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Exercise: knee osteoarthritis


Exercise is recommended as a core treatment for osteoarthritis in all clinical guidelines regardless of patient age, pain levels or disease severity.


Intervention

Regular land- or water-based therapeutic exercise for adults with knee osteoarthritis (OA).

Exercise programs may be delivered face to face or via the internet.

Indication

Adults with knee OA. The aim is to reduce the pain and improve the physical function of the knee.

Precautions

  • Confirm the patient has appropriate footwear for exercising.
  • Emphasise the need to perform the exercise correctly and at medium speed, to minimise the risk of injury.
  • Ensure safety: advise the patient to use a chair or bench for support when exercising in standing positions.

Contraindications

There are few contraindications; however, comorbidities, such as cardiovascular disease, asthma and diabetes should be considered.

Adverse Effects

Adverse effects are generally infrequent, mild and transient. They include increased pain, exercise-related injury, falls and fall-related injury.

Availability

Exercise is readily available. It can be performed at home, in a group setting or at a local gym. Exercise is effective, whether it is individual or group-based.

Exercise is usually optimised when a home-based program is initially and subsequently periodically individually supervised. Discussing the planned regimen with a health practitioner before commencement and periodically subsequently encourages patient adherence.

While there is evidence that ongoing contact with a health practitioner is beneficial, this may not need to be in person. Internet delivered exercise programs show good uptake and adherence. Internet delivery includes teleconferencing (eg Skype™) with a physiotherapist or using internet based programs/apps. Some programs also have a pain coping skills component.

Description

A range of exercise types have been found to be moderately effective for adults with knee OA (refer to Figure 1).

Evidence suggests that a combination of strength, aerobic and flexibility exercise is most likely to improve pain and physical function outcomes in adults with knee OA.

There is limited evidence about the ‘dosage’ of exercise (frequency, duration, intensity) required for effective management of knee OA. Outcomes do not appear to be related to exercise intensity or to the duration of the exercise sessions.

General tips for types and dosage of exercises

 

Strength

Flexibility

Aerobic

Tips

Include quadriceps, hip abductor, hamstring and calf muscle strengthening exercises.

Perform exercises in functional ways, such as chair raises, step-ups, step-downs, squats, heel raises and bridging where appropriate.

Where appropriate, prescribe exercises to target increased range of movement in the knee and hip, and flexibility of the associated muscles.

Perform regular bouts of aerobic physical activity (e.g. walking, cycling or water exercise), aiming for decreased sedentary time and increased active time.

How often?

Regularly, at least 3 times per week, and maintained in order to gain longer-term benefits.

Regularly, at least 3 times per week, and maintained in order to gain longer-term benefits.

At least 30 minutes of moderate intensity aerobic exercise on most days.

The 30 minutes can be done in bouts of at least 10 minutes.

Exercise intensity

8–12 repetitions in 1 set. Repeat 2–3 times with 1–2 minutes rest between sets.

To get stronger safely, the exercise should feel like it was ‘hard’ or ‘very hard’ rather than ‘easy’ or ‘extremely hard’.

Each stretch should be held 15–30 seconds and repeated 2– 4 times.

Moderate intensity means working ‘somewhat hard’ (ie puffing but still able to talk).

The consumer resource section contains links to specific knee exercises for patients that can be done at home.

Tips

  • The exercise program should be individualised, taking into account the patient’s age, severity of OA, mobility, comorbidities and exercise preferences.
  • Physiotherapists or exercise physiologists can provide advice about a training program. Consider a referral under the Enhanced Primary Care (EPC) Program so that eligible patients can receive a Medicare rebate.
  • Internet based programs may be useful and cost effective alternatives for patients who cannot or choose not to access physiotherapy. These may also offer help with pain coping skills.
  • Feeling some discomfort or pain during exercise is normal; however, revise the exercise regimen if:
    • the pain is excessive
    • the pain remains elevated for more than 2 hours after exercise
    • there is increased joint swelling the next day.
  • Encourage overweight patients to lose weight. This may help alleviate the symptoms of their knee OA by reducing the load on their knees.
  • A graded approach to exercise, starting with 2–3 simple exercises and progressing to more challenging exercises may improve uptake and patient adherence.

Grading

NHMRC Level 1 evidence.

Reference

Consumer resources

The knee strengthening exercises below in Downloads, describes basic knee strengthening exercises that patients can do at home. A simple graded approach to exercise has been provided. These exercises have been provided and reproduced with permission from Professor Kim Bennell, Centre for Health Exercise and Sports Medicine, Department of Physiotherapy, University of Melbourne.

There is ample information on the internet about knee exercises but it is not possible to assess the quality of all the information available. The following are reputable sites where patients can access further information:

Figure 1: Forest plot of pain and physical function outcomes with exercise in lower limb osteoarthritis (mainly knee osteoarthritis)*

Reference = no exercise

Forest plot of pain and physical

*44/60 randomised controlled trials were in knee OA.

First published: October 2014 - Updated: November 2017

Downloads

PDF

Knee strengthening exercises (pdf 2MB)

These exercises have been provided and reproduced with permission from Professor Kim Bennell, Centre for Health Exercise and Sports Medicine, Department of Physiotherapy, University of Melbourne.

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