i c a l

a c t i v i t y f o r t h e

d u r a t i o n o f t h e

i n v e s t i g a t i o n .

P e a k t o r q u e ( N m )

R O M ( ° )

N / A

3 t i m e s a

w e e k f o r

6 w k

N / A

1 , 0 , 0








A p p e n d i x 2 .



A u t h o r /

Y e a r

S a m p l e

S i z e


S y m p t o m

D u r a t i o n

A g e ( y )


C o m p a r i s o n

G r o u p

O u t c o

m e s

C o n c u r r e n t

T h e r a p y

F r e q u e n c y


F o l l o w - u p

D u r a t i o n

Q u a l i t y

( R ,

B ,

W )

T o p p e t a l , 4

2

2 0 0 2

R C T T o t a l : 1 0 2

G r 1 : 3 5

G r 2 : 3 2

G r 3 : 3 5


w i t h a d i a g n o s i s o f

k n e e O A a n d a s c o r e

o f 5 o r m o r e o n t h e

W e s t e r n O n t a r i o a n d

M c M a s t e r U n i v

e r s i t i e s

O s t e o a r t h r i t i s I n d e x

p a i n s u b s c a l e

N / A

G r 1 : X 6 0 . 9 4 ,

S D 1 0 . 7 7

G r 2 : X 6 5 . 5 7 ,

S D 1 0 . 7 7

G r 3 : X 6 3 . 5 3 ,

S D 1 0 . 7 5

G r 1 :

d y n a m i c r e s i s t a n c e

w i t h T h e r a - B a n d

e l a s t i c b a n d s ; w a r m -

u p

5 m i n , s t r e n g t h

t r a

i n i n g 3 0 m i n , c o o l -

d o

w n 5 m i n

G r 2 :

s t a n d a r d i s o m e t r i c

t r a

i n i n g t e c h n i q u e s ;

r e s i s t a n c e w i t h T h e r a -

B a

n d e l a s t i c b a n d s

t h a t p a t i e n t s w e r e

u n

a b l e t o s t r e t c h

G r 1 a n d G r 2 : m u s c l e s

w e r e a n k l e p l a n t a r

f l e

x o r s a n d

d o

r s i f l e x o r s , k n e e

e x

t e n s o r s a n d f l e x o r s ,

a n

d h i p e x t e n s o r s

a n

d f l e x o r s

G r 3 : n o

i n t e r v e n t i o n

W O M A C – s t i f f n e s s

W O M A C – f u n c t i o n a l

l i m i t a t i o n


T i m e t o

g e t d o w n t o

f l o o r ( s )

T i m e t o

g e t u p f r o m

f l o o r ( s )

T i m e t o

g o u p s t a i r s

( s )

T i m e t o

g o d o w n

s t a i r s ( s )

P a i n w

h i l e g e t t i n g

d o w

n t o f l o o r

P a i n w

h i l e g e t t i n g u p

f r o m

f l o o r

P a i n w

h i l e g o i n g u p

s t a i r s

P a i n w

h i l e g o i n g

d o w

n s t a i r s

N o n e

3 t i m e s a

w e e k

( t w i c e a t

h o m e

a n d o n c e

u n d e r

s u p e r v i s i o n )

N o n e

1 , 0 , 1

v a n B a a r e t

a l , 8 2 1 9 9 8

R C T T o t a l : 1 9 1

G r 1 : 9 3

G r 2 : 9 8


w i t h O A o f t h e

h i p o r

k n e e a c c o r d i n g

t o t h e

c l i n i c a l c r i t e r i a

o f t h e

A C R

N / A

G r 1 : X 6 8 . 3 ,

S D 8 . 4

G r 2 : X 6 7 . 7 ,

S D 9 . 2

G r 1 :

E x e r c i s e s f o r

m u s c l e f u n c t i o n s

( f o

r c e a n d l e n g t h ) ,

m o b i l i t y , a n d

c o

o r d i n a t i o n a n d

e x

e r c i s e s f o r

e l e m e n t a r y m o v e m e n t

a b

i l i t i e s a n d

l o c o m o t i o n a b i l i t i e s .

I n s t r u c t i o n s f o r t h e

a d

a p t a t i o n o f A D L

a n

d h o m e e x e r c i s e s

w e r e g i v e n .

C o m b i n e d w i t h

c o

n c u r r e n t t h e r a p y .



I m p r o v

e m e n t i n p a i n

a t a

s s e s s m e n t ,

V A S

( 0 – 1 0 0 ,

0 n o p a i n )

C h a n g

e i n p a i n i n

p a s t w e e k

I m p r o v

e m e n t i n p a i n

i n p

a s t m o n t h ,

V A S

( 0 – 1 0 0 ,

0 n o p a i n )

I m p r o v

e m e n t i n h i p

R O M

I m p r o v

e m e n t i n k n e e

R O M

I m p r o v

e m e n t i n h i p

m u s

c l e f o r c e

I m p r o v

e m e n t i n k n e e

m u s

c l e f o r c e

I m p r o v

e m e n t i n s e l f -

r e p o r t e d

d i s a

b i l i t y ,

I n f l u

e n c e o f

R h e u m a t i c D i s e a s e

o n G e n e r a l H e a l t h

a n d

L i f e s t y l e

I m p r o v

e m e n t i n

p h y s c i a l a c t i v i t y

T x b y t h e g e n e r a l

p r a c t i t i o n e r :

p r e s c r i p t i o n o f

m e d i c a t i o n

( p a t i e n t s w e r e


u s e a s l i t t l e a s

p o s s i b l e ) a n d

p a t i e n t

e d u c a t i o n

t h r o u g h

b r o c h u r e

t o p i c s ,

i n c l u d i n g

d i a g n o s i s ,

p r o g n o s i s ,

a d v i c e

c o n c e r n i n g

r e s t , d a i l y

a c t i v i t i e s a n d

d i e t , u s e o f

a i d s , a n d

m e d i c a l T x

G r 1 : 1 - 3

t i m e s a

w e e k ,

d e p e n d i n g

o n p a i n

l e v e l , f o r

1 2 w k

G r 2 : p a t i e n t s

c o n s u l t e d

t h e i r

g e n e r a l

p r a c t i t i o n e r

a t l e a s t

t w i c e , a t

w e e k s 0

a n d 1 2 ,

a n d w h e n

n e e d e d

2 4 w k

2 , 0 , 1











A p p e n d i x 2 .



A u t h o r /

Y e a r

S a m p l e

S i z e


S y m p t o m

D u r a t i o n

A g e ( y )


C o m p a r i s o n

G r o u p

O u t c o

m e s

C o n c u r r e n t

T h e r a p y

F r e q u e n c y


F o l l o w - u p

D u r a t i o n

Q u a l i t y

( R ,

B ,

W )

v a n B a a r e t

a l , 8 3 2 0 0 1

R C T T o t a l : 2 0 0

G r 1 : 9 8

G r 2 : 1 0 2


w i t h O A o f t h e

h i p o r

k n e e a c c o r d i n g

t o t h e

c l i n i c a l c r i t e r i a

o f t h e

A C R

N / A

G r 1 : X 6 8 . 3 ,

S D 8 . 4

G r 2 : X 6 7 . 7 ,

S D 9 . 2

G r 1 :

E x e r c i s e s f o r

m u s c l e f u n c t i o n s

( f o

r c e a n d l e n g t h ) ,

m o b i l i t y , a n d

c o

o r d i n a t i o n a n d

e x

e r c i s e s f o r

e l e m e n t a r y m o v e m e n t

a b

i l i t i e s a n d

l o c o m o t i o n a b i l i t i e s .

I n s t r u c t i o n s f o r t h e

a d

a p t a t i o n o f A D L

a n

d h o m e e x e r c i s e s

w e r e g i v e n . E x e r c i s e s

o c

c u r r e d 1 – 3 t i m e s a

w e e k , d e p e n d i n g o n

p a

i n l e v e l , 3 0 m i n

p e

r s e s s i o n .



P a i n , V

A S ( 0 – 1 0 0 ,

0 n o p a i n ,

1 0 0

v e r y s e v e r e

p a i n )

O b s e r v e d d i s a b i l i t y

( 5 - m

w a l k i n g t i m e ,

s t a n

d - t o - s i t t i m e ,

s t a n

d - t o - r e c l i n e

t i m e

, a n d l e v e l s o f

c a u t i o n a n d

r i g i d i t y d u r i n g

p e r f o r m a n c e o f

t h e t a s k s )

G e n e r a l

p r a c t i t i o n e r

p r e s c r i b e d

a c e t a m i n o p h e n ;

p r e s c r i p t i o n o f

N S A I D s

r e s t r i c t e d t o

n a p r o x e n ,

d i c l o f e n a c

n a t r i u m , a n d

i b u p r o f e n .

P a t i e n t s


u s e a s f e w a s

p o s s i b l e .

B r o c h u r e f o r

p a t i e n t

e d u c a t i o n

c o v e r i n g

d i a g n o s i s ,

p r o g n o s i s ,

a d v i c e a b o u t

r e s t , d a i l y

a c t i v i t i e s a n d

d i e t , u s e o f

a i d s , a n d

m e d i c a l T x .

1 – 3 t i m e s a

w e e k f o r

1 2 w k

2 4 , 3 6 w k

2 , 0 , 1

a

R r a n d o m i z a t i o n : 2 p o i n t s m a x i m u m ( J a d a d s c a l e 1 5 ) , B b l i n d i n g : 2 p o i n t s m a x i m u m ( J a d a

d s c a l e 1 5 ) , W w i t h d r a w a l s : 1 p o i n t m a x i m u m ( J a d a d s c a l e 1 5 ) , A C R A m e r i c a n C o l l e g e o f R h e u m a t o l o g y , A D L a c t i v i t i e s o f

d a i l y l i v i n g , A I M S A r t h r i t i s I m p a c t M e a s u r e m

e n t S c a l e s , A I M S 2 A r t h r i t i s I m p a c t M e a s u r e m e

n t S c a l e s 2 , A R O M a c t i v e r a n g e o f m o t i o n , C C

T c o n t r o l l e d c l i n i c a l t r i a l , G r g r o u p , H R h e a

r t r a t e , L E l o w e r e x t r e m i t y ,

N / A n o t a v a i l a b l e , N / M n o t m e n t i o n e d , N H

P N o t t i n g h a m H e a l t h P r o f i l e , N S A I D n o n s t e

r o i d a l a n t i - i n f l a m m a t o r y d r u g , O A o s t e o a r t h r i t i s , P R O M p a s s i v e r a n g e o f m o t i o n , P T p h y s i c a

l t h e r a p y , R A r h e u m a t o i d

a r t h r i t i s , R C T r a n d o m i z e d c o n t r o l l e d t r i a l , R

O M r a n g e o f m o t i o n , S D s t a n d a r d d e v i a t i o n ,

S F - 3 6 M e d i c a l O u t c o m e s S t u d y 3 6 - I t e m S h o r t - F

o r m H e a l t h S u r v e y q u e s t i o n n a i r e , S L R s t r a i g h t l e g r a i s i n g , T K A t o t a l

k n e e a r t h o p l a s t y , T x t r e a t m e n t , V A S v i s u a l a n a l o g s c a l e , W O M A C W e s t e r n O n t a r i o a n d M c M a s t e r U n i v e r s i t i e s O s t e o a r t h r i t i s I n d e x .

b

A l t m a n R , A l a r c o n G , A p p e l r o u t h D , e t a l . T

h e A m e r i c a n C o l l e g e o f R h e u m a t o l o g y c r i t e r i a f o r t h e c l a s s i f i c a t i o n a n d r e p o r t i n g o f o s t e o a r t h r

i t i s o f t h e h a n d .

A r t h r i t i s R h e u m . 1 9 9 0 ; 3 3 : 1 6 0 1 – 1

6 1 0 .

c T h e H y g e n i c C o r p , 1 2 4 5 H o m e A v e , A k r o n ,

O H 4 4 3 1 0 - 2 5 7 5 .

d

D y c e m L t d , U n i t s 2 - 4 , A s h l e y H i l l T r a d i n g E s t a t e , B r i s t o l B S 2 9 B B , U n i t e d K i n g d o m .

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 Physical

Therapy Association from: Ottawa Panel Evidence-

Based Clinical Practice Guidelines for Therapeutic

Exercises in the Management of Rheumatoid Arthritis

in Adults. Phys.Ther. 2004;84:934–972.







Appendix 4.Evidence-Based Clinical Practice Guidelinesa

Strengthening Exercises

Lower-extremity strengthening versus control, level 1 (RCT, n345): 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 peak torque (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, n102): grade A for pain getting down to and up from floor (clinically important benefit); grade C for pain getting down and up stairs and timed functional tasks (clinical benefit); grade C for stiffness and functional 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 for quadriceps 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, n32): grade C for muscle force (no benefit). Patients with primary diagnosis of OA of the knee.

Eccentric resistance training (Cybex*) for knee versus control, level 1 (RCT, n32): 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, n23): grade A for pain at rest and during activities (clinically important benefit); 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, n23): grade A for pain at rest and during specific functional activities: 15-m walk and stair climbing/descending time (clinically important benefit). Patients with knee OA bilaterally and grade II or III OA.

Home program strengthening for knee versus control, level 1 (CCT, n81): 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 of the knee.

General LE exercise program (including muscle force, flexibility, and mobility/coordination) versus control, level 1 (RCT, n490): 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, n179): grade A for pain at rest and ROM (clinically important benefit); grade C for stiffness and functional status (no benefit). Patients with radiographic evidence of OA in the tibiofemoral compartment.

Hand strengthening versus control, level 1 (RCT, n40): grade A for pain and grip force (clinically important benefit). Patients who met the American College of Rheumatology criteria for hand OA.154

***

General Physical Activity, Including Fitness and Aerobic Exercises

Whole-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, n1,089): 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 (clinical benefit); grade C for walking speed, disability toileting, disability dressing, blood pressure, morning stiffness, and quality of life (no benefit). Patients with OA.

Jogging in water versus control, level 1 (RCT, n115): 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 current symptoms of chronic pain and stiffness in involved weight-bearing joints.

Water exercises versus control, level 1 (RCT, n30): 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, n30): 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 of

the fingers. ***

Combination of Exercises

Manual therapy combined with exercise versus control, level 1 (RCT, n83): grade A for pain (clinically important benefit); grade C for functional status (no benefit). Patients with a diagnosis of OA.

a RCTrandomized controlled trial, OA osteoarthritis, CCTcontrolled clinical trial, ROMrange of motion, ADLactivities of daily living, RA rheumatoid

arthritis, LElower extremity.

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










2005; 85:907-971.PHYS THER.Gerry Arts and Marnie Lamb

Haines-Wangda, Marion Russell-Doreleyers, Martha Hall,Légaré, Catherine Caron, Sydney Lineker, AngelaSarah Milne, Mary Bell, Hillel M Finestone, FranceRobinson, Lucie Pelland, Jessie McGowan, Maria Judd,

AEgan, Claire-Jehanne Dubouloz, Lynn Casimiro, VivianLucie Brosseau, George A Wells, Peter Tugwell, MaryTherapy in the Management of OsteoarthritisGuidelines for Therapeutic Exercises and ManualOttawa Panel Evidence-Based Clinical Practice

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