Review
A review of the clinical evidence for exercise in osteoarthritis of the hip and knee

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Abstract

Osteoarthritis (OA) is a chronic joint disease with the hip and knee being commonly affected lower limb sites. Osteoarthritis causes pain, stiffness, swelling, joint instability and muscle weakness, all of which can lead to impaired physical function and reduced quality of life. This review of evidence provides recommendations for exercise prescription in those with hip or knee OA. A narrative review was performed. Conservative non-pharmacological strategies, particularly exercise, are recommended by all clinical guidelines for the management of OA and meta-analyses support these exercise recommendations. Aerobic, strengthening, aquatic and Tai chi exercise are beneficial for improving pain and function in people with OA with benefits seen across the range of disease severities. The optimal exercise dosage is yet to be determined and an individualized approach to exercise prescription is required based on an assessment of impairments, patient preference, co-morbidities and accessibility. Maximising adherence is a key element dictating success of exercise therapy. This can be enhanced by the use of supervised exercise sessions (possibly in class format) in the initial exercise period followed by home exercises. Bringing patients back for intermittent consultations with the exercise practitioner, or attendance at “refresher” group exercise classes may also assist long-term adherence and improved patient outcomes. Few studies have evaluated the effects of exercise on structural disease progression and there is currently no evidence to show that exercise can be disease modifying. Exercise plays an important role in managing symptoms in those with hip and knee OA.

Section snippets

Background

This paper provides an overview of appropriate exercise intervention for the special needs of people with osteoarthritis (OA) of the hip or knee. It is beyond the scope of this paper to discuss exercise prescription for the prevention of OA or following joint replacement surgery. Instead, it will focus on exercise for the management of symptoms in those with established hip and knee OA and briefly mention the limited research into the effects of exercise on structural disease progression.

Role of exercise in treatment of hip and knee osteoarthritis

Given the large body of evidence demonstrating the beneficial clinical effects of exercise in people with lower limb OA varying in severity from mild to severe, exercise therapy is regarded as the corner-stone of conservative management for the disease.3, 4, 5 The main goals of exercise in this patient group are to reduce pain, improve physical function and optimize participation in social, domestic, occupational and recreational pursuits 5. Regular exercise can improve physiological

Exercise prescription – boundaries of evidence

There are a number of areas where evidence is limited or research has not been undertaken. Relative to knee OA, there is far less research on exercise for hip OA and findings from studies involving patients with knee OA cannot necessarily be directly extrapolated to the hip given differences in biomechanics, impairments, rapidity of progression and risk factors. Therefore, while current international treatment guidelines recommend therapeutic exercise for people with symptomatic hip OA,26, 27

Exercise prescription – recommendations

Recommendations for exercise prescription in those with hip or knee OA have been developed by Roddy et al.26 and are summarized in Table 1. Essentially exercise therapy should be individualized and patient-centred taking into account factors such as patient age, mobility, co-morbidities and preferences. An assessment of specific impairments such as strength, range of motion, aerobic fitness and balance is needed to determine the most appropriate exercise regime.

Type of exercise. There are

Special considerations

Safety. In general, exercise is safe and well tolerated by most people with lower limb OA including those with severe disease and there are few contraindications to exercise resulting from the OA per se although co-morbidities need to be considered. It is not uncommon for patients to experience some discomfort at the affected joint during exercise and patients should be advised that this is normal and does not indicate a worsening of their OA disease. Exercise practitioners should not adopt a

Summary

Exercise is a key component of the management of OA symptoms and has been shown to be beneficial for individuals with OA disease of all severities. Exercise practitioners play an important role in prescribing appropriate exercise for patients taking into account individual symptoms, problems and preferences. Encouraging exercise adherence behaviours and reinforcing healthy lifestyle habits will assist in optimizing outcomes from treatment. Furthermore, exercise programs should be combined with

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