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Ottawa Panel Evidence-Based Clinical Practice Guidelines for Therapeutic Exercises and Manual Therapy in the Management of Osteoarthritis

Ottawa Methods Group

Lucie Brosseau

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

Department of Epidemiology and Community Medicine, University of Ottawa

Peter Tugwell

Centre for Global Health, Institute of Population Health, University of Ottawa

Mary Egan

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

Claire-Jehanne Dubouloz

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

Lynn Casimiro

Physiotherapy Program, School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa

Vivian A Robinson

Centre for Global Health, Institute of Population Health

Lucie Pelland

Physiotherapy Program, School of Rehabilitation Sciences, Queen' University, Kingston, Ontario, Canada

Jessie McGowan

Medical Library, Centre for Global Health, Institute of Population Health, University of Ottawa

Maria Judd

Canadian Physiotherapy Association, Ottawa, Ontario, Canada

Sarah Milne

Department of Epidemiology and Community Medicine, University of Ottawa

External Experts

Mary Bell

Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada

Hillel M Finestone

Sisters of Charity of Ottawa Health Service, Ottawa, Ontario, Canada

France Légaré

University of Laval, Québec City, Québec, Canada

Catherine Caron

Sisters of Charity of Ottawa Health Service

Sydney Lineker

The Arthritis Society, Ontario Division, Research Co-ordinator, Toronto, Ontario, Canada

Angela Haines-Wangda

Ottawa Hospital, General Campus, Ottawa, Ontario, Canada

Marion Russell-Doreleyers

Canadian Physiotherapy Association and Ottawa Arthritis Rehabilitation and Education Program, Ottawa, Ontario, Canada

Martha Hall

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

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 (Lucie.Brosseau{at}uottawa.ca)

	Abstract

 
Background and Purpose. Osteoarthritis (OA) affects a large and growing proportion of the population. The purpose of this project was to create guidelines for the use of therapeutic exercises and manual therapy in the management 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 impairments were excluded. Methods. The Ottawa Methods Group used Cochrane Collaboration methods to find and synthesize evidence from comparative controlled trials and then asked stakeholder groups to nominate representatives to serve on a panel of experts. The Ottawa Panel agreed on criteria for grading the strength of the recommendations and their supporting evidence. Of the 609 potential articles on therapeutic exercises 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 clinical benefit 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 with OA. Discussion and Conclusion. The Ottawa Panel recommends the use of therapeutic exercises alone, or combined with manual therapy, for managing patients with OA. There were a total of 16 positive recommendations: 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.

Key Words: Clinical practice guidelines • Epidemiology • Evidence-based practice • Osteoarthritis • Physical rehabilitation • Rheumatology

	Introduction

Top Abstract Introduction Methods Results of Literature Search Discussion Limitations Therapeutic Exercises Manual Therapy Implications for Practice Appendix 1 Appendix 2 Appendix 3 Appendix 4 References

 
Osteoarthritis (OA) affects a large proportion of the population. Its prevalence is increasing dramatically as the populations of industrialized countries age and the baby boomers enter older adulthood.¹ It has been estimated that the prevalence will increase in the United States from 43 million in 1997 to 60 million in 2020.² Similarly, in Canada, an increase from 2.9 in 1991 to 6.5 million in 2033 (a 124% increase) is expected.³ Osteoarthritis is recognized as a substantial source of disability with significant social and financial costs due to surgical and medical interventions and frequent absenteeism from work.^1,4 In 1994, the total cost for arthritis and rheumatism in Canada was estimated to be between Can $4.3 billion and $7.3 billion,⁵ and the estimated medical expenses (excluding cost of time lost from paid or unpaid work) were estimated to be between Can $1.7 billion and $2.5 billion.⁶

Efficiency and efficacy of rehabilitation interventions in OA 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 their rehabilitative efforts. Evidence-based clinical practice guidelines are systematically developed statements to help practitioners and clients choose proper health care for specific clinical circumstances⁷ and can improve both a patient's health outcomes and the process of care.⁸ A rapid and exponential growth in evidence-based clinical practice guideline (EBCPG) development has been observed in the last decade and may have resulted in several occasions of conflicting guidelines on the same topic.^9,10 These inconsistencies are attributed to variations in EBCPG development processes and quality.^9,11,12 Several authors^10,13,14 have recommended that all EBCPGs be assessed in a systematic manner using a standardized appraisal tool.

The Ottawa Panel was convened to evaluate the strength of the scientific evidence on the efficacy of therapeutic exercises (TE) for patients with OA. A previous and similar article, using the rigorous methodology,¹⁵ was written by the Ottawa Panel on rheumatoid arthritis (RA).¹⁶ The Ottawa Panel also is preparing EBCPGs on the use of TE, electrotherapy, and thermotherapy modalities and on patient education and splinting and orthosis for patients with OA. In this article, the Ottawa Panel considers various types of TE: specific strengthening exercises, general physical activity, and manual therapy combined with exercises.

Several systematic reviews and meta-analyses on the effectiveness of TE for patients with OA have been published in the scientific literature, demonstrating a strong interest in this intervention. Two meta-analyses using Cochrane Collaboration methods have been conducted for the management of patients with OA: the effectiveness of exercise for managing patients with hip and knee OA¹⁷ and the ideal intensity of exercise for OA management.¹⁸ Of 3 systematic reviews on the effectiveness of exercise for managing patients with OA, one was published a few years ago in a scientific journal¹⁹ and 2 were completed more recently and focused on the efficacy of strengthening exercises²⁰ and fitness exercises.²¹ Eight other reviews^22–29 exist on TE for arthritis. Several of these reviews need updating, were not systematic, or were not specific to OA. Nevertheless, all of these reviews unanimously agreed that TE are beneficial for patients with OA, depending on the type and application of exercises (eg, strengthening, fitness, or combination of manual therapy and exercise), the outcomes, the specific joint affected, and the stage of the disease. To our knowledge, no reviews are available on manual therapy (alone or combined with exercises); only one randomized controlled 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 have been developed mainly for medical and surgical interventions and are often not precise regarding rehabilitation interventions. Only British Medical Journal³⁴ has published recommendations on exercise, but they were based on existing systematic reviews that had not been recently updated (Appendix 1). All of the aforementioned EBCPGs are generally flawed. The authors did not use a systematic literature search to find the studies that ultimately formed the basis of the EBCPGs, and although the authors reviewed the scientific results of each study, they did not synthesize the studies. The guidelines were developed for limited clinical practice areas. Although the EBCPGs were based on the current scientific literature, their authors used a nonstandardized approach to combine the scientific results; thus, the evidence of intervention efficacy is confusing, particularly in the presence of contradictory results. The authors also did not use a rigorous grading system to assess the evidence. Finally, with one exception, none of the guidelines have been updated recently. The Ottawa Panel is proposing more precise EBCPGs (involving specific joints, outcomes, periods of intervention, and disease stages) based on a rigorous quantitative method.¹⁵ We believe that various people could benefit from using our guidelines, including patients, physical therapists, rheumatologists, physiatrists, orthopedic surgeons, occupational therapists, and family physicians. Our aim in developing the guidelines was to advance the proper use of the interventions studied (in this article, TE and manual therapy).

	Methods

Top Abstract Introduction Methods Results of Literature Search Discussion Limitations Therapeutic Exercises Manual Therapy Implications for Practice Appendix 1 Appendix 2 Appendix 3 Appendix 4 References

 
For 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 observational studies were identified and synthesized using methods defined by the Cochrane Collaboration that minimize bias by using a systematic approach to literature search, study selection, data extraction, and data synthesis. At the start of our OA project, we defined an a priori protocol that was used for separate systematic reviews of trials relating to each intervention. The strength of evidence was graded as level I for RCTs or level II for nonrandomized studies. An expert panel developed 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% relative to a control based on panel expertise and empiric results) in patient-important outcomes was required for a recommendation. Statistical significance also was required 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 or improvement"³⁷), quality of life, and return to work, providing that these outcomes were assessed with a validated scale that yields reliable data.¹⁵

Target Population

Studies of adult patients (>18 years of age) with classical or definite OA as defined by Klippel et al³⁸ were included in our literature search. Patients with OA that affected peripheral joints were eligible to participate. Patients at different stages of the disease participated in the included clinical trials; some trials involved patients with both chronic and acute conditions. All stages of the disease were included in our analysis. The recommendations state the disease stage for which the intervention is most appropriate. If, however, the trial on which the recommendation was based did not mention disease stage, neither does our recommendation (Appendix 2). Most trials involved patients with chronic OA (>12 year' duration).

Various exclusion criteria were established:

• Studies of patients with OA involving spinal problems (excluded due to the numerous associated signs and symptoms and because the Philadelphia Panel guidelines for low back pain³⁹ and neck pain⁴⁰ were recently developed by the same methodologists);
  
• Studies of patients who recently had surgery;
  
• Patients with other rheumatologic or musculoskeletal problems (eg, fractures, tendinitis, or bursitis), clinically important medical problems, or psychiatric conditions that could hamper rehabilitation or reduce functional status;
  
• Studies of subjects without known pathology or impairments; and
  
• Studies of subjects with mixed arthritic conditions such as the sample in a study by D'Lima et al.⁴¹
  

Table 1 lists the complete inclusion and exclusion criteria.

Other excluded interventions comprised surgery, drug, or psychosocial (nonphysical) interventions. For instance, the RCTs on exercises after a total hip replacement for severe hip OA were excluded; RCTs with frequent use of continuous passive motion (CPM) following a total knee arthroplasty for severe knee OA^49–61 also were excluded. However, practitioners can refer to a recent meta-analysis on the efficacy of CPM combined with physical therapy versus physical therapy alone (n=799) following a total knee arthroplasty for knee OA⁶² to find further recommendations on these postsurgery interventions (grade A for flexion deformity and time to achieve 90 degrees of flexion and grade C+ for active knee flexion range of motion [ROM], pain related to analgesic use, and number of patients needing postoperative manual therapy). Postsurgery intervention studies usually allowed samples with varying proportions of patients with OA and RA. Most of the RCTs on efficacy of postsurgery interventions such as CPM recruited subjects with mixed arthritic conditions, which is the reason they are excluded in this article.

Subjects who received placebo, were untreated, or received routine conventional therapeutic approaches were acceptable control groups. If concurrent interventions (eg, electroanalgesia and medication) were provided to the experimental and control groups, these interventions 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 studies based on the quality of their methods. However, we did consider quality when grading our recommendations.

The categories of interventions selected were approved by the Ottawa Panel according to the study's description of the intervention. Category selection also was influenced by previous work performed by the Ottawa Methods Group¹⁵ and by the Ottawa Panel on TE for patients with RA.¹⁶

	Results of Literature Search

Top Abstract Introduction Methods Results of Literature Search Discussion Limitations Therapeutic Exercises Manual Therapy Implications for Practice Appendix 1 Appendix 2 Appendix 3 Appendix 4 References

 
Through a literature search (Appendix 3), 609 potential articles on TE and manual therapy for OA were identified. Based on the selection criteria checklist (Tab. 1), 113 studies were potentially relevant; 26 of these studies were ultimately included^{30,42,45,47,48,63–83} (Appendix 2). One of the 26 studies had a follow-up study, so we have counted these 2 studies as one, using the number of patients in the original study when calculating patient numbers (Appendix 2). The other trials were excluded for various reasons (Tab. 2).^{19,32,41,43,44,46,49–61,84–153} The search identified 31 articles on manual therapy, 3 of which were initially seen as relevant.^30,122,132 Only one article³⁰ was included (Appendix 2).

Therapeutic Exercises

EBCPGs Related to Strengthening Exercises

Lower-extremity (LE) strengthening versus control, level 1 (3 RCTs, n=103): grade A for pain getting up and down from floor and functional status (clinically important benefit); grade C+ for pain during walking, pain while climbing and descending stairs, arthritis activity, functional tasks, and quadriceps femoris muscle peak torque (clinically important 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 (1 RCT, n=67): 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 quadriceps femoris and hamstring muscles, level 1 (1 RCT, n=15): 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 quadriceps femoris and hamstring muscles versus control, level 1 (1 RCT, n=18): grade C for muscle force (no benefit). Patients with primary diagnosis of OA of the knee.

Eccentric resistance training (Cybex^*) for quadriceps femoris and hamstring muscles versus control, level 1 (1 RCT, n=17): grade C for muscle force (no benefit). Patients with primary diagnosis of OA of the knee.

Concentric resistance training for quadriceps femoris and hamstring muscles versus control, level 1 (1 RCT, n=15): 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 quadriceps femoris and hamstring muscles versus control, level 1 (1 RCT, n=14): 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 strengthening program for quadriceps femoris muscle versus control, level 1 (1 controlled clinical trial [CCT], n=53): grade A for pain, functional status, energy level, and ROM in flexion (clinically important benefit); grade C for physical mobility, muscle force, swelling, and exercise (no benefit). Patients with OA of the knee.

General LE exercise program (including muscle force resistance, flexibility, and mobility/coordination) versus control, level 1 (8 RCTs, n=876): 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 physical activity (no benefit). Patients with a diagnosis of OA.

Progression versus no-progression LE strengthening exercises, level 1 (1 RCT, n=179): 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 (1 RCT, n=40): 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, Including Fitness and Aerobic Exercises

Whole-body functional exercise versus control, level 1 (4 RCTs, n=864): 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 with OA of the knee.

Walking program versus control, level 1 (6 RCTs, n=711): grade A for pain, functional status, stride length, disability transferring from bed, disability bathing, aerobic capacity, exercise endurance, energy level, physical activity, and sleep (clinically important benefit); grade C+ for disability in ADL (clinical benefit); grade C for walking speed, disability toileting, disability dressing and stairs, morning stiffness, and quality of life (no benefit). Patients with OA.

Jogging in water versus control, level 1 (1 RCT, n=79): grade A for physical activity (clinically important benefit); grade C for walking time, morning stiffness, pain, 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 (1 RCT, n=30): grade C for hip and shoulder abduction torque and ROM (no benefit). Patients with OA or RA diagnosed by a rheumatologist or an orthopedic physician.

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

EBCPGs Related to the Combination of Exercises

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

Summary of Trials

Twenty-nine trials (n=2,486 patients) evaluated different types of TE for managing OA-affected joints of the upper extremities and LEs. Most of the trials compared these exercises with a control, but the trials examined different kinds of TE. The strengthening exercise trials were as follows: LE strengthening (n=345),^42,70,71,79 LE isometric strengthening (n=102),⁴² isotonic resistance training versus isotonic combined with isokinetic (Kinetron) resistance training for the knee (n=32),⁷⁰ isotonic combined with isokinetic (Kinetron) resistance training for the knee (n=32),⁷⁰ eccentric resistance training (Cybex) for the knee (n=32),⁷⁰ concentric resistance training for the knee (n=23),⁶⁷ concentric-eccentric resistance training for the knee (n=23),⁶⁷ home program strengthening for the knee (n=81),⁴⁷ general LE exercise program (including muscle force, flexibility, and mobility/coordination) (n=490),^{64,65,68,77,78,82,83} progression in LE strengthening exercises versus no progression (n=179),⁷⁵ and home program hand strengthening (n=40).⁸⁰

Several RCTs examined general physical activities, including fitness and aerobic exercises, such as whole-body functional exercises (n=864),^{45,63,72,73,76} walking program (n=1,089),^{45,47,48,69,73,74,76} jogging in water (n=115),⁴⁸ water exercise (n=30),⁸¹ and yoga (n=30).⁶⁶ One trial was related to the combination of manual therapy and exercises (n=83).³⁰

Twenty-three included trials were RCTs^{42,45,47,48,63–67,69–76,78,80–83} and 3 trials were CCTs^47,68,77 (Appendix 2). We used the Jadad scale to decide whether a study was an RCT or a CCT.¹⁵

The trials examined 2 basic types of exercises. The first type involved strengthening exercises, such as resistance isometric, stretching, eccentric, and concentric exercises; these exercises were specific to different muscles. The other type focused on whole-body functional strengthening programs and included aerobic conditioning and general fitness. Program duration, treatment schedule for exercise intervention, and length of exercise session varied from 4 weeks⁶⁴ to 18 months^45,73,76 for program duration, from once a week⁶⁶ to 10 times a day⁸⁰ (depending on the phase of the program) for treatment schedule, and from 5 minutes to longer per exercise session (length of exercise session increased depending on tolerance)⁷⁴ (Appendix 2).

Strengthening Exercises

Lower-extremity strengthening versus control (4 RCTs, n=345),^42,70,71,79 showed clinical benefits for pain during walking, pain ascending and descending the stairs, quadriceps femoris muscle peak torque, and timed functional tasks (Tab. 3). Statistically significant differences were found for pain (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]; Fig. 1a), pain while getting up from the floor (weighted mean differ-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 significant. Outcomes were measured at the end of intervention (4 months for Topp et al⁴² and 8 weeks for Kreindler et al⁷⁰ and Schilke et al⁷⁹) or at follow-up (6 weeks for Kreindler et al⁷⁰) (Figs. 1a–f).

View larger version (29K): [in this window] [in a new window]   Figure 1. Lower-extremity strengthening versus control. AIMS=Arthritis Impact Measurement Scales, FU=follow-up, LE=lower extremity, OASI=Osteoarthritis Screening Index, WOMAC=Western Ontario and McMaster Universities Osteoarthritis Index.

View larger version (33K): [in this window] [in a new window]   Figure 2. Lower-extremity isometric strengthening versus control. LE=lower extremity, WOMAC=Western Ontario and McMaster Universities Osteoarthritis Index.

View larger version (25K): [in this window] [in a new window]   Figure 3. Isokinetic resistance training versus isotonic plus isokinetic resistance training. FU=follow-up, LE=lower extremity.

View larger version (23K): [in this window] [in a new window]   Figure 4. Isotonic and isokinetic (Kinetron) versus control. FU=follow-up, LE=lower extremity.

View larger version (23K): [in this window] [in a new window]   Figure 5. Eccentric resistance training (Cybex) versus control. FU=follow-up, LE=lower extremity.

View larger version (22K): [in this window] [in a new window]   Figure 6. Concentric versus control: pain.

View larger version (20K): [in this window] [in a new window]   Figure 7. Concentric versus control: functional status.

View larger version (20K): [in this window] [in a new window]   Figure 8. Concentric-eccentric versus control.

View larger version (27K): [in this window] [in a new window]   Figure 9. Home strengthening program versus control. FU=follow-up, NHP=Nottingham Health Profile, ROM=range of motion, VAS=visual analog scale, WOMAC=Western Ontario and McMaster Universities Osteoarthritis Index.

• ROM in knee flexion, most affected knee at 10–12 weeks (WMD=10.00°, 95% CI=5.91° to 14.09°) (Fig. 10a);
  
• ROM in knee flexion, least affected knee at 10–12 weeks (WMD=10.00°, 95% CI=7.75° to 12.25°) (Fig. 10a);
  
• ROM in knee flexion, least affected knee at 12-month follow-up (WMD=12.00°, 95% CI=7.06° to 16.94°) (results not shown);
  
• isometric quadriceps femoris muscle force at 6 weeks (WMD=73 N, 95% CI=25.75 to 120.25 N) (Fig. 10b);
  
• quadriceps femoris muscle voluntary activation at 6 weeks (WMD=14.0%, 95% CI=5.87% to 22.13%) (Fig. 10b);
  
• aggregate functional performance time at 6 weeks (WMD=–8.47, 95% CI=–16.79 to –0.15) (Fig. 10d);
  
• functional status at 6 weeks (WMD=–3.50, 95% CI=–4.94 to –2.06) (Fig. 10d);
  
• mean change in physical function score at 3-month follow-up (WMD=–3.54, 95% CI=–6.04 to –1.04) (Fig. 10d);
  
• mean change in WOMAC-pain at 8 weeks (WMD=–12.10, 95% CI=–14.24 to –9.96) (Fig. 10e);
  
• mean change in pain at 10 to 12 weeks (WMD=–17.10, 95% CI=–29.99 to –4.21) (Fig. 10e);
  
• mean change in global pain score at 6-month follow-up (WMD=–1.87, 95% CI=–2.76 to –0.98) (Fig. 10e);
  
• mean change in pain (VAS), walking at 10 to 12 weeks (WMD=–7.07, 95% CI=–13.90 to –0.24) (Fig. 10e);
  
• mean change in pain (VAS), stairs (WMD=–10.42, 95% CI=–18.58 to –2.26) (results not shown);
  
• pain at night at 12-month follow-up (WMD=–4.00, 95% CI=–5.94 to –2.06) (Fig. 10e);
  
• pain at rest at 10 to 12 weeks (WMD=–1.50, 95% CI=–2.80 to –0.20) (Fig. 10e);
  
• pain on weight bearing at 10 to 12 weeks (WMD=–2.00, 95% CI=–3.02 to –0.98) (Fig. 10e);
  
• mean change in isometric knee extensor muscle force at 8 weeks (WMD=13.20 N, 95% CI=11.96 to 14.44 N) (Fig. 10g);
  
• mean change in isometric knee flexor muscle force at 8 weeks (WMD=9.00 N, 95% CI=8.04 to 9.96 N) (Fig. 10g);
  
• mean change in fast speed at 8 weeks (WMD=6.70 cm/s, 95% CI=6.34 to 7.06 cm/s) (Fig. 10h);
  
• mean change in fast cadence at 8 weeks (WMD=1.60 steps/min, 95% CI=1.40 to 1.80 steps/min) (Fig. 10h);
  
• mean change in fast stride length at 8 weeks (WMD=4.30 cm, 95% CI=3.99 to 4.61 cm) (Fig. 10h);
  
• quality of life measured with Medical Outcomes Study 36-Item Short-Form Health Survey questionnaire (SF–36) at 8 weeks (WMD=3.10, 95% CI=2.76 to 3.44) (Fig. 10i);
  
• mean change in WOMAC-function at 8 weeks (WMD=–7.80, 95% CI=–8.48 to –7.12) (Fig. 10k);
  
• improvement in self-reported disability at 24-week follow-up (WMD=–1.10, 95% CI=–1.91 to –0.29) (Fig. 10k);
  
• mean change in left quadriceps femoris muscle force at 6-week follow-up (WMD=10.86%, 95% CI=3.15% to 18.57%) (results not shown); and
  
• mean change in SF-36-physical function at 8 weeks (results not shown).
  

View larger version (84K): [in this window] [in a new window]   Figure 10. General lower-extremity exercise program versus control. ADL=activities of daily living, AFI=Algofunctional Index, FU=follow-up, HSS=Health Status Survey, IRLG=Influence of Rheumatic Disease on General Health and Lifestyle, LE=lower extremity, MVC=maximal voluntary contraction, ROM=range of motion, VAS=visual analog scale, SF–36 PCS=Medical Outcomes Study 36-Item Short-Form Health Survey questionnaire Physical Component Summary, WOMAC=Western Ontario and McMaster Universities Osteoarthritis Index.

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

View larger version (28K): [in this window] [in a new window]   Figure 11. Progression versus no-progression lower-extremity exercises. LE=lower extremity, ROM=range of motion, VAS=visual analog scale, WOMAC=Western Ontario and McMaster Universities Osteoarthritis Index.

View larger version (13K): [in this window] [in a new window]   Figure 12. Hand strengthening versus control. VAS=visual analog scale.

• pain frequency in transfer at 9 months (WMD=0.88, 95% CI=0.49 to 1.27) (Fig. 13a);
  
• pain intensity in transfer at 3 months (WMD=–0.94, 95% CI=–1.33 to –0.55), at 9 months (WMD=–0.46, 95% CI=–0.84 to –0.08), and at 18 months (WMD=–0.37, 95% CI=–0.70 to –0.04) (Fig. 13a);
  
• pain (WMD=–0.80, 95% CI=–1.29 to –0.31) (Fig. 13b);
  
• functional status measured with the Arthritis Impact Measurement Scales (AIMS) (WMD=5.49, 95% CI=3.92 to 7.06) (results not shown);
  
• functional status measured with the Arthritis Impact 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 (WMD=–0.50, 95% CI=–0.93 to –0.07) favoring the control group (Fig. 13c);
  
• functional status measured with AIMS2: walking and bending at 12 weeks (WMD=–1.25, 95% CI=–2.08 to –0.42) (Fig. 13c);
  
• functional status measured with AIMS2: level of tension at 12 weeks (WMD=2.58, 95% CI=1.88 to 3.28) (Fig. 13c);
  
• hamstring muscle and low back flexibility at 12 weeks (WMD=3.63 in, 95% CI=2.04 to 5.22 in) (Fig. 13d);
  
• 5-minute walk test at 12 weeks (WMD=42.19 m, 95% CI=14.19 to 70.19 m) (Fig. 13e);
  
• hamstring muscle isometric torque at 30 degrees: most affected LE at 12 weeks (WMD=8.85 N·m, 95% CI=1.91 to 15.79 N·m) (Fig. 13f);
  
• hamstring muscle isometric torque at 30 degrees: least affected LE at 12 weeks (WMD=10.51 N·m, 95% CI=3.24 to 17.78 N·m) (Fig. 13f);
  
• quadriceps femoris muscle isometric torque at 60 degrees: most affected LE at 12 weeks (WMD=19.80 N·m, 95% CI=4.75 to 34.85 N·m) (Fig. 13f);
  
• quadriceps femoris muscle isometric torque at 60 degrees: least affected LE at 12 weeks (WMD=17.03 N·m, 95% CI=1.08 to 32.98 N·m) (Fig. 13f);
  
• hamstring muscle isometric torque at 60 degrees: most affected LE at 12 weeks (WMD=8.02 N·m, 95% CI=0.88 to 15.16 N·m) (Fig. 13f);
  
• hamstring muscle isometric torque at 60 degrees: least affected LE at 12 weeks (WMD=10.99 N·m, 95% CI=3.68 to 18.30 N·m) (Fig. 13g);
  
• hamstring muscle isokinetic torque at 30°/s: most affected LE at 12 weeks (WMD=10.98 N·m, 95% CI=0.38 to 21.58 N·m) (Fig. 13g);
  
• hamstring muscle isokinetic torque at 30°/s: least affected LE at 12 weeks (WMD=10.51 N·m, 95% CI=3.24 to 17.78 N·m) (Fig. 13g);
  
• hamstring muscle isokinetic torque at 90°/s: most affected LE at 12 weeks (WMD=9.73 N·m, 95% CI=–1.40 to 20.86 N·m) (Fig. 13g);
  
• cadence at 3 months (WMD=0.87 steps/min, 95% CI=0.33 to 1.41 steps/min) (Fig. 13h), at 9 months (WMD=0.94 steps/min, 95% CI=0.37 to 1.51 steps/min), and at 18 months (WMD=2.08 steps/min, 95% CI=1.56 to 2.60 steps/min) (results not shown);
  
• stride length at 3 months (WMD=2.17 cm, 95% CI=1.18 to 3.16 cm), at 9 months (WMD=2.84 cm, 95% CI=1.77 to 3.91 cm), and at 18 months (WMD=6.49 cm, 95% CI=5.49 to 7.49 cm) (Fig. 13i);
  
• walking speed at 3 months (WMD=3.77 cm/s, 95% CI=2.60 to 4.94 cm/s), at 9 months (WMD=4.37 cm/s, 95% CI=3.12 to 5.62 cm/s), and at 18 months (WMD=7.79 cm/s, 95% CI=6.60 to 8.98 cm/s) (Fig. 13j);
  
• stance time at 3 months (WMD=–0.01 s, 95% CI=–0.01 to –0.01 s) and at 18 months (WMD=–0.02 s, 95% CI=–0.02 to –0.02 s) (Fig. 13k);
  
• percentage of swing at 3 months (WMD=0.39, 95% CI=0.18 to 0.60), at 9 months (WMD=–0.36, 95% CI=–0.59 to –0.13), and 18 months (WMD=0.54, 95% CI=0.32 to 0.76) (Fig. 13k);
  
• stair-climbing time at 18 months (WMD=–1.92 s, 95% CI=–2.01 to –1.83 s) (Fig. 13l);
  
• climbing self-efficacy score at 18 months (WMD=9.32, 95% CI=8.86 to 9.78) (Fig. 13l);
  
• quality of life (WMD=3.10, 95% CI=2.97 to 3.23) (results not shown); and
  
• disability in bathing (WMD=0.41, 95% CI=0.18 to 0.91) (results not shown).
  

View larger version (79K): [in this window] [in a new window]   Figure 13. Whole-body functional exercises versus control. AIMS=Arthritis Impact Measurement Scales, AIMS2=Arthritis Impact Measurement Scales 2, FU=follow-up, HIKF=hamstring muscle isokinetic force, HIF=hamstring muscle isometric force, QIKF=quadriceps femoris muscle isokinetic force, QIF=quadriceps femoris muscle isometric force, VAS=visual analog scale.

Six RCTs and 1 CCT examined walking versus control (n=1,089),^{45,47,48,69,73,74,76} and trials discovered clinical benefits for pain, functional status, stride length, disability transferring from bed, disability bathing, disability in ADL, energy level, medication use, aerobic capacity, and quality of life (Tabs. 13 and 14). No clinical benefits were found for walking speed (Tab. 13), pain in ambulation (results not shown), disability toileting, or disability dressing (Fig. 13e, both at 18-month follow-up). Statistically significant results were shown for the following outcomes:

• pain frequency in ambulation at 3 months (WMD=–0.56, 95% CI=–1.07 to –0.05) and in transfer (WMD=–0.42, 95% CI=–0.77 to –0.07) (results not shown);
  
• pain intensity in transfer at 3 months (WMD=–0.55, 95% CI=–1.02 to –0.08), at 9 months (WMD=–0.46, 95% CI=–0.84 to –0.08), and at 18 months (WMD=–0.41, 95% CI=–0.76 to –0.06) (results 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 (WMD=3.69 cm/s, 95% CI=2.47 to 4.91 cm/s), at 9 months (WMD=10.29 cm/s, 95% CI=9.05 to 11.53 cm/s), and at 18 months (WMD=10.29 cm/s, 95% CI=9.07 to 11.51 cm/s) (Tab. 13);
  
• cadence at 3 months (WMD=3.56 steps/min, 95% CI=3.00 to 4.12 steps/min), at 9 months (WMD=3.69 steps/min, 95% CI=3.12 to 4.26 steps/min), and at 18 months (WMD=3.77 steps/min, 95% CI=3.21 to 4.33 steps/min) (Tab. 13);
  
• stance time at 3 months (WMD=–0.04 s, 95% CI=0.04 to –0.04 s), at 9 months (WMD=–0.03 s, 95% CI=–0.03 to –0.03 s), and at 18 months (WMD=–0.03 s, 95% CI=–0.03 to –0.03 s) (results not shown);
  
• percentage of swing at 3 months (WMD=0.86, 95% CI=0.64 to 1.08) and at 18 months (WMD=0.54, 95% CI=0.32 to 0.76) (Tab. 13);
  
• stride length at 9 months (WMD=7.53 cm, 95% CI=6.48 to 8.58 cm) and at 18 months (WMD=7.54 cm, 95% CI=6.52 to 8.56 cm) (Tab. 13);
  
• climbing self-efficacy score at 18-month follow-up (WMD=8.00, 95% CI=7.55 to 8.45) (Fig. 14a);
  
• 6-minute walk test at 8 weeks (WMD=111.50 m, 95% CI=76.24 to 146.77 m) (Fig. 14b);
  
• stair-climbing time at 18-month follow-up (WMD=–1.41, 95% CI=–1.51 to –1.31) (Fig. 14c);
  
• general health status at 18-month follow-up (WMD=3.59, 95% CI=3.46 to 3.72) (Fig. 14d);
  
• incidence of disability at 18-month follow-up (WMD=0.52, 95% CI=0.28 to 0.96) (Fig. 14e);
  
• disability in transferring from a bed to a chair at 18-month follow-up (WMD=0.42, 95% CI=0.22 to 0.79) (Fig. 14e);
  
• disability in bathing (WMD=0.38, 95% CI=0.17 to 0.84) (Tab. 14) and in dressing at 18-month follow-up (WMD=0.28, 95% CI=0.10 to 0.83) (Fig. 14e);
  
• fast speed at 8 weeks (WMD=15.00 m/min, 95% CI=6.53 to 23.47 m/min) (Fig. 14f);
  
• fast stride at 8 weeks (WMD=0.20 m, 95% CI=0.03 to 0.37 m) (Fig. 14f);
  
• free speed at 8 weeks (WMD=7.00 m/min, 95% CI=0.34 to 13.66 m/min) (Fig. 14g);
  
• free stride at 8 weeks (WMD=0.20 m, 95% CI=0.08 to 0.32 m) (Fig. 14g);
  
• AIMS-pain at 8 weeks (WMD=–1.00, 95% CI=–1.79 to –0.21) (Fig. 14i);
  
• AIMS-physical activity at 8 weeks (WMD=–2.22, 95% CI=–3.25 to –1.19) (Tab. 13) and at 12 weeks (WMD=–1.30, 95% CI=–2.48 to –0.12) (Tab. 14, Fig. 14j);
  
• AIMS-medication use (WMD=2.74, 95% CI=1.93 to 3.55) (Tab. 13);
  
• 15.2-m (50-ft) walking time at 8 weeks (WMD=–2.00 s, 95% CI=–2.97 to –1.03 s) and at 12 weeks (WMD=–0.90 s, 95% CI=–1.71 to –0.09 s) (Fig. 14p for 12 weeks only);
  
• exercise heart rate at 12 weeks (WMD=16.00 bpm, 95% CI=3.94 to 28.06 bpm) (Fig. 14s);
  
• aerobic capacity at 12 weeks (WMD=5.10 mL/kg min^–1, 95% CI=2.88 to 7.32 mL/kg min^–1) (Fig. 14s); and
  
• exercise endurance at 12 weeks (WMD=3.30 min, 95% CI=1.12 to 5.48 min) (Fig. 14).
  

View larger version (107K): [in this window] [in a new window]   Figure 14. Walking program versus control. ADL=activities of daily living, AIMS=Arthritis Impact Measurement Scales, FU=follow-up, NHP=Nottingham Health Profile, VAS=visual analog scale, WOMAC=Western Ontario and McMaster Universities Osteoarthritis Index.

Physical activity and aerobic capacity yielded clinically important benefits favoring jogging in water versus control (one RCT, n=115)⁴⁸ (Tab. 15). However, no clinical benefits were shown for functional status (AIMS-physical activity) at 12 weeks (Tab. 15), pain at 12 weeks and 9-month follow-up (results not shown), morning stiffness at 12 weeks and 9-month follow-up (results not shown), trunk ROM at 12 weeks and 9-month follow-up (results not shown), exercise heart rate (Tab. 15), or exercise endurance at 12 weeks (Tab. 15). Statistically significant differences were found for AIMS-physical activity at 12 weeks (WMD=–1.20, 95% CI=–2.29 to –0.11) (Fig. 15a), 15.2-m (50-ft) walking time at 12 weeks (WMD=–1.10 s, 95% CI=–2.12 to –0.08 s) (Fig. 15e), exercise heart rate at 12 weeks (WMD=13.00 bpm, 95% CI=1.32 to 24.68 bpm) (Fig. 15f), exercise endurance at 12 weeks (WMD=2.80 min, 95% CI=0.23 to 5.37 min) (Fig. 15h), and aerobic capacity (WMD=5.90 mL/kg min¹, 95% CI=3.30 to 8.50 mL/kg min¹) (results not shown). AIMS-pain, morning stiffness, grip force, trunk flexibility, and resting blood pressure offered no statistically significant differences (results not shown for last). One RCT that compared water exercises with control (n=30)⁸¹ yielded no statistically significant differences and no clinical benefits for torque or ROM at 6 weeks (Figs. 16a–b).

View larger version (50K): [in this window] [in a new window]   Figure 15. Jogging in water versus control. FU=follow-up, ROM=range of motion, AIMS=Arthritis Impact Measurement Scales.

View larger version (17K): [in this window] [in a new window]   Figure 16. Water exercises versus control. ROM=range of motion.

View larger version (27K): [in this window] [in a new window]   Figure 17. Yoga versus control. HAQ=Health Assessment Questionnaire, ROM=range of motion, VAS=visual analog scale.