Subject: Ottawa Panel Evidence-Based Clinical Practice Guidelines for Therapeutic Exercises and Manual Therapy in the Management of Osteoarthritis -- Ottawa Panel Members et al. 85 (9): 907 -- Physical Therapy

PHYS THER

Vol. 85, No. 9, September 2005, pp. 907-971

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Therapeutic Exercises and Manual Therapy in the Management of Osteoarthritis

Ottawa Panel Members

Ottawa Methods Group

Lucie Brosseau

University Research Chair in Evidence-Based Practice in Rehabilitation, Physiotherapy Program, School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada

George A Wells

Department of Epidemiology and Community Medicine, University of Ottawa

Peter Tugwell

Centre for Global Health, Institute of Population Health, University of Ottawa

Mary Egan

Occupational Therapy Program, School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa

Claire-Jehanne Dubouloz

Occupational Therapy Program, School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa

Lynn Casimiro

Physiotherapy Program, School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa

Vivian A Robinson

Centre for Global Health, Institute of Population Health

Lucie Pelland

Physiotherapy Program, School of Rehabilitation Sciences, Queen' University, Kingston, Ontario, Canada

Jessie McGowan

Medical Library, Centre for Global Health, Institute of Population Health, University of Ottawa

Maria Judd

Canadian Physiotherapy Association, Ottawa, Ontario, Canada

Sarah Milne

Department of Epidemiology and Community Medicine, University of Ottawa

External Experts

Mary Bell

Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada

Hillel M Finestone

Sisters of Charity of Ottawa Health Service, Ottawa, Ontario, Canada

France Légaré

University of Laval, Québec City, Québec, Canada

Catherine Caron

Sisters of Charity of Ottawa Health Service

Sydney Lineker

The Arthritis Society, Ontario Division, Research Co-ordinator, Toronto, Ontario, Canada

Angela Haines-Wangda

Ottawa Hospital, General Campus, Ottawa, Ontario, Canada

Marion Russell-Doreleyers

Canadian Physiotherapy Association and Ottawa Arthritis Rehabilitation and Education Program, Ottawa, Ontario, Canada

Martha Hall

Canadian Association of Occupational Therapists and Ottawa Arthritis Rehabilitation and Education Program

Gerry Arts

person with osteoarthritis (named with her written permission)

Assistant Manuscript Writer

Marnie Lamb

School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa

Address all correspondence and requests for reprints to: Lucie Brosseau, PhD, Physiotherapy Program, School of Rehabilitation Sciences, Faculty of Health Sciences, 451 Smyth Rd, University of Ottawa, Ottawa, Ontario, Canada K1H 8M5 (Lucie.Brosseau@uottawa.ca)

 
Background and Purpose. Osteoarthritis (OA) affects a large and growing proportion of the population. The purpose of this project was to create guidelines for the use of therapeutic exercises and manual therapy in the management of adult patients (>18 years of age) with a diagnosis of OA. All stages of the disease were included in the analysis, and studies of patients who had recent surgery or other rheumatologic, musculoskeletal, or spinal problems or of subjects without known pathology or impairments were excluded. Methods. The Ottawa Methods Group used Cochrane Collaboration methods to find and synthesize evidence from comparative controlled trials and then asked stakeholder groups to nominate representatives to serve on a panel of experts. The Ottawa Panel agreed on criteria for grading the strength of the recommendations and their supporting evidence. Of the 609 potential articles on therapeutic exercises for OA that were identified, 113 were considered potentially relevant, and 26 randomized controlled trials and controlled clinical trials were ultimately used. Results. Sixteen positive recommendations of clinical benefit were developed for therapeutic exercises, especially strengthening exercises and general physical activity, particularly for the management of pain and improvement of functional status. Manual therapy combined with exercises also is recommended in the management of patients with OA. Discussion and Conclusion. The Ottawa Panel recommends the use of therapeutic exercises alone, or combined with manual therapy, for managing patients with OA. There were a total of 16 positive recommendations: 13 grade A and 3 grade C+. The Ottawa Panel recommends the use of therapeutic exercises because of the strong evidence (grades A, B, and C+) in the literature.

Key Words: Clinical practice guidelines • Epidemiology • Evidence-based practice • Osteoarthritis • Physical rehabilitation • Rheumatology

 
Osteoarthritis (OA) affects a large proportion of the population. Its prevalence is increasing dramatically as the populations of industrialized countries age and the baby boomers enter older adulthood.1 It has been estimated that the prevalence will increase in the United States from 43 million in 1997 to 60 million in 2020.2 Similarly, in Canada, an increase from 2.9 in 1991 to 6.5 million in 2033 (a 124% increase) is expected.3 Osteoarthritis is recognized as a substantial source of disability with significant social and financial costs due to surgical and medical interventions and frequent absenteeism from work.1^,4 In 1994, the total cost for arthritis and rheumatism in Canada was estimated to be between Can $4.3 billion and $7.3 billion,5 and the estimated medical expenses (excluding cost of time lost from paid or unpaid work) were estimated to be between Can $1.7 billion and $2.5 billion.6

Efficiency and efficacy of rehabilitation interventions in OA management have an obvious bearing on the direct and indirect costs of the disease. The development of evidence-based clinical practice guidelines (EBCPGs) will assist patients and clinicians in maximizing their rehabilitative efforts. Evidence-based clinical practice guidelines are systematically developed statements to help practitioners and clients choose proper health care for specific clinical circumstances7 and can improve both a patient's health outcomes and the process of care.8 A rapid and exponential growth in evidence-based clinical practice guideline (EBCPG) development has been observed in the last decade and may have resulted in several occasions of conflicting guidelines on the same topic.9^,10 These inconsistencies are attributed to variations in EBCPG development processes and quality.9^,11^,12 Several authors10^,13^,14 have recommended that all EBCPGs be assessed in a systematic manner using a standardized appraisal tool.

The Ottawa Panel was convened to evaluate the strength of the scientific evidence on the efficacy of therapeutic exercises (TE) for patients with OA. A previous and similar article, using the rigorous methodology,15 was written by the Ottawa Panel on rheumatoid arthritis (RA).16 The Ottawa Panel also is preparing EBCPGs on the use of TE, electrotherapy, and thermotherapy modalities and on patient education and splinting and orthosis for patients with OA. In this article, the Ottawa Panel considers various types of TE: specific strengthening exercises, general physical activity, and manual therapy combined with exercises.

Several systematic reviews and meta-analyses on the effectiveness of TE for patients with OA have been published in the scientific literature, demonstrating a strong interest in this intervention. Two meta-analyses using Cochrane Collaboration methods have been conducted for the management of patients with OA: the effectiveness of exercise for managing patients with hip and knee OA17 and the ideal intensity of exercise for OA management.18 Of 3 systematic reviews on the effectiveness of exercise for managing patients with OA, one was published a few years ago in a scientific journal19 and 2 were completed more recently and focused on the efficacy of strengthening exercises20 and fitness exercises.21 Eight other reviews22^–29 exist on TE for arthritis. Several of these reviews need updating, were not systematic, or were not specific to OA. Nevertheless, all of these reviews unanimously agreed that TE are beneficial for patients with OA, depending on the type and application of exercises (eg, strengthening, fitness, or combination of manual therapy and exercise), the outcomes, the specific joint affected, and the stage of the disease. To our knowledge, no reviews are available on manual therapy (alone or combined with exercises); only one randomized controlled trial (RCT) has been published on this topic.30

Several EBCPGs are available for the management of patients with OA using TE.31^–36 These EBCPGs have been developed mainly for medical and surgical interventions and are often not precise regarding rehabilitation interventions. Only British Medical Journal34 has published recommendations on exercise, but they were based on existing systematic reviews that had not been recently updated (Appendix 1). All of the aforementioned EBCPGs are generally flawed. The authors did not use a systematic literature search to find the studies that ultimately formed the basis of the EBCPGs, and although the authors reviewed the scientific results of each study, they did not synthesize the studies. The guidelines were developed for limited clinical practice areas. Although the EBCPGs were based on the current scientific literature, their authors used a nonstandardized approach to combine the scientific results; thus, the evidence of intervention efficacy is confusing, particularly in the presence of contradictory results. The authors also did not use a rigorous grading system to assess the evidence. Finally, with one exception, none of the guidelines have been updated recently. The Ottawa Panel is proposing more precise EBCPGs (involving specific joints, outcomes, periods of intervention, and disease stages) based on a rigorous quantitative method.15 We believe that various people could benefit from using our guidelines, including patients, physical therapists, rheumatologists, physiatrists, orthopedic surgeons, occupational therapists, and family physicians. Our aim in developing the guidelines was to advance the proper use of the interventions studied (in this article, TE and manual therapy).

 
For this project, we used the same methods15 as those of a previous study conducted by the Ottawa Panel on TE for patients with RA.16 Evidence from RCTs and observational studies were identified and synthesized using methods defined by the Cochrane Collaboration that minimize bias by using a systematic approach to literature search, study selection, data extraction, and data synthesis. At the start of our OA project, we defined an a priori protocol that was used for separate systematic reviews of trials relating to each intervention. The strength of evidence was graded as level I for RCTs or level II for nonrandomized studies. An expert panel developed a set of criteria for grading the strength of both the evidence and the recommendation. The Ottawa Panel decided that evidence of clinically important benefit (defined as a difference of more than 15% relative to a control based on panel expertise and empiric results) in patient-important outcomes was required for a recommendation. Statistical significance also was required but was insufficient alone. Patient-important outcomes were decided by consensus as being pain, functional status, patient global assessment (defined as "patient's assessment of overall disease activity or improvement"37), quality of life, and return to work, providing that these outcomes were assessed with a validated scale that yields reliable data.15

TARGET POPULATION

Studies of adult patients (>18 years of age) with classical or definite OA as defined by Klippel et al38 were included in our literature search. Patients with OA that affected peripheral joints were eligible to participate. Patients at different stages of the disease participated in the included clinical trials; some trials involved patients with both chronic and acute conditions. All stages of the disease were included in our analysis. The recommendations state the disease stage for which the intervention is most appropriate. If, however, the trial on which the recommendation was based did not mention disease stage, neither does our recommendation (Appendix 2). Most trials involved patients with chronic OA (>12 year' duration).

Various exclusion criteria were established:

• Studies of patients with OA involving spinal problems (excluded due to the numerous associated signs and symptoms and because the Philadelphia Panel guidelines for low back pain39 and neck pain40 were recently developed by the same methodologists); 
• Studies of patients who recently had surgery; 
• Patients with other rheumatologic or musculoskeletal problems (eg, fractures, tendinitis, or bursitis), clinically important medical problems, or psychiatric conditions that could hamper rehabilitation or reduce functional status; 
• Studies of subjects without known pathology or impairments; and 
• Studies of subjects with mixed arthritic conditions such as the sample in a study by D'Lima et al.41 

Table 1 lists the complete inclusion and exclusion criteria.

STUDY INCLUSION/EXCLUSION CRITERIA

Generally, comparisons of 2 active interventions (head-to-head studies) were excluded for the same reasons explained in the previous publication on the Ottawa Panel EBCPGs on RA.16 Examples of head-to-head studies include dynamic exercises versus isometric exercises,42 individual versus group exercises,43 home exercises versus aquatics,44 walking versus patient education,45 sham electrical stimulation versus patient education combined with TE,46 aerobics (walking) versus strengthening exercises,45^,47 and walking versus jogging in water.48 Some studies had several comparative groups, and only some of the group comparisons were eligible to be included.

Other excluded interventions comprised surgery, drug, or psychosocial (nonphysical) interventions. For instance, the RCTs on exercises after a total hip replacement for severe hip OA were excluded; RCTs with frequent use of continuous passive motion (CPM) following a total knee arthroplasty for severe knee OA49^–61 also were excluded. However, practitioners can refer to a recent meta-analysis on the efficacy of CPM combined with physical therapy versus physical therapy alone (n=799) following a total knee arthroplasty for knee OA62 to find further recommendations on these postsurgery interventions (grade A for flexion deformity and time to achieve 90 degrees of flexion and grade C+ for active knee flexion range of motion [ROM], pain related to analgesic use, and number of patients needing postoperative manual therapy). Postsurgery intervention studies usually allowed samples with varying proportions of patients with OA and RA. Most of the RCTs on efficacy of postsurgery interventions such as CPM recruited subjects with mixed arthritic conditions, which is the reason they are excluded in this article.

Subjects who received placebo, were untreated, or received routine conventional therapeutic approaches were acceptable control groups. If concurrent interventions (eg, electroanalgesia and medication) were provided to the experimental and control groups, these interventions were included. However, interventions where the patient acts as his or her own control were not included. A priori, we did not include or exclude studies based on the quality of their methods. However, we did consider quality when grading our recommendations.

The categories of interventions selected were approved by the Ottawa Panel according to the study's description of the intervention. Category selection also was influenced by previous work performed by the Ottawa Methods Group15 and by the Ottawa Panel on TE for patients with RA.16

 
Through a literature search (Appendix 3), 609 potential articles on TE and manual therapy for OA were identified. Based on the selection criteria checklist (Tab. 1), 113 studies were potentially relevant; 26 of these studies were ultimately included30^,42^,45^,47^,48^,63^–83 (Appendix 2). One of the 26 studies had a follow-up study, so we have counted these 2 studies as one, using the number of patients in the original study when calculating patient numbers (Appendix 2). The other trials were excluded for various reasons (Tab. 2).19^,32^,41^,43^,44^,46^,49^–61^,84^–153 The search identified 31 articles on manual therapy, 3 of which were initially seen as relevant.30^,122^,132 Only one article30 was included (Appendix 2).

It was not possible to pool data to develop the following EBCPGs. Each statement of recommendation represents one trial for a specific intervention (in terms of session/treatment duration and frequency) for a specific clinical outcome and a specific period of time. The included studies were gathered into general (ie, strengthening, general physical activity, combination of exercises) and more specific (eg, isometric, isotonic, isokinetic, eccentric, concentric, aerobic) types of TE according to the description by the trial investigators. The reader needs to refer to the tables of included studies to find more details about the characteristics of the therapeutic application of a specific TE included in the following EBCPGs.

THERAPEUTIC EXERCISES

EBCPGs Related to Strengthening Exercises

Lower-extremity (LE) strengthening versus control, level 1 (3 RCTs, n=103): grade A for pain getting up and down from floor and functional status (clinically important benefit); grade C+ for pain during walking, pain while climbing and descending stairs, arthritis activity, functional tasks, and quadriceps femoris muscle peak torque (clinically important benefit); grade C for stiffness, mobility, quadriceps femoris muscle force, muscle activation, and quality of life (no benefit). Patients with a diagnosis of OA of the knee.

Lower-extremity isometric strengthening versus control, level 1 (1 RCT, n=67): grade A for pain getting down to and up from floor (clinically important benefit); grade C+ for pain getting down and up stairs and timed functional tasks (clinical benefit); grade C for stiffness and functional status (no benefit). Patients with a diagnosis of OA of the knee.

Isotonic resistance training versus isotonic combined with isokinetic (Kinetron*) resistance training for quadriceps femoris and hamstring muscles, level 1 (1 RCT, n=15): grade C for quadriceps femoris muscle peak torque (no benefit). Patients with a primary diagnosis of OA of the knee.

Isotonic combined with isokinetic (Kinetron*) resistance training for quadriceps femoris and hamstring muscles versus control, level 1 (1 RCT, n=18): grade C for muscle force (no benefit). Patients with primary diagnosis of OA of the knee.

Eccentric resistance training (Cybex*) for quadriceps femoris and hamstring muscles versus control, level 1 (1 RCT, n=17): grade C for muscle force (no benefit). Patients with primary diagnosis of OA of the knee.

Concentric resistance training for quadriceps femoris and hamstring muscles versus control, level 1 (1 RCT, n=15): grade A for pain at rest and during activities (clinically important benefit); grade C for global functional status (no benefit). Patients with knee OA bilaterally and grade II or III OA.

Concentric-eccentric resistance training for quadriceps femoris and hamstring muscles versus control, level 1 (1 RCT, n=14): grade A for pain at rest and during specific functional activities: 15-m walk and stair climbing/descending time (clinically important benefit). Patients with knee OA bilaterally and grade II or III OA.

Home strengthening program for quadriceps femoris muscle versus control, level 1 (1 controlled clinical trial [CCT], n=53): grade A for pain, functional status, energy level, and ROM in flexion (clinically important benefit); grade C for physical mobility, muscle force, swelling, and exercise (no benefit). Patients with OA of the knee.

General LE exercise program (including muscle force resistance, flexibility, and mobility/coordination) versus control, level 1 (8 RCTs, n=876): grade A for pain at night and ability on stairs (clinically important benefit); grade C for knee flexion ROM, muscle force, knee joint position sense, kinesthesia, stance, gait, functional status, quality of life, muscle activation, stiffness, and physical activity (no benefit). Patients with a diagnosis of OA.

Progression versus no-progression LE strengthening exercises, level 1 (1 RCT, n=179): grade A for pain at rest and ROM (clinically important benefit); grade C for stiffness and functional status (no benefit). Patients with radiographic evidence of OA in the tibiofemoral compartment.

Hand strengthening versus control, level 1 (1 RCT, n=40): grade A for pain and grip force (clinically important benefit). Patients who met the American College of Rheumatology criteria for hand OA.154

EBCPGs Related to General Physical Activity, Including Fitness and Aerobic Exercises

Whole-body functional exercise versus control, level 1 (4 RCTs, n=864): grade A for pain and functional status (mobility, walking, work, disability in activities of daily living [ADL]) (clinically important benefit); grade C for knee flexion ROM, quadriceps femoris muscle force, hamstring muscle force, gait, stair climbing time, climbing self-efficacy, and quality of life (no benefit). Patients with OA of the knee.

Walking program versus control, level 1 (6 RCTs, n=711): grade A for pain, functional status, stride length, disability transferring from bed, disability bathing, aerobic capacity, exercise endurance, energy level, physical activity, and sleep (clinically important benefit); grade C+ for disability in ADL (clinical benefit); grade C for walking speed, disability toileting, disability dressing and stairs, morning stiffness, and quality of life (no benefit). Patients with OA.

Jogging in water versus control, level 1 (1 RCT, n=79): grade A for physical activity (clinically important benefit); grade C for walking time, morning stiffness, pain, grip force, trunk ROM, functional status, and exercise endurance (no benefit). Patients with current symptoms of chronic pain and stiffness in involved weight-bearing joints.

Water exercises versus control, level 1 (1 RCT, n=30): grade C for hip and shoulder abduction torque and ROM (no benefit). Patients with OA or RA diagnosed by a rheumatologist or an orthopedic physician.

Yoga versus control, level 1 (1 RCT, n=30): grade A for pain during activity and ROM (clinically important benefit); grade C for tenderness, grip force, swelling, and hand function (no benefit). Patients with OA of the distal interphalangeal or proximal interphalangeal joints of the fingers.

EBCPGs Related to the Combination of Exercises

Manual therapy combined with exercise versus control, level 1 (1 RCT, n=83): grade A for pain (clinically important benefit); grade C for 6-minute walk distance (no benefit). Patients with a diagnosis of OA.

SUMMARY OF TRIALS

Twenty-nine trials (n=2,486 patients) evaluated different types of TE for managing OA-affected joints of the upper extremities and LEs. Most of the trials compared these exercises with a control, but the trials examined different kinds of TE. The strengthening exercise trials were as follows: LE strengthening (n=345),42^,70^,71^,79 LE isometric strengthening (n=102),42 isotonic resistance training versus isotonic combined with isokinetic (Kinetron) resistance training for the knee (n=32),70 isotonic combined with isokinetic (Kinetron) resistance training for the knee (n=32),70 eccentric resistance training (Cybex) for the knee (n=32),70 concentric resistance training for the knee (n=23),67 concentric-eccentric resistance training for the knee (n=23),67 home program strengthening for the knee (n=81),47 general LE exercise program (including muscle force, flexibility, and mobility/coordination) (n=490),64^,65^,68^,77^,78^,82^,83 progression in LE strengthening exercises versus no progression (n=179),75 and home program hand strengthening (n=40).80

Several RCTs examined general physical activities, including fitness and aerobic exercises, such as whole-body functional exercises (n=864),45^,63^,72^,73^,76 walking program (n=1,089),45^,47^,48^,69^,73^,74^,76 jogging in water (n=115),48 water exercise (n=30),81 and yoga (n=30).66 One trial was related to the combination of manual therapy and exercises (n=83).30

Twenty-three included trials were RCTs42^,45^,47^,48^,63^–67^,69^–76^,78^,80^–83 and 3 trials were CCTs47^,68^,77 (Appendix 2). We used the Jadad scale to decide whether a study was an RCT or a CCT.15

The trials examined 2 basic types of exercises. The first type involved strengthening exercises, such as resistance isometric, stretching, eccentric, and concentric exercises; these exercises were specific to different muscles. The other type focused on whole-body functional strengthening programs and included aerobic conditioning and general fitness. Program duration, treatment schedule for exercise intervention, and length of exercise session varied from 4 weeks64 to 18 months45^,73^,76 for program duration, from once a week66 to 10 times a day80 (depending on the phase of the program) for treatment schedule, and from 5 minutes to longer per exercise session (length of exercise session increased depending on tolerance)74 (Appendix 2).

STRENGTHENING EXERCISES

Lower-extremity strengthening versus control (4 RCTs, n=345),42^,70^,71^,79 showed clinical benefits for pain during walking, pain ascending and descending the stairs, quadriceps femoris muscle peak torque, and timed functional tasks (Tab. 3). Statistically significant differences were found for pain (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]; Fig. 1a), pain while getting up from the floor (weighted mean differ-ence [WMD]=–2.36, 95% confidence interval [CI]=–4.22 to –0.50; Fig. 1a), and functional status (Tab. 3). However, other outcomes were not statistically significant. Outcomes were measured at the end of intervention (4 months for Topp et al42 and 8 weeks for Kreindler et al70 and Schilke et al79) or at follow-up (6 weeks for Kreindler et al70) (Figs. 1a–f).

For LE isometric strengthening versus control (1 RCT, n=102),42 clinical benefits were found for pain getting down and up from the floor, pain while going up and down stairs, and timed functional tasks but not for stiffness and functional status (Tab. 4). Statistically significant differences were found for pain while getting down to the floor (WMD=–2.05, 95% CI=–3.62 to –0.48) and up from the floor (WMD=–2.14, 95% CI=–4.01 to –0.27). Stiffness, functional limitation, pain, time to get down to the floor and to get up, and time to go up and down the stairs were not considered to be clinically important benefits at 4 months (Figs. 2a–d).

One trial (RCT, n=32)70 showed no statistically significant difference or clinically important benefit for quadriceps femoris muscle peak torque in patients with OA either at the end of a 6-week intervention or at a 6-week follow-up. This trial compared isokinetic resistance training versus isotonic and isokinetic (Kinetron) resistance training for the knee (Fig. 3), resistance training and Kinetron versus control (Fig. 4), and eccentric resistance training (Cybex) for the knee versus control (Fig. 5).

Statistically significant differences favored concentric exercises over control (1 RCT, n=23)67 for pain (WMD=–17.7, 95% CI=–22.79 to –12.61) and functional status (WMD=–10.85, 95% CI=–21.34 to –0.36) at 8 weeks (Figs. 6 and 7). A clinically important benefit was observed for pain (Tab. 5) but not for functional status.

For concentric-eccentric versus control (1 RCT, n=23),67 clinically important benefits and statistically significant differences were observed for pain (WMD=–11.40, 95% CI=–17.95 to –4.85) (Tab. 6, Fig. 8) and functional status (WMD=–12.15, 95% CI=–22.67 to –1.63) (Tab. 6) at 8 weeks. Results for 15-m walk, stair-climbing time, and stair-descending time also were significant, as were results for pain at night, pain sitting, pain rising from a chair, pain standing, and pain climbing stairs (Tab. 6).

One CCT examined home program strengthening for knee versus control (n=81)47 and showed clinically important benefits for pain, functional status, energy level (Tab. 7), and ROM (results not shown) but not for physical mobility (Tab. 7). Statistically significant data were found for WOMAC–pain (WMD=3.00, 95% CI=1.58 to 4.42), visual analog scale (VAS)–pain (WMD=3.30, 95% CI=2.62 to 3.98), WOMAC physical function index (WMD=9.90, 95% CI=8.08 to 11.72), Nottingham Health Profile (NHP)–pain (WMD=10.60, 95% CI=8.90 to 12.30), NHP–energy (WMD=15.90, 95% CI=14.87 to 16.93), NHP–physical mobility (WMD=7.10, 95% CI=4.14 to 10.06), NHP–sleep (WMD=3.40, 95% CI=0.89 to 5.91) (Figs. 9a–c, all at follow-up of 6 months), swelling (WMD=12.5, 95% CI=5.51 to 19.49), and ROM (WMD=19.5°, 95% CI=5.69° to 33.31°) (results not shown). However, no statistically significant difference was observed for muscle force or exercise tolerance (results not shown). No clinically important effects were found for muscle force, swelling, or exercise tolerance.

Several trials examined general LE exercise programs (including muscle force, flexibility, and mobility/coordination) versus control (7 RCTs, n=690).64^,65^,68^,77^,78^,82^,83 Important benefits were demonstrated for pain intensity and ability to step down but not for ROM, muscle force, gait, functional status, quality of life (Tabs. 8 and 9), knee joint position at 6 weeks (Fig. 10f), or muscle activation at 6 weeks (Fig. 10b). Statistically significant differences were found for the following outcomes:

• ROM in knee flexion, most affected knee at 10–12 weeks (WMD=10.00°, 95% CI=5.91° to 14.09°) (Fig. 10a); 
• ROM in knee flexion, least affected knee at 10–12 weeks (WMD=10.00°, 95% CI=7.75° to 12.25°) (Fig. 10a); 
• ROM in knee flexion, least affected knee at 12-month follow-up (WMD=12.00°, 95% CI=7.06° to 16.94°) (results not shown); 
• isometric quadriceps femoris muscle force at 6 weeks (WMD=73 N, 95% CI=25.75 to 120.25 N) (Fig. 10b); 
• quadriceps femoris muscle voluntary activation at 6 weeks (WMD=14.0%, 95% CI=5.87% to 22.13%) (Fig. 10b); 
• aggregate functional performance time at 6 weeks (WMD=–8.47, 95% CI=–16.79 to –0.15) (Fig. 10d); 
• functional status at 6 weeks (WMD=–3.50, 95% CI=–4.94 to –2.06) (Fig. 10d); 
• mean change in physical function score at 3-month follow-up (WMD=–3.54, 95% CI=–6.04 to –1.04) (Fig. 10d); 
• mean change in WOMAC-pain at 8 weeks (WMD=–12.10, 95% CI=–14.24 to –9.96) (Fig. 10e); 
• mean change in pain at 10 to 12 weeks (WMD=–17.10, 95% CI=–29.99 to –4.21) (Fig. 10e); 
• mean change in global pain score at 6-month follow-up (WMD=–1.87, 95% CI=–2.76 to –0.98) (Fig. 10e); 
• mean change in pain (VAS), walking at 10 to 12 weeks (WMD=–7.07, 95% CI=–13.90 to –0.24) (Fig. 10e); 
• mean change in pain (VAS), stairs (WMD=–10.42, 95% CI=–18.58 to –2.26) (results not shown); 
• pain at night at 12-month follow-up (WMD=–4.00, 95% CI=–5.94 to –2.06) (Fig. 10e); 
• pain at rest at 10 to 12 weeks (WMD=–1.50, 95% CI=–2.80 to –0.20) (Fig. 10e); 
• pain on weight bearing at 10 to 12 weeks (WMD=–2.00, 95% CI=–3.02 to –0.98) (Fig. 10e); 
• mean change in isometric knee extensor muscle force at 8 weeks (WMD=13.20 N, 95% CI=11.96 to 14.44 N) (Fig. 10g); 
• mean change in isometric knee flexor muscle force at 8 weeks (WMD=9.00 N, 95% CI=8.04 to 9.96 N) (Fig. 10g); 
• mean change in fast speed at 8 weeks (WMD=6.70 cm/s, 95% CI=6.34 to 7.06 cm/s) (Fig. 10h); 
• mean change in fast cadence at 8 weeks (WMD=1.60 steps/min, 95% CI=1.40 to 1.80 steps/min) (Fig. 10h); 
• mean change in fast stride length at 8 weeks (WMD=4.30 cm, 95% CI=3.99 to 4.61 cm) (Fig. 10h); 
• quality of life measured with Medical Outcomes Study 36-Item Short-Form Health Survey questionnaire (SF–36) at 8 weeks (WMD=3.10, 95% CI=2.76 to 3.44) (Fig. 10i); 
• mean change in WOMAC-function at 8 weeks (WMD=–7.80, 95% CI=–8.48 to –7.12) (Fig. 10k); 
• improvement in self-reported disability at 24-week follow-up (WMD=–1.10, 95% CI=–1.91 to –0.29) (Fig. 10k); 
• mean change in left quadriceps femoris muscle force at 6-week follow-up (WMD=10.86%, 95% CI=3.15% to 18.57%) (results not shown); and 
• mean change in SF-36-physical function at 8 weeks (results not shown). 

No statistically significant data were found for the remaining outcomes: ROM in knee extension and flexion (Fig. 10a); improvement in hip and knee ROM at 24-week follow-up (Fig. 10a); improvement in knee or hip muscle force at 24-week follow-up (Fig. 10c); Health Status Survey (HSS) score (Fig. 10d); pain, pain during walking, and pain at night at 10 to 12 weeks (Fig. 10e); knee joint position sense at 6 weeks (Fig. 10f); peak torque of the knee extensors and flexors at 10 to 12 weeks (Fig. 10g); step frequency and stride length at 10 to 12 weeks (Fig. 10h); stance at 10 to 12 weeks or at 12-month follow-up for most affected and least affected LEs (Fig. 10j); walking speed and stair-climbing time at 10 to 12 weeks or at 12-month follow-up (Fig. 10l); Algofunctional Index–pain at 10 to 12 weeks or at 12-month follow-up (Fig. 10m); improvement in physical activity at 10 to 12 weeks (Fig. 10n); and ability to step down (Fig. 10o).

For progression versus no-progression LE strengthening exercises (one RCT, n=179),75 clinical benefits (Tab. 10) and statistically significant differences were found for ROM in knee flexion (WMD=13°, 95% CI=11.55° to 14.45°) and pain at rest (WMD=–23 mm, 95% CI=–24.03 to –21.97). No important differences were found for WOMAC–stiffness, WOMAC–pain, or pain after walk test. Outcomes were measured after 8 weeks (Figs. 11a–c).

Hand strengthening versus control (one RCT, n=40)80 showed clinically important benefits for pain and grip force at 3 months (Tabs. 11 and 12, Figs. 12a–b). Statistically significant differences were found for pain (WMD=7.43, 95% CI=1.78 to 31.04) and change in grip force in the right hand (WMD=0.11, 95% CI=0.09 to 0.13) and the left hand (WMD=0.10, 95% CI=0.09 to 0.11) (Fig. 12b).

GENERAL PHYSICAL ACTIVITIES, INCLUDING FITNESS AND AEROBIC EXERCISES

For whole-body functional exercise versus control (5 RCTs, n=864),45^,63^,72^,73^,76 clinically important benefits were found for pain and functional status (mobility, walking, work, and disability on ADL). Statistically significant differences were found for numerous outcomes:

• pain frequency in transfer at 9 months (WMD=0.88, 95% CI=0.49 to 1.27) (Fig. 13a); 
• pain intensity in transfer at 3 months (WMD=–0.94, 95% CI=–1.33 to –0.55), at 9 months (WMD=–0.46, 95% CI=–0.84 to –0.08), and at 18 months (WMD=–0.37, 95% CI=–0.70 to –0.04) (Fig. 13a); 
• pain (WMD=–0.80, 95% CI=–1.29 to –0.31) (Fig. 13b); 
• functional status measured with the Arthritis Impact Measurement Scales (AIMS) (WMD=5.49, 95% CI=3.92 to 7.06) (results not shown); 
• functional status measured with the Arthritis Impact Measurement Scales 2 (AIMS2): arthritis pain (WMD=–0.85, 95% CI=–1.52 to –0.18) (Fig. 13b); 
• functional status measured with AIMS2: mobility level at 12 weeks (WMD=–0.50, 95% CI=–0.93 to –0.07) favoring the control group (Fig. 13c); 
• functional status measured with AIMS2: walking and bending at 12 weeks (WMD=–1.25, 95% CI=–2.08 to –0.42) (Fig. 13c); 
• functional status measured with AIMS2: level of tension at 12 weeks (WMD=2.58, 95% CI=1.88 to 3.28) (Fig. 13c); 
• hamstring muscle and low back flexibility at 12 weeks (WMD=3.63 in, 95% CI=2.04 to 5.22 in) (Fig. 13d); 
• 5-minute walk test at 12 weeks (WMD=42.19 m, 95% CI=14.19 to 70.19 m) (Fig. 13e); 
• hamstring muscle isometric torque at 30 degrees: most affected LE at 12 weeks (WMD=8.85 N·m, 95% CI=1.91 to 15.79 N·m) (Fig. 13f); 
• hamstring muscle isometric torque at 30 degrees: least affected LE at 12 weeks (WMD=10.51 N·m, 95% CI=3.24 to 17.78 N·m) (Fig. 13f); 
• quadriceps femoris muscle isometric torque at 60 degrees: most affected LE at 12 weeks (WMD=19.80 N·m, 95% CI=4.75 to 34.85 N·m) (Fig. 13f); 
• quadriceps femoris muscle isometric torque at 60 degrees: least affected LE at 12 weeks (WMD=17.03 N·m, 95% CI=1.08 to 32.98 N·m) (Fig. 13f); 
• hamstring muscle isometric torque at 60 degrees: most affected LE at 12 weeks (WMD=8.02 N·m, 95% CI=0.88 to 15.16 N·m) (Fig. 13f); 
• hamstring muscle isometric torque at 60 degrees: least affected LE at 12 weeks (WMD=10.99 N·m, 95% CI=3.68 to 18.30 N·m) (Fig. 13g); 
• hamstring muscle isokinetic torque at 30°/s: most affected LE at 12 weeks (WMD=10.98 N·m, 95% CI=0.38 to 21.58 N·m) (Fig. 13g); 
• hamstring muscle isokinetic torque at 30°/s: least affected LE at 12 weeks (WMD=10.51 N·m, 95% CI=3.24 to 17.78 N·m) (Fig. 13g); 
• hamstring muscle isokinetic torque at 90°/s: most affected LE at 12 weeks (WMD=9.73 N·m, 95% CI=–1.40 to 20.86 N·m) (Fig. 13g); 
• cadence at 3 months (WMD=0.87 steps/min, 95% CI=0.33 to 1.41 steps/min) (Fig. 13h), at 9 months (WMD=0.94 steps/min, 95% CI=0.37 to 1.51 steps/min), and at 18 months (WMD=2.08 steps/min, 95% CI=1.56 to 2.60 steps/min) (results not shown); 
• stride length at 3 months (WMD=2.17 cm, 95% CI=1.18 to 3.16 cm), at 9 months (WMD=2.84 cm, 95% CI=1.77 to 3.91 cm), and at 18 months (WMD=6.49 cm, 95% CI=5.49 to 7.49 cm) (Fig. 13i); 
• walking speed at 3 months (WMD=3.77 cm/s, 95% CI=2.60 to 4.94 cm/s), at 9 months (WMD=4.37 cm/s, 95% CI=3.12 to 5.62 cm/s), and at 18 months (WMD=7.79 cm/s, 95% CI=6.60 to 8.98 cm/s) (Fig. 13j); 
• stance time at 3 months (WMD=–0.01 s, 95% CI=–0.01 to –0.01 s) and at 18 months (WMD=–0.02 s, 95% CI=–0.02 to –0.02 s) (Fig. 13k); 
• percentage of swing at 3 months (WMD=0.39, 95% CI=0.18 to 0.60), at 9 months (WMD=–0.36, 95% CI=–0.59 to –0.13), and 18 months (WMD=0.54, 95% CI=0.32 to 0.76) (Fig. 13k); 
• stair-climbing time at 18 months (WMD=–1.92 s, 95% CI=–2.01 to –1.83 s) (Fig. 13l); 
• climbing self-efficacy score at 18 months (WMD=9.32, 95% CI=8.86 to 9.78) (Fig. 13l); 
• quality of life (WMD=3.10, 95% CI=2.97 to 3.23) (results not shown); and 
• disability in bathing (WMD=0.41, 95% CI=0.18 to 0.91) (results not shown). 

No clinically important benefits were found for quadriceps femoris and hamstring muscle force at 12 weeks (Figs. 13a–b), knee flexor ROM, gait, or quality of life (results not shown). No statistical data were found for pain intensity and frequency in ambulation at 3, 9, and 18 months (Fig. 13a); pain frequency in transfer at 9 and 18 months (Fig. 13a); AIMS2 hand and finger functional status, arm functional status, self-care tasks, household tasks, social activity, support from friends, work, or mood at 12 weeks (Fig. 13c); quadriceps femoris muscle isometric and isokinetic torque at 30 degrees (Figs. 13f–g), quadriceps femoris muscle isokinetic torque at 90 degrees (Fig. 13g), or hamstring muscle isokinetic torque at 90 degrees (Fig. 13g), all at 12 weeks; stance time at 9 months (Fig. 13k); or incidence of disability in ADL, disability in transferring from a bed to a chair, disability in toileting, disability in dressing and eating, or quality of life measured by HSS score (results not shown).

Six RCTs and 1 CCT examined walking versus control (n=1,089),45^,47^,48^,69^,73^,74^,76 and trials discovered clinical benefits for pain, functional status, stride length, disability transferring from bed, disability bathing, disability in ADL, energy level, medication use, aerobic capacity, and quality of life (Tabs. 13 and 14). No clinical benefits were found for walking speed (Tab. 13), pain in ambulation (results not shown), disability toileting, or disability dressing (Fig. 13e, both at 18-month follow-up). Statistically significant results were shown for the following outcomes:

• pain frequency in ambulation at 3 months (WMD=–0.56, 95% CI=–1.07 to –0.05) and in transfer (WMD=–0.42, 95% CI=–0.77 to –0.07) (results not shown); 
• pain intensity in transfer at 3 months (WMD=–0.55, 95% CI=–1.02 to –0.08), at 9 months (WMD=–0.46, 95% CI=–0.84 to –0.08), and at 18 months (WMD=–0.41, 95% CI=–0.76 to –0.06) (results not shown); 
• NHP-physical mobility, –pain, –energy, and –sleep (Tab. 13); 
• WOMAC-physical function and –pain (Tab. 13); 
• VAS-pain (Tab. 13); 
• walking speed at 3 months (WMD=3.69 cm/s, 95% CI=2.47 to 4.91 cm/s), at 9 months (WMD=10.29 cm/s, 95% CI=9.05 to 11.53 cm/s), and at 18 months (WMD=10.29 cm/s, 95% CI=9.07 to 11.51 cm/s) (Tab. 13); 
• cadence at 3 months (WMD=3.56 steps/min, 95% CI=3.00 to 4.12 steps/min), at 9 months (WMD=3.69 steps/min, 95% CI=3.12 to 4.26 steps/min), and at 18 months (WMD=3.77 steps/min, 95% CI=3.21 to 4.33 steps/min) (Tab. 13); 
• stance time at 3 months (WMD=–0.04 s, 95% CI=0.04 to –0.04 s), at 9 months (WMD=–0.03 s, 95% CI=–0.03 to –0.03 s), and at 18 months (WMD=–0.03 s, 95% CI=–0.03 to –0.03 s) (results not shown); 
• percentage of swing at 3 months (WMD=0.86, 95% CI=0.64 to 1.08) and at 18 months (WMD=0.54, 95% CI=0.32 to 0.76) (Tab. 13); 
• stride length at 9 months (WMD=7.53 cm, 95% CI=6.48 to 8.58 cm) and at 18 months (WMD=7.54 cm, 95% CI=6.52 to 8.56 cm) (Tab. 13); 
• climbing self-efficacy score at 18-month follow-up (WMD=8.00, 95% CI=7.55 to 8.45) (Fig. 14a); 
• 6-minute walk test at 8 weeks (WMD=111.50 m, 95% CI=76.24 to 146.77 m) (Fig. 14b); 
• stair-climbing time at 18-month follow-up (WMD=–1.41, 95% CI=–1.51 to –1.31) (Fig. 14c); 
• general health status at 18-month follow-up (WMD=3.59, 95% CI=3.46 to 3.72) (Fig. 14d); 
• incidence of disability at 18-month follow-up (WMD=0.52, 95% CI=0.28 to 0.96) (Fig. 14e); 
• disability in transferring from a bed to a chair at 18-month follow-up (WMD=0.42, 95% CI=0.22 to 0.79) (Fig. 14e); 
• disability in bathing (WMD=0.38, 95% CI=0.17 to 0.84) (Tab. 14) and in dressing at 18-month follow-up (WMD=0.28, 95% CI=0.10 to 0.83) (Fig. 14e); 
• fast speed at 8 weeks (WMD=15.00 m/min, 95% CI=6.53 to 23.47 m/min) (Fig. 14f); 
• fast stride at 8 weeks (WMD=0.20 m, 95% CI=0.03 to 0.37 m) (Fig. 14f); 
• free speed at 8 weeks (WMD=7.00 m/min, 95% CI=0.34 to 13.66 m/min) (Fig. 14g); 
• free stride at 8 weeks (WMD=0.20 m, 95% CI=0.08 to 0.32 m) (Fig. 14g); 
• AIMS-pain at 8 weeks (WMD=–1.00, 95% CI=–1.79 to –0.21) (Fig. 14i); 
• AIMS-physical activity at 8 weeks (WMD=–2.22, 95% CI=–3.25 to –1.19) (Tab. 13) and at 12 weeks (WMD=–1.30, 95% CI=–2.48 to –0.12) (Tab. 14, Fig. 14j); 
• AIMS-medication use (WMD=2.74, 95% CI=1.93 to 3.55) (Tab. 13); 
• 15.2-m (50-ft) walking time at 8 weeks (WMD=–2.00 s, 95% CI=–2.97 to –1.03 s) and at 12 weeks (WMD=–0.90 s, 95% CI=–1.71 to –0.09 s) (Fig. 14p for 12 weeks only); 
• exercise heart rate at 12 weeks (WMD=16.00 bpm, 95% CI=3.94 to 28.06 bpm) (Fig. 14s); 
• aerobic capacity at 12 weeks (WMD=5.10 mL/kg min^–1, 95% CI=2.88 to 7.32 mL/kg min^–1) (Fig. 14s); and 
• exercise endurance at 12 weeks (WMD=3.30 min, 95% CI=1.12 to 5.48 min) (Fig. 14). 

No statistically significant data were found for the following: pain intensity in ambulation (results not shown), pain frequency in ambulation at 9 and 18 months (results not shown), pain frequency in transfer at 9 and 18 months (results not shown), stride length (Tab. 13), disability in toileting and in eating at 18-month follow-up (Fig. 14e), fast cadence at 8 weeks (Fig. 14f), free cadence at 8 weeks (Fig. 14g), NHP-physical mobility and WOMAC-physical function at 6-month follow-up (Fig. 14h), AIMS-pain at 12 weeks and 9-month follow-up (Tab. 13, Fig. 14i), AIMS-physical activity at 9-month follow-up (Fig. 14j), AIMS-arthritis impact at 8 weeks (Fig. 14k), grip force at 12 weeks and 9-month follow-up (Fig. 14m), NHP-pain at 6-week follow-up (Fig. 14n), morning stiffness at 12 weeks and 9-month follow-up (Fig. 14o), 15.2-m (50-ft) walking time at 9-month follow-up (Fig. 14p), resting systolic blood pressure and resting diastolic blood pressure at 12 weeks and 9-month follow-up and exercise heart rate at 9-month follow-up (Fig. 14q), trunk flexibility at 12 weeks (Fig. 14r), and aerobic capacity and exercise endurance at 9-month follow-up (Fig. 14s).

Physical activity and aerobic capacity yielded clinically important benefits favoring jogging in water versus control (one RCT, n=115)48 (Tab. 15). However, no clinical benefits were shown for functional status (AIMS-physical activity) at 12 weeks (Tab. 15), pain at 12 weeks and 9-month follow-up (results not shown), morning stiffness at 12 weeks and 9-month follow-up (results not shown), trunk ROM at 12 weeks and 9-month follow-up (results not shown), exercise heart rate (Tab. 15), or exercise endurance at 12 weeks (Tab. 15). Statistically significant differences were found for AIMS-physical activity at 12 weeks (WMD=–1.20, 95% CI=–2.29 to –0.11) (Fig. 15a), 15.2-m (50-ft) walking time at 12 weeks (WMD=–1.10 s, 95% CI=–2.12 to –0.08 s) (Fig. 15e), exercise heart rate at 12 weeks (WMD=13.00 bpm, 95% CI=1.32 to 24.68 bpm) (Fig. 15f), exercise endurance at 12 weeks (WMD=2.80 min, 95% CI=0.23 to 5.37 min) (Fig. 15h), and aerobic capacity (WMD=5.90 mL/kg min1, 95% CI=3.30 to 8.50 mL/kg min1) (results not shown). AIMS-pain, morning stiffness, grip force, trunk flexibility, and resting blood pressure offered no statistically significant differences (results not shown for last). One RCT that compared water exercises with control (n=30)81 yielded no statistically significant differences and no clinical benefits for torque or ROM at 6 weeks (Figs. 16a–b).

For yoga versus control (one RCT, n=30),66 clinically important benefits were found for ROM and pain during activity at 6 weeks (Figs. 17b–c but not for tenderness, swelling, hand functional status, or grip force at 6 weeks (Figs. 17a, d, e, and f). Statistically significant data were found for mean change in tenderness of right hand (WMD=1.80, 95% CI=0.99 to 2.61) and left hand (WMD=1.73, 95% CI=0.63 to 2.83), mean change in pain during activity (WMD= –3.29, 95% CI=–5.30 to –1.28), and mean change in ROM of right hand (WMD=10.02, 95% CI=6.50 to 13.54), all at 6 weeks (Figs. 17a–c). No statistical data were found for mean change in hand pain at rest, mean change in ROM of left hand, mean change in circumference of the hands, mean change in hand functional status, or mean change in grip force of both hands (Figs. 17b–f).

MANUAL THERAPY COMBINED WITH THERAPEUTIC EXERCISES

One RCT (n=83)30 was found on manual therapy combined with exercises, and this RCT compared the intervention with a control. Important clinical benefits were demonstrated for pain but not functional status (Tab. 16). Statistically significant data were found for all the outcomes: 6-minute walk test at 4 weeks (WMD=81.90 m, 95% CI=22.85 to 140.95 m) and at 8 weeks (WMD=77.70 m, 95% CI=18.59 to 136.81 m) (Fig. 18a) and pain at 4 weeks (WMD=–416.00, 95% CI=–618.15 to –213.85) and at 8 weeks (WMD=–471.90, 95% CI=–732.81 to –210.99) (Fig. 18b).

STRENGTH OF PUBLISHED EVIDENCE COMPARED WITH OTHER GUIDELINES

Good evidence (level I, RCT) shows that various kinds of exercises and manual therapy are useful for patients with OA, with different outcomes occurring depending on the intervention: strengthening exercises relieve pain at rest and during functional activities and improve knee ROM, quadriceps femoris muscle peak torque, grip force, level of energy, and functional status; general physical activities, including fitness and aerobic exercises, relieve pain during functional activities and improve stride length, functional status, and aerobic capacity; and manual therapy combined with TE relieves pain.

Three sources have considered the strength of evidence: The Philadelphia Panel,36 American Pain Society,33 and Ontario Program for Optimal Therapeutics.35 All 3 sources reported good-quality evidence for TE, including strengthening exercises and general physical activities (Appendix 1). To our knowledge, the scientific literature offers no guidelines on manual therapy for patients with OA.

CLINICAL RECOMMENDATIONS COMPARED WITH OTHER GUIDELINES

The Ottawa Panel concluded that good evidence exists supporting the inclusion of all of the following main categories of interventions in the management of patients with OA: strengthening exercises (grade A for pain at rest and during functional activities, ROM, grip force, level of energy, and functional status; grade C+ for quadriceps femoris muscle peak torque, specific functional activities, and timed functional activities); general physical activities, including fitness and aerobic exercises (grade A for pain during functional activities, stride length, functional status, energy level, aerobic capacity, and medication use; grade C+ for disability in ADL); and manual therapy combined with exercises (grade A for pain). The recommendations related to strengthening exercises and general physical activities generally concur with all other existing guidelines.31^–36

PRACTITIONER' RESPONSE TO OTTAWA PANEL GUIDELINES

The 5 practitioners who reviewed our guidelines agreed with the recommendations. Four practitioners found the recommendations to be clear; 1 practitioner was uncertain which type of exercise was effective. The Ottawa Panel explained that, depending on the specific outcome, interventions with grade A, B, or C+ are beneficial. Guideline summaries (see evidence-based clinical practice guidelines in Appendix 4) were rewritten for better comprehension. A decision aid was created to clarify the application of the guidelines. This aid can be found on the University of Ottawa Web site (www.health.uottawa.ca/rehabguidelines).

 
The Ottawa Panel EBCPGs (grouped together in Appendix 4) were rigorously developed15^,16 using an extensive systematic review of TE (Figs. 1,                –18). Numerous grade A (n=13) and C+ (n=3) recommendations have been developed for TE for patients with OA. Various outcomes useful for rehabilitation practitioners and patients with OA were considered, such as pain, functional status, and quality of life. However, more evidence is needed to determine the efficacy of TE in the management of patients with OA. Evidence on the effectiveness of the specific type of muscle contraction to be used during resistance training, on water exercises, and on hip strengthening is lacking, as is indicated by the grade C recommendations for these interventions. No harmful side effects were reported.

 
Even though the Ottawa Panel EBCPGs on OA were developed using a rigorous methodology,15 similar methodological weaknesses were identified compared with the Ottawa Panel EBCPGs on RA.16 More precise characteristics of the therapeutic application (eg, dosage, type of exercise used, intensity, frequency) need to be reported by investigators to reproduce the exercise programs (eg, quadriceps femoris and hamstring muscle strengthening), especially when they were proven effective.76^,78

The Ottawa Panel EBCPGs for the management of patients with OA, however, were in concordance with Appraisal of Guidelines Research and Evaluation (AGREE) criteria155 and yielded results identical to those of the previous Ottawa Panel EBCPGs developed for RA16 (see University of Ottawa Web site [www.health.uottawa.ca/rehabguidelines]). Furthermore, the Ottawa Panel EBCPGs generally concur with previous and relatively recent EBCPGs31^–36 and systematic reviews for OA19^–29^,156 and fit entirely with the recommendations from the Work Group on physical activity.157^,158

 
The Ottawa Panel concluded that TE is beneficial for patients with OA. Benefits are recognized for pain at rest and during functional activities, knee ROM, quadriceps femoris muscle peak torque, grip force, stride length, level of energy, functional status, and aerobic capacity. Quality of life also was enhanced (statistical significance only) after an 8-week LE strengthening exercise program65 and 18 months after a walking program.76

Progressive exercises75 are promising prospects for OA patient management, but results were inconclusive regarding the ideal intensity of the exercise program.18 Results for RA, however, were conclusive, with low-intensity exercises being recommended for patients with RA.16

All 3 main categories of exercises and physical activity are widely used and are effective for the management of patients with OA. The efficacy of exercises is mainly based on the results of short-term RCTs, RCTs that are relatively good quality, considering that exercise is a physical intervention and thus blinding is an issue.159 Exercises and physical activity are promising interventions for reducing pain and improving functional status, aerobic capacity, and quality of life.47^,48^,67^,79 They also offer the potential to reduce body weight160 and to prevent biomechanical problems161^,162 and further joint damage in patients with OA.163

Information on the long-term effect of the exercise program and specifications of the therapeutic application (intensity and dosage) are lacking. Researchers believe that the long-term efficacy of exercises for patients with OA (with or without other interventions) is influenced by a variety of factors, including physiological, biomechanical, psychosocial, and environmental factors.161^,163^,164 Thus, researchers157^,158^,162^,165^,166 have suggested multidimensional clinical management of patients with OA due to the multivariate nature of the disease.

Patients with OA tend to adopt sedentary lifestyles.167 The main challenge is to find effective strategies to help these patients adopt and sustain regular physical activity habits so that they can benefit from the positive effects and avoid the negative consequences and vicious cycle of inactivity. Inactivity can lead to chronic comorbidity problems (eg, obesity, cardiovascular conditions, diabetes) that affect joint health, functional status, and quality of life in patients with OA.126^,168^,169 Change in lifestyle among patients with OA is necessary to promote sustained physical activity.164^,170 Fortunately, the level of participation in regular aerobic physical activity can be modified through behavioral interventions.171^–173

The identification of predisposing, enabling, and reinforcing factors174 for increasing the level of participation in regular physical activity and exercise is essential. Addressing these factors collectively may increase the likelihood of intrapersonal, interpersonal, and environmental changes that are desirable for sustaining a new behavior regarding TE and physical activity. Predisposing intrapersonal and interpersonal factors include psychological factors (eg, attitude, perceived behavioral control, self-efficacy, motivation, perceived health, expected benefits, depressive symptoms, fear of exercise and of experiencing pain, perceived stress and effort), biological factors (eg, comorbidities, body mass index, smoking status, functional capacity), and demographic factors (eg, age, sex, education). These characteristics may interact with the format of the program and ultimately will determine the success of the physical activity intervention. Enabling factors are factors that affect behavior directly or indirectly through an environmental indicator163^,175 and include the structure of the intervention program, the necessary physical activity skills and equipment, the format of the program (community-based versus clinical setting), the type and frequency of expert supervision and guidance provided, accessibility, time, weather, and the costs incurred by the participant. Reinforcing factors appear subsequent to the change in behavior and provide continuing reward or incentive for the new behavior to be maintained by the individual. Primary reinforcing factors include social support, health practitioner influence, peer influence, feedback from significant others, vicarious reinforcement, incentives, mastery, self-monitoring activity, goal attainment, and enjoyment of the activity. Reinforcing factors will ultimately determine whether the patient continues with the physical activity program and thus will have an impact on the long-term quality of life.

Future studies examining the benefits of TE programs in the management of patients with OA will need to identify an effective physical activity program, enhance a sustained physical activity program integrating behavioral interventions, be patient specific, develop a patient education program, and facilitate regular physical activity in the community.163 The Work Group recommends increasing the awareness of EBCPGs on exercise and physical activity programs among patients with arthritis, practitioners, health care administrators, educators, and policy makers.157

 
One study55 with an acceptable research design was identified. Yet, although the combination of manual therapy and exercise reduces pain in patients with OA, the specific effect of manual therapy could not be determined in that study. Indeed, the reduction of pain after exercise is observed in patients with arthritis in general.176^–178 In the study by Deyle et al,30 exercise may have contributed to the reduction of pain, but the magnitude was not measured. A recent head-to-head RCT110 that compared the relative efficacy of manual therapy compared with exercise therapy alone for hip OA showed that manual therapy was significantly more effective than TE for patient global assessment, pain, stiffness, functional status, and ROM after 5 weeks (9 consecutive treatment sessions). Considering these recent scientific results, further research is needed on the individual effects of manual therapy for patients with OA.

 
The Ottawa Panel has found evidence to recommend and support the use of TE (on their own or combined with manual therapy), especially strengthening exercises and general physical activity, for patients with OA, particularly for the management of pain and improvement of functional status. These recommendations are limited by methodological considerations, such as the relatively good quality, but generally poorly reported description, of TE programs and the selection of outcomes of the included primary trials.

 
This study was financially supported by The Arthritis Society (Canada) (Grant TAS-319); the Ontario Ministry of Health and Long-Term Care (Canada) (Grant HRPD-05225); the Career Scientist Salary Support Program (HRPD-05225), for Dr Brosseau; the University Research Chair Program, for research staff salary support for Dr Brosseau; the Centre National de Formation en Santé/Health Canada; and the Ministry of Human Resources, Summer Students Program, Government of Canada.

Acknowledgments: The Ottawa Panel is indebted to Ms Catherine Lamothe, Ms Gabriele Wieschollek, Ms Judith Robitaille, Ms Lucie Lavigne, Mr Michel Boudreau, Mr Guillaume Michaud, Ms Michelle Vaillant, Ms Chantal Lavoie, and Mr Guillaume Lemieux for their technical support and help in data extraction.

^* Cybex International Inc, 10 Trotter Dr, Medway, MA 02053.  

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