Guideline for the management of knee and hip osteoarthritis

Recommendations

Exercise

Guideline for the management of knee and hip osteoarthritis
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Last revised: 01 Jul 2018

Non-pharmacological interventions 

Exercise


 

Land-based exercise – Knee

Recommendation

We strongly recommend offering land-based exercise for all people with knee osteoarthritis (OA) to improve pain and function, regardless of their age, structural disease severity, functional status or pain levels. Exercise has also been found to be beneficial for other comorbidities and overall health. 

We strongly recommend walking, muscle-strengthening exercise and Tai Chi. It may be appropriate to offer stationary cycling and/or Hatha yoga for some people with knee OA. Clinicians should prescribe an individualised exercise program, taking into account the person’s preference, capability, and the availability of resources and local facilities. Realistic goals should be set. Dosage should be progressed with full consideration given to the frequency, duration and intensity of exercise sessions, number of sessions, and the period over which sessions should occur.

Attention should be paid to strategies to optimise adherence. Referral to an exercise professional to assist with exercise prescription and to provide supervision either in person or remotely may be appropriate for some people. 

Strength of recommendation

Strong for recommendation  
(all land-based exercise, walking, musclestrengthening exercise, Tai Chi)

Conditional for recommendation
(stationary cycling, Hatha yoga)

Quality of evidence

Low
(landbased, Tai Chi)

Very low
(walking, muscle strengthening, stationary cycling, Hatha yoga)

What is it? 

This recommendation is specific to exercise performed on land for people with knee OA, including muscle strengthening, stretching/range of motion, aerobic conditioning, neuromuscular/balance, cycling, Tai Chi and yoga. Exercise dosage can vary in frequency, intensity and duration. Additionally, the exercise can involve expensive, specialised equipment, or no equipment at all; it can be delivered in a group setting or individually, either in-person or remotely via telephone or videoconference. 

Rationale 

There is low-quality evidence from a large number of randomised controlled trials (RCTs) that found that land-based exercise overall has significant and clinically relevant benefits for pain, function and quality of life in the short-to-medium term in people with knee OA (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). The benefits for pain and function are moderate in size, and are seen irrespective of the patients’ age, structural disease severity, pain levels and functional status. In addition to these benefits, other advantages of exercise include its benefits for comorbidities and overall health, and is readily available and cheap. There is evidence that long-term therapeutic exercise is safe and not associated with an increased risk of structural disease progression.80 There are various forms of land-based exercise that may be adopted for knee OA. The working group strongly recommended walking, muscle-strengthening exercise and Tai Chi, based on low-quality evidence of significant benefits for pain and function, accessibility of such exercise modes (often as community-based group programs), and identified impairments in muscle strength and functional ability in many people. Tai Chi was also recommended as it has additional benefits for balance and falls, thus may be particularly suitable for people in whom an increased risk of falling has been identified – something common among people with knee OA. 

The working group conditionally recommended stationary cycling and Hatha yoga based on very low-quality evidence from a limited number of RCTs (1 for cycling and 2 for Hatha yoga), with small samples sizes showing benefits for pain (stationary cycling and Hatha yoga) and function (Hatha yoga). However, Hatha yoga should only be considered as an adjunctive form of exercise, and only for short-term management. Clinicians should educate the individual about the benefits of regular exercise, and prescribe an individualised progressive exercise program by taking into account individual presentation, functional capacity, comorbidities, preferences and exercise availability. Clinicians should emphasise that some discomfort may be experienced with exercise, but that this is not likely to be associated with harm. Some people may benefit from referral to an exercise professional (eg physiotherapist, exercise physiologist) to assist with exercise prescription and supervision. Attention should be paid to adherence strategies (eg written material, logbooks, text message reminders). 

Harms

There is a very low likelihood of serious adverse effects; most are minor and include temporary increased pain at the affected joint or pain at other sites. 

Land-based exercise – Hip

Recommendation

We strongly recommend offering land-based exercise for all people with hip OA to improve pain and function, regardless of their age, structural disease severity, functional status or pain levels. Exercise has also been found to be beneficial for other comorbidities and overall health. However, we are unable to specifically recommend either for or against different types of land-based exercise at this stage. Clinicians should prescribe an individualised progressive exercise program, taking into account the person’s preference, capability and the availability of local facilities. Realistic goals should be set. Dosage should be progressed with full consideration given to the frequency, duration and intensity of exercise sessions, number of sessions, and the period over which sessions should occur. The clinician should monitor the person’s response to the exercise program and could try a different form of land-based exercise if improvements are not evident. Attention should be paid to strategies to optimise adherence. Referral to an exercise professional to assist with exercise prescription and provide supervision either in person or remotely may be useful for some individuals.

Strength of recommendation

Strong for recommendation
(when combining all studies of land-based exercise)

Conditional (neutral) for recommending one type of land-based exercise over another
(eg walking, muscle strengthening, stationary cycling, Tai Chi, Hatha yoga)

Quality of evidence

Moderate (land-based)
Very low (walking, muscle strengthening, stationary cycling, Tai Chi, Hatha yoga)

What is it?

This recommendation is specific to exercise performed on land for people with hip OA, including muscle strengthening, stretching/ range of motion, aerobic conditioning, neuromuscular/balance, cycling, Tai Chi and yoga. Exercise dosage can vary in terms of frequency, intensity and duration. Additionally, the exercise can involve expensive, specialised equipment, or no equipment at all; it can be delivered in a group setting or individually, either in-person or remotely via telephone or videoconference.

Rationale

Overall, there is moderate-quality evidence from a limited number of trials in people specifically with hip OA to support the short-term benefits of land-based exercise – conducted either at home or in groups – on pain and function (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). Exercise is also beneficial for other comorbidities and overall health. Most studies included multi-modal exercise programs comprising strengthening, range of motion and functional exercise. However, we are unable to recommend either for or against any specific type of exercise for hip OA because of limited or non-existent trials in people with hip OA that isolate the effects of different types of exercise. Clinicians should educate the individual about the benefits of regular exercise, and prescribe an individualised progressive exercise program, taking into account patient presentation, functional capacity, comorbidities, preferences and resource availability. Clinicians should emphasise that some discomfort may be experienced with exercise, but that this is not likely to be associated with harm. Some people may benefit from referral to an exercise professional (eg physiotherapist, exercise physiologist) to assist with exercise prescription and supervision. Attention should be paid to adherence strategies (eg written material, logbooks, SMS reminders).

Harms

There is a very low likelihood of serious adverse effects; most are minor and include temporary increased pain at the affected joint or pain at other sites.

Aquatic exercise/ hydrotherapy – Knee and/or hip

Recommendation

It may be appropriate to offer aquatic exercise/hydrotherapy for some people with knee and/or hip OA. This will depend upon personal preference and the availability of local facilities.

Strength of recommendation

Conditional for recommendation

Quality of evidence

Low

What is it?

Aquatic exercise/hydrotherapy are low impact exercise undertaken in water. Water also offers natural resistance, which can be used to strengthen muscles. It may be undertaken individually or in group classes located in community settings. In some settings, classes may be specific to those with arthritis and/or musculoskeletal conditions.

Rationale 

There is low-quality evidence that aquatic exercise lead to small statistically significant improvements in pain, physical function and quality of life in people with knee and/or hip OA (Appendix 5 of the Guideline for the management of knee and hip osteoarthritis: Technical document). There is a low risk of harm with aquatic exercise. Participation in aquatic exercise requires access to a pool, and usually comes at a small financial cost to participants. In addition, some people with OA may not feel comfortable, or be willing, to exercise in an aquatic environment. Clinicians should thus discuss personal exercise preferences and access to local pool facilities to determine if a person should be advised to undertake aquatic exercise. Although the benefits in pain reduction and function from aquatic exercise therapy in the treatment of hip and/or knee OA are smaller than the effects from land-based exercise therapy, people who experience too much pain to exercise in a full weight-bearing environment can benefit from aquatic exercise therapy. 

Harms

There is a very low likelihood of serious adverse effects; most are minor and include temporary increased pain at the affected joint or pain at other sites. 

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