Table 1.
Systematic Reviews of Exercise as a Treatment for Osteoarthritis
| Study | Study Purpose | Design and Procedures |
Number of Studies Reviewed |
Number of Participants |
Types of Intervention and Duration |
Study Results and Conclusions |
|---|---|---|---|---|---|---|
| Mixed Land-Based Exercise Programs | ||||||
| Fransen et al,21 | To determine whether land-based exercise reduces joint pain or improved function in people with hip OA when compared with no exercise. | Meta-analysis; systematic review of 5 electronic databases from 1966–2008. All RCTs recruited people with hip OA and land-based therapeutic exercise groups were compared with nonexercise groups. | 5 RCTs, but only 1 exclusively recruited people with hip OA. The other 4 RCTs also recruited participants with knee OA. | 204 with hip OA for pain outcomes; 187 with hip OA for physical function outcomes. | Interventions were 6–12 wks. Class-based exercise interventions included strengthening, Tai Chi, and resistance. Classes were conducted 1–3 times per week. | Small improvement in pain (SMD, 0.38; 95% CI: 0.09–0.67). No change in self-reported function (SMD, 0.02; 95% CI, −0.31 to 0.28). Important limitations were the small number of studies with the small sample for this area of research. |
| Fransen& McConnell, 23 | To determine whether land-based exercise reduces joint pain or improved function in people with knee OA when compared with no exercise. | Meta-analysis; systematic review of 5 electronic databases up until December 2007 | 32 RCTs | 3616 subjects with knee pain data and 3719 subjects with self-reported physical function data. | Programs were either delivered individually or in a class-based format, and most were home programs. Programs ranged from straight leg raises and mostly aerobic walking to very complex, comprehensive programs (manual therapy, strengthening, balance training and Tai Chi). Study duration ranged from 6–72 wks with sessions occurring 2–4 times per week. | Land-based exercise programs were beneficial (SMD, 0.40; 95% CI, 0.30–0.50; SMD, 0.37; 95% CI, 0.25–0.49) for physical function. Providing a greater number of directly supervised sessions (≥ 12 visits) improved knee pain and physical function outcomes. |
| Roddy et al24 | To compare aerobic walking and home-based quadriceps strengthening exercises in patients with knee OA. | Meta-analysis of 5 electronic databases and the Cochrane Central Register of Controlled Trials (searched 1966–2003) for RCTs of subjects with knee OA. | 13 RCTs total. 3 studies included an aerobic intervention, 9 studies included home-based strengthening exercises, and 1 aerobic walking with home-based strengthening program. | 156 subjects from aerobic studies and 1709 subjects from strength training trials | Interventions were 8–24 weeks for aerobic walking and 8 wks–2 yrs for strengthening. | Pooled ES for pain: 0.52 for aerobic walking (95% CI, 0.34–0.70) and 0.32 for strengthening (95% CI, 0.23–0.41). Pooled ES for disability: 0.46 for aerobic walking (95% CI, 0.25–0.67) and 0.32 for strengthening (95% CI, 0.23–0.41). Both aerobic walking and home-based quadriceps strengthening exercises are effective in reducing pain and disability in knee OA. |
| Strength Training Programs | ||||||
| Liu and Latham,29 | To assess the effectiveness of PRT in older people. | Systematic review searching 8 electronic databases (1966–2008) plus reference lists of articles. Conference abstracts were reviewed and authors were contacted. | RCTs reporting physical outcomes of PRT for older people. 121 trials were identified, and 6 had participants with knee or hip OA. | 503 participants with knee or hip OA | PRT was performed 2–3 times per week and at a high intensity. | Participants with OA reported a reduction in pain following PRT (SMD,−0.30; 95% CI, −0.487 to −0.13). |
| Latham & Liu,30 | To determine the effectiveness of PRT in older adults with OA | Meta-analysis with systematic review of 9 databases. | 8 RCTs. 7 trials of patients (mean age, 65) with knee OA and 1 trial included patients with hip and knee OA. | 907 participants with 20–295 people in each study. | Moderate- to high-intensity programs that include 1–9 exercises. In 7 studies, participants exercised 3 times per week; 1 study had participants exercise 5 times per week. Duration of the programs ranged from 6–72 wks. | Reduced pain (SMD, −0.35; 95% CI, −0.52 to−0.18), improved function (SMD 0.33, 95% CI 0.18, 0.49), and improved leg extensor strength (SMD, 0.33; 95% CI 0.12–0.54) for PRT compared with nonstrength training control groups. |
| Pelland et al38 | To determine the effectiveness of PRT programs in adults with OA. | Meta-analysis; a systematic review of 3 databases up to and including 2004; included RCTs of strengthening exercises and participants with OA. | 21 trials | 2325 patients with a primary diagnosis of OA. | Exercise types: isometric, isotonic, isokinetic, concentric, concentric/eccentric, dynamic; alone or with other exercises (stretching, ROM); facility-based, home-based or both. | Strengthening exercises improved pain, range of motion, strength, and functional status in patients with OA. The combination of joint-specific strengthening with general strength and progression of the program were key components. |
| Balance and Neuromuscular Training | ||||||
| Silva et a146 | To examine the effectiveness of exercise on the balance in women with OA. | Systematic review; 6 electronic databases and the Cochrane Collaboration RCTs published 2000–2010. | 9 RCTs | 833 participants | Exercise programs included: aerobic exercise and strength training, Tai Chi, hydrotherapy, vibrating platform exercise, balance exercises, and educational programs. | Interventions were 4 wks to 18 mo and a wide range of pain and balance assessments were used. Overall, balance of women with knee OA improved following exercise. |
| Smith et al59 | To determine the effectiveness of proprioceptive exercises for knee OA. | Meta-analysis; systematic review of 7 published and 4 unpublished trial/registry (n=4) databases. | 7 RCTs comparing a proprioceptive exercise program with a nonproprioceptive exercise program or nontreatment control for adults with OA. | 560 patients with mean age of 63; 203 males and 357 females. | All proprioceptive exercises were weight-bearing, based on functional activities (ie, stepping, standing, walking, or balancing). Nonproprioceptive exercise programs were lower extremity exercises. Duration of the programs was 4–8 wks in duration. | Proprioceptive exercises significantly improved functional outcomes compared with nontreatment (P < 0.02). Outcomes were similar between proprioceptive and nonproprioceptive programs except results were better for the proprioceptive programs for joint position sense-related measurements (ie, timed walk over uneven ground [P = 0.03] and joint position angulation error [P <0.01]. |
| Water-Based Programs | ||||||
| Bartels et al64 | To compare the effectiveness and safety of aquatic-exercise interventions in knee and hip OA. | Meta-analysis; 5 electronic databases were searched (1945–2006). | 6 RCTs were identified, 4 included patients with hip or knee OA (N=672), 1 had subjects with hip OA only (N=28), and 1 had subjects with knee OA only (N=43). | 800 participants | All types of exercises in therapeutic or heated indoor pool (range of motion, dynamics, aerobics, etc.) were included. | Small-to-moderate effect on function (SMD, 0.26; 95% CI, 0.11–0.42) and a small-to-moderate effect on quality of life (SMD, 0.32; 95% CI, 0.03–0.61). |
| Batterham et al72 | To examine the effectiveness of aquatic compared with land-based exercise on function in people with arthritis. | Systematic review of 4 databases with meta-analysis. | 10 RCTs compared land with aquatic exercise for adults with rheumatoid or OA. Land-based exercise could include any exercise training for strength, endurance, resistance, or aerobic capacity, whether gym or home-based. | 354 water-based participants, 305 land-based participants, and 113 controls. | 7 of the RCTs described the exercises in their land-based and aquatic programs. Duration was 4–18 wks. Aquatic exercise included running, jumping, cycling and walking, and strengthening exercises (ie, hip and knee flexion and extension, hip adduction and abduction, calf raises, and squats). | Results did not differ for the 2 rehabilitation strategies. The authors suggested that when people have difficulty with land based exercises, aquatic programs may be a good alternative. |
| Mixed Water-Based and Land-Based Programs (land-based, aquatic, and mixed) | ||||||
| Escalante et al76 | To examine the effectiveness and structure of exercise programs on pain in patients with hip and knee OA. | Systematic review of 5 electronic databases. | 33 studies total with 22 land-based intervention studies (ie, strengthening, Tai Chi, aerobic), 5 aquatic studies, and 6 mixed exercise programs. | 1507 subjects from land-based studies; 569 from aquatic studies, and 603 from mixed exercise program subjects | Study intervention duration lasted 6–72 wks (most often 8 wks) with 1–7 sessions/wk (most with 3 sessions/wk). 30–60 min sessions, with most at 30 min. | Pain decreased in 80% of strength interventions (ES, 0.01–1.12), 70% of Tai Chi studies (ES, 0.28–1.67), and 80% of the aquatic studies (ES, 0.19–0.72). Pain decreased in 1 of 2 aerobic studies (ES=1.06). Only 1 of the 6 mixed programs resulted in reduced pain (ES=0.40). |
| Escalante et al77 | To examine the effectiveness and structure of exercise programs on functional aerobic capacity in individuals with hip and knee OA. | Systematic review of 7 databases. | 20 studies; included 19 RCTs and 1 controlled clinical trial. | Total of 2142 subjects: the 19 RCTs included 2093 subjects; controlled clinical trial included 49 subjects. | Interventions included aerobic programs (n=4), strength programs (n=2), Tai Chi programs (n=3) mixed programs (n=8), and hydrotherapy programs (n=3). The outcome measure used was the 6-minute walk test. | Functional aerobic capacity improved in Tai Chi program (ES = 0.66; 95% CI, 0.23–1.09), aerobic programs (ES = 0.90; 95% CI, 0.70–1.10), and mixed programs (ES = 0.47, 95% CI, –0.38 to 0.39). Hydrotherapy programs did not improve functional aerobic capacity (ES 0.00; 95% CI,–0.38 to 0.39). |
Abbreviations: ES, effect size; OA, osteoarthritis; PRT, progressive resistive training; RCT, randomized controlled trial; SMD, standardized mean difference.