Rehabilitation, Education & Wellness Activity
We recommend that patients with symptomatic osteoarthritis of the knee participate in self-management programs, strengthening, low-impact aerobic exercises, and neuromuscular education; and engage in physical activity consistent with national guidelines.

Rationale
This recommendation is rated strong because of seven high-strength studies of which five showed beneficial outcomes. The exercise interventions were predominantly conducted under supervision, most often by a physical therapist. The self-management interventions were led by various healthcare providers including rheumatologists, nurses, physical and occupational therapists, and health educators. The evidence supports the use of self-management programs in primary care patients with knee osteoarthritis. One of the studies used an existing evidence-based program, the Arthritis Self-Management Program (ASMP), which was modified to include an exercise component.20 In a high-strength study by Coleman et al.,21 patients in a 6-week self-management program demonstrated statistically significant and possibly minimum clinically important improvements in WOMAC Pain, Stiffness, Function, and Total scores at eight weeks as compared to wait-listed controls. The program in that study was based on the same theoretical framework as the ASMP, but included content that was specifically tailored to patients with knee osteoarthritis.

Studies in this review reported improvements in 29 of 37 outcomes favoring strength training over a control (usual care, education, or no treatment). Statistically significant and clinically important improvements were reported for VAS Pain, WOMAC Pain, and WOMAC Function scores.

In addition, 7 of 23 outcomes indicated statistically significant improvements with strengthening exercises, when performed as part of a physical therapy treatment program, versus control. 22-24 Three of the seven outcomes were clinically significant and one was possibly clinically significant. One study reported statistically significant and possibly clinically significant improvement in WOMAC Total score following a combination of knee exercise and manual physical therapy as compared to subtherapeutic ultrasound (control).25

Studies also addressed the type and setting for strength training. Long-term outcomes did not vary among isometric, isotonic, or isokinetic exercises.26 Both weight-bearing and nonweight-bearing exercises were superior to control in improving physical function, however, the results were conflicting when the exercises were compared to each other.27 High-resistance strength training led to significantly faster walk times on spongy surfaces as compared to low-resistance training28. Ebnezar et al.29-31 compared a combination of yoga and physical therapy to physical therapy alone. All eight outcomes were statistically and clinically significant favoring the combined treatment group measured by WOMAC Function and the SF-36 Physical Function and Bodily Pain subscales. Aquatic therapy was also deemed a suitable alternative to land-based strengthening exercises.32 Of the three studies that investigated exercise in the home setting, the highest strength study favored home exercise versus no exercise in reducing patients’ global pain rating; however, this finding did not meet the minimum clinically important improvement threshold.33

Three studies the effects of aerobic walking versus health education and one compared it to usual care in adults with osteoarthritis of the knee. There were statistically significant improvements with aerobic exercise in all but one of the performance-based functional tasks as compared to the education group. In the study by Kovar et al.,34 favorable outcomes were reported by the supervised walking group rather than usual care with statistically significant improvements in 6-minute walking distance and the Arthritis Impact Measurement Scale (AIMS) Physical Activity and Pain subscales.

For neuromuscular education, three of four outcomes were statistically significant favoring combined kinesthesia, balance, and strength training exercises versus strength training alone. A high-strength study by Fitzgerald et al.35 applied an effective treatment for anterior cruciate ligament injury to patients with osteoarthritis of the knee; they found that standard exercise combined with agility and perturbation therapy was not more effective than standard exercise therapy alone. Five of five outcomes were statistically significant for proprioception training. Lin et al.36 randomized 108 patients to nonweight-bearing proprioception training, nonweight-bearing strength training, and non treatment groups. Both proprioception and strength training were significantly more effective in improving WOMAC Pain and Function scores than no treatment.

A number of fitness-related organizations have disseminated guidelines for physical activity. They generally emphasize the importance of aerobic conditioning and muscle- and bone-strengthening, regular activity, and balance exercises for older adults. In 2008, the federal government for the first time published national guidelines. Here is the link to the US Department of Health and Human Service’s physical activity guidelines: http://www.health.gov/paguidelines/guidelines/default.aspx.

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