Supervised Exercise
Supervised exercise, unsupervised exercise, and/or aquatic exercise are recommended over no exercise to improve pain and function for treatment of knee osteoarthritis.

Rationale

Ten high quality studies were reviewed that compared a supervised exercise program to a non-exercise control (e.g., no treatment, heat only, education, usual primary care). (Christensen 2015,Holsgaard-Larsen 2018, Oliveira 2012, Willamson 2007,  de Rooij 2017, Imoto 2012, Topp 2002, Hu 2020, Kim 2013, Chen 2014) Seven of these studies found greater improvements in pain, function, or both pain and function over the non-exercise control group (Oliveira 2002, de Rooij 2017, Imoto 2012, Topp 2002, Hu 2020, Kim 2013, Chen 2014).

One high quality study and four moderate quality studies were reviewed that compared supervised exercise to a non-supervised exercise program (e.g., home program, internet-based program, exercise brochure). (McCarthy 2004, Allen 2018, Yilmaz 2019, Tunay 2010, Bennell 2014). Patients from both groups received benefit from the interventions but there were mixed results as to whether supervised exercise was superior to the non-supervised exercise programs. It appears that both supervised or non-supervised exercise programs can result in improved pain and function in people with knee osteoarthritis.

Four high quality studies and one moderate quality study were reviewed that compared aquatic exercise to either usual primary care, education, or self-management. (Kuptniratsaikul 2019, Rewald 2020, Waller 2017, Munukka 2020, Dias 2017.) Three high quality studies reported greater improvements in pain, function, or global ratings of improvement for the aquatic groups over the control groups. (Kuptniratsaikul 2019, Rewald 2020, Dias 2017) One high quality study reported increased leisure time activity for the aquatic group compared to the control. (Waller 2017) One moderate quality study compared aquatic exercise to land-based exercise. (Silva 2008) There was no difference in WOMAC pain and function scores reported between groups for this study, but the aquatic exercise group had less pain with walking compared to the land-based group. Although there may be some benefit from aquatic exercise, inconsistent results do not allow us to recommend aquatic exercise over land-based exercise at this time.

Several studies examined clinical outcomes for different modes of exercise in patients with knee osteoarthritis. Ebnezar 2012 reported some improvement in anxiety measures when comparing yoga to non-yoga exercise. (Ebnezar 2012) Other studies compared weightbearing to non-weightbearing exercise (Bennell 2020, Jan 2009), high versus low resistance training (Jan 2008), isokinetic, isometric, and isotonic exercise (Huang 2005), and leg versus hip exercise (Lun 2015) and did not find substantial differences in the mode of exercise. It appears that exercise is beneficial, but the mode of exercise may not matter as much as engaging in any exercise program.

Benefits/Harms of Implementation

Most patients can expect an improvement in pain and function with exercise. Patients may experience a temporary increase in knee pain or muscle soreness when engaging in an exercise program.

Cost Effectiveness/Resource Utilization

One study by Bove, et al, 2018 examined the cost-effectiveness of delivering physical therapy supervised exercise and manual therapy in booster (treatment sessions spread out periodically over 1 year) vs no-booster (treatment sessions delivered consecutively over 9 weeks) session approaches. It appeared that the booster delivery approach may be more cost-effective than the non-booster delivery approach.

Feasibility

Most exercise programs would be considered feasible. However, some patients may have difficulty with access to supervised exercise due to travel or co-pay concerns. Aquatic programs would not be feasible for patients who do not have access to a pool or walking tank.

Future Research

Identifying factors that could discriminate between people who would likely benefit from supervised programs vs independent exercise programs is an area of research that could improve clinical decision-making for prescribing exercise. More studies are also needed to examine delivery of exercise through telerehabilitation compared with in-person supervised programs. Studies should also examine differences in outcomes between varying modes of delivering telerehabilitation exercise programs. More research would also be beneficial in examining the role of booster session delivery of exercise programs.