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Olsen AL, Magnussen LH, Skjaerven LH, Assmus J, Sundal MA, Furnes O, Hallan G, Strand LI. Basic Body Awareness Therapy versus standard care in hip osteoarthritis. A randomized controlled trial. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2021; 27:e1930. [PMID: 34811841 DOI: 10.1002/pri.1930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 06/10/2021] [Accepted: 10/09/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Compensational movement patterns in hip osteoarthritis (HOA) are associated with hip dysfunction. Basic Body Awareness Therapy (BBAT) promotes functional movement quality and might, accordingly, be beneficial in HOA. OBJECTIVE To examine the outcomes of BBAT compared to standard care in people with HOA after first receiving patient education (PE). STUDY DESIGN A prospective, assessor-blinded, and block-randomized controlled trial. METHODS Community-living adults with HOA participating in PE were randomly allocated to an intervention group receiving BBAT in groups (12 sessions offered once a week), or a comparison group. Data at baseline (pretest) and at 6 months (posttest) were analyzed. Primary outcomes were pain during walking assessed by the Numeric Rating Scale (NRS) and function by the Hip Osteoarthritis Outcome Score, subscale ADL (HOOS A). Secondary outcomes addressed physical capacity, movement quality, and self-reported aspects of function and health. RESULTS At pretest, there were no significant differences in demographic and test data between the intervention (n = 51) and the comparison (n = 50) group. Forty-one intervention and 45 comparison participants completed the posttest. At posttest, no significant differences in change between groups were found on NRS (p = 0.694, effect size (ES) = 0.02) or HOOS A (p = 0.783, ES = 0.07). Among secondary outcomes, movement quality improved significantly more (p < 0.001, ES = 0.84) in the intervention group. Compliance with BBAT varied substantially. Per-protocol analysis showed changes in favor of the intervention group for self-efficacy (p = 0.049, ES = 0.36), health (p = 0.037, ES = 0.44), and function (p = 0.029, ES = 0.53) when only intervention participants who completed at least 10 sessions of BBAT were included. CONCLUSIONS BBAT was not found to be a more effective treatment modality than self-initiated standard care to reduce pain during walking and improve daily functioning in people with HOA. Movement quality was significantly more improved in participants receiving BBAT, and improvement in other health aspects was associated with sufficient therapy compliance.
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Affiliation(s)
- Aarid Liland Olsen
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Liv Heide Magnussen
- Department of Health and Function, Western Norway University of Applied Sciences, Bergen, Norway
| | - Liv Helvik Skjaerven
- Department of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Jörg Assmus
- Centre of Competence on Clinical Research, Haukeland University Hospital, Bergen, Norway
| | - Mary-Anne Sundal
- Department of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Ove Furnes
- Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Geir Hallan
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Liv Inger Strand
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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Power Training in Older Adults With Hip Osteoarthritis and Total Hip Arthroplasty. TOPICS IN GERIATRIC REHABILITATION 2021. [DOI: 10.1097/tgr.0000000000000300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Krauss I, Hein T, Steinhilber B, Janßen P. A 12-week exercise program for patients with hip osteoarthritis has no influence on gait parameters: A secondary analysis of a randomized controlled trial. Gait Posture 2020; 78:6-12. [PMID: 32151918 DOI: 10.1016/j.gaitpost.2020.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 02/07/2020] [Accepted: 03/01/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Hip osteoarthritis is a major musculoskeletal disorder in the elderly. Evidence is given for the efficacy of exercise interventions in terms of self-reported physical functioning and pain. However, it has not yet been fully examined whether exercises influence gait. RESEARCH QUESTION The purpose of this RCT therefore was to evaluate effects of a 12-week exercise program on kinematic gait variables in subjects with hip osteoarthritis. METHODS 210 participants were randomly assigned to exercise, non-treated control, or placebo ultrasound groups. The 12-week exercise intervention combined a weekly group session with home-based exercises (2/week), which entailed exercises for motor learning, flexibility, strengthening, and balance. Placebo ultrasound was given once a week. A 6-camera motion capture system was used for data collection. Data were derived from shod walking at self-selected speeds. Spatio-temporal and hip and knee joint angles of the stance phase were calculated. Data were averaged across five trials. Measurements were taken prior to and immediately after the intervention period. ANOVA/Kruskall-Wallis-Tests were used to analyze between-group effects for differences between test days. Pairwise comparisons were subsequently conducted in case of significant model effects. Data were analyzed per protocol (n = 185). RESULTS No statistically significant differences were detected for any of the outcome measures. SIGNIFICANCE Although hip muscle strength and gait quality are related, strength training of the hip-surrounding musculature without specific gait training elements cannot improve spatio-temporal gait characteristics or hip and knee joint angles in subjects with mild to moderate hip osteoarthritis. If gait should explicitly be improved through exercise, interventions must incorporate a relevant portion of gait-related tasks.
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Affiliation(s)
- Inga Krauss
- Medical Clinic, Department of Sports Medicine, University of Tuebingen, Germany; Interfaculty Research Institute for Sports and Physical Activity Tuebingen, Department of Sports Medicine, University Hospital Tuebingen, Germany.
| | | | - Benjamin Steinhilber
- Institute of Occupational and Social Medicine and Health Services Research, University Hospital Tuebingen, Germany
| | - Pia Janßen
- Medical Clinic, Department of Sports Medicine, University of Tuebingen, Germany; Interfaculty Research Institute for Sports and Physical Activity Tuebingen, Department of Sports Medicine, University Hospital Tuebingen, Germany
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Rashid SA, Moiz JA, Sharma S, Raza S, Rashid SM, Hussain ME. Comparisons of Neuromuscular Training Versus Quadriceps Training on Gait and WOMAC Index in Patients With Knee Osteoarthritis and Varus Malalignment. J Chiropr Med 2019; 18:1-8. [PMID: 31193211 DOI: 10.1016/j.jcm.2018.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 07/06/2018] [Accepted: 07/06/2018] [Indexed: 10/27/2022] Open
Abstract
Objective The purpose of this study was to compare the effects of neuromuscular training (NMT) and quadriceps training (QT) on the altered gait patterns and Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index in patients with knee osteoarthritis (OA) and varus malalignment. Methods Sixty-six patients with knee pain ≥2 on 100-mm visual analog scale, radiographic knee OA changes ≥2 on Kellgren-Lawrence grading scale, and genu varum were allocated randomly into either the neuromuscular training group or quadriceps training group. Twelve weeks of supervised exercise protocol was given to the participants of both groups, which included 3 sessions per week. Primary outcomes were gait variables and self-reported physical function (WOMAC index). Results Of 66 knee OA patients, only 31 (94%) in the NMT group and 28 (84.8%) in the QT group completed the exercise protocol and were included in the analysis. There was a significant improvement in gait velocity (P = .022), stride length (P = .009), and global WOMAC index (P = .011) in the NMT group compared to the QT group. However, the scores of cadence (P = .226), gait cycle (P = .332), and double limb support (P = .054) were not found significant in the NMT group compared with the QT group. Conclusion The NMT group showed improvement in some of the gait parameters as well as improvement in pain, stiffness, and functional limitation compared with conventional QT. No additional improvement was found in cadence, gait cycle, and double limb support in patients who received NMT.
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Affiliation(s)
- Shahzada Aaadil Rashid
- Centre for Physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia, New Delhi, India
| | - Jamal Ali Moiz
- Centre for Physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia, New Delhi, India
| | - Saurabh Sharma
- Centre for Physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia, New Delhi, India
| | - Shahid Raza
- Centre for Physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia, New Delhi, India
| | - S Mudasir Rashid
- Division of Veterinary Biochemistry, Faculty of Veterinary Sciences, Sher-e-Kashmir University of Agricultural Sciences and Technology, Shuhama, Srinagar, Kashmir, India
| | - Mohammad Ejaz Hussain
- Centre for Physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia, New Delhi, India
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Capin JJ, Khandha A, Zarzycki R, Arundale AJH, Ziegler ML, Manal K, Buchanan TS, Snyder-Mackler L. Gait mechanics and tibiofemoral loading in men of the ACL-SPORTS randomized control trial. J Orthop Res 2018; 36:2364-2372. [PMID: 29575090 PMCID: PMC6157011 DOI: 10.1002/jor.23895] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 03/09/2018] [Indexed: 02/04/2023]
Abstract
The risk for post-traumatic osteoarthritis is elevated after anterior cruciate ligament reconstruction (ACLR), and may be especially high among individuals with aberrant walking mechanics, such as medial tibiofemoral joint underloading 6 months postoperatively. Rehabilitation training programs have been proposed as one strategy to address aberrant gait mechanics. We developed the anterior cruciate ligament specialized post-operative return-to-sports (ACL-SPORTS) randomized control trial to test the effect of 10 post-operative training sessions consisting of strength, agility, plyometric, and secondary prevention exercises (SAPP) or SAPP plus perturbation (SAPP + PERT) training on gait mechanics after ACLR. A total of 40 male athletes (age 23 ± 7 years) after primary ACLR were randomized to SAPP or SAPP + PERT training and tested at three distinct, post-operative time points: 1) after impairment resolution (Pre-training); 2) following 10 training sessions (Post-training); and 3) 2 years after ACLR. Knee kinematic and kinetic variables as well as muscle and joint contact forces were calculated via inverse dynamics and a validated electromyography-informed musculoskeletal model. There were no significant improvements from Pre-training to Post-training in either intervention group. Smaller peak knee flexion angles, extension moments, extensor muscle forces, medial compartment contact forces, and tibiofemoral contact forces were present across group and time, however the magnitude of interlimb differences were generally smaller and likely not meaningful 2 years postoperatively. Neither SAPP nor SAPP + PERT training appears effective at altering gait mechanics in men in the short-term; however, meaningful gait asymmetries mostly resolved between post-training and 2 years after ACLR regardless of intervention group. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2364-2372, 2018.
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Affiliation(s)
- Jacob J. Capin
- Biomechanics and Movement Science, University of Delaware, Newark, DE, USA
| | | | - Ryan Zarzycki
- Biomechanics and Movement Science, University of Delaware, Newark, DE, USA
| | | | - Melissa L. Ziegler
- Biostatistics Core, College of Health Sciences, University of Delaware, Newark, DE, USA
| | - Kurt Manal
- Mechanical Engineering, University of Delaware, Newark, DE, USA
| | - Thomas S. Buchanan
- Biomedical Engineering, University of Delaware, Newark, DE, USA
- Mechanical Engineering, University of Delaware, Newark, DE, USA
| | - Lynn Snyder-Mackler
- Biomechanics and Movement Science, University of Delaware, Newark, DE, USA
- Biomedical Engineering, University of Delaware, Newark, DE, USA
- Physical Therapy, University of Delaware, Newark, DE, USA
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Education and Social Support as Key Factors in Osteoarthritis Management Programs: A Scoping Review. ARTHRITIS 2018; 2018:2496190. [PMID: 29854457 PMCID: PMC5964569 DOI: 10.1155/2018/2496190] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 02/07/2018] [Accepted: 03/07/2018] [Indexed: 11/18/2022]
Abstract
Systematic reviews of self-management programs for osteoarthritis suggest minimal evidence of benefit and indicate substantial heterogeneity in interventions. The purpose of this scoping review was to describe the nature of self-management interventions provided to patients with osteoarthritis focusing on the inclusion and type of education and social support components. We searched PsycINFO, EMBASE, MEDLINE, and Cochrane Library databases from 1990 to 2016 to identify studies addressing community-based management strategies for osteoarthritis that included aspects of disease-specific education and ongoing social support. Results are presented as a narrative synthesis to facilitate integration of diverse evidence. Data were extracted from 23 studies that met our inclusion and exclusion criteria, describing complex, multicomponent interventions for osteoarthritis. All studies included education components, and 18 of these were osteoarthritis-specific. Social support was most often offered through peers and health care professionals, but also through exercise trainers/instructors and researchers, and lasted between 5 and 52 weeks. We charted positive social interaction offered by peers in group settings and emotional/informational support offered by health care professionals. Overall, descriptions of self-management provided limited documentation of the rationale or content of the programs. This suggests that more precise definitions of the theoretical underpinnings, components, and mechanisms would be useful for greater insight into best practices for osteoarthritis self-management programs.
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Report of the Primary Outcomes for Gait Mechanics in Men of the ACL-SPORTS Trial: Secondary Prevention With and Without Perturbation Training Does Not Restore Gait Symmetry in Men 1 or 2 Years After ACL Reconstruction. Clin Orthop Relat Res 2017; 475:2513-2522. [PMID: 28224442 PMCID: PMC5599383 DOI: 10.1007/s11999-017-5279-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Movement asymmetries during walking are common after anterior cruciate ligament (ACL) injury and reconstruction and may influence the early development of posttraumatic osteoarthritis. Preoperative neuromuscular training (like perturbation training, which is neuromuscular training requiring selective muscle activation in response to surface perturbations) improves gait asymmetries and functional outcomes among people who are ACL-deficient, but the effect of postoperative perturbation training on gait mechanics after ACL reconstruction is unknown. QUESTIONS/PURPOSES Among men undergoing ACL reconstruction, we sought to compare strength, agility, and secondary prevention (SAP) treatment with SAP plus perturbation training (SAP+PERT) with respect to (1) gait mechanics; and (2) elimination of gait asymmetries 1 and 2 years after ACL reconstruction. METHODS Forty men were randomized into a SAP group or a SAP+PERT group after ACL reconstruction and before returning to preinjury activities. Participants were required to achieve ≥ 80% quadriceps muscle strength symmetry, minimal knee effusion, full ROM, no reports of pain, and completion of a running progression (all between 3 and 9 months postoperatively) before enrollment. Of 94 potentially eligible athletic male patients evaluated < 9 months after ACL reconstruction, 54 were excluded for prespecified reasons. Participants underwent motion analysis during overground walking at 1 and 2 years postoperatively. Variables of interest included (1) sagittal and frontal plane hip and knee angles and moments at peak knee flexion angle; (2) sagittal plane hip and knee angles and moments at peak knee extension angle; (3) sagittal plane hip and knee excursion during weight acceptance; and (4) sagittal plane hip and knee excursion during midstance. We also calculated the proportion of athletes in each group who walked with clinically meaningful interlimb asymmetry in sagittal plane hip and knee variables and compared these proportions using odds ratios. There was no differential loss to followup between groups. RESULTS There were no differences between the SAP or SAP+PERT groups for the biomechanical gait variables. The involved limb's knee excursion during midstance for the SAP (mean ± SD: 1 year: 15° ± 5°; 2 years: 16° ± 5°) and SAP+PERT (1 year: 16° ± 5°; 2 years: 15° ± 4°) athletes was not different between groups at 1 year (mean difference: -1°; 95% confidence interval [CI], -5° to 2°; p = 0.49) or 2 years (mean difference: 1°; 95% CI, -2° to 4°; p = 0.54). There were no differences between SAP and SAP+PERT athletes regarding the elimination of gait asymmetries, and gait asymmetries persisted to a large degree in both groups 1 and 2 years postoperatively. At 1 year, 11 of 18 SAP and 11 of 20 SAP+PERT athletes walked with truncated knee excursions during weight acceptance (odds ratio: 0.8, p = 0.70) and midstance (SAP 12 of 18, SAP+PERT 12 of 20; odds ratio: 0.8, p = 0.67), whereas at 2 years postoperatively, truncated knee excursions during weight acceptance (SAP seven of 17, SAP+PERT eight of 19; odds ratio: 1.0, p = 0.96) and midstance (SAP five of 17, SAP+PERT 11 of 19; odds ratio: 3.3, p = 0.09) remained prevalent. CONCLUSIONS We found that a comprehensive, progressive return-to-sport training program with or without perturbation was not effective at restoring interlimb symmetry among men 1 or 2 years after ACL reconstruction. Although gait asymmetries improved from 1 to 2 years postoperatively, meaningful asymmetries persisted in both groups. To restore gait symmetry after ACL reconstruction, additional interventions likely are necessary. LEVEL OF EVIDENCE Level II, therapeutic study.
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Schmidt A, Meurer A, Lenarz K, Vogt L, Froemel D, Lutz F, Barker J, Stief F. Unilateral hip osteoarthritis: The effect of compensation strategies and anatomic measurements on frontal plane joint loading. J Orthop Res 2017; 35:1764-1773. [PMID: 27664397 DOI: 10.1002/jor.23444] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 09/15/2016] [Indexed: 02/04/2023]
Abstract
In order to reduce pain caused by the affected hip joint, unilateral hip osteoarthritis patients (HOAP) adopt characteristic gait patterns. However, it is unknown if the knee and hip joint loading in the non-affected (limbnon-affected ) and the affected (limbaffected ) limb differ from healthy controls (HC) and which gait parameters correlate with potential abnormal joint loading. Instrumented 3D-gait analysis was performed on 18 HOAP and 18 sex, age, and height matched HC. The limbnon-affected showed greater first and second peak external hip adduction moments (first HAM: +15%, p = 0.014; second HAM: +15%, p = 0.021, respectively), than seen in HC. In contrast, the second peak external knee adduction moment (KAM) in the limbaffected is reduced by about 23% and 30% compared to the limbnon-affected and HC, respectively. Furthermore, our patients showed characteristic gait compensation strategies including reduced peak vertical forces (pvF), a greater foot progression angle (FPA), and reduced knee range of motion (ROM) in the limbaffected . The limbaffected was 5.6 ± 3.8 mm shorter than the limbnon-affected . Results of stepwise regression analyses showed that increased first pvF explain 16% of first HAM alterations, whereas knee ROM and FPA explain 39% of second KAM alterations. We therefore expect an increased rate of progression of OA in the hip joint of the limbnon-affected and suggest that the shift in the medial-to-lateral knee joint load distribution may impact the rate of progression of OA in the limbaffected . The level of evidence is III. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1764-1773, 2017.
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Affiliation(s)
- André Schmidt
- Experimental Orthopedics and Trauma Surgery, Frankfurt Initiative for Regenerative Medicine, Johann Wolfgang Goethe University Frankfurt, Marienburgstraße 2, 60528, Frankfurt/Main, Germany.,Orthopedic University Hospital Friedrichsheim gGmbH, Marienburgstraße 2, 60528, Frankfurt/Main, Germany
| | - Andrea Meurer
- Orthopedic University Hospital Friedrichsheim gGmbH, Marienburgstraße 2, 60528, Frankfurt/Main, Germany
| | - Katharina Lenarz
- Department of Sports Medicine, Johann Wolfgang Goethe University Frankfurt, Ginnheimer Landstraße 39, 60487, Frankfurt/Main, Germany
| | - Lutz Vogt
- Department of Sports Medicine, Johann Wolfgang Goethe University Frankfurt, Ginnheimer Landstraße 39, 60487, Frankfurt/Main, Germany
| | - Dara Froemel
- Orthopedic University Hospital Friedrichsheim gGmbH, Marienburgstraße 2, 60528, Frankfurt/Main, Germany
| | - Frederick Lutz
- Frankfurt University of Applied Sciences, Nibelungenplatz 1, 60318, Frankfurt/Main, Germany
| | - John Barker
- Experimental Orthopedics and Trauma Surgery, Frankfurt Initiative for Regenerative Medicine, Johann Wolfgang Goethe University Frankfurt, Marienburgstraße 2, 60528, Frankfurt/Main, Germany
| | - Felix Stief
- Orthopedic University Hospital Friedrichsheim gGmbH, Marienburgstraße 2, 60528, Frankfurt/Main, Germany
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Long-Term Effect of Exercise Therapy and Patient Education on Impairments and Activity Limitations in People With Hip Osteoarthritis: Secondary Outcome Analysis of a Randomized Clinical Trial. Phys Ther 2016; 96:818-27. [PMID: 26678445 DOI: 10.2522/ptj.20140520] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 12/06/2015] [Indexed: 02/09/2023]
Abstract
BACKGROUND The effect of exercise on specific impairments and activity limitations in people with hip osteoarthritis (OA) is limited. OBJECTIVE The study objective was to evaluate the long-term effect of exercise therapy and patient education on range of motion (ROM), muscle strength, physical fitness, walking capacity, and pain during walking in people with hip OA. DESIGN This was a secondary outcome analysis of a randomized clinical trial. SETTING The setting was a university hospital. PARTICIPANTS One hundred nine people with clinically and radiographically evident hip OA were randomly allocated to receive both exercise therapy and patient education (exercise group) or patient education only (control group). INTERVENTION All participants attended a patient education program consisting of 3 group meetings led by 2 physical therapists. Two other physical therapists were responsible for providing the exercise therapy program, consisting of 2 or 3 weekly sessions of strengthening, functional, and stretching exercises over 12 weeks. Both interventions were conducted at a sports medicine clinic. MEASUREMENTS Outcome measures included ROM, isokinetic muscle strength, predicted maximal oxygen consumption determined with the Astrand bicycle ergometer test, and distance and pain during the Six-Minute Walk Test (6MWT). Follow-up assessments were conducted 4, 10, and 29 months after enrollment by 5 physical therapists who were unaware of group allocations. RESULTS No significant group differences were found for ROM, muscle strength, predicted maximal oxygen consumption, or distance during the 6MWT over the follow-up period, but the exercise group had less pain during the 6MWT than the control group at 10 months (mean difference=-8.5 mm; 95% confidence interval=-16.1, -0.9) and 29 months (mean difference=-9.3 mm; 95% confidence interval=-18.1, -0.6). LIMITATIONS Limitations of the study were reduced statistical power and 53% rate of adherence to the exercise therapy program. CONCLUSIONS The previously described effect of exercise on self-reported function was not reflected by beneficial results for ROM, muscle strength, physical fitness, and walking capacity, but exercise in addition to patient education resulted in less pain during walking in the long term.
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