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

Efficacy of proprioceptive neuromuscular facilitation on functioning in patients with bilateral hip osteoarthritis: A pilot randomized controlled trial

BACKGROUND

Hip osteoarthritis (OA) is a chronic progressive disease that impresses a noticeable burden to society and healthcare systems. Physical exercise constitutes the first-line hip OA treatment approach, nevertheless, there is currently no gold standard method to treat this disease.

OBJECTIVE

To evaluate the efficacy of proprioceptive neuromuscular facilitation (PNF) on functioning in patients with hip OA.

METHOD

A pilot randomized controlled trial (RCT) was carried out on patients with painful bilateral hip OA with a body mass index (BMI) < 30 kg/m2. After the randomization, the experimental group was treated with PNF protocol and the control group with conventional physical therapy (10 sessions of manual therapy, 5 sessions/week for 2 weeks). The Harris Hip Score (HHS) was the primary outcome, whereas we assessed as secondary outcomes: pain, range of motion, and muscle strength of hip, physical performance, and quality of life.

RESULTS

Twenty patients (40 hips) were enrolled and randomized into two groups: PNF group (mean age: 70.7 ± 8.07; BMI: 25.1 ± 3.07; 7 females and 3 males) and control group (mean age: 74.9 ± 10.72; BMI: 26.8 ± 3.78; 6 females and 4 males). The results showed a statistically significant improvement of HHS in the study group (T1: 90.6 ± 5.63) than in the control group (T1: 77.3 ± 10.9) (between-group p value < 0.001). Three months after the treatment we have statistically significant maintenance in the PNF group (T2:89.6±6.32, within-group ΔT0-T2 p< 0.01) while the control group did not maintain the improvements recorded at T1 (T2: 71.4 ± 15.8).

CONCLUSION

The results of this pilot RCT showed that incorporating PNF exercises into the rehabilitation program yielded notable enhancements in improving lower limb function, strength and ROM in hip OA patients. Nonetheless, further prospective studies including wider sample size are needed to implement scientific knowledge on this physical therapy approach, in patients with hip osteoarthritis.

Progressive resistance training compared to neuromuscular exercise in patients with hip osteoarthritis and the additive effect of exercise booster sessions: protocol for a multicentre cluster randomised controlled trial (The Hip Booster Trial)

INTRODUCTION

The primary aim of this randomised controlled trial is to investigate the effectiveness of 3 months of progressive resistance training (PRT) compared to neuromuscular exercise (NEMEX) on functional performance in patients with hip osteoarthritis (OA). Secondary aims are to investigate the effectiveness of exercise booster sessions (EBS) in prolonging the effects of the initial exercise interventions as well as to investigate the cost-effectiveness of PRT, NEMEX and EBS at 12-month follow-up.

METHODS AND ANALYSIS

This multicentre cluster randomised controlled trial will be conducted at hospitals and physiotherapy clinics across Denmark. A total of 160 participants with clinically diagnosed hip OA will be recruited. Participants will be cluster randomised to a 3-month intervention of either PRT or NEMEX and to receive EBS or not, resulting in four treatment arms.The primary outcome is change in functional performance, measured by the 30 s chair stand test at 3 months for the primary comparison and at 12 months for the EBS comparisons. Secondary outcomes include changes in 40 m fast-paced walk test, 9-step timed stair climb test, leg extensor muscle power and maximal strength, Hip disability and Osteoarthritis Outcome Score subscales, EuroQol Group 5-dimension, global perceived effect, physical activity and pain. Outcomes are measured at baseline, after the initial 3 months of intervention, and at 6-month, 9-month and 12-month follow-up. An intention-to-treat approach will be used for analysing changes in the primary and secondary outcome measures.

ETHICS AND DISSEMINATION

The trial has been approved by the Central Denmark Region Committee on Biomedical Research Ethics (Journal No 1-10-72-267-20) and registered at the Danish Data Protection Agency (Journal No 1-16-02-11-21). Results will be published in international peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT04714047.

The Role of 6-Minute Walk Test Guided by Impedance Cardiography in the Rehabilitation Following Knee Arthroplasty: A Randomized Controlled Trial

Objective: To explore the effect of the 6-minute walk test (6MWT) guided by non-invasive cardiac output on the rehabilitation of patients with knee osteoarthritis following artificial total knee arthroplasty.

Methods: About 66 patients with knee osteoarthritis planned to undergo artificial total knee arthroplasty were included from March 2019 to October 2019, and randomly assigned to the intervention group or control group. Under the guidance of a clinical rehabilitation physician, orthopedic physician, and cardiologist, a home rehabilitation exercise program based on 6MWT and non-invasive cardiac output was formulated for patients with knee osteoarthritis. The participants of the intervention group conducted full rehabilitation training supervision and guidance through the WeChat platform to ensure their rehabilitation pieces of training were completed safely and effectively. As for the control group, patients were just given rehabilitation training manuals at the time of discharge and completed the training by themselves.

Results: At 6 months post-operatively, 6-minute walk distance (413.88 ± 44.61 vs. 375.00 ± 40.53 m, P < 0.05), active metabolic equivalent (4.13 ± 0.29 vs. 3.88 ± 0.27, P < 0.05), stroke volume after 6MWT (114.97 ± 12.05 vs. 98.38 ± 16.43 ml, P < 0.05), and cardiac output (11.92 ± 1.68 vs. 9.79 ± 1.82 l/min, P < 0.05) of the intervention group were significantly higher than those of the control group. The symptom evaluation scores of the intervention group were also better than those of the control group.

Conclusions: The multidisciplinary post-operative rehabilitation exercise training program is beneficial to the recovery of lower limb function and the improvement of exercise capacity after knee replacement, and it also helps to improve the non-invasive hemodynamic indicators related to the cardiac function of the patient.

Clinical Trial Registration:http://www.chictr.org.cn/index.aspx.

Efficacy of Exercise-Based Rehabilitation Programs for Improving Muscle Function and Size in People with Hip Osteoarthritis: A Systematic Review with Meta-Analysis

Objective: To determine the effect of exercise-based rehabilitation programs on hip and knee muscle function and size in people with hip osteoarthritis. Methods: Seven databases were systematically searched in order to identify studies that assessed muscle function (strength or power) and size in people with hip osteoarthritis after exercise-based rehabilitation programs. Studies were screened for eligibility and assessed for quality of evidence using the GRADE approach. Data were pooled, and meta-analyses was completed on 7 of the 11 included studies. Results: Six studies reported hip and/or knee function outcomes, and two reported muscle volumes that could be included in meta-analyses. Meta-analyses were conducted for four strength measures (hip abduction, hip extension, hip flexion, and knee extension) and muscle size (quadriceps femoris volume). For hip abduction, there was a low certainty of evidence with a small important effect (effect size = 0.28, 95% CI = 0.01, 0.54) favouring high-intensity resistance interventions compared to control. There were no other comparisons or overall meta-analyses that identified benefits for hip or knee muscle function or size. Conclusion: High-intensity resistance programs may increase hip abduction strength slightly when compared with a control group. No differences were identified in muscle function or size when comparing a high versus a low intensity group. It is unclear whether strength improvements identified in this review are associated with hypertrophy or other neuromuscular factors.

Effects of rural community-based integrated exercise and health education programs on the mobility function of older adults with knee osteoarthritis

AIM

To examine the effects of a rural community-based program integrating health education and self-directed home-based resistance training on the mobility function of older women with knee osteoarthritis (OA).

METHODS

Participants were assigned to the control (CON) or intervention (INT) group. Participants completed a mobility function assessment and questionnaire evaluation. The CON group received only the health education program and the INT group also participated in resistance training for 5 months. Primary outcomes were mobility function measured using a timed chair stand (TCS), timed up & go (TUG), gait speed (GS), and knee extensor strength (KES). We evaluated body composition and questionnaire results (WOMAC score, SARC-F scale, and SOF index) as secondary outcomes.

RESULTS

There were significant differences in the interactions of group-by-time effects for TCS (p < 0.001), TUG (p = 0.006), GS (p = 0.020), and knee strength (p = 0.010). In the CON group, TCS (p = 0.003) and TUG (p = 0.005) increased compared with baseline, while in the INT group, TCS decreased significantly (p < 0.001) and TUG tended to decrease after the intervention. The INT group showed improvement in GS (p < 0.001) and KES (p = 0.003) after the intervention. By contrast, the CON group showed decreasing GS (p = 0.021) and KES (p = 0.011) compared with baseline. The SARC-F scale differed significantly in the interaction of group-by-time effects (p = 0.030), while the body composition, SOF index, and WOMAC score did not differ.

CONCLUSION

These results suggest that an integrated intervention program combining self-directed home-based resistance training with health education effectively improves the mobility function of older adults with knee OA dwelling in rural areas.

How to objectively assess and observe maladaptive pain behaviors in clinical rehabilitation: a systematic search and review

Background

Cognitive-affective factors influence the perception of pain and disability. These factors can lead to pain behaviors (PB) that can persist and become maladaptive. These maladaptive PB will further increase the risk of chronicity or persistence of symptoms and disability. Thus, clinicians must be prepared to recognize maladaptive PB in a clinical context. To date, in the context of assessment in a rehabilitation setting, PB in clinical settings are poorly documented. The main objective of this study was to identify direct observation methods and critically appraise them in order to propose recommendations for practice. As a secondary objective, we explored and extracted the different observable PB that patients could exhibit and that clinicians could observe.

Methods

We conducted a comprehensive review on four databases with a generic search strategy in order to obtain the largest range of PB. For the first objective, a two-step critical appraisal used clinical criteria (from qualitative studies on barriers to implement routine measures) and psychometric criteria (from Brink and Louw critical appraisal tool) to determine which observation methods could be recommended for clinical practice. For the second objective, we extracted PB found in the literature to list potential PB that patients could exhibit, and clinicians could observe.

Results

From the 3362 retrieved studies, 47 met the inclusion criteria for the first objective. The clinical criteria allowed us to select three observation methods. After the psychometric step, two observation methods were retained and recommended for clinical practice: the Behavioral Avoidance Test-Back Pain (BAT-Back) and the Pain Behaviour Scale (PaBS). For the second objective, 107 studies met the inclusion criteria. The extraction of the PB allowed us to list a large range of PB and classify the data in 7 categories of PB.

Conclusion

Our results allowed us to recommend two observation methods for clinical practice. However, these methods have limitations and are validated only in chronic low back pain populations. With the extraction of PB presented in the literature, we contribute to better prepare clinicians to recognize PB in all patients who are experiencing pain.

Impacts of exercise interventions on different diseases and organ functions in mice

Background

In recent years, much evidence has emerged to indicate that exercise can benefit people when performed properly. This review summarizes the exercise interventions used in studies involving mice as they are related to special diseases or physiological status. To further understand the effects of exercise interventions in treating or preventing diseases, it is important to establish a template for exercise interventions that can be used in future exercise-related studies.

Methods

PubMed was used as the data resource for articles. To identify studies related to the effectiveness of exercise interventions for treating various diseases and organ functions in mice, we used the following search language: (exercise [Title] OR training [Title] OR physical activity [Title]) AND (mice [title/abstract] OR mouse [title/abstract] OR mus [title/abstract]). To limit the range of search results, we included 2 filters: one that limited publication dates to "in 10 years" and one that sorted the results as "best match". Then we grouped the commonly used exercise methods according to their similarities and differences. We then evaluated the effectiveness of the exercise interventions for their impact on diseases and organ functions in 8 different systems.

Results

A total of 331 articles were included in the analysis procedure. The articles were then segmented into 8 systems for which the exercise interventions were used in targeting and treating disorders: motor system (60 studies), metabolic system (45 studies), cardio-cerebral vascular system (58 studies), nervous system (74 studies), immune system (32 studies), respiratory system (7 studies), digestive system (1 study), and the system related to the development of cancer (54 studies). The methods of exercise interventions mainly involved the use of treadmills, voluntary wheel-running, forced wheel-running, swimming, and resistance training. It was found that regardless of the specific exercise method used, most of them demonstrated positive effects on various systemic diseases and organ functions. Most diseases were remitted with exercise regardless of the exercise method used, although some diseases showed the best remission effects when a specific method was used.

Conclusion

Our review strongly suggests that exercise intervention is a cornerstone in disease prevention and treatment in mice. Because exercise interventions in humans typically focus on chronic diseases, national fitness, and body weight loss, and typically have low intervention compliance rates, it is important to use mice models to investigate the molecular mechanisms underlying the health benefits from exercise interventions in humans.

Exercise as a prescription for patients with various diseases

A growing understanding of the benefits of exercise over the past few decades has prompted researchers to take an interest in the possibilities of exercise therapy. Because each sport has its own set of characteristics and physiological complications that tend to occur during exercise training, the effects and underlying mechanisms of exercise remain unclear. Thus, the first step in probing the effects of exercise on different diseases is the selection of an optimal exercise protocol. This review summarizes the latest exercise prescription treatments for 26 different diseases: musculoskeletal system diseases (low back pain, tendon injury, osteoporosis, osteoarthritis, and hip fracture), metabolic system diseases (obesity, type 2 diabetes, type 1 diabetes, and nonalcoholic fatty liver disease), cardio-cerebral vascular system diseases (coronary artery disease, stroke, and chronic heart failure), nervous system diseases (Parkinson's disease, Huntington's disease, Alzheimer's disease, depression, and anxiety disorders), respiratory system diseases (chronic obstructive pulmonary disease, interstitial lung disease, and after lung transplantation), urinary system diseases (chronic kidney disease and after kidney transplantation), and cancers (breast cancer, colon cancer, prostate cancer, and lung cancer). Each exercise prescription is displayed in a corresponding table. The recommended type, intensity, and frequency of exercise prescriptions are summarized, and the effects of exercise therapy on the prevention and rehabilitation of different diseases are discussed.

Priorities for the effective implementation of osteoarthritis management programs: an OARSI international consensus exercise

OBJECTIVE

The Joint Effort Initiative was endorsed by Osteoarthritis Research Society International (OARSI) in 2018 as a collaboration between international researchers and clinicians with an interest in the implementation of osteoarthritis management programs (OAMPs). This study aimed to identify and prioritise activities for future work of the Joint Effort Initiative.

DESIGN

A survey was emailed to delegates of the 2018 OARSI World Congress attending a pre-conference workshop or with a known interest in OAMPs (n = 115). Delegates were asked about the most important issues regarding OAMP implementation. The top 20 issues were synthesised into 17 action statements, and respondents were invited to participate in a priority ranking exercise to determine the order of importance of the statements.

RESULTS

Survey respondents (n = 51, 44%) were most commonly female (71%), with an allied health background (57%), affiliated with universities (73%) from Oceania (37%), and Europe/UK (45%). The five highest ranked action statements were: CONCLUSION: Prioritising statements will bring focus to the future work of the Joint Effort Initiative in the future and provide a basis for longer-term actions.

Exercise in the management of knee and hip osteoarthritis

PURPOSE OF REVIEW

This review focuses on studies published during July 2001 to August 2017 of exercise as an intervention in knee and hip osteoarthritis, including its influence on an array of patient outcomes.

RECENT FINDINGS

Studies continue to illustrate the efficacy of exercise in treating and managing osteoarthritis, with current literature more focused on the knee compared with the hip joint. Both traditional (e.g. strength, aerobic, flexibility) and more nontraditional (e.g. yoga, Tai Chi, aquatic) training modes improve patient outcomes related to joint symptoms, mobility, quality of life, psychological health, musculoskeletal properties, body composition, sleep, and fatigue. Exercise that is adequately dosed (e.g. frequency, intensity) and progressive in nature demonstrated the greatest improvements in patient outcomes. Supervised, partially supervised, and nonsupervised interventions can be successful in the treatment of osteoarthritis, but patient preference regarding level of supervision and mode of exercise may be key predictors in exercise adherence and degree of outcome improvement. A topic of increasing interest in osteoarthritis is the supplementary role of behavior training in exercise interventions.

SUMMARY

Osteoarthritis is a complex, multifactorial disease that can be successfully managed and treated through exercise, with minimal risk for negative consequences. However, to have greatest impact, appropriate exercise prescription is needed. Efforts to achieve correct exercise doses and mitigate patient nonadherence are needed to lessen the lifelong burden of osteoarthritis.

Effects of exercise and physical activity promotion: meta-analysis informing the 2018 EULAR recommendations for physical activity in people with rheumatoid arthritis, spondyloarthritis and hip/knee osteoarthritis

Objective

To evaluate the effectiveness of exercise and physical activity (PA) promotion on cardiovascular fitness, muscle strength, flexibility, neuromotor performance (eg, balance) and daily PA in people with rheumatoid arthritis (RA), spondyloarthritis (SpA) and hip/knee osteoarthritis (HOA/KOA).

Methods

systematic review (SR) and meta-analysis (MA) were performed searching the databases PubMed/Medline, CENTRAL, Embase, Web of Science, Emcare and PsycInfo until April 2017. We included randomised controlled trials (RCTs) in adults (≥18 years) with RA, SpA and HOA/KOA, investigating the effects of exercise or PA promotion according to the public health PA recommendations by the American College of Sports Medicine. The time point of interest was the first assessment after the intervention period. If suitable, data were pooled in a MA using a random-effects model presented as standardised mean difference (SMD).

Results

The SR included 63 RCTs, of which 49 (3909 people with RA/SpA/HOA/KOA) were included in the MA. Moderate effects were found of aerobic exercises and resistance training on cardiovascular fitness (SMD 0.56 (95% CI 0.38 to 0.75)) and muscle strength (SMD 0.54 (95% CI 0.35 to 0.72)), respectively, but no effect of combined strength/aerobic/flexibility exercises on flexibility (SMD 0.12 (95% CI -0.16 to 0.41)). PA promotion interventions produced a small increase in PA behaviour (SMD 0.21 (95% CI 0.03 to 0.38)).

Conclusion

Exercises and PA promotion according to public health recommendations for PA improved cardiovascular fitness, muscle strength and PA behaviour, with moderate effect sizes in people with SpA, RA and HOA/KOA.

Trial registration number

CRD42017082131.

Effects of non-pharmacological conservative treatment on pain, range of motion and physical function in patients with mild to moderate hip osteoarthritis. A systematic review

OBJECTIVE

The purpose of this review was to identify the effects of non-pharmacological conservative treatment on pain, range of motion and physical function in patients with mild to moderate hip osteoarthritis.

DESIGN

A systematic review based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

SETTING

We searched MEDLINE, PEDro, Scopus and the Cochrane Library databases for randomized controlled trials related to non-pharmacological conservative treatments for hip osteoarthritis with the following keywords: "hip osteoarthritis," "therapeutics," "physical therapy modalities," and "combined physical therapy". The PEDro scale was used for methodological quality assessment and the Oxford Centre of Evidence-Based Medicine scale was used to assess the level of evidence. Outcomes measures related to pain, hip range of motion and physical function were extracted from these studies.

RESULTS

Twelve studies met the inclusion criteria. Most of the studies showed high level of evidence and only two showed low level of evidence. High quality of evidence showed that manual therapy and exercise therapy are effective in improving pain, hip range of motion and physical function. However, high quality studies based on combined therapies showed controversy in their effects on pain, hip range of motion and physical function.

CONCLUSIONS

Exercise therapy and manual therapy and its combination with patient education provides benefits in pain and improvement in physical function. The effects of combined therapies remain unclear. Further investigation is necessary to improve the knowledge about the effects of non-pharmacological conservative treatments on pain, hip range of motion and physical function.

Individuals with mild-to-moderate hip osteoarthritis have lower limb muscle strength and volume deficits

Background

Individuals with advanced hip osteoarthritis (OA) exhibit generalized muscle weakness of the affected limb and so clinical practice guidelines recommend strength training for the management of hip OA. However, the extent and pattern of muscle weakness, including any between-limb asymmetries, in early stages of the disease are unclear. This study compared hip and knee muscle strength and volumes between individuals with mild-to-moderate symptomatic and radiographic hip OA and a healthy control group.

Methods

Nineteen individuals with mild-to-moderate symptomatic and radiographic hip OA (n = 12 unilateral; n = 7 bilateral) and 23 age-matched, healthy controls without radiographic hip OA or hip pain participated. Isometric strength of the hip and knee flexors and extensors, and hip abductors and adductors were measured. Hip and thigh muscle volumes were measured from lower limb magnetic resonance images. A full-factorial, two-way General Linear Model was used to assess differences between groups and between limbs.

Results

Participants in the hip OA group demonstrated significantly lower knee flexor, knee extensor, hip flexor, hip extensor and hip abductor strength compared to controls and had significantly lower volume of the adductor, hamstring and quadriceps groups, and gluteus maximus and gluteus minimus muscles, but not tensor fasciae latae or gluteus medius muscles. There were no between-limb strength differences or volume differences within either group.

Conclusions

Atrophic, bilateral hip and knee muscle weakness is a feature of individuals with mild-to-moderate hip OA. Early interventions to target muscle weakness and prevent the development of strength asymmetries that are characteristic of advanced hip OA appear warranted.

2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis

Regular physical activity (PA) is increasingly promoted for people with rheumatic and musculoskeletal diseases as well as the general population. We evaluated if the public health recommendations for PA are applicable for people with inflammatory arthritis (iA; Rheumatoid Arthritis and Spondyloarthritis) and osteoarthritis (hip/knee OA) in order to develop evidence-based recommendations for advice and guidance on PA in clinical practice. The EULAR standardised operating procedures for the development of recommendations were followed. A task force (TF) (including rheumatologists, other medical specialists and physicians, health professionals, patient-representatives, methodologists) from 16 countries met twice. In the first TF meeting, 13 research questions to support a systematic literature review (SLR) were identified and defined. In the second meeting, the SLR evidence was presented and discussed before the recommendations, research agenda and education agenda were formulated. The TF developed and agreed on four overarching principles and 10 recommendations for PA in people with iA and OA. The mean level of agreement between the TF members ranged between 9.8 and 8.8. Given the evidence for its effectiveness, feasibility and safety, PA is advocated as integral part of standard care throughout the course of these diseases. Finally, the TF agreed on related research and education agendas. Evidence and expert opinion inform these recommendations to provide guidance in the development, conduct and evaluation of PA-interventions and promotion in people with iA and OA. It is advised that these recommendations should be implemented considering individual needs and national health systems.

Osteoarthritis year in review 2017: rehabilitation and outcomes

OBJECTIVE

The purpose of this systematic review was to describe studies examining rehabilitation for people with osteoarthritis (OA) and to summarize findings from selected key systematic reviews (SRs) and randomized controlled trials (RCTs).

DESIGN

A systematic search was performed using Pubmed, Embase and Cochrane databases from April 1^st 2016 to May 15^th 2017 using the terms 'osteoarthritis', 'randomized controlled trial', and 'systematic review'. Inclusion criteria were: clinically or radiologically diagnosed patients with OA, rehabilitation treatment, RCT or SRs. A selection of the included studies is discussed based on study quality and perceived importance to the field; including those that are innovative, inform the direction of the field or generate controversy. Methodological quality of the included studies was assessed using the PEDro-scale for RCTs and the Amstar guideline for SRs.

RESULTS

From 1211 articles, 80 articles met the eligibility criteria including 21 SRs and 61 RCTs. The median of the methodological quality of the SRs and RCTs was 7 (2-9) and 6 (3-10), respectively. The studies were grouped into several themes, covering the most important rehabilitation fields.

CONCLUSIONS

Striking is the small number of studies investigating another joint (18%) than the knee (82%). Exercise is the most common treatment evaluated and should be accompanied with education to effectuate a behavioural change in physical activity of people with OA. No new insights in the field of braces (or orthoses) and in the field of acupuncture were found.

The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part two: strengthening exercise programs

OBJECTIVE

To identify effective strengthening exercise programs and provide rehabilitation teams and patients with updated, high-quality recommendations concerning traditional land-based exercises for knee osteoarthritis.

METHODS

A systematic search and adapted selection criteria included comparative controlled trials with strengthening exercise programs for patients with knee osteoarthritis. A panel of experts reached consensus on the recommendations using a Delphi survey. A hierarchical alphabetical grading system (A, B, C+, C, D, D+ or D-) was based on statistical significance ( p < 0.5) and clinical importance (⩾15% improvement).

RESULTS

The 26 high-quality studies identified demonstrated that various strengthening exercise programs with/without other types of therapeutic exercises are generally effective for improving knee osteoarthritis management within a six-month period. Strengthening exercise programs demonstrated a significant improvement for pain relief (four Grade A, ten Grade B, two Grade C+), physical function (four Grade A, eight Grade B) and quality of life (three Grade B). Strengthening in combination with other types of exercises (coordination, balance, functional) showed a significant improvement in pain relief (three Grade A, 11 Grade B, eight Grade C+), physical function (two Grade A, four Grade B, three Grade C+) and quality of life (one Grade A, one Grade C+).

CONCLUSION

There are a variety of choices for strengthening exercise programs with positive recommendations for healthcare professionals and knee osteoarthritis patients. There is a need to develop combined behavioral and muscle-strengthening strategies to improve long-term maintenance of regular strengthening exercise programs.