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52 © The Physician and Sportsmedicine, Volume 40, Issue 4, November 2012, ISSN – 0091-3847ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]
A Comprehensive Review of the Effectiveness of Different Exercise Programs for Patients with Osteoarthritis
Yvonne M. Golightly, PT, PhD1,2,3 Kelli D. Allen, PhD4,5 Dennis J. Caine, PhD6
1Research Assistant Professor, Department of Epidemiology, University of North Carolina, Chapel Hill, NC; 2Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC; 3Injury Prevention Research Center, University of North Carolina, Chapel Hill, NC; 4Associate Research Professor, Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, NC; 5Research Health Scientist, Health Services Research and Development Service, Durham Veterans Affairs Medical Center, Durham, NC; 6Professor and Interim Dean, College of Education and Human Development, University of North Dakota, Grand Forks, ND
Correspondence: Yvonne M. Golightly, PT, PhD,University of North Carolina,Thurston Arthritis Research Center,3300 Thurston Building,Campus Box No. 7280,Chapel Hill, NC 27599-7280.Tel: 919-843-6618Fax: 919-966-1739E-mail: [email protected]
DOI: 10.3810/psm.2012.11.1988
Abstract:�([HUFLVH� LV� UHFRPPHQGHG� DV� D�¿UVW�OLQH� FRQVHUYDWLYH� LQWHUYHQWLRQ� DSSURDFK� IRU�RVWHRDUWKULWLV��2$���$�ZLGH�UDQJH�RI�H[HUFLVH�SURJUDPV�DUH�DYDLODEOH�DQG�VFLHQWL¿F�HYLGHQFH�LV�QHFHVVDU\�IRU�FKRRVLQJ�WKH�RSWLPDO�VWUDWHJ\�RI�WUHDWPHQW�IRU�HDFK�SDWLHQW��7KH�SXUSRVH�RI�WKLV�UHYLHZ�LV�WR�GLVFXVV�WKH�HIIHFWLYHQHVV�RI�GLIIHUHQW�W\SHV�RI�H[HUFLVH�SURJUDPV�IRU�2$�EDVHG�RQ�WULDOV��V\VWHPDWLF�UHYLHZV��DQG�PHWD�DQDO\VHV�LQ�WKH�OLWHUDWXUH��3XEOLFDWLRQV�IURP�-DQXDU\������WR�-XO\������ZHUH�VHDUFKHG�LQ���HOHFWURQLF�GDWDEDVHV�XVLQJ�WKH�WHUPV�RVWHRDUWKULWLV��H[HUFLVH��H[HUFLVH�SURJUDP��HIIHFWLYHQHVV��DQG�WUHDWPHQW�RXWFRPH��6WURQJ�HYLGHQFH�VXSSRUWV�WKDW�DHURELF�DQG�VWUHQJWKHQLQJ�H[HUFLVH�SURJUDPV��ERWK�ODQG��DQG�ZDWHU�EDVHG��DUH�EHQH¿FLDO�IRU�LPSURYLQJ�SDLQ�DQG�SK\VLFDO�IXQFWLRQ�LQ�DGXOWV�ZLWK�PLOG�WR�PRGHUDWH�NQHH�DQG�KLS�2$��$UHDV�WKDW�UHTXLUH�IXUWKHU� UHVHDUFK� LQFOXGH�H[DPLQDWLRQ�RI� WKH� ORQJ�WHUP�HIIHFWV�RI�H[HUFLVH�SURJUDPV�IRU�2$��EDODQFH�WUDLQLQJ�IRU�2$��H[HUFLVH�SURJUDPV�IRU�VHYHUH�2$��WKH�HIIHFW�RI�H[HUFLVH�SURJUDPV�RQ�SURJUHVVLRQ�RI�2$��WKH�HIIHFWLYHQHVV�RI�H[HUFLVH�IRU�MRLQW�VLWHV�RWKHU�WKDQ�WKH�NQHH�RU�KLS��DQG�WKH�HIIHFWLYHQHVV�RI�H[HUFLVH�IRU�2$�E\�VXFK�IDFWRUV�DV�DJH��VH[��DQG�REHVLW\��(IIRUWV�WR�LPSURYH�DGKHUHQFH�WR�HYLGHQFH�EDVHG�H[HUFLVH�SURJUDPV�IRU�2$�DQG�WR�SURPRWH�WKH�GLVVHPLQDWLRQ�DQG�LPSOHPHQWDWLRQ�RI�WKHVH�SURJUDPV�DUH�FUXFLDO�
Keywords:�RVWHRDUWKULWLV��H[HUFLVH��SK\VLFDO�DFWLYLW\��WUHDWPHQW�RXWFRPH��HIIHFWLYHQHVV
Introduction
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05_Golightly.indd 52 12/28/12 11:18 AM
Exercise Programs for OA
© The Physician and Sportsmedicine, Volume 40, Issue 4, November 2012, ISSN – 0091-3847 53
ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]
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$OWKRXJK�LQFUHDVHG�ULVN�RI�2$�KDV�EHHQ�DVVRFLDWHG�ZLWK�MRLQW�LQMXU\�VXIIHUHG�LQ�VSRUW����SK\VLFDO�DFWLYLW\�LV�EHQH¿FLDO�IRU�MRLQW�WLVVXHV�DQG�FDQ�KHOS�GHFUHDVH�V\PSWRPV�DQG�LPSURYH�IXQFWLRQ����$FFRUGLQJO\��SK\VLFDO�DFWLYLW\�KDV�EHHQ�QRWHG�DV�D�FHQWUDO�FRPSRQHQW�LQ�WKH�&HQWHUV�IRU�'LVHDVH�&RQWURO�DQG�3UHYHQWLRQ��&'&��DQG�$UWKULWLV�)RXQGDWLRQ¶V������SXEOLFD�WLRQ��A National Public Health Agenda for Osteoarthritis�� ([HUFLVH�SURJUDPV�IRU�2$�PD\�EH�ODQG��RU�ZDWHU�EDVHG�DQG�LQFOXGH�DFWLYLWLHV�IRFXVHG�RQ�HQGXUDQFH��HJ��ZDONLQJ���UDQJH�RI�PRWLRQ�ÀH[LELOLW\��VWUHQJWKHQLQJ��EDODQFH��RU�DQ\�FRPELQD�WLRQ�RI�WKHVH�FRPSRQHQWV�
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Materials and Methods
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Land-Based Exercise Programs for OAMixed Land-Based Exercise Programs/DQG�EDVHG�H[HUFLVH�SURJUDPV�KDYH�LQFOXGHG�DHURELF�RU�HQGXU�DQFH�DFWLYLWLHV� �HJ��ZDONLQJ�DQG�F\FOLQJ��� VWUHQJWK� WUDLQLQJ�ZLWK�DQG�ZLWKRXW�ZHLJKWV��DQG�EDODQFH�WUDLQLQJ��7KUHH�V\V�WHPDWLF�UHYLHZV�RI�5&7V�KDYH�EURDGO\�H[DPLQHG�WKH�HIIHFWV�RI�ODQG�EDVHG�H[HUFLVH�SURJUDPV�RQ�SDLQ�DQG�SK\VLFDO�IXQFWLRQ�UHODWHG�WR�NQHH�DQG�KLS�2$��7DEOH�����7KH�UHVXOWV�RI�D�V\VWHP�DWLF�UHYLHZ�RI���5&7V�FRPSDULQJ�ODQG�EDVHG�H[HUFLVH�ZLWK�QRQH[HUFLVH�DPRQJ�SHRSOH�ZLWK�KLS�2$�VKRZHG�RQO\�VPDOO�LPSURYHPHQW�LQ�SDLQ��VWDQGDUGL]HG�PHDQ�GLIIHUHQFH�>60'@������������&,������±������������EXW�QR�EHQH¿FLDO�FKDQJH�LQ�VHOI�UHSRUWHG�IXQFWLRQ��60'��−����������&,��−�����WR��������7KH�DXWKRUV�FRPPHQWHG�WKDW�WKH�OLPLWHG�QXPEHU�DQG�VPDOO�VDPSOH�VL]H�RI�WKH�LQFOXGHG�5&7V��DORQJ�ZLWK�WKH�KHWHURJHQHLW\�RI�WKH�VWXGLHV��PLQLPL]H�WKH�LQWHUSUHWDELOLW\�RI�WKHVH�UHVXOWV�
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05_Golightly.indd 53 12/28/12 11:18 AM
Golightly et al
54 © The Physician and Sportsmedicine, Volume 40, Issue 4, November 2012, ISSN – 0091-3847ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]
Table 1. Systematic Reviews of Exercise as a Treatment for OA
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 al21 To determine whether land-based exercise reduced 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 and McConnell23
To determine whether land-based exercise reduced 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 EHQHÀFLDO��60'��������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 study combined aerobic walking with a 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 were effective in reducing pain and disability in knee OA.
Strength Training Programs
Liu and Latham29
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 ZHUH�LGHQWLÀHG��DQG�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).
(Continued)
05_Golightly.indd 54 12/28/12 11:18 AM
Exercise Programs for OA
© The Physician and Sportsmedicine, Volume 40, Issue 4, November 2012, ISSN – 0091-3847 55
ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]
Table 1. (Continued)
Study Study Purpose Design and
Procedures
Number of
Studies Reviewed
Number of
Participants
Types of
Intervention and
Duration
Study Results and
Conclusions
Latham and Liu30
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 included 1–9 exercises. In 7 studies, participants exercised 3 times per week; 1study had partici-pants 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 RCTs 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 RI�MRLQW�VSHFLÀF�strengthening with general strength and pro-gression of the program were key components.
Balance and Neuromuscular Training
Silva et a146 To examine the effectiveness of exercise on 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, hydro-therapy, vibrating plat-form exercise, balance exercises, and educa-tional programs.
Interventions ran 4 wks to 18 mo and a wide range of pain and bal-ance assessments were used. Overall, balance in women with knee OA improved following exercise.
Smith et al59 To determine the effectiveness of propriocep-tive exercises for knee OA.
Meta-analysis; systematic review of 7 published and 4 unpublished trials/registries databases.
7 RCTs comparing a proprioceptive exer-cise 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 VLJQLÀFDQWO\�LPSURYHG�functional outcomes compared with non-treatment (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 angula-tion 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 LGHQWLÀHG����LQFOXGHG�patients with hip or knee OA (N = 672), 1 RCT had subjects with hip OA only (N = 28), and 1 RCT 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).
(Continued)
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Golightly et al
56 © The Physician and Sportsmedicine, Volume 40, Issue 4, November 2012, ISSN – 0091-3847ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]
Table 1. (Continued)
Study Study Purpose Design and
Procedures
Number of
Studies Reviewed
Number of
Participants
Types of
Intervention and
Duration
Study Results and
Conclusions
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 included 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 of the legs and walking, and strengthening exercises (ie, hip and knee ÁH[LRQ�DQG�H[WHQVLRQ��hip adduction and abduction, calf raises, and squats).
Results did not differ for the 2 rehabilitation strategies. The authors suggested that when SHRSOH�KDYH�GLIÀFXOW\�with land-based exercises, aquatic programs may be a good alternative.
Mixed Water-Based and Land-Based Programs
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 subjects from aquatic studies, and 603 subjects from mixed-exercise programs.
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.
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05_Golightly.indd 56 12/28/12 11:18 AM
Exercise Programs for OA
© The Physician and Sportsmedicine, Volume 40, Issue 4, November 2012, ISSN – 0091-3847 57
ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]
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05_Golightly.indd 57 12/28/12 11:18 AM
Golightly et al
58 © The Physician and Sportsmedicine, Volume 40, Issue 4, November 2012, ISSN – 0091-3847ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]
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05_Golightly.indd 58 12/28/12 11:18 AM
Exercise Programs for OA
© The Physician and Sportsmedicine, Volume 40, Issue 4, November 2012, ISSN – 0091-3847 59
ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]
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05_Golightly.indd 59 12/28/12 11:18 AM
Golightly et al
60 © The Physician and Sportsmedicine, Volume 40, Issue 4, November 2012, ISSN – 0091-3847ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]
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05_Golightly.indd 60 12/28/12 11:18 AM
Exercise Programs for OA
© The Physician and Sportsmedicine, Volume 40, Issue 4, November 2012, ISSN – 0091-3847 61
ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]
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05_Golightly.indd 61 12/28/12 11:18 AM
Golightly et al
62 © The Physician and Sportsmedicine, Volume 40, Issue 4, November 2012, ISSN – 0091-3847ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]
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05_Golightly.indd 62 12/28/12 11:18 AM
Exercise Programs for OA
© The Physician and Sportsmedicine, Volume 40, Issue 4, November 2012, ISSN – 0091-3847 63
ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]
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� ��� $PHULFDQ�$FDGHP\�RI�2UWKRSDHGLF�6XUJHRQV��The Burden of Mus-culoskeletal Diseases in the United States: Prevalence, Societal, and Economic Cost��5RVHPRQW�� ,/��$PHULFDQ�$FDGHP\�RI�2UWKRSDHGLF�6XUJHRQV�������
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05_Golightly.indd 63 12/28/12 11:18 AM
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64 © The Physician and Sportsmedicine, Volume 40, Issue 4, November 2012, ISSN – 0091-3847ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]
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05_Golightly.indd 64 12/28/12 11:18 AM
Exercise Programs for OA
© The Physician and Sportsmedicine, Volume 40, Issue 4, November 2012, ISSN – 0091-3847 65
ResearchSHARE®: www.research-share.com • Permissions: [email protected] • Reprints: [email protected]
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