- Email: [email protected]
Osteoarthritis year in review 2019: rehabilitation and outcomes
Journal Pre-proof Osteoarthritis Year in Review 2019: Rehabilitation and Outcomes Monica R. Maly, Kendal A. Marriott, Jaclyn N. Chopp-Hurley PII:
S1063-4584(19)31295-6
DOI:
https://doi.org/10.1016/j.joca.2019.11.008
Reference:
YJOCA 4566
To appear in:
Osteoarthritis and Cartilage
Received Date: 31 July 2019 Revised Date:
14 November 2019
Accepted Date: 18 November 2019
Please cite this article as: Maly MR, Marriott KA, Chopp-Hurley JN, Osteoarthritis Year in Review 2019: Rehabilitation and Outcomes, Osteoarthritis and Cartilage, https://doi.org/10.1016/j.joca.2019.11.008. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Ltd on behalf of Osteoarthritis Research Society International.
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Osteoarthritis Year in Review 2019: Rehabilitation and Outcomes
1
Monica R. Maly1,2, Kendal A. Marriott1*, Jaclyn N. Chopp-Hurley2,3* Department of Kinesiology, University of Waterloo ([email protected]) 2 School of Rehabilitation Science, McMaster University 3 School of Kinesiology and Health Science, York University *Denotes equal authorship
Abstract Word Count: 250 Manuscript Word Count: 4,012
Key Words: Arthritis, Hand, Hip, Knee, Outcome Assessment (Health Care), Recovery of Function, Review Literature as Topic
Corresponding Author: Monica R. Maly Department of Kinesiology, University of Waterloo Room 1036 Burt Matthews Hall 200 University Avenue Waterloo, Ontario, Canada N2L 3G1 T: (519) 888-4567 x 37916 F: (519) 885-4070 [email protected]
1
46
Abstract
47
Objective: Inactivity and obesity are risk factors for osteoarthritis (OA) progression. The purpose of
48
this review was to highlight intervention parameters of exercise and lifestyle diet interventions on
49
clinical outcomes in OA that were published over 15 months, starting January 1, 2018.
50 51
Design: Systematic literature searches were performed in Medline (Pubmed, OVID), Scopus,
52
CINAHL, CENTRAL and Embase from January 1, 2018 to April 1, 2019. Key words included
53
osteoarthritis, exercise, physical activity, diet and nutrition. Randomized controlled designs and data
54
synthesis papers (systematic reviews, meta-analyses, clinical guidelines) written in English, that
55
included humans with OA of any joint were included. Trials were evaluated using the Physiotherapy
56
Evidence Database (PEDro) critical appraisal tool and the Template for Intervention Description and
57
Replication (TIDieR). Systematic reviews and meta-analyses were evaluated using A MeaSurement
58
Tool to Assess systematic Reviews 2 (AMSTAR 2). Intervention details (RCTs) and key finding from
59
papers were summarized.
60 61
Results: Of 540 titles and abstracts retrieved, 147 full articles were reviewed and 53 met the inclusion
62
criteria, comprised of 39 RCTs and 14 synthesis papers. By addressing inactivity, exercise effectively
63
improves clinical outcomes and, based on low-moderate quality evidence, without further damage to
64
cartilage or synovial tissue. By comparison, much less work focused on minimizing obesity. Diet
65
must be combined with exercise to improve pain, but alone, can improve physical function.
66 67
Conclusions: Future work is necessary to identify the ideal exercise frequency and intensity and
68
lifestyle diet intervention parameters. Improved adherence to reporting guidelines in future work will
69
greatly enhance the OA rehabilitation field.
2
70
Introduction
71
Despite the diversity of osteoarthritis (OA) pathogenesis, the literature consistently cites obesity and
72
inactivity as risk factors for initiation and progression (1). Obesity elevates the risk for OA (2). In
73
combination with excessive joint loading (3), obesity degrades joint tissues through inflammatory
74
pathways that interact with abnormal immune responses (4-6). Inactivity is the fourth leading risk for
75
mortality globally (7), and in OA, is linked to worsening structural disease (8, 9) and disability (10).
76
Inactivity reduces cartilage thickness and quality, compromises muscle structure and function,
77
increases risk for comorbidities and diminishes quality of life in OA (9, 11, 12). Because obesity and
78
inactivity can be modified using diet and exercise, these are excellent targets for rehabilitation, where
79
the scope of rehabilitation includes conservative approaches to optimize or restore physical ability and
80
quality of life.
81 82
The efficacy of exercise and diet in OA is established (5, 13-15). “Exercise” refers to any bodily
83
movement via skeletal muscles that is planned, structured and repeated with an objective to improve or
84
maintain one or more elements of health-related or skill-related fitness (16). “Lifestyle diet” refers to
85
any structured guide to the habitual intake of foods. The optimal intervention parameters for exercise
86
and diet remain unclear for several reasons. First, there exists great heterogeneity in exercise and diet
87
prescription (17, 18). It is likely that some exercise trials underdose resulting in ineffective
88
interventions, while others overdose thereby exacerbating pain. Second, the exercise or diet
89
prescription is often unclear due to incomplete reporting (19). Third, OA complicates exercise
90
prescription through impairments in muscle activation (via arthrogenic inhibition and altered
91
proprioception) and systemic cardiorespiratory impairments (via inflammation, co-morbidity and
92
inactive lifestyle). Fourth, there may be a disconnect between exercise recommendations by the
93
Canadian Society for Exercise Physiology (CSEP) and American Society of Sports Medicine (ACSM)
94
with effective exercise parameters in OA. CSEP and ACSM recommend concurrent aerobic and 3
95
resistance training (20, 21), while systematic reviews provide conflicting conclusions on whether the
96
best clinical outcomes in OA result from exercise programs with one aim (17) versus multiple aims
97
(22). Similarly, we lack clarity on the optimal parameters for diet in OA. The purpose of this year in
98
review is to highlight intervention parameters documented in studies that evaluate the impact of
99
exercise and lifestyle diet interventions on clinical outcomes in OA published over 15 months starting
100
January 1, 2018.
101 102
Methods
103
Systematic literature searches were performed in Medline (Pubmed, OVID), Scopus, CINAHL,
104
CENTRAL, and Embase from January 1, 2018 to April 1, 2019. Key words included osteoarthritis,
105
exercise, physical activity, diet and nutrition using the explode command. Documentation (in the
106
manuscript or supplemental material) detailing a planned, structured and repeated program for exercise,
107
or a structured, habitual guide for food intake, was required for inclusion. The search was limited to
108
human, full-text and English. Randomized controlled trials (RCTs) that enrolled participants with OA,
109
including cluster, pilot and feasibility designs, were included. Clinical guidelines, systematic reviews
110
and meta-analyses were included. Secondary analyses, uncontrolled trials, protocols, qualitative,
111
retrospective, case studies, cost-analyses and narrative or scoping reviews were excluded. Studies of
112
surgery, oral or injectable medications, electrothermal modalities, neutraceuticals, vitamins or food
113
additives, and devices were also excluded. Among studies with heterogeneous samples, studies that
114
did not isolate analyses to OA were excluded.
115 116
Titles and abstracts were reviewed for inclusion by two authors (KAM, JNCH). In the case of
117
discrepancies, full papers were reviewed by all authors to reach agreement.
118
4
119
A summary of the intervention dosage, exercise adherence, primary outcomes and main findings was
120
created for RCTs. These details were extracted by two authors (KAM, JNCH) and confirmed by the
121
third author (MRM). These papers were evaluated using the Physiotherapy Evidence Database
122
(PEDro) critical appraisal tool, which produces valid and reliable scores that reflect the risk of bias in
123
clinical trials (23, 24). Studies can be rated as high (≥7/10), moderate (4-6/10) or low quality (≤3/10).
124
The Template for Intervention Description and Replication (TIDieR) checklist and guide were used
125
(25, 26). The TIDieR checklist expands upon the 2010 Consolidated Standards of Reporting Trials
126
(CONSORT) guidelines. Studies can be rated as good (≥9/12), moderate (6-8/12) or poor description
127
(≤5/12). For both the PEDro and TIDieR, we present consensus scores from two raters. Finally, we
128
selected a subgroup of RCTs for a narrative review to highlight intervention dosage and high quality
129
trials.
130 131
For synthesis papers, key themes were summarized and a subgroup was included in a narrative review.
132
Also, systematic reviews and meta-analyses were evaluated using A MeaSurement Tool to Assess
133
systematic Reviews 2 (AMSTAR 2) (27, 28). This 16-item tool evaluates review quality by identifying
134
critical flaws (protocol registration, search, study exclusion justification, risk of bias, meta-analytical
135
methods, interpretation, publication bias) (27). Consensus scores from two raters on the confidence in
136
the review were high (0-1 non-critical weakness), moderate (>1 non-critical weakness), low (1 critical
137
flaw), and critically low (>1 critical flaw) (27).
138 139
Results
140
After duplicates were removed, 540 titles and abstracts were retrieved. Of these, 147 full articles were
141
identified for full-text review (Figure 1). Fifty-three full articles met the inclusion criteria, comprised
142
of 39 RCTs and 14 synthesis articles.
143 5
144
Randomized Controlled Trials
145
Of the 39 RCTs, all documented exercise. Thirty-three focused on knee (29-61), one on hip (62), three
146
on hand (63-65), one on hip and knee (66) and one on a mixed sample with peripheral joint pain
147
consistent with OA (67). These RCTs documented exercise interventions in a variety of themes:
148
integrated exercise with other care (14 studies, cumulative n=1,607) of which 4 studies combined
149
exercise with a thermal or electrical modality; exercise delivered or supported with technology (4
150
studies, cumulative n=748); resistance and/or sensory-motor (n=8, cumulative n=660); aerobic (n=3,
151
cumulative n=150); aquatic (n=2, cumulative n=140); balance (n=2, cumulative n=132); mind-body
152
approaches (n=3, cumulative n=120); gait retraining (n=2, cumulative n=102); and participatory
153
ergonomics (n=1, n=75).
154 155
Intervention parameters varied widely, where the total number of exercise sessions ranged from five to
156
168, duration of care ranged from two to 104 weeks, and frequency per week ranged from fewer than
157
one to 14. (Supplemental material displays dosage parameters and effect sizes for WOMAC/KOOS
158
outcomes, where effect size calculation was possible). PEDro scores (out of 10) identified low (n=3),
159
moderate (n=16) and high (n=20) quality trials. The most common sources of bias included an
160
inability to blind the participant and intervention provider and failure to use and/or clearly document an
161
intention-to-treat analysis. Intervention descriptions fulfilled between two to 12 of 12 TIDieR criteria.
162
The most common challenges were unclear/absent descriptions of intervention materials and
163
procedures, delivery parameters and an a priori plan for adherence tracking.
164 165
Table 1 summarizes details of these trials. From these, we selected papers for narrative review to
166
discuss trials that explicitly examine dosage parameters and/or highlight high quality trials among the
167
largest four themes identified. Values reported are as presented in the original article.
168 6
169
Exercise Integrated with Other Care
170
Exercise was combined with physician consultation and self-management (37, 65, 67) , as well as self-
171
management alone (48), manual therapy (30, 57), dry needling (55, 56), and bracing or taping (44, 52).
172
Exercise was also combined with thermal (63, 64) and electrical (34, 51) modalities.
173 174
When combined with a functional consultation, daily exercise was effective in improving grip strength
175
among adults living with hand OA. An RCT compared the effectiveness of home exercise combined
176
with functional consultation against standard care in 151 participants with hand OA (65). The
177
intervention arm received a functional consultation (two face-to-face visits) on pain, activities of daily
178
living, assistive devices such as thumb orthoses, and a home program of hand exercises. The exercises
179
were active range of motion and strengthening using therapy putty daily for eight weeks (total of 56
180
sessions). Adherence was tracked by viewing wear of the therapy putty; where 28 of 74 participants in
181
the intervention arm (38%) adhered. At eight weeks follow-up, dominant-hand grip strength increased
182
in the intervention arm (mean difference 0.03 (standard deviation (SD) 0.11)) and decreased in the
183
control arm (mean difference −0.03 (SD 0.13), p=0.001) (65).
184 185
Over the past year, trials incorporated exercise within self-management programs for OA. A two-arm
186
cluster RCT (n=525) examined the effectiveness of implementing the core National Institute for Health
187
and Care Excellence (NICE) OA recommendations in England, across eight medical practices (67).
188
The intervention arm received physician consultation, a guidebook on self-management and up to four
189
follow-ups with a nurse practitioner providing goal-setting, weight management and exercise/physical
190
activity (67). Dosage and adherence to exercise were not reported. At six month follow-up, no
191
difference in the physical component score of the Short-Form 12 was found between intervention
192
versus usual care arms (mean difference -0.37, 95% Confidence Interval (95%CI) -2.32 to 1.57) (67).
193
This trial highlights the challenges of implementing OA self-management in a real-world setting. A 7
194
traditional trial of 80 people with knee OA examined the effectiveness of a self-management program
195
combined with exercise, delivered in a group format, compared to an education control (48). For 12
196
weeks, participants allocated to the intervention arm received a 90 min session twice weekly (total 24
197
sessions), composed of 30 min of self-management (including self-efficacy, exercise/physical activity,
198
communication, healthy eating, managing medicines) and 60 min of strength, flexibility and balance
199
exercise. The control arm received three educational sessions and a book. Adherence was not
200
reported. Pain and symptoms were no different between arms at the 12-week follow-up. However, 6
201
min walk [effect size (partial eta squared) 0.068, p=0.035] and sit-to-stand [effect size (partial eta
202
squared) 0.09, p=0.015] were better in the intervention relative to control arm (48). These studies
203
suggest that, even when other treatment opportunities are provided to patients, adherence to an exercise
204
prescription with adequate dosage is necessary to improve OA symptoms.
205 206
Delivering Exercise with Technology
207
Four studies used technologies to enhance exercise. Of these, three delivered exercise instruction
208
electronically (29, 62, 66) and one used electromyography biofeedback to enhance resistance training
209
(54).
210 211
The importance of technology in daily living makes it an area of key interest to provide or support
212
exercise in OA. A three-arm trial (n=350) compared an internet-based exercise training (IBET)
213
program versus physiotherapy and a wait list control in knee OA (29). The IBET arm received no face-
214
to-face contact. The IBET program featured exercise instruction (including videos, photographs),
215
progression, automated reminders and progress tracking. Participants were encouraged to complete
216
strengthening and stretching exercise three times per week for 52 weeks (total of 156 sessions).
217
Participants in the physiotherapy arm received up to eight visits. The average usage was 5.7 visits and
218
nearly all received therapeutic exercise two to three times per week (total of 104 to 156 sessions). 8
219
Adherence was not tracked. Improvements in WOMAC were no different for either the IBET or
220
physiotherapy arms compared with the wait list control at 16 weeks [IBET: mean -2.70, 95%CI (-6.24,
221
0.85), p=0.14; PT: mean -3.36, 95% CI (-6.84, 0.12), p=0.06] or at 52 weeks [IBET: mean -2.63,
222
95%CI (-6.37, 1.11), p=0.17; PT: mean -1.59, 95%CI (-5.26, 2.08), p=0.39] (29). In contrast, a two-
223
arm trial of 144 participants with hip OA compared internet-based pain coping skills training versus an
224
education control (62). Both arms were asked to complete home exercise three times per week for 16
225
weeks (total of 48 sessions) and this home exercise program was supported by five face-to-face
226
physiotherapy sessions. Adherence was tracked with multiple methods, with 72% and 77% home
227
exercise completion in the intervention and control arms respectively. In the eight weeks prior to
228
initiating the home exercise, the intervention arm received an online program on pain coping skills
229
including relaxation, activity-rest cycling, pleasant activity scheduling and imagery, distraction and
230
problem-solving. At the 24-week follow-up, both arms experienced improved pain during walking and
231
WOMAC physical function, with no between-group differences (walking pain: 0.5 units, 95%CI -0.3 to
232
1.3; function: -0.9 units, 95%CI -4.8 to 2.9). Those in the pain coping skills training group also
233
experienced improved pain coping skills at eight, 24 and 52 weeks (62). Face-to-face interactions,
234
albeit of a lower frequency than traditional programs, may be a necessary adjunct to technology-
235
supported exercise in OA.
236 237
Resistance and Aerobic Exercise
238
We selected two small trials of resistance and aerobic exercise interventions that explicitly compared
239
different exercise intensities. The resistance training study examined whether blood flow restriction
240
could enhance low-intensity muscle training to yield benefits equivalent to high-intensity training (36).
241
Permitting arterial flow while restricting venous return may stimulate greater muscle activation and
242
protein synthesis by reflecting metabolic overload. Forty-eight women with knee OA were randomized
243
into three arms. All were offered supervised quadriceps exercise twice per week for 12 weeks (total of 9
244
24 sessions). The high-intensity arm completed contractions at 80% of 1-repetition maximum (1RM);
245
low-intensity at 30% 1RM. The third arm repeated the low-intensity training at 30% 1RM with an air
246
cuff at the inguinal fold to restrict venous flow. Adherence, tracked by a research assistant, was 90%,
247
85% and 91% for the high, low and blood flow restriction arms. However, four of 16 participants in
248
the high-intensity arm were excluded due to pain. After 12 weeks, the high-intensity and blood flow
249
restriction arms showed greater improvement in leg press, knee extension 1RM, and quadriceps cross-
250
sectional area compared to the low-intensity arm (36). Blood flow restriction with low-intensity
251
resistance training may produce comparable improvements in muscle morphology and capacity to high-
252
intensity resistance training but with a lower risk for pain.
253 254
A feasibility trial explored high-intensity interval training (HIIT) for knee OA (43). In 27 adults with
255
knee OA who were cleared for this protocol by a physician, HIIT was compared with moderate-
256
intensity continuous training on a stationary bicycle. Participants in both arms were provided with a
257
written guide and a familiarization session to teach proper bicycle fit and the exercise program. Both
258
programs were four times per week for eight weeks (total of 32 sessions). Adherence and adverse
259
events were recorded in a diary. Exercise adherence was 94% and 88% in the HIIT and moderate
260
cycling arms respectively; however, 26 adverse events were reported in the HIIT arm, with 24 by one
261
participant attributed to a Bakers cyst. Both groups experienced improvements in WOMAC. The HIIT
262
resulted in greater improvement in the Timed Up and Go (TUG) compared to the moderate-intensity
263
continuous cycling group (p<0.043). However, the magnitude of change in the TUG within the HIIT
264
group pre-post intervention was 1.1 s, which is unlikely to be clinically meaningful. In a sample
265
cleared by a physician for high-intensity exercise, HIIT may have outperformed moderate intensity
266
aerobic exercise by a small margin but also may have increased adverse events (43).
267 268
Synthesis Papers 10
269
Fourteen synthesis papers were identified. Two were clinical guidelines from the European League
270
Against Rheumatism (EULAR) on pain management (68) and hand OA (69). One systematic review
271
was dedicated to the hand (70); and two were dedicated to diet (14, 71). The remaining focused on
272
exercise (18, 72-77), including aquatic (78) and gait (79). AMSTAR 2 scores were critically low
273
(n=4), low (n=4), moderate (n=3) and high (n=2). (One recommendation paper did not include a
274
systematic review and was not scored.) The most frequent reasons that limited confidence in the
275
review findings were a lack of reporting of the funding source of included papers, failure to select
276
articles and/or extract data in duplicate, and inadequate methods to assess and interpret bias.
277 278
Table 2 summarizes these synthesis papers. We selected papers for narrative review to highlight
279
recommendations, discuss dosage parameters and present high quality systematic reviews and/or meta-
280
analyses.
281 282
EULAR Clinical Guidelines
283
A multidisciplinary task force including health professionals and patients contributed a systematic
284
review of systematic reviews on pain-management for inflammatory arthritis and OA (68). Scientific
285
evidence (73) was integrated with four overarching principles. First, patient preferences, needs and
286
values should guide shared clinical decision-making. Second, a biopsychosocial model was
287
recommended. Third, core knowledge of inflammatory arthritis and OA is essential. Finally, the skill
288
to differentiate between localized, generalized and coexisting local and general pain is required. The
289
resulting recommendations encourage health professionals to work through a “stepped-care approach”
290
including proper assessment that invites patients to disclose the impact of their pain, expectations and
291
preferences; shared decision-making; education; specific treatments (exercise/physical activity,
292
orthotics, psychological/social, sleep, weight management, pharmacological); and finally
293
multidisciplinary treatment (68). 11
294 295
Similarly, a multidisciplinary task force of health professionals and patients formed clinical guidelines
296
for the management of hand OA (69). The overarching principles included a focus on controlling
297
symptoms and optimizing hand function for quality of life, education and self-management,
298
individualized care, shared decision-making and a multidisciplinary approach. Key points included the
299
following: (i) replace “joint protection” (which infers reducing hand use) with education, ergonomic
300
supports and pacing; (ii) while exercise produces small effect sizes, the risk for severe adverse events is
301
low, and (iii) thumb orthoses likely require three months before observing improvements. Topical
302
treatments are recommended over systemic. Generally, glucocorticoids and disease-modifying anti-
303
rheumatics should not be used. Surgery should be considered for patients with structural abnormalities
304
when conservative approaches have failed (69).
305 306
Diet
307
A high quality systematic review (19 publications) and meta-analysis (9 publications) showed that diet-
308
induced weight loss does not reduce pain in obese people with knee OA (standardized mean differences
309
(SMD) -0.13; 95%CI -0.37 to 0.10) (14). The authors highlighted that because pain is multifactorial, it
310
is not surprising that diet alone failed to reduce pain. Diet combined with exercise moderately reduced
311
pain (SMD -0.37; 95%CI -0.69 to -0.04). Interestingly, diet alone and diet with exercise had similar
312
standardized mean differences for physical function (diet alone SMD -0.30; 95%CI -0.52 to -0.08; diet
313
with exercise SMD -0.32; 95%CI -0.56, to -0.08) (14).
314 315
Exercise
316
Highlights of the systematic reviews and meta-analyses of exercise included optimal exercise
317
prescription parameters and the impact of long-term exercise on knee structure.
318 12
319
A systematic review explored exercise doses associated with reduced pain and improved function in
320
common knee disorders, including OA (77). Twenty-four exercise studies in knee OA provided
321
sufficient detail to calculate effect sizes. The authors noted large variation in exercise prescriptions.
322
Though not statistically evaluated, the authors commented that 24 total exercise sessions, and durations
323
of care between 8 to 12 weeks, were most frequently associated with large effects on pain and physical
324
function (77).
325 326
A frequent concern of patients with OA is fear that activity will worsen their joints (80-82). A high
327
quality systematic review and meta-analysis examined whether exercise longer than six months
328
contributed to progressive radiographic or cartilage damage, or bone marrow lesions, synovitis and
329
effusions (83). Across four studies (n=879), participants experienced no effect of exercise on
330
tibiofemoral radiographic severity (SMD 0.06, 95%CI -0.07 to 0.20). In 196 participants in two
331
studies, cartilage morphology was not reduced by long-term exercise (SMD 0.06, 95%CI -0.20 to
332
0.36). On the other hand, data from two studies (n=196) showed that long-term exercise increased the
333
odds of worsening tibiofemoral BML severity (Odds Ratio (OR) 1.90, 95%CI 1.1, 3.26). Because the
334
meta-analysis was informed by relatively small samples, these findings must be interpreted with
335
caution (83).
336 337
Discussion
338
Key messages from this Year in Review are that (i) rehabilitation can effectively modify important risk
339
factors for OA progression, including inactivity and obesity, and (ii) diet received relatively little
340
attention in OA research over the past year. Scientific contributions on OA rehabilitation in 2018
341
focused on exercise to mitigate inactivity (84, 85). Of 39 RCTs identified in this review, none
342
examined a lifestyle diet intervention. Yet, weight management is a critical therapeutic target for OA.
343
By 2024, we expect that 20% of Canadians will be seniors and the majority will be overweight or obese 13
344
(86) and therefore at elevated odds of developing OA (2). Diet alone can concurrently manage both
345
obesity and OA-related physical dysfunction for these individuals (14) but more work must be done.
346
Diet interventions in OA typically focused on altering dietary intake for weight loss (14). This
347
approach is likely useful in the short-term, but requires integration with education, exercise, behaviour
348
modification and social supports for long-term success (87). Ultimately, balancing rehabilitation
349
research across the goals of managing obesity and inactivity could have a substantive impact on OA
350
outcomes (Box 1).
351 352
Exercise is a first-line treatment for OA. Studies and reviews published in 2018 show benefits to pain,
353
physical function, mobility and quality of life (68, 69). These findings are consistent with a recent
354
review of 42 studies in knee OA (n=6,863) that shows the effect size of exercise for positive outcomes
355
is established (15). Long-term exercise does not appear to damage joint structure (83). A similar
356
conclusion was drawn through systematic reviews of cartilage morphometry, morphology and
357
composition from MRI (88) and molecular biomarkers (89) that included trials with participants at risk
358
for knee OA. Nevertheless, the quality of data supporting this conclusion is of low or moderate quality
359
– more data is necessary to corroborate that exercise does not damage joints. Future work can also
360
address the next set of questions underpinning exercise for all with OA. Exercise dosage in OA
361
remains unclear largely due to tremendous variation in dosage captured in this and other (18, 69, 77,
362
90-94) reviews. Observations in the current review were that (i) more frequent exercise may be
363
associated with larger positive effects on clinical outcomes and (ii) studies requesting that participants
364
exercise seven to 14 exercise sessions per week included a small number of exercises. There may exist
365
an overall exercise volume that participants with OA are likely to tolerate. Finally, OA-specific
366
variables such as phenotype, pain intensity and pain sensitivity to physical activity likely also influence
367
response to exercise and these confounders may require accommodations in the optimal exercise
368
prescription. 14
369 370
Direct comparisons of different dosage (i.e., intensity, duration of care), delivery (e.g., home,
371
supervised, internet-facilitated), modality (e.g., interval, continuous, functional, machine-based),
372
combinations with other treatments, and total volume are necessary to identify the optimal range of
373
exercise dosage in OA. Data from smaller trials published in 2018 suggest that higher intensity
374
exercise may confer greater benefit (perhaps to a small degree) to people living with OA, but only if
375
tolerated (36, 43). Exercise delivered using electronic means produced mixed results, which may be
376
attributed to variations in the amount of face-to-face contact, adherence, duration of care and exercise
377
volume. Qualitative data captured in a review also emphasized the patient’s desire for
378
individualization, education about the safety of exercise, and concrete strategies to support adherence.
379
Rehabilitation specialists focused on OA could improve support for patients and front-line clinicians by
380
tackling these complexities of exercise prescription.
381 382
The most frequent outcomes to quantify treatment effect identified in the current year in review
383
included symptoms (most often pain intensity), self-reported physical function and mobility
384
performance, with a handful of other outcomes of disease, biomechanics and joint tissue structure. As
385
noted previously (18), quality of life outcomes were not primary. Data thus far suggests the impact of
386
exercise on psychological outcomes appears small (18). Given that OA-related chronic pain and
387
immobility are sources of psychological distress and degraded quality of life, future work exploring the
388
impact of rehabilitation on quality of life measures as primary outcomes could advance the field.
389 390
Lack of reporting was frequent. Incomplete reporting limits the ability to interpret effectiveness and
391
efficacy or make reasonable comparisons between interventions. The a priori plans to track adherence,
392
as well as adherence results, were often undocumented and of those reported, diverse. Improving
393
adherence to treatment in chronic disease may have a greater impact on patient outcomes than any 15
394
other innovation (95). Adherence is challenging in OA (96-100), particularly among those with pain
395
(100) – arguably those with the greatest need. Unfortunately, pain relief disappears after ceasing
396
rehabilitation (96) and only 33% of seniors with chronic conditions maintain home exercise (98).
397 398
Finally, similar to previous years in review, hand and hip OA are under-studied but, given that the
399
available data strongly suggest that rehabilitation strategies are recommended, much more work in
400
these joints is warranted.
401 402
Conclusions
403
By addressing inactivity, exercise improves clinical outcomes and, based on low-moderate quality
404
evidence, without further damage to cartilage or synovial tissue. No new trials of diet were found.
405
Diet must be combined with exercise to improve pain, but alone, can improve physical function.
406
Future work is necessary to identify the ideal range of dosages for exercise and diet interventions in
407
OA.
408 409 410 411
Author Contributions
412
Each author made substantial contributions to the study conception and design, literature search, data
413
extraction and quality rating, and analysis and interpretation of data. Each author was involved in
414
drafting the manuscript or revising it critically for important intellectual content. All authors have read
415
and approved the final submitted manuscript.
416 417
Acknowledgements
16
418
Dr. Jaclyn Chopp-Hurley was supported through a Canadian Institutes of Health Research (CIHR)
419
fellowship award. This work was supported by Natural Sciences and Engineering Research Council of
420
Canada (NSERC) Discovery grant (353715 MRM).
421 422
Role of the Funding Source
423
The study sponsors were not involved in the study design, collection, analysis and interpretation of
424
data, writing of the manuscript or decision to submit the manuscript for publication.
425 426
Competing Interest Statement
427
No financial support or other benefits from commercial sources have been received for the work
428
reported on in the manuscript.
429
17
Table 1. Summary of the design and interventions evaluated in 39 Randomized Control Trials (RCT) of exercise for osteoarthritis. The Physiotherapy Evidence Database critical appraisal tool (PEDRO) and Template for Intervention Description and Replication (TIDieR) were consensus scores from two authors. Author
Design
OA Joint
Baseline n
Study Arms
Total Number of Sessions (A) 10 paraffin and 14 exercise, (B) 14
Duration of Care
Frequency per Week
Adherence
Primary Outcomes
Follow-up
Findings
PEDRO (/10)
TIDieR (/12)
Aksoy
RCT
Hand
61 (53F, 8M)
(A) paraffin therapy and home exercise, (B) home exercise alone
2w
(A) 5 paraffin, 14 exercise, (B) 14
Not reported
2, 6 w
A>B
6
3
(A) physical therapy evidencebased approach, (B) internet-based exercise training, (C) wait list control (A) osteopathic manipulative treatment and exercise (B) exercise alone (A) isokinetic exercise, (B) aerobic exercise, (C) isometric exercise
(A) 8 PT and 104-156 exercise, (B) 156, (C) 2
52 w
(A) 2-3, (B) 3, (C) 0
16, 52 w
A=B=C
8
8
Not reported
Not reported
(A) 2 clinic and 14 home, (B), 14
(A) 5.7 PT visits and exercise not reported, (B) Not reported, (C) Not applicable Not reported
VAS (pain), Austalian/Canadian Osteoarthritis Hand Index, Health Assessment Questionnaire, hand grip strength, finger pinch strength WOMAC
Allen
RCT
Knee
350 (251F, 99M)
Altinbilek
RCT
Knee
100 (76F, 9M)
WOMAC, VAS, 50 m walk time
4w
A>B
6
6
Benli Kucuk
RCT
Knee
45 (45F)
(A) 20, (B) 20, (C) 20
4w
(A) 5, (B) 5, (C) 5
Not reported
Not documented
A=B=C
6
5
(A) online education, home exercise and online pain coping skills training, (B) online education and home exercise
(A) 8 online education sessions, 48 home exercise, 5 physiotherapy visits, (B) 8 online education sessions, 5 physiotherapy
24 w
(A) 3, (B) 3
(A) selfreported 7.7/10 adherence, completed 72% home exercise, (B) self-reported 8.2/10 adherence, completed
VAS, WOMAC, Lequesne Index, isokinetic knee muscle strength, patellar and femoral cartilage volumes Pain, WOMAC
Bennell
RCT
Hip
144 (82F, 62M)
8, 24, 52 w
B>A pain coping
10
12
18
Braghin
RCT
Knee
42 (31F, 11M)
Cheung
RCT
Knee
23 (10F, 10M, 3LTF)
de Paula Gomes
RCT
Knee
60 (55F, 5M)
DeVita
RCT
Knee
30 (18F, 12M)
Dziedzic
Cluster RCT
Peripheral joint pain
8 general practices; 525 (313F, 212M)
Ferraz
RCT
Knee
48 (48F)
(A) balance physical exercises, (B) no exercises (A) gait retraining, (B) walking exercise (A) exercise alone, (B) exercise and active phototherapy, (C) exercise and placebo phototherapy (A) quadriceps strengthening, (B) control
(A) model OA consultation which included consultation, education and OA guidebook on self-management and three followups with nurse, (B) usual care (A) low-intensity resistance training associated blow flow restriction, (B) low-intensity
visits, 48 home exercise, 8 online pain coping sessions (A) 16, (B) 0
77% home exercise
8w
(A) 2, (B) 2
Not reported
history of falls, WOMAC, balance, functionality
8w
A>B
4
5
(A) 6, (B) 6
6w
(A) 1, (B) 1
Not reported
KAM, KFM, WOMAC
24 w
A>B
7
8
(A) 10, (B) 10, (C) 10
5w
(A) 2, (B) 2, (C) 2
(A) 10, (B) 10, (C) 9.6
WOMAC, LEFS, NPRS, PPT, functional reach test
5w
B>A=C
8
9
(A) 36, (B) 0
12 w
(A) 3, (B) 0
(A) all completed at least 30 sessions
12 w
A>B
5
8
(A) 4, (B) 0
12 w
(A) 0.5, (B)
Not reported
Quadriceps muscle force, power and work, knee compressive force in 1st half stance, WOMAC SF-12 physical component
24 w
A=B
7
11
(A) 24, (B) 24, (C) 24
12 w
(A) 2, (B) 2, (C) 2
(A) 91%, (B) 85%, (C) 90%
12 w
A
7
8
quadriceps CSA, functionality (timed stand test, TUG), WOMAC
19
Gilbert
RCT
Knee
155 (93F, 62M)
Gomiero
RCT
Knee
64 (61F, 3M)
Huang
RCT
Knee
250 (150F, 50M)
Hunt
RCT
Knee
79 (55F, 24M)
resistance training, (C) high-intensity resistance training (A) brief physician recommendation to increase physical activity to meet national guidelines (control), (B) same brief physician recommendation, motivational interviewing session at baseline, 3, 6, 12 months (intervention) (A) sensorymotor training, (B) resistance training
(A) quadriceps isometric contraction exercise, (B) traditional treatment control (A) increase walking activity with toe-out gait modification, (B) increase walking activity without toe-out gait modification
(A) 5, (B) 0
104 w
(A) 0.05, (B) 0
Not reported
WOMAC physical function and pain, accelerometermeasured physical activity
12, 24, 52, 104 w
A
7
7
(A) 32, (B) 32
16 w
(A) 2, (B) 2
Not reported
16 w
A=B
8
7
Not reported
Not reported
(A) 14, (B) Not reported
Not reported
VAS, isometric quadriceps force (dynamometer), TUG, Tinetti balance scale, WOMAC, SF-36, QOL VAS pain, WOMAC pain
4, 12 w
A>B
4
3
(A) 8, (B) 8
16 w
(A) 0.5, (B) 0.5
(A) 7.1 of 8 sessions, (B) 7.2 of 8 sessions
16 w
A>B
8
8
WOMAC, foot progression angles, knee joint loading (KAM), timed stair climb, KFM during gait
20
Isaramalai
Cluster RCT
Knee
3 work sites; 75 (58F 17M)
Kabiri
RCT
Knee
78 (64F, 14M, 4LTF)
Kang
RCT
Hand
29 (29M)
Keogh
Feasibility RCT
Knee
27 (13F, 4M, 10LTF)
Kloek
Cluster RCT
Hip, Knee
Missing clusters of PT practices; 208 (141F, 67M)
(A) participatory ergonomic management (PEM) and nonweightbearing exercise, (B) PEM and progressive resistance exercise, (C) standard treatment (A) treadmill and resistance training, (2) cycle ergometer and resistance training, (3) arm ergometer and resistance training (A) Finger exercise and paraffin bath therapy, (B) paraffin bath therapy (A) high-intensity interval cycling, (B) moderateintensity continuous cycling
(A) e-exercise, (B) usual physical therapy
(A) 24, (B) 24, (C) 1
8w
(A) 3, (B) 3, (C) 0
Not reported
self-care, functional ability (pain, stiffness, physical function)
9w
A=B>C
7
7
(A) 12, (B) 12, (C) 12
4w
(A) 3, (B) 3, (C) 3
VAS (pain), KOOS, functional performance (6MWT, TUG, chair stand)
8w
A=B
7
5
(A) 40, (B) 40
8w
(A) 5, (B) 5
Nonadherence not different between groups but adherence measurement was not reported Not reported
Hand grip strength, Australian/Canadian Osteoarthritis Hand Index
8w
A>B
7
8
(A) 32, (B) 32
8w
(A) 4, (B) 4
(A) 94%, (B) 88%%
8w
A>B
4
9
(A) 5, (B) 12
12 w
Not reported
(A) 81% completed 8 of 12 emodules, (B) not reported
enrolment rate, withdrawal rate, exercise adherence, adverse effects, WOMAC, Lequesne Index, TUG, sit-to-stand, gait speed, BMI, body fat %, muscle mass physical functioning, freeliving physical activity, KOOS/HOOS, tiredness, QOL,
12, 52 w
A=B
4
7
21
self-efficacy, number of physical therapy sessions Kolisek
RCT
Knee
60 (27F, 33M)
Kuntz
RCT
Knee
31 (31F)
Kuptniratsaikul
RCT
Knee
80 (75F, 5M)
Lai
RCT
Knee
40 (32F, 2M, 6LTF)
Marconcin
RCT
Knee
80 (47F, 20M, 13LTF)
Mazloum
RCT
Knee
41 (13F, 28M)
Nahayatbin
RCT
Knee
48 (sex not documented)
(A) brace only, (B) exercise (2 exercises), (C) brace and exercise (A) yoga, (B) traditional exercise, (C) meditation (attention control)
(A) 0, (B) 168, (C) 168
12 w
(A) 0, (B) 14, (C) 14
Not reported
Quadriceps muscle strength, self-paced walk test, TUG, VAS, LEFS, VR-12
6, 12 w
A=B=C
2
2
(A) 36, (B) 36, (C) 36
12 w
(A) 3, (B) 3, (C) 3
KOOS, mobility performance, knee strength depression, QOL
12 w
A=B>C
8
10
(A) underwater treadmill and home exercise, (B) home exercise
(A) 12, (B) Not reported
4w
(A) 3, (B) Not reported
Pain, 6MWT, Quad Strength, Body weight
4w
A=B
8
10
(A) education (control), (B) strength exercise (A) selfmanagement and exercise, (B) education (control)
(A) 0, (B) 24
8w
(A) 0, (B) 3
(A) 3 sessions per week, (B) 2.7 sessions per week, (C) 2.7 sessions per week (A) 27.5 home exercise sessions, (B) 22.8 home exercise sessions Not reported
knee and ankle proprioception
8w
A
6
3
(A) 24, (B) 3
12 w
(A) 2, (B) Not reported
Not reported
12 w
A=B
6
6
(A) pilates, (B) conventional therapeutic exercise, (C) control (A) closed kinetic chain exercise, (B) Tai Chi, (C) no exercise
(A) 24, (B) 24, (C) 0
8w
(A) 3, (B) 3, (C) 0
Not reported
Not documented
A>B>C
4
4
(A) 12, (B) 12, (C) 0
4w
(A) 3, (B) 3, (C) 0
Not reported
KOOS pain and other symptoms, self-management behaviours, functional lower limb strength functional performance, Lequesne, joint position sense (Biodex) 6MWT, KOOS
4w
B>A=C
3
3
22
Nazari
RCT
Knee
93 (49F, 41M, 3LTF)
(A) high-intensity laser therapy (B) conventional physical therapy (C) exercise therapy (A) taping and exercise (B) exercise
(A) 12, (B) 12, (C) 168
(A) 4, (B) 4, (C) 12
(A) 3, (B) 3, (C) 14
Not reported
pain, knee flexion ROM, TUG, 6MWT, WOMAC
4, 12 w
A>B=C
7
5
Parekh
RCT
Knee
50 (sex not documented)
(A) 3, (B) Not reported
1w
(A) 3, (B) Not reported
Not reported
WOMAC, TUG
1w
Between group not documented
3
3
Pazit
Pilot RCT
Knee
28 (15F, 13M)
(A) control, (2) high-speed resistance training, (3) highspeed resistance training and balance exercises
(A) 0, (B) 16, (C) 16
8w
(A) 0, (B) 2, (C) 2
(A) Not reported, (B) 99.3%, (C) 96.8%
8w
A
6
6
Knee
46 (39F, 2M, 5LTF)
(A) 12, (B) 12
8w
(A) 1.5, (B) 1.5
Not reported
8w
A=B
6
8
Pilot RCT
Knee
20 (12F, 8M)
(A) 24, (B) 24, (C) 24
12 w
(A) 2, (B) 2, (C) 2
Not reported
NRS, WOMAC
12 w
A=B=C
8
6
Sanchez Romero
RCT
Knee
65 (18F, 44M, 3LTF)
(A) sham electromyography and isometric exercise (control), (B) electromyography biofeedback and exercise (A) dry needling and exercise, (B) sham dry needling and exercise, (C) exercise (A) dry needling and exercise, (B) sham dry needling and exercise
Feasibility & safety - adherence, dropout rate, adverse events, pain. Also, strength, mobility, functional tests, pain, executive function, satisfaction VAS, VMO muscle thickness, WOMAC, Lequesne, EMG VMO
Raeissadat
RCT
SanchezRomero
12 w
(A) 2, (B) 2
Not reported
NRS, WOMAC, EQ-5D, BI, TUG
12, 24, 52 w
A=B
9
5
Sit
RCT
Knee
208 (167F, 41M)
(A) 24 exercise and 6 dry needling, (B) 24 exercise and 6 sham dry needling (A) 3 patellar mobilization and 336 home
24 w
(A) 14, (B) 0
(A) 5.2 days per week
WOMAC pain, function
24 w
A>B
8
5
(A) patellar mobilization therapy and home
23
Stoffer-Marx
RCT
Hand
151 (127F, 24M)
Suzuki
RCT
Preradiographic Knee
100 (29F, 23M, 48LTF)
Taglietti
RCT
Knee
60 (41F, 19M)
Uzunkualoglu
RCT
Knee
90 (64F, 26M)
Wang
RCT
Knee
100 (76F, 24M)
exercise, (B) control
exercise, (B) 0
(A) combined interdisciplinary consultation intervention, (B) routine care and placebo (massage ball) (A) knee and hip strengthening and stretching, (B) quadriceps strengthening
(A) 2 consultation and 56 home exercise, (B) 0
8w
(A) 7, (B) 0
(A) 38%, (B) Not applicable
grip strength, JTHFT AUSCAN
8w
A>B
8
11
(A) 20, (B) 20
4w
(A) 5, (B) 5
(A) 96.6%, (B) 100%
4w
A>B
6
7
(A) 16, (B) 8
8w
(A) 2, (B) 1
Not reported
knee pain, selfreported function, isometric maximum knee extensor muscle strength, adherence WOMAC, QOL, functional mobility and depression
8, 12 w
A>B
7
7
(A) 12, (B) 12 individual training and 84 home exercise, (C) 12 individual training and 84 home exercise (A) 36, (B) 36
4w
(A) 3, (B) 3 individual and 21 home, (C) 3 individual and 21 home
Not reported
4w
A=B
6
3
12 w
(A) 3, (B) 3
Not reported
?
A>B
4
2
(A) aquatic exercise, (B) educational program (A) kinesthetic ability trainer, (B) flamingo training, (3) combined training
(A) exercise therapy, (B) quadriceps training)
Berg balance scale, kinesthetic ability trainer static and dynamic scores, TUG, walking speed, activities specific balance confidence, functional reach WOMAC, gait parameters
F=female, M=male, LTF =lost to follow-up, w=week(s) 6MWT=Six Minute Walk Test AUSCAN=Australian/Canadian Osteoarthritis Hand Index BI=Barthel Index BMI=Body Mass Index CSA=Cross-sectional Area EQ-5D=EuroQoL Group 5-Dimension Self-Report Questionnaire EMG=Electromyography HOOS=Hip injury and Osteoarthritis Outcome Score
24
JTHFT=Jebsen-Taylor Hand Function Test KAM=Knee Adduction Moment KFM=Knee Flexion Moment KOOS=Knee injury and Osteoarthritis Outcome Score LEFS=Lower Extremity Functional Scale NPRS=Numeric Pain Rating Scale NRS=Numeric Rating Scale PPT=Pressure Pain Threshold ROM=Range of Motion QOL=Quality of Life SF-12=Short Form-12 SF-36=Short Form-36 TUG=Timed Up and Go VAS=Visual Analogue Scale VR-12=Veterans RAND 12 Item Health Survey VMO=Vastus Medialis Oblique WOMAC=Western Ontario McMaster Universities Osteoarthritis Index
25
Table 2. Summary of 14 synthesis papers on diet and exercise interventions for osteoarthritis (OA). A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR 2) is a consensus score from two authors. First Author Balasukumaran
Design Systematic Review and Meta-analysis
Sample Neurological and Musculoskeletal Disorders (n=232 with Knee OA)
Beasley
Systematic Review
Hand OA
Briani
Systematic Review and Meta-analysis
Knee OA
To systematically review evidence of primary outcomes from randomized controlled trials examining the effect of treatment strategies on quality of life or psychosocial factors in individuals with knee OA.
Dong
Systematic Review and Meta-analysis
Knee OA
Umbrella Review
Knee OA
To systematically review the effectiveness of aquatic exercise compared to land-based exercise in treating knee OA. To update the last known umbrella review and summarize the available high-quality evidence from systematic reviews on the effectiveness of non-
Ferreira
Objective To investigate effectiveness of backward walking as treatment for people with gait impairments. (Backward walking eliminates heel contact thus reduces patellofemoral contact forces; requires greater reliance on systems other than vision and increases spatial parameters while reducing temporal parameters.) To evaluate the evidence supporting conservative therapeutic interventions for the treatment of OA finger joints.
Outcomes Pain, functional disability, muscle strength, gait parameters, balance, stability and plantar pressure
Conclusions In knee OA, significant standardized mean difference values in favour of backward walking (compared with conventional PT for 2-4 weeks) to reduce pain, functional disability and to improve quadriceps strength.
Recommendations NA
AMSTAR 2* LOW
Physical function, pain (at rest and during activity), range of motion, grip strength, pinch strength, stiffness, arthritis selfefficacy pain, Patient Specific Functional Scale Health-related quality of life (QOL), kneerelated QOL, QOL, psychosocial factors
Current evidence varies in quality and effect size but generally supports active range of motion, resistive exercise, joint protection, electromagnetic therapy, paraffin wax, balneotherapy and distal interphalangeal orthoses.
NA
CRITICALLY LOW
NA
MODERATE
Pain, physical function, quality of life
Exercise (with or without other interventions) is effective in improving health-related, kneerelated QOL or psychosocial factors. Exercise was superior compared to self-management booklets and antiinflammatory drugs. Cognitive behavioural therapies (with or without exercise) effective for improving self-efficacy, depression, psychological distress. No differences between aquatic and land-based but adherence and satisfaction appears higher in aquatic.
NA
MODERATE
Pain, functional status, stiffness, inflammation, quality of life and patient global assessment
Gold evidence: Exercise (aerobic, resistance) reduce pain and improve physical function however it is unclear if one of low versus high intensity exercise is superior. Silver
NA
CRITICALLY LOW
26
pharmacological and non-surgical interventions for people with knee OA.
Geenen
EULAR Recommendations
Inflammatory Arthritis and OA
To evaluate the existing scientific evidence associated with the benefits of the health professional's approach to pain management for people with inflammatory arthritis and OA, and to use this evidence and expert opinion to provide recommendations that enable health professionals to provide knowledgeable pain-management support.
Pain
Hall
Systematic Review and Meta-analysis
Knee OA
To determine the effect of dietonly treatments and combined diet and exercise treatments on pain and physical function; and to explore the effect of these treatments on inflammatory biomarkers in overweight and obese adults with knee OA.
Pain, physical function, inflammatory biomarkers
Mixed Methods Review
Hip, Knee or Hip and Knee OA
To improve our understanding of the complex inter-relationship between pain, psychosocial effects, physical function and exercise.
Pain, physical function, self-efficacy, depression, anxiety, quality of life
Hurley
evidence: Acupuncture, aquatic exercise, electro-acupuncture, interferential current, taping, manual therapy, moxibustion, pulsed electromagnetic field, Tai Chi, ultrasound, yoga and whole body vibration. Effects on pain were most uniformly positive for physical activity and exercise interventions and for psychological interventions. Reviews do not answer the question whether high intensity exercise is as safe as low intensity exercise.
Diet-only treatments did not reduce pain but diet combined with exercise did reduce pain moderately. Diet only and diet combined with exercise improved physical function moderately. Diet only treatments reduced IL-6. Diet-only interventions do not address the multifactorial nature of pain. There were large variations in exercise program's content, mode of delivery, frequency and duration, participant's symptoms, duration of symptoms, outcomes measured, methodological quality and reporting. Moderate quality evidence that exercise reduced pain by 6%, improved physical function by 5.6%. Low quality evidence that selfefficacy was increased by 1.7%.
(1) Assessment include patient (needs, preferences, priorities), pain characteristics, previous treatment and efficacy, current pain sources, psychosocial influences. (2) Personalized management plan developed as a shared decision making process, evidence-based treatment, and a stepped approach with education and self-management first, more treatment second, multidisciplinary treatment last. (4) Physical activity and exercise. (5) Orthotics. (6) Psychological and social interventions. (7) Sleep interventions. (8) Weight management. (9) Pharmacological. (10) Multidisciplinary. NA
LOW
NA
LOW
HIGH
27
EULAR Recommendations
Hand OA
To update recommendations for the management of hand OA since 2007.
Symptoms (pain, stiffness); function; activities (participation, quality of life)
Morales-Ivorra
Systematic Review
OA
Quality of life
Rausch Osthoff
Meta-analysis
Rheumatoid Arthritis, Spondylo-arthritis (SpA), Hip and
To systematically review and analyze the epidemiological evidence in humans on the Mediterranean diet and its association with OA. To evaluate the effectiveness of exercise and physical activity (PA) promotion on cardiovascular fitness, muscle
Kloppenburg
Cardiovascular fitness, muscle strength, flexibility, neuromotor performance
Moderate quality evidence that exercise improved depressive symptoms by 2.4%. No effect on anxiety. Low quality evidence that exercise improved social function by 7.9%. Qualitative synthesis showed that people avoid activity for fear of causing harm; and from the patient's perspective, exercise delivery could be improved with (a) better information and advice about the safety and value of exercise, (b) exercise tailored to individual preferences abilities and needs, and (c) better support and challenge to inappropriate health beliefs. "Joint protection" is considered an outdated term because it implies the patient should refrain from using their joints. It is replaced with education, training in ergonomics and pacing activity. Seven trials of exercise in hand OA were summarized in a Cochrane review, and produced small beneficial effects on pain function stiffness and grip strength with few, non-severe adverse events. Beneficial effects of a thumb base orthosis for pain and function but not grip strength after 3 months (long term use advocated). Topical pharmacologics preferred over systemic. Avoid diseasemodifying anti-rheumatics. Positive association between adherence to the Mediterranean diet and quality of life.
Moderate effectiveness on cardiorespiratory and muscle strength, as well as physical activity promotion interventions in arthritis
(1) Education, ergonomics, pacing activity. (2) Exercise should be considered for every patient. (3) Longterm use of orthoses should be considered for symptom relief in patients with thumb OA. (4) Topical treatments preferred over systemic (topical first treatment of choice). (5) Oral NSAIDs used for a limited period only. (6) Chondroitin sulfate may be used. (7) Intra-articular glucocorticoid injections should not be used, but considered in painful IP joints. (8) Avoid diseasemodifying anti-rheumatics. (9) Surgery for structural disease. (10) Long-term follow up to match patient needs.
NA
NA
CRITICALLY LOW
NA
MODERATE
28
Knee OA
strength, flexibility, neuro-motor performance (balance) and daily PA in people with Rheumatoid Arthritis, SpA and hip or knee OA.
(balance) and daily PA
To assess the effect between exercises compared to diet for chronic pain management, physical and mental function in obese patients with chronic musculoskeletal problems. To investigate the effects of longterm exercise therapy for people with knee OA on radiographic disease severity and cartilage integrity as well as severity of bone marrow lesions, synovitis and effusion.
Pain, mobility, physical function, mental function
To specify doses of exercise related to improved outcomes of pain and function in individuals with common knee disorders, categorized by effect size.
Pain, physical function
Tamin
Systematic Review and Meta-analysis
Obese with chronic musculoskeletal pain (all four studies included were knee OA)
VanGinckel
Systematic Review and Meta-analysis
Knee OA
Systematic Review
Knee disorders including an isolated analysis of Knee OA
Young
Radiographic disease severity and cartilage integrity as well as severity of bone marrow lesions, synovitis and effusion
(including hip/knee OA alone). No evidence was found for the effects of flexibility exercises. Low compliance rate is one of the most compelling challenges for exercise and physical activity interventions in arthritis. Exercise can improve mobility but cannot reduce pain in obese patients with chronic musculoskeletal problems.
Long-term exercise therapy did not change knee radiographic disease severity, cartilage morphology or synovitis/effusion, but may slightly increase bone marrow lesion severity. There was limited evidence suggesting some protective effects on patellar cartilage. 24 therapeutic exercise sessions and 8- to 12- week durations were observed with large effects by the authors. An exercise frequency of once per week was associated with no effect. 4-6 week durations of care have medium, small or no effect.
NA
CRITICALLY LOW
NA
HIGH
NA
LOW
NA=Not Applicable NSAID=Non-steroidal anti-inflammatory drug *AMSTAR 2 scored consistent with the recommendations presented in Shea BJ et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ (Clinical research ed). 2017;358:j4008
29
Box 1: Areas for Future Rehabilitation Research •
Advance rehabilitation approaches that contribute to long-term weight management in OA.
•
Directly compare dosage, delivery, modality and duration of exercise and lifestyle diet interventions to find the optimal range of intervention parameters.
•
Track and promote adherence to rehabilitation interventions.
•
Identify confounders of treatment response to exercise and lifestyle diet interventions.
•
Identify responders versus non-responders to exercise and lifestyle diet interventions.
•
Build further evidence regarding the impact of long-term exercise on hand, hip and knee structures.
•
Explore quality of life and psychological outcomes as primary outcomes in rehabilitation studies.
30
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exercises on knee osteoarthritis: A comparative clinical trial. Iran Red Crescent Med J. 2018;May:e62600. 51. Nazari A, Moezy A, Nejati P, Mazaherinezhad A. Efficacy of high-intensity laser therapy in comparison with conventional physiotherapy and exercise therapy on pain and function of patients with knee osteoarthritis: a randomized controlled trial with 12-week follow up. Lasers in medical science. 2019;34(3):505-16. 52. Parekh S, Vaghela N. Immediate effect of taping in physical performance of osteoarthritis of knee joint. Nat J Physiol, Pharm, Pharmacol. 2018;8(4):470-4. 53. Pazit L, Jeremy D, Nancy B, Michael B, George E, Hill KD. Safety and feasibility of high speed resistance training with and without balance exercises for knee osteoarthritis: A pilot randomised controlled trial. Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine. 2018;34:154-63. 54. Raeissadat SA, Rayegani SM, Sedighipour L, Bossaghzade Z, Abdollahzadeh MH, Nikray R, et al. The efficacy of electromyographic biofeedback on pain, function, and maximal thickness of vastus medialis oblique muscle in patients with knee osteoarthritis: a randomized clinical trial. Journal of pain research. 2018;11:2781-9. 55. Sanchez Romero EA, Fernandez-Carnero J, Calvo-Lobo C, Ochoa Saez V, Burgos Caballero V, Pecos-Martin D. Is a Combination of Exercise and Dry Needling Effective for Knee OA? Pain medicine (Malden, Mass). 2019. 56. Sanchez-Romero EA, Pecos-Martin D, Calvo-Lobo C, Ochoa-Saez V, Burgos-Caballero V, Fernandez-Carnero J. Effects of dry needling in an exercise program for older adults with knee osteoarthritis: A pilot clinical trial. Medicine. 2018;97(26):e11255. 57. Sit RWS, Chan KKW, Zou D, Chan DCC, Yip BHK, Zhang DD, et al. Clinic-Based Patellar Mobilization Therapy for Knee Osteoarthritis: A Randomized Clinical Trial. Annals of family medicine. 2018;16(6):521-9. 58. Suzuki Y, Iijima H, Tashiro Y, Kajiwara Y, Zeidan H, Shimoura K, et al. Home exercise therapy to improve muscle strength and joint flexibility effectively treats pre-radiographic knee OA in community-dwelling elderly: a randomized controlled trial. Clinical rheumatology. 2019;38(1):133-41. 59. Taglietti M, Facci LM, Trelha CS, de Melo FC, da Silva DW, Sawczuk G, et al. Effectiveness of aquatic exercises compared to patient-education on health status in individuals with knee osteoarthritis: a randomized controlled trial. Clinical rehabilitation. 2018;32(6):766-76. 60. Uzunkulaoğlu A, Yildirim I, Aytekin M, Ay S. Effect of Flamingo exercises on balance in patients with balance impairment due to senile osteoarthritis. Arch Gerontol Geriatrics. 2018;81:48-52. 61. Wang H, Ma Y, Guo Y, Pan Y. Effects of exercise therapy for knee osteoarthritis. Int J Clin Exp Med. 2018;11(9):10009-14. 62. Bennell KL, Nelligan RK, Rini C, Keefe FJ, Kasza J, French S, et al. Effects of internet-based pain coping skills training before home exercise for individuals with hip osteoarthritis (HOPE trial): a randomised controlled trial. Pain. 2018;159(9):1833-42. 63. Aksoy M, Altan L. Short-term efficacy of paraffin therapy and home-based exercise programs in the treatment of symptomatic hand osteoarthritis. Turk J Phys Med Rehab. 2018;64(2):108-13. 64. Kang TW, Lee JH, Park DH, Cynn HS. Effects of a finger exercise program on hand function in automobile workers with hand osteoarthritis: A randomized controlled trial. Hand surgery & rehabilitation. 2019;38(1):59-66. 65. Stoffer-Marx MA, Klinger M, Luschin S, Meriaux-Kratochvila S, Zettel-Tomenendal M, NellDuxneuner V, et al. Functional consultation and exercises improve grip strength in osteoarthritis of the hand - a randomised controlled trial. Arthritis research & therapy. 2018;20(1):253. 66. Kloek CJJ, Bossen D, Spreeuwenberg PM, Dekker J, de Bakker DH, Veenhof C. Effectiveness of a Blended Physical Therapist Intervention in People With Hip Osteoarthritis, Knee Osteoarthritis, or Both: A Cluster-Randomized Controlled Trial. Phys Ther. 2018;98(7):560-70. 34
67. Dziedzic KS, Healey EL, Porcheret M, Afolabi EK, Lewis M, Morden A, et al. Implementing core NICE guidelines for osteoarthritis in primary care with a model consultation (MOSAICS): a cluster randomised controlled trial. Osteoarthritis and cartilage. 2018;26(1):43-53. 68. Geenen R, Overman CL, Christensen R, Asenlof P, Capela S, Huisinga KL, et al. EULAR recommendations for the health professional's approach to pain management in inflammatory arthritis and osteoarthritis. Ann Rheum Dis. 2018;77(6):797-807. 69. Kloppenburg M, Kroon FP, Blanco FJ, Doherty M, Dziedzic KS, Greibrokk E, et al. 2018 update of the EULAR recommendations for the management of hand osteoarthritis. Ann Rheum Dis. 2019;78(1):16-24. 70. Beasley J, Ward L, Knipper-Fisher K, Hughes K, Lunsford D, Leiras C. Conservative therapeutic interventions for osteoarthritic finger joints: A systematic review. Journal of hand therapy : official journal of the American Society of Hand Therapists. 2019;32(2):153-64.e2. 71. Morales-Ivorra I, Romera-Baures M, Roman-Vinas B, Serra-Majem L. Osteoarthritis and the Mediterranean Diet: A Systematic Review. Nutrients. 2018;10(8). 72. Ferreira RM, Duarte JA, Goncalves RS. Non-pharmacological and non-surgical interventions to manage patients with knee osteoarthritis: An umbrella review. Acta reumatologica portuguesa. 2018;43(3):182-200. 73. Rausch Osthoff AK, Juhl CB, Knittle K, Dagfinrud H, Hurkmans E, Braun J, et al. Effects of exercise and physical activity promotion: meta-analysis informing the 2018 EULAR recommendations for physical activity in people with rheumatoid arthritis, spondyloarthritis and hip/knee osteoarthritis. RMD open. 2018;4(2):e000713. 74. Tamin TZ, Murdana N, Pitoyo Y, Safitri ED. Exercise Intervention for Chronic Pain Management, Muscle Strengthening, and Functional Score in Obese Patients with Chronic Musculoskeletal Pain: A Systematic Review and Meta-analysis. Acta medica Indonesiana. 2018;50(4):299-308. 75. Briani RV, Ferreira AS, Pazzinatto MF, Pappas E, De Oliveira Silva D, Azevedo FM. What interventions can improve quality of life or psychosocial factors of individuals with knee osteoarthritis? A systematic review with meta-analysis of primary outcomes from randomised controlled trials. British journal of sports medicine. 2018;52(16):1031-8. 76. Van Ginckel A, Hall M, Dobson F, Calders P. Effects of long-term exercise therapy on knee joint structure in people with knee osteoarthritis: A systematic review and meta-analysis. Seminars in arthritis and rheumatism. 2019;48(6):941-9. 77. Young JL, Rhon DI, Cleland JA, Snodgrass SJ. The Influence of Exercise Dosing on Outcomes in Patients With Knee Disorders: A Systematic Review. The Journal of orthopaedic and sports physical therapy. 2018;48(3):146-61. 78. Dong R, Wu Y, Xu S, Zhang L, Ying J, Jin H, et al. Is aquatic exercise more effective than land-based exercise for knee osteoarthritis? Medicine. 2018;97(52):e13823. 79. Balasukumaran T, Olivier B, Ntsiea MV. The effectiveness of backward walking as a treatment for people with gait impairments: a systematic review and meta-analysis. Clinical rehabilitation. 2019;33(2):171-82. 80. Thorstensson CA, Roos EM, Petersson IF, Arvidsson B. How do middle-aged patients conceive exercise as a form of treatment for knee osteoarthritis? Disability and rehabilitation. 2006;28(1):51-9. 81. Hurley MV, Walsh N, Bhavnani V, Britten N, Stevenson F. Health beliefs before and after participation on an exercised-based rehabilitation programme for chronic knee pain: doing is believing. BMC musculoskeletal disorders. 2010;11:31. 82. Maly M, Cott C. Being careful: A grounded theory of emergent chronic knee problems. Arthritis Care Res. 2009;61:937-43.
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Figures Fig. 1. Flow chart documenting the identification of randomized controlled trials and synthesis papers to be included in this review of studies of exercise and diet in osteoarthritis (OA) published between January 1, 2018 and April 1, 2019, from all of the potential titles and abstracts yielded by a search of health-related databases.
S1063-4584(19)31295-6
DOI:
https://doi.org/10.1016/j.joca.2019.11.008
Reference:
YJOCA 4566
To appear in:
Osteoarthritis and Cartilage
Received Date: 31 July 2019 Revised Date:
14 November 2019
Accepted Date: 18 November 2019
Please cite this article as: Maly MR, Marriott KA, Chopp-Hurley JN, Osteoarthritis Year in Review 2019: Rehabilitation and Outcomes, Osteoarthritis and Cartilage, https://doi.org/10.1016/j.joca.2019.11.008. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Ltd on behalf of Osteoarthritis Research Society International.
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Osteoarthritis Year in Review 2019: Rehabilitation and Outcomes
1
Monica R. Maly1,2, Kendal A. Marriott1*, Jaclyn N. Chopp-Hurley2,3* Department of Kinesiology, University of Waterloo ([email protected]) 2 School of Rehabilitation Science, McMaster University 3 School of Kinesiology and Health Science, York University *Denotes equal authorship
Abstract Word Count: 250 Manuscript Word Count: 4,012
Key Words: Arthritis, Hand, Hip, Knee, Outcome Assessment (Health Care), Recovery of Function, Review Literature as Topic
Corresponding Author: Monica R. Maly Department of Kinesiology, University of Waterloo Room 1036 Burt Matthews Hall 200 University Avenue Waterloo, Ontario, Canada N2L 3G1 T: (519) 888-4567 x 37916 F: (519) 885-4070 [email protected]
1
46
Abstract
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Objective: Inactivity and obesity are risk factors for osteoarthritis (OA) progression. The purpose of
48
this review was to highlight intervention parameters of exercise and lifestyle diet interventions on
49
clinical outcomes in OA that were published over 15 months, starting January 1, 2018.
50 51
Design: Systematic literature searches were performed in Medline (Pubmed, OVID), Scopus,
52
CINAHL, CENTRAL and Embase from January 1, 2018 to April 1, 2019. Key words included
53
osteoarthritis, exercise, physical activity, diet and nutrition. Randomized controlled designs and data
54
synthesis papers (systematic reviews, meta-analyses, clinical guidelines) written in English, that
55
included humans with OA of any joint were included. Trials were evaluated using the Physiotherapy
56
Evidence Database (PEDro) critical appraisal tool and the Template for Intervention Description and
57
Replication (TIDieR). Systematic reviews and meta-analyses were evaluated using A MeaSurement
58
Tool to Assess systematic Reviews 2 (AMSTAR 2). Intervention details (RCTs) and key finding from
59
papers were summarized.
60 61
Results: Of 540 titles and abstracts retrieved, 147 full articles were reviewed and 53 met the inclusion
62
criteria, comprised of 39 RCTs and 14 synthesis papers. By addressing inactivity, exercise effectively
63
improves clinical outcomes and, based on low-moderate quality evidence, without further damage to
64
cartilage or synovial tissue. By comparison, much less work focused on minimizing obesity. Diet
65
must be combined with exercise to improve pain, but alone, can improve physical function.
66 67
Conclusions: Future work is necessary to identify the ideal exercise frequency and intensity and
68
lifestyle diet intervention parameters. Improved adherence to reporting guidelines in future work will
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greatly enhance the OA rehabilitation field.
2
70
Introduction
71
Despite the diversity of osteoarthritis (OA) pathogenesis, the literature consistently cites obesity and
72
inactivity as risk factors for initiation and progression (1). Obesity elevates the risk for OA (2). In
73
combination with excessive joint loading (3), obesity degrades joint tissues through inflammatory
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pathways that interact with abnormal immune responses (4-6). Inactivity is the fourth leading risk for
75
mortality globally (7), and in OA, is linked to worsening structural disease (8, 9) and disability (10).
76
Inactivity reduces cartilage thickness and quality, compromises muscle structure and function,
77
increases risk for comorbidities and diminishes quality of life in OA (9, 11, 12). Because obesity and
78
inactivity can be modified using diet and exercise, these are excellent targets for rehabilitation, where
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the scope of rehabilitation includes conservative approaches to optimize or restore physical ability and
80
quality of life.
81 82
The efficacy of exercise and diet in OA is established (5, 13-15). “Exercise” refers to any bodily
83
movement via skeletal muscles that is planned, structured and repeated with an objective to improve or
84
maintain one or more elements of health-related or skill-related fitness (16). “Lifestyle diet” refers to
85
any structured guide to the habitual intake of foods. The optimal intervention parameters for exercise
86
and diet remain unclear for several reasons. First, there exists great heterogeneity in exercise and diet
87
prescription (17, 18). It is likely that some exercise trials underdose resulting in ineffective
88
interventions, while others overdose thereby exacerbating pain. Second, the exercise or diet
89
prescription is often unclear due to incomplete reporting (19). Third, OA complicates exercise
90
prescription through impairments in muscle activation (via arthrogenic inhibition and altered
91
proprioception) and systemic cardiorespiratory impairments (via inflammation, co-morbidity and
92
inactive lifestyle). Fourth, there may be a disconnect between exercise recommendations by the
93
Canadian Society for Exercise Physiology (CSEP) and American Society of Sports Medicine (ACSM)
94
with effective exercise parameters in OA. CSEP and ACSM recommend concurrent aerobic and 3
95
resistance training (20, 21), while systematic reviews provide conflicting conclusions on whether the
96
best clinical outcomes in OA result from exercise programs with one aim (17) versus multiple aims
97
(22). Similarly, we lack clarity on the optimal parameters for diet in OA. The purpose of this year in
98
review is to highlight intervention parameters documented in studies that evaluate the impact of
99
exercise and lifestyle diet interventions on clinical outcomes in OA published over 15 months starting
100
January 1, 2018.
101 102
Methods
103
Systematic literature searches were performed in Medline (Pubmed, OVID), Scopus, CINAHL,
104
CENTRAL, and Embase from January 1, 2018 to April 1, 2019. Key words included osteoarthritis,
105
exercise, physical activity, diet and nutrition using the explode command. Documentation (in the
106
manuscript or supplemental material) detailing a planned, structured and repeated program for exercise,
107
or a structured, habitual guide for food intake, was required for inclusion. The search was limited to
108
human, full-text and English. Randomized controlled trials (RCTs) that enrolled participants with OA,
109
including cluster, pilot and feasibility designs, were included. Clinical guidelines, systematic reviews
110
and meta-analyses were included. Secondary analyses, uncontrolled trials, protocols, qualitative,
111
retrospective, case studies, cost-analyses and narrative or scoping reviews were excluded. Studies of
112
surgery, oral or injectable medications, electrothermal modalities, neutraceuticals, vitamins or food
113
additives, and devices were also excluded. Among studies with heterogeneous samples, studies that
114
did not isolate analyses to OA were excluded.
115 116
Titles and abstracts were reviewed for inclusion by two authors (KAM, JNCH). In the case of
117
discrepancies, full papers were reviewed by all authors to reach agreement.
118
4
119
A summary of the intervention dosage, exercise adherence, primary outcomes and main findings was
120
created for RCTs. These details were extracted by two authors (KAM, JNCH) and confirmed by the
121
third author (MRM). These papers were evaluated using the Physiotherapy Evidence Database
122
(PEDro) critical appraisal tool, which produces valid and reliable scores that reflect the risk of bias in
123
clinical trials (23, 24). Studies can be rated as high (≥7/10), moderate (4-6/10) or low quality (≤3/10).
124
The Template for Intervention Description and Replication (TIDieR) checklist and guide were used
125
(25, 26). The TIDieR checklist expands upon the 2010 Consolidated Standards of Reporting Trials
126
(CONSORT) guidelines. Studies can be rated as good (≥9/12), moderate (6-8/12) or poor description
127
(≤5/12). For both the PEDro and TIDieR, we present consensus scores from two raters. Finally, we
128
selected a subgroup of RCTs for a narrative review to highlight intervention dosage and high quality
129
trials.
130 131
For synthesis papers, key themes were summarized and a subgroup was included in a narrative review.
132
Also, systematic reviews and meta-analyses were evaluated using A MeaSurement Tool to Assess
133
systematic Reviews 2 (AMSTAR 2) (27, 28). This 16-item tool evaluates review quality by identifying
134
critical flaws (protocol registration, search, study exclusion justification, risk of bias, meta-analytical
135
methods, interpretation, publication bias) (27). Consensus scores from two raters on the confidence in
136
the review were high (0-1 non-critical weakness), moderate (>1 non-critical weakness), low (1 critical
137
flaw), and critically low (>1 critical flaw) (27).
138 139
Results
140
After duplicates were removed, 540 titles and abstracts were retrieved. Of these, 147 full articles were
141
identified for full-text review (Figure 1). Fifty-three full articles met the inclusion criteria, comprised
142
of 39 RCTs and 14 synthesis articles.
143 5
144
Randomized Controlled Trials
145
Of the 39 RCTs, all documented exercise. Thirty-three focused on knee (29-61), one on hip (62), three
146
on hand (63-65), one on hip and knee (66) and one on a mixed sample with peripheral joint pain
147
consistent with OA (67). These RCTs documented exercise interventions in a variety of themes:
148
integrated exercise with other care (14 studies, cumulative n=1,607) of which 4 studies combined
149
exercise with a thermal or electrical modality; exercise delivered or supported with technology (4
150
studies, cumulative n=748); resistance and/or sensory-motor (n=8, cumulative n=660); aerobic (n=3,
151
cumulative n=150); aquatic (n=2, cumulative n=140); balance (n=2, cumulative n=132); mind-body
152
approaches (n=3, cumulative n=120); gait retraining (n=2, cumulative n=102); and participatory
153
ergonomics (n=1, n=75).
154 155
Intervention parameters varied widely, where the total number of exercise sessions ranged from five to
156
168, duration of care ranged from two to 104 weeks, and frequency per week ranged from fewer than
157
one to 14. (Supplemental material displays dosage parameters and effect sizes for WOMAC/KOOS
158
outcomes, where effect size calculation was possible). PEDro scores (out of 10) identified low (n=3),
159
moderate (n=16) and high (n=20) quality trials. The most common sources of bias included an
160
inability to blind the participant and intervention provider and failure to use and/or clearly document an
161
intention-to-treat analysis. Intervention descriptions fulfilled between two to 12 of 12 TIDieR criteria.
162
The most common challenges were unclear/absent descriptions of intervention materials and
163
procedures, delivery parameters and an a priori plan for adherence tracking.
164 165
Table 1 summarizes details of these trials. From these, we selected papers for narrative review to
166
discuss trials that explicitly examine dosage parameters and/or highlight high quality trials among the
167
largest four themes identified. Values reported are as presented in the original article.
168 6
169
Exercise Integrated with Other Care
170
Exercise was combined with physician consultation and self-management (37, 65, 67) , as well as self-
171
management alone (48), manual therapy (30, 57), dry needling (55, 56), and bracing or taping (44, 52).
172
Exercise was also combined with thermal (63, 64) and electrical (34, 51) modalities.
173 174
When combined with a functional consultation, daily exercise was effective in improving grip strength
175
among adults living with hand OA. An RCT compared the effectiveness of home exercise combined
176
with functional consultation against standard care in 151 participants with hand OA (65). The
177
intervention arm received a functional consultation (two face-to-face visits) on pain, activities of daily
178
living, assistive devices such as thumb orthoses, and a home program of hand exercises. The exercises
179
were active range of motion and strengthening using therapy putty daily for eight weeks (total of 56
180
sessions). Adherence was tracked by viewing wear of the therapy putty; where 28 of 74 participants in
181
the intervention arm (38%) adhered. At eight weeks follow-up, dominant-hand grip strength increased
182
in the intervention arm (mean difference 0.03 (standard deviation (SD) 0.11)) and decreased in the
183
control arm (mean difference −0.03 (SD 0.13), p=0.001) (65).
184 185
Over the past year, trials incorporated exercise within self-management programs for OA. A two-arm
186
cluster RCT (n=525) examined the effectiveness of implementing the core National Institute for Health
187
and Care Excellence (NICE) OA recommendations in England, across eight medical practices (67).
188
The intervention arm received physician consultation, a guidebook on self-management and up to four
189
follow-ups with a nurse practitioner providing goal-setting, weight management and exercise/physical
190
activity (67). Dosage and adherence to exercise were not reported. At six month follow-up, no
191
difference in the physical component score of the Short-Form 12 was found between intervention
192
versus usual care arms (mean difference -0.37, 95% Confidence Interval (95%CI) -2.32 to 1.57) (67).
193
This trial highlights the challenges of implementing OA self-management in a real-world setting. A 7
194
traditional trial of 80 people with knee OA examined the effectiveness of a self-management program
195
combined with exercise, delivered in a group format, compared to an education control (48). For 12
196
weeks, participants allocated to the intervention arm received a 90 min session twice weekly (total 24
197
sessions), composed of 30 min of self-management (including self-efficacy, exercise/physical activity,
198
communication, healthy eating, managing medicines) and 60 min of strength, flexibility and balance
199
exercise. The control arm received three educational sessions and a book. Adherence was not
200
reported. Pain and symptoms were no different between arms at the 12-week follow-up. However, 6
201
min walk [effect size (partial eta squared) 0.068, p=0.035] and sit-to-stand [effect size (partial eta
202
squared) 0.09, p=0.015] were better in the intervention relative to control arm (48). These studies
203
suggest that, even when other treatment opportunities are provided to patients, adherence to an exercise
204
prescription with adequate dosage is necessary to improve OA symptoms.
205 206
Delivering Exercise with Technology
207
Four studies used technologies to enhance exercise. Of these, three delivered exercise instruction
208
electronically (29, 62, 66) and one used electromyography biofeedback to enhance resistance training
209
(54).
210 211
The importance of technology in daily living makes it an area of key interest to provide or support
212
exercise in OA. A three-arm trial (n=350) compared an internet-based exercise training (IBET)
213
program versus physiotherapy and a wait list control in knee OA (29). The IBET arm received no face-
214
to-face contact. The IBET program featured exercise instruction (including videos, photographs),
215
progression, automated reminders and progress tracking. Participants were encouraged to complete
216
strengthening and stretching exercise three times per week for 52 weeks (total of 156 sessions).
217
Participants in the physiotherapy arm received up to eight visits. The average usage was 5.7 visits and
218
nearly all received therapeutic exercise two to three times per week (total of 104 to 156 sessions). 8
219
Adherence was not tracked. Improvements in WOMAC were no different for either the IBET or
220
physiotherapy arms compared with the wait list control at 16 weeks [IBET: mean -2.70, 95%CI (-6.24,
221
0.85), p=0.14; PT: mean -3.36, 95% CI (-6.84, 0.12), p=0.06] or at 52 weeks [IBET: mean -2.63,
222
95%CI (-6.37, 1.11), p=0.17; PT: mean -1.59, 95%CI (-5.26, 2.08), p=0.39] (29). In contrast, a two-
223
arm trial of 144 participants with hip OA compared internet-based pain coping skills training versus an
224
education control (62). Both arms were asked to complete home exercise three times per week for 16
225
weeks (total of 48 sessions) and this home exercise program was supported by five face-to-face
226
physiotherapy sessions. Adherence was tracked with multiple methods, with 72% and 77% home
227
exercise completion in the intervention and control arms respectively. In the eight weeks prior to
228
initiating the home exercise, the intervention arm received an online program on pain coping skills
229
including relaxation, activity-rest cycling, pleasant activity scheduling and imagery, distraction and
230
problem-solving. At the 24-week follow-up, both arms experienced improved pain during walking and
231
WOMAC physical function, with no between-group differences (walking pain: 0.5 units, 95%CI -0.3 to
232
1.3; function: -0.9 units, 95%CI -4.8 to 2.9). Those in the pain coping skills training group also
233
experienced improved pain coping skills at eight, 24 and 52 weeks (62). Face-to-face interactions,
234
albeit of a lower frequency than traditional programs, may be a necessary adjunct to technology-
235
supported exercise in OA.
236 237
Resistance and Aerobic Exercise
238
We selected two small trials of resistance and aerobic exercise interventions that explicitly compared
239
different exercise intensities. The resistance training study examined whether blood flow restriction
240
could enhance low-intensity muscle training to yield benefits equivalent to high-intensity training (36).
241
Permitting arterial flow while restricting venous return may stimulate greater muscle activation and
242
protein synthesis by reflecting metabolic overload. Forty-eight women with knee OA were randomized
243
into three arms. All were offered supervised quadriceps exercise twice per week for 12 weeks (total of 9
244
24 sessions). The high-intensity arm completed contractions at 80% of 1-repetition maximum (1RM);
245
low-intensity at 30% 1RM. The third arm repeated the low-intensity training at 30% 1RM with an air
246
cuff at the inguinal fold to restrict venous flow. Adherence, tracked by a research assistant, was 90%,
247
85% and 91% for the high, low and blood flow restriction arms. However, four of 16 participants in
248
the high-intensity arm were excluded due to pain. After 12 weeks, the high-intensity and blood flow
249
restriction arms showed greater improvement in leg press, knee extension 1RM, and quadriceps cross-
250
sectional area compared to the low-intensity arm (36). Blood flow restriction with low-intensity
251
resistance training may produce comparable improvements in muscle morphology and capacity to high-
252
intensity resistance training but with a lower risk for pain.
253 254
A feasibility trial explored high-intensity interval training (HIIT) for knee OA (43). In 27 adults with
255
knee OA who were cleared for this protocol by a physician, HIIT was compared with moderate-
256
intensity continuous training on a stationary bicycle. Participants in both arms were provided with a
257
written guide and a familiarization session to teach proper bicycle fit and the exercise program. Both
258
programs were four times per week for eight weeks (total of 32 sessions). Adherence and adverse
259
events were recorded in a diary. Exercise adherence was 94% and 88% in the HIIT and moderate
260
cycling arms respectively; however, 26 adverse events were reported in the HIIT arm, with 24 by one
261
participant attributed to a Bakers cyst. Both groups experienced improvements in WOMAC. The HIIT
262
resulted in greater improvement in the Timed Up and Go (TUG) compared to the moderate-intensity
263
continuous cycling group (p<0.043). However, the magnitude of change in the TUG within the HIIT
264
group pre-post intervention was 1.1 s, which is unlikely to be clinically meaningful. In a sample
265
cleared by a physician for high-intensity exercise, HIIT may have outperformed moderate intensity
266
aerobic exercise by a small margin but also may have increased adverse events (43).
267 268
Synthesis Papers 10
269
Fourteen synthesis papers were identified. Two were clinical guidelines from the European League
270
Against Rheumatism (EULAR) on pain management (68) and hand OA (69). One systematic review
271
was dedicated to the hand (70); and two were dedicated to diet (14, 71). The remaining focused on
272
exercise (18, 72-77), including aquatic (78) and gait (79). AMSTAR 2 scores were critically low
273
(n=4), low (n=4), moderate (n=3) and high (n=2). (One recommendation paper did not include a
274
systematic review and was not scored.) The most frequent reasons that limited confidence in the
275
review findings were a lack of reporting of the funding source of included papers, failure to select
276
articles and/or extract data in duplicate, and inadequate methods to assess and interpret bias.
277 278
Table 2 summarizes these synthesis papers. We selected papers for narrative review to highlight
279
recommendations, discuss dosage parameters and present high quality systematic reviews and/or meta-
280
analyses.
281 282
EULAR Clinical Guidelines
283
A multidisciplinary task force including health professionals and patients contributed a systematic
284
review of systematic reviews on pain-management for inflammatory arthritis and OA (68). Scientific
285
evidence (73) was integrated with four overarching principles. First, patient preferences, needs and
286
values should guide shared clinical decision-making. Second, a biopsychosocial model was
287
recommended. Third, core knowledge of inflammatory arthritis and OA is essential. Finally, the skill
288
to differentiate between localized, generalized and coexisting local and general pain is required. The
289
resulting recommendations encourage health professionals to work through a “stepped-care approach”
290
including proper assessment that invites patients to disclose the impact of their pain, expectations and
291
preferences; shared decision-making; education; specific treatments (exercise/physical activity,
292
orthotics, psychological/social, sleep, weight management, pharmacological); and finally
293
multidisciplinary treatment (68). 11
294 295
Similarly, a multidisciplinary task force of health professionals and patients formed clinical guidelines
296
for the management of hand OA (69). The overarching principles included a focus on controlling
297
symptoms and optimizing hand function for quality of life, education and self-management,
298
individualized care, shared decision-making and a multidisciplinary approach. Key points included the
299
following: (i) replace “joint protection” (which infers reducing hand use) with education, ergonomic
300
supports and pacing; (ii) while exercise produces small effect sizes, the risk for severe adverse events is
301
low, and (iii) thumb orthoses likely require three months before observing improvements. Topical
302
treatments are recommended over systemic. Generally, glucocorticoids and disease-modifying anti-
303
rheumatics should not be used. Surgery should be considered for patients with structural abnormalities
304
when conservative approaches have failed (69).
305 306
Diet
307
A high quality systematic review (19 publications) and meta-analysis (9 publications) showed that diet-
308
induced weight loss does not reduce pain in obese people with knee OA (standardized mean differences
309
(SMD) -0.13; 95%CI -0.37 to 0.10) (14). The authors highlighted that because pain is multifactorial, it
310
is not surprising that diet alone failed to reduce pain. Diet combined with exercise moderately reduced
311
pain (SMD -0.37; 95%CI -0.69 to -0.04). Interestingly, diet alone and diet with exercise had similar
312
standardized mean differences for physical function (diet alone SMD -0.30; 95%CI -0.52 to -0.08; diet
313
with exercise SMD -0.32; 95%CI -0.56, to -0.08) (14).
314 315
Exercise
316
Highlights of the systematic reviews and meta-analyses of exercise included optimal exercise
317
prescription parameters and the impact of long-term exercise on knee structure.
318 12
319
A systematic review explored exercise doses associated with reduced pain and improved function in
320
common knee disorders, including OA (77). Twenty-four exercise studies in knee OA provided
321
sufficient detail to calculate effect sizes. The authors noted large variation in exercise prescriptions.
322
Though not statistically evaluated, the authors commented that 24 total exercise sessions, and durations
323
of care between 8 to 12 weeks, were most frequently associated with large effects on pain and physical
324
function (77).
325 326
A frequent concern of patients with OA is fear that activity will worsen their joints (80-82). A high
327
quality systematic review and meta-analysis examined whether exercise longer than six months
328
contributed to progressive radiographic or cartilage damage, or bone marrow lesions, synovitis and
329
effusions (83). Across four studies (n=879), participants experienced no effect of exercise on
330
tibiofemoral radiographic severity (SMD 0.06, 95%CI -0.07 to 0.20). In 196 participants in two
331
studies, cartilage morphology was not reduced by long-term exercise (SMD 0.06, 95%CI -0.20 to
332
0.36). On the other hand, data from two studies (n=196) showed that long-term exercise increased the
333
odds of worsening tibiofemoral BML severity (Odds Ratio (OR) 1.90, 95%CI 1.1, 3.26). Because the
334
meta-analysis was informed by relatively small samples, these findings must be interpreted with
335
caution (83).
336 337
Discussion
338
Key messages from this Year in Review are that (i) rehabilitation can effectively modify important risk
339
factors for OA progression, including inactivity and obesity, and (ii) diet received relatively little
340
attention in OA research over the past year. Scientific contributions on OA rehabilitation in 2018
341
focused on exercise to mitigate inactivity (84, 85). Of 39 RCTs identified in this review, none
342
examined a lifestyle diet intervention. Yet, weight management is a critical therapeutic target for OA.
343
By 2024, we expect that 20% of Canadians will be seniors and the majority will be overweight or obese 13
344
(86) and therefore at elevated odds of developing OA (2). Diet alone can concurrently manage both
345
obesity and OA-related physical dysfunction for these individuals (14) but more work must be done.
346
Diet interventions in OA typically focused on altering dietary intake for weight loss (14). This
347
approach is likely useful in the short-term, but requires integration with education, exercise, behaviour
348
modification and social supports for long-term success (87). Ultimately, balancing rehabilitation
349
research across the goals of managing obesity and inactivity could have a substantive impact on OA
350
outcomes (Box 1).
351 352
Exercise is a first-line treatment for OA. Studies and reviews published in 2018 show benefits to pain,
353
physical function, mobility and quality of life (68, 69). These findings are consistent with a recent
354
review of 42 studies in knee OA (n=6,863) that shows the effect size of exercise for positive outcomes
355
is established (15). Long-term exercise does not appear to damage joint structure (83). A similar
356
conclusion was drawn through systematic reviews of cartilage morphometry, morphology and
357
composition from MRI (88) and molecular biomarkers (89) that included trials with participants at risk
358
for knee OA. Nevertheless, the quality of data supporting this conclusion is of low or moderate quality
359
– more data is necessary to corroborate that exercise does not damage joints. Future work can also
360
address the next set of questions underpinning exercise for all with OA. Exercise dosage in OA
361
remains unclear largely due to tremendous variation in dosage captured in this and other (18, 69, 77,
362
90-94) reviews. Observations in the current review were that (i) more frequent exercise may be
363
associated with larger positive effects on clinical outcomes and (ii) studies requesting that participants
364
exercise seven to 14 exercise sessions per week included a small number of exercises. There may exist
365
an overall exercise volume that participants with OA are likely to tolerate. Finally, OA-specific
366
variables such as phenotype, pain intensity and pain sensitivity to physical activity likely also influence
367
response to exercise and these confounders may require accommodations in the optimal exercise
368
prescription. 14
369 370
Direct comparisons of different dosage (i.e., intensity, duration of care), delivery (e.g., home,
371
supervised, internet-facilitated), modality (e.g., interval, continuous, functional, machine-based),
372
combinations with other treatments, and total volume are necessary to identify the optimal range of
373
exercise dosage in OA. Data from smaller trials published in 2018 suggest that higher intensity
374
exercise may confer greater benefit (perhaps to a small degree) to people living with OA, but only if
375
tolerated (36, 43). Exercise delivered using electronic means produced mixed results, which may be
376
attributed to variations in the amount of face-to-face contact, adherence, duration of care and exercise
377
volume. Qualitative data captured in a review also emphasized the patient’s desire for
378
individualization, education about the safety of exercise, and concrete strategies to support adherence.
379
Rehabilitation specialists focused on OA could improve support for patients and front-line clinicians by
380
tackling these complexities of exercise prescription.
381 382
The most frequent outcomes to quantify treatment effect identified in the current year in review
383
included symptoms (most often pain intensity), self-reported physical function and mobility
384
performance, with a handful of other outcomes of disease, biomechanics and joint tissue structure. As
385
noted previously (18), quality of life outcomes were not primary. Data thus far suggests the impact of
386
exercise on psychological outcomes appears small (18). Given that OA-related chronic pain and
387
immobility are sources of psychological distress and degraded quality of life, future work exploring the
388
impact of rehabilitation on quality of life measures as primary outcomes could advance the field.
389 390
Lack of reporting was frequent. Incomplete reporting limits the ability to interpret effectiveness and
391
efficacy or make reasonable comparisons between interventions. The a priori plans to track adherence,
392
as well as adherence results, were often undocumented and of those reported, diverse. Improving
393
adherence to treatment in chronic disease may have a greater impact on patient outcomes than any 15
394
other innovation (95). Adherence is challenging in OA (96-100), particularly among those with pain
395
(100) – arguably those with the greatest need. Unfortunately, pain relief disappears after ceasing
396
rehabilitation (96) and only 33% of seniors with chronic conditions maintain home exercise (98).
397 398
Finally, similar to previous years in review, hand and hip OA are under-studied but, given that the
399
available data strongly suggest that rehabilitation strategies are recommended, much more work in
400
these joints is warranted.
401 402
Conclusions
403
By addressing inactivity, exercise improves clinical outcomes and, based on low-moderate quality
404
evidence, without further damage to cartilage or synovial tissue. No new trials of diet were found.
405
Diet must be combined with exercise to improve pain, but alone, can improve physical function.
406
Future work is necessary to identify the ideal range of dosages for exercise and diet interventions in
407
OA.
408 409 410 411
Author Contributions
412
Each author made substantial contributions to the study conception and design, literature search, data
413
extraction and quality rating, and analysis and interpretation of data. Each author was involved in
414
drafting the manuscript or revising it critically for important intellectual content. All authors have read
415
and approved the final submitted manuscript.
416 417
Acknowledgements
16
418
Dr. Jaclyn Chopp-Hurley was supported through a Canadian Institutes of Health Research (CIHR)
419
fellowship award. This work was supported by Natural Sciences and Engineering Research Council of
420
Canada (NSERC) Discovery grant (353715 MRM).
421 422
Role of the Funding Source
423
The study sponsors were not involved in the study design, collection, analysis and interpretation of
424
data, writing of the manuscript or decision to submit the manuscript for publication.
425 426
Competing Interest Statement
427
No financial support or other benefits from commercial sources have been received for the work
428
reported on in the manuscript.
429
17
Table 1. Summary of the design and interventions evaluated in 39 Randomized Control Trials (RCT) of exercise for osteoarthritis. The Physiotherapy Evidence Database critical appraisal tool (PEDRO) and Template for Intervention Description and Replication (TIDieR) were consensus scores from two authors. Author
Design
OA Joint
Baseline n
Study Arms
Total Number of Sessions (A) 10 paraffin and 14 exercise, (B) 14
Duration of Care
Frequency per Week
Adherence
Primary Outcomes
Follow-up
Findings
PEDRO (/10)
TIDieR (/12)
Aksoy
RCT
Hand
61 (53F, 8M)
(A) paraffin therapy and home exercise, (B) home exercise alone
2w
(A) 5 paraffin, 14 exercise, (B) 14
Not reported
2, 6 w
A>B
6
3
(A) physical therapy evidencebased approach, (B) internet-based exercise training, (C) wait list control (A) osteopathic manipulative treatment and exercise (B) exercise alone (A) isokinetic exercise, (B) aerobic exercise, (C) isometric exercise
(A) 8 PT and 104-156 exercise, (B) 156, (C) 2
52 w
(A) 2-3, (B) 3, (C) 0
16, 52 w
A=B=C
8
8
Not reported
Not reported
(A) 2 clinic and 14 home, (B), 14
(A) 5.7 PT visits and exercise not reported, (B) Not reported, (C) Not applicable Not reported
VAS (pain), Austalian/Canadian Osteoarthritis Hand Index, Health Assessment Questionnaire, hand grip strength, finger pinch strength WOMAC
Allen
RCT
Knee
350 (251F, 99M)
Altinbilek
RCT
Knee
100 (76F, 9M)
WOMAC, VAS, 50 m walk time
4w
A>B
6
6
Benli Kucuk
RCT
Knee
45 (45F)
(A) 20, (B) 20, (C) 20
4w
(A) 5, (B) 5, (C) 5
Not reported
Not documented
A=B=C
6
5
(A) online education, home exercise and online pain coping skills training, (B) online education and home exercise
(A) 8 online education sessions, 48 home exercise, 5 physiotherapy visits, (B) 8 online education sessions, 5 physiotherapy
24 w
(A) 3, (B) 3
(A) selfreported 7.7/10 adherence, completed 72% home exercise, (B) self-reported 8.2/10 adherence, completed
VAS, WOMAC, Lequesne Index, isokinetic knee muscle strength, patellar and femoral cartilage volumes Pain, WOMAC
Bennell
RCT
Hip
144 (82F, 62M)
8, 24, 52 w
B>A pain coping
10
12
18
Braghin
RCT
Knee
42 (31F, 11M)
Cheung
RCT
Knee
23 (10F, 10M, 3LTF)
de Paula Gomes
RCT
Knee
60 (55F, 5M)
DeVita
RCT
Knee
30 (18F, 12M)
Dziedzic
Cluster RCT
Peripheral joint pain
8 general practices; 525 (313F, 212M)
Ferraz
RCT
Knee
48 (48F)
(A) balance physical exercises, (B) no exercises (A) gait retraining, (B) walking exercise (A) exercise alone, (B) exercise and active phototherapy, (C) exercise and placebo phototherapy (A) quadriceps strengthening, (B) control
(A) model OA consultation which included consultation, education and OA guidebook on self-management and three followups with nurse, (B) usual care (A) low-intensity resistance training associated blow flow restriction, (B) low-intensity
visits, 48 home exercise, 8 online pain coping sessions (A) 16, (B) 0
77% home exercise
8w
(A) 2, (B) 2
Not reported
history of falls, WOMAC, balance, functionality
8w
A>B
4
5
(A) 6, (B) 6
6w
(A) 1, (B) 1
Not reported
KAM, KFM, WOMAC
24 w
A>B
7
8
(A) 10, (B) 10, (C) 10
5w
(A) 2, (B) 2, (C) 2
(A) 10, (B) 10, (C) 9.6
WOMAC, LEFS, NPRS, PPT, functional reach test
5w
B>A=C
8
9
(A) 36, (B) 0
12 w
(A) 3, (B) 0
(A) all completed at least 30 sessions
12 w
A>B
5
8
(A) 4, (B) 0
12 w
(A) 0.5, (B)
Not reported
Quadriceps muscle force, power and work, knee compressive force in 1st half stance, WOMAC SF-12 physical component
24 w
A=B
7
11
(A) 24, (B) 24, (C) 24
12 w
(A) 2, (B) 2, (C) 2
(A) 91%, (B) 85%, (C) 90%
12 w
A
7
8
quadriceps CSA, functionality (timed stand test, TUG), WOMAC
19
Gilbert
RCT
Knee
155 (93F, 62M)
Gomiero
RCT
Knee
64 (61F, 3M)
Huang
RCT
Knee
250 (150F, 50M)
Hunt
RCT
Knee
79 (55F, 24M)
resistance training, (C) high-intensity resistance training (A) brief physician recommendation to increase physical activity to meet national guidelines (control), (B) same brief physician recommendation, motivational interviewing session at baseline, 3, 6, 12 months (intervention) (A) sensorymotor training, (B) resistance training
(A) quadriceps isometric contraction exercise, (B) traditional treatment control (A) increase walking activity with toe-out gait modification, (B) increase walking activity without toe-out gait modification
(A) 5, (B) 0
104 w
(A) 0.05, (B) 0
Not reported
WOMAC physical function and pain, accelerometermeasured physical activity
12, 24, 52, 104 w
A
7
7
(A) 32, (B) 32
16 w
(A) 2, (B) 2
Not reported
16 w
A=B
8
7
Not reported
Not reported
(A) 14, (B) Not reported
Not reported
VAS, isometric quadriceps force (dynamometer), TUG, Tinetti balance scale, WOMAC, SF-36, QOL VAS pain, WOMAC pain
4, 12 w
A>B
4
3
(A) 8, (B) 8
16 w
(A) 0.5, (B) 0.5
(A) 7.1 of 8 sessions, (B) 7.2 of 8 sessions
16 w
A>B
8
8
WOMAC, foot progression angles, knee joint loading (KAM), timed stair climb, KFM during gait
20
Isaramalai
Cluster RCT
Knee
3 work sites; 75 (58F 17M)
Kabiri
RCT
Knee
78 (64F, 14M, 4LTF)
Kang
RCT
Hand
29 (29M)
Keogh
Feasibility RCT
Knee
27 (13F, 4M, 10LTF)
Kloek
Cluster RCT
Hip, Knee
Missing clusters of PT practices; 208 (141F, 67M)
(A) participatory ergonomic management (PEM) and nonweightbearing exercise, (B) PEM and progressive resistance exercise, (C) standard treatment (A) treadmill and resistance training, (2) cycle ergometer and resistance training, (3) arm ergometer and resistance training (A) Finger exercise and paraffin bath therapy, (B) paraffin bath therapy (A) high-intensity interval cycling, (B) moderateintensity continuous cycling
(A) e-exercise, (B) usual physical therapy
(A) 24, (B) 24, (C) 1
8w
(A) 3, (B) 3, (C) 0
Not reported
self-care, functional ability (pain, stiffness, physical function)
9w
A=B>C
7
7
(A) 12, (B) 12, (C) 12
4w
(A) 3, (B) 3, (C) 3
VAS (pain), KOOS, functional performance (6MWT, TUG, chair stand)
8w
A=B
7
5
(A) 40, (B) 40
8w
(A) 5, (B) 5
Nonadherence not different between groups but adherence measurement was not reported Not reported
Hand grip strength, Australian/Canadian Osteoarthritis Hand Index
8w
A>B
7
8
(A) 32, (B) 32
8w
(A) 4, (B) 4
(A) 94%, (B) 88%%
8w
A>B
4
9
(A) 5, (B) 12
12 w
Not reported
(A) 81% completed 8 of 12 emodules, (B) not reported
enrolment rate, withdrawal rate, exercise adherence, adverse effects, WOMAC, Lequesne Index, TUG, sit-to-stand, gait speed, BMI, body fat %, muscle mass physical functioning, freeliving physical activity, KOOS/HOOS, tiredness, QOL,
12, 52 w
A=B
4
7
21
self-efficacy, number of physical therapy sessions Kolisek
RCT
Knee
60 (27F, 33M)
Kuntz
RCT
Knee
31 (31F)
Kuptniratsaikul
RCT
Knee
80 (75F, 5M)
Lai
RCT
Knee
40 (32F, 2M, 6LTF)
Marconcin
RCT
Knee
80 (47F, 20M, 13LTF)
Mazloum
RCT
Knee
41 (13F, 28M)
Nahayatbin
RCT
Knee
48 (sex not documented)
(A) brace only, (B) exercise (2 exercises), (C) brace and exercise (A) yoga, (B) traditional exercise, (C) meditation (attention control)
(A) 0, (B) 168, (C) 168
12 w
(A) 0, (B) 14, (C) 14
Not reported
Quadriceps muscle strength, self-paced walk test, TUG, VAS, LEFS, VR-12
6, 12 w
A=B=C
2
2
(A) 36, (B) 36, (C) 36
12 w
(A) 3, (B) 3, (C) 3
KOOS, mobility performance, knee strength depression, QOL
12 w
A=B>C
8
10
(A) underwater treadmill and home exercise, (B) home exercise
(A) 12, (B) Not reported
4w
(A) 3, (B) Not reported
Pain, 6MWT, Quad Strength, Body weight
4w
A=B
8
10
(A) education (control), (B) strength exercise (A) selfmanagement and exercise, (B) education (control)
(A) 0, (B) 24
8w
(A) 0, (B) 3
(A) 3 sessions per week, (B) 2.7 sessions per week, (C) 2.7 sessions per week (A) 27.5 home exercise sessions, (B) 22.8 home exercise sessions Not reported
knee and ankle proprioception
8w
A
6
3
(A) 24, (B) 3
12 w
(A) 2, (B) Not reported
Not reported
12 w
A=B
6
6
(A) pilates, (B) conventional therapeutic exercise, (C) control (A) closed kinetic chain exercise, (B) Tai Chi, (C) no exercise
(A) 24, (B) 24, (C) 0
8w
(A) 3, (B) 3, (C) 0
Not reported
Not documented
A>B>C
4
4
(A) 12, (B) 12, (C) 0
4w
(A) 3, (B) 3, (C) 0
Not reported
KOOS pain and other symptoms, self-management behaviours, functional lower limb strength functional performance, Lequesne, joint position sense (Biodex) 6MWT, KOOS
4w
B>A=C
3
3
22
Nazari
RCT
Knee
93 (49F, 41M, 3LTF)
(A) high-intensity laser therapy (B) conventional physical therapy (C) exercise therapy (A) taping and exercise (B) exercise
(A) 12, (B) 12, (C) 168
(A) 4, (B) 4, (C) 12
(A) 3, (B) 3, (C) 14
Not reported
pain, knee flexion ROM, TUG, 6MWT, WOMAC
4, 12 w
A>B=C
7
5
Parekh
RCT
Knee
50 (sex not documented)
(A) 3, (B) Not reported
1w
(A) 3, (B) Not reported
Not reported
WOMAC, TUG
1w
Between group not documented
3
3
Pazit
Pilot RCT
Knee
28 (15F, 13M)
(A) control, (2) high-speed resistance training, (3) highspeed resistance training and balance exercises
(A) 0, (B) 16, (C) 16
8w
(A) 0, (B) 2, (C) 2
(A) Not reported, (B) 99.3%, (C) 96.8%
8w
A
6
6
Knee
46 (39F, 2M, 5LTF)
(A) 12, (B) 12
8w
(A) 1.5, (B) 1.5
Not reported
8w
A=B
6
8
Pilot RCT
Knee
20 (12F, 8M)
(A) 24, (B) 24, (C) 24
12 w
(A) 2, (B) 2, (C) 2
Not reported
NRS, WOMAC
12 w
A=B=C
8
6
Sanchez Romero
RCT
Knee
65 (18F, 44M, 3LTF)
(A) sham electromyography and isometric exercise (control), (B) electromyography biofeedback and exercise (A) dry needling and exercise, (B) sham dry needling and exercise, (C) exercise (A) dry needling and exercise, (B) sham dry needling and exercise
Feasibility & safety - adherence, dropout rate, adverse events, pain. Also, strength, mobility, functional tests, pain, executive function, satisfaction VAS, VMO muscle thickness, WOMAC, Lequesne, EMG VMO
Raeissadat
RCT
SanchezRomero
12 w
(A) 2, (B) 2
Not reported
NRS, WOMAC, EQ-5D, BI, TUG
12, 24, 52 w
A=B
9
5
Sit
RCT
Knee
208 (167F, 41M)
(A) 24 exercise and 6 dry needling, (B) 24 exercise and 6 sham dry needling (A) 3 patellar mobilization and 336 home
24 w
(A) 14, (B) 0
(A) 5.2 days per week
WOMAC pain, function
24 w
A>B
8
5
(A) patellar mobilization therapy and home
23
Stoffer-Marx
RCT
Hand
151 (127F, 24M)
Suzuki
RCT
Preradiographic Knee
100 (29F, 23M, 48LTF)
Taglietti
RCT
Knee
60 (41F, 19M)
Uzunkualoglu
RCT
Knee
90 (64F, 26M)
Wang
RCT
Knee
100 (76F, 24M)
exercise, (B) control
exercise, (B) 0
(A) combined interdisciplinary consultation intervention, (B) routine care and placebo (massage ball) (A) knee and hip strengthening and stretching, (B) quadriceps strengthening
(A) 2 consultation and 56 home exercise, (B) 0
8w
(A) 7, (B) 0
(A) 38%, (B) Not applicable
grip strength, JTHFT AUSCAN
8w
A>B
8
11
(A) 20, (B) 20
4w
(A) 5, (B) 5
(A) 96.6%, (B) 100%
4w
A>B
6
7
(A) 16, (B) 8
8w
(A) 2, (B) 1
Not reported
knee pain, selfreported function, isometric maximum knee extensor muscle strength, adherence WOMAC, QOL, functional mobility and depression
8, 12 w
A>B
7
7
(A) 12, (B) 12 individual training and 84 home exercise, (C) 12 individual training and 84 home exercise (A) 36, (B) 36
4w
(A) 3, (B) 3 individual and 21 home, (C) 3 individual and 21 home
Not reported
4w
A=B
6
3
12 w
(A) 3, (B) 3
Not reported
?
A>B
4
2
(A) aquatic exercise, (B) educational program (A) kinesthetic ability trainer, (B) flamingo training, (3) combined training
(A) exercise therapy, (B) quadriceps training)
Berg balance scale, kinesthetic ability trainer static and dynamic scores, TUG, walking speed, activities specific balance confidence, functional reach WOMAC, gait parameters
F=female, M=male, LTF =lost to follow-up, w=week(s) 6MWT=Six Minute Walk Test AUSCAN=Australian/Canadian Osteoarthritis Hand Index BI=Barthel Index BMI=Body Mass Index CSA=Cross-sectional Area EQ-5D=EuroQoL Group 5-Dimension Self-Report Questionnaire EMG=Electromyography HOOS=Hip injury and Osteoarthritis Outcome Score
24
JTHFT=Jebsen-Taylor Hand Function Test KAM=Knee Adduction Moment KFM=Knee Flexion Moment KOOS=Knee injury and Osteoarthritis Outcome Score LEFS=Lower Extremity Functional Scale NPRS=Numeric Pain Rating Scale NRS=Numeric Rating Scale PPT=Pressure Pain Threshold ROM=Range of Motion QOL=Quality of Life SF-12=Short Form-12 SF-36=Short Form-36 TUG=Timed Up and Go VAS=Visual Analogue Scale VR-12=Veterans RAND 12 Item Health Survey VMO=Vastus Medialis Oblique WOMAC=Western Ontario McMaster Universities Osteoarthritis Index
25
Table 2. Summary of 14 synthesis papers on diet and exercise interventions for osteoarthritis (OA). A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR 2) is a consensus score from two authors. First Author Balasukumaran
Design Systematic Review and Meta-analysis
Sample Neurological and Musculoskeletal Disorders (n=232 with Knee OA)
Beasley
Systematic Review
Hand OA
Briani
Systematic Review and Meta-analysis
Knee OA
To systematically review evidence of primary outcomes from randomized controlled trials examining the effect of treatment strategies on quality of life or psychosocial factors in individuals with knee OA.
Dong
Systematic Review and Meta-analysis
Knee OA
Umbrella Review
Knee OA
To systematically review the effectiveness of aquatic exercise compared to land-based exercise in treating knee OA. To update the last known umbrella review and summarize the available high-quality evidence from systematic reviews on the effectiveness of non-
Ferreira
Objective To investigate effectiveness of backward walking as treatment for people with gait impairments. (Backward walking eliminates heel contact thus reduces patellofemoral contact forces; requires greater reliance on systems other than vision and increases spatial parameters while reducing temporal parameters.) To evaluate the evidence supporting conservative therapeutic interventions for the treatment of OA finger joints.
Outcomes Pain, functional disability, muscle strength, gait parameters, balance, stability and plantar pressure
Conclusions In knee OA, significant standardized mean difference values in favour of backward walking (compared with conventional PT for 2-4 weeks) to reduce pain, functional disability and to improve quadriceps strength.
Recommendations NA
AMSTAR 2* LOW
Physical function, pain (at rest and during activity), range of motion, grip strength, pinch strength, stiffness, arthritis selfefficacy pain, Patient Specific Functional Scale Health-related quality of life (QOL), kneerelated QOL, QOL, psychosocial factors
Current evidence varies in quality and effect size but generally supports active range of motion, resistive exercise, joint protection, electromagnetic therapy, paraffin wax, balneotherapy and distal interphalangeal orthoses.
NA
CRITICALLY LOW
NA
MODERATE
Pain, physical function, quality of life
Exercise (with or without other interventions) is effective in improving health-related, kneerelated QOL or psychosocial factors. Exercise was superior compared to self-management booklets and antiinflammatory drugs. Cognitive behavioural therapies (with or without exercise) effective for improving self-efficacy, depression, psychological distress. No differences between aquatic and land-based but adherence and satisfaction appears higher in aquatic.
NA
MODERATE
Pain, functional status, stiffness, inflammation, quality of life and patient global assessment
Gold evidence: Exercise (aerobic, resistance) reduce pain and improve physical function however it is unclear if one of low versus high intensity exercise is superior. Silver
NA
CRITICALLY LOW
26
pharmacological and non-surgical interventions for people with knee OA.
Geenen
EULAR Recommendations
Inflammatory Arthritis and OA
To evaluate the existing scientific evidence associated with the benefits of the health professional's approach to pain management for people with inflammatory arthritis and OA, and to use this evidence and expert opinion to provide recommendations that enable health professionals to provide knowledgeable pain-management support.
Pain
Hall
Systematic Review and Meta-analysis
Knee OA
To determine the effect of dietonly treatments and combined diet and exercise treatments on pain and physical function; and to explore the effect of these treatments on inflammatory biomarkers in overweight and obese adults with knee OA.
Pain, physical function, inflammatory biomarkers
Mixed Methods Review
Hip, Knee or Hip and Knee OA
To improve our understanding of the complex inter-relationship between pain, psychosocial effects, physical function and exercise.
Pain, physical function, self-efficacy, depression, anxiety, quality of life
Hurley
evidence: Acupuncture, aquatic exercise, electro-acupuncture, interferential current, taping, manual therapy, moxibustion, pulsed electromagnetic field, Tai Chi, ultrasound, yoga and whole body vibration. Effects on pain were most uniformly positive for physical activity and exercise interventions and for psychological interventions. Reviews do not answer the question whether high intensity exercise is as safe as low intensity exercise.
Diet-only treatments did not reduce pain but diet combined with exercise did reduce pain moderately. Diet only and diet combined with exercise improved physical function moderately. Diet only treatments reduced IL-6. Diet-only interventions do not address the multifactorial nature of pain. There were large variations in exercise program's content, mode of delivery, frequency and duration, participant's symptoms, duration of symptoms, outcomes measured, methodological quality and reporting. Moderate quality evidence that exercise reduced pain by 6%, improved physical function by 5.6%. Low quality evidence that selfefficacy was increased by 1.7%.
(1) Assessment include patient (needs, preferences, priorities), pain characteristics, previous treatment and efficacy, current pain sources, psychosocial influences. (2) Personalized management plan developed as a shared decision making process, evidence-based treatment, and a stepped approach with education and self-management first, more treatment second, multidisciplinary treatment last. (4) Physical activity and exercise. (5) Orthotics. (6) Psychological and social interventions. (7) Sleep interventions. (8) Weight management. (9) Pharmacological. (10) Multidisciplinary. NA
LOW
NA
LOW
HIGH
27
EULAR Recommendations
Hand OA
To update recommendations for the management of hand OA since 2007.
Symptoms (pain, stiffness); function; activities (participation, quality of life)
Morales-Ivorra
Systematic Review
OA
Quality of life
Rausch Osthoff
Meta-analysis
Rheumatoid Arthritis, Spondylo-arthritis (SpA), Hip and
To systematically review and analyze the epidemiological evidence in humans on the Mediterranean diet and its association with OA. To evaluate the effectiveness of exercise and physical activity (PA) promotion on cardiovascular fitness, muscle
Kloppenburg
Cardiovascular fitness, muscle strength, flexibility, neuromotor performance
Moderate quality evidence that exercise improved depressive symptoms by 2.4%. No effect on anxiety. Low quality evidence that exercise improved social function by 7.9%. Qualitative synthesis showed that people avoid activity for fear of causing harm; and from the patient's perspective, exercise delivery could be improved with (a) better information and advice about the safety and value of exercise, (b) exercise tailored to individual preferences abilities and needs, and (c) better support and challenge to inappropriate health beliefs. "Joint protection" is considered an outdated term because it implies the patient should refrain from using their joints. It is replaced with education, training in ergonomics and pacing activity. Seven trials of exercise in hand OA were summarized in a Cochrane review, and produced small beneficial effects on pain function stiffness and grip strength with few, non-severe adverse events. Beneficial effects of a thumb base orthosis for pain and function but not grip strength after 3 months (long term use advocated). Topical pharmacologics preferred over systemic. Avoid diseasemodifying anti-rheumatics. Positive association between adherence to the Mediterranean diet and quality of life.
Moderate effectiveness on cardiorespiratory and muscle strength, as well as physical activity promotion interventions in arthritis
(1) Education, ergonomics, pacing activity. (2) Exercise should be considered for every patient. (3) Longterm use of orthoses should be considered for symptom relief in patients with thumb OA. (4) Topical treatments preferred over systemic (topical first treatment of choice). (5) Oral NSAIDs used for a limited period only. (6) Chondroitin sulfate may be used. (7) Intra-articular glucocorticoid injections should not be used, but considered in painful IP joints. (8) Avoid diseasemodifying anti-rheumatics. (9) Surgery for structural disease. (10) Long-term follow up to match patient needs.
NA
NA
CRITICALLY LOW
NA
MODERATE
28
Knee OA
strength, flexibility, neuro-motor performance (balance) and daily PA in people with Rheumatoid Arthritis, SpA and hip or knee OA.
(balance) and daily PA
To assess the effect between exercises compared to diet for chronic pain management, physical and mental function in obese patients with chronic musculoskeletal problems. To investigate the effects of longterm exercise therapy for people with knee OA on radiographic disease severity and cartilage integrity as well as severity of bone marrow lesions, synovitis and effusion.
Pain, mobility, physical function, mental function
To specify doses of exercise related to improved outcomes of pain and function in individuals with common knee disorders, categorized by effect size.
Pain, physical function
Tamin
Systematic Review and Meta-analysis
Obese with chronic musculoskeletal pain (all four studies included were knee OA)
VanGinckel
Systematic Review and Meta-analysis
Knee OA
Systematic Review
Knee disorders including an isolated analysis of Knee OA
Young
Radiographic disease severity and cartilage integrity as well as severity of bone marrow lesions, synovitis and effusion
(including hip/knee OA alone). No evidence was found for the effects of flexibility exercises. Low compliance rate is one of the most compelling challenges for exercise and physical activity interventions in arthritis. Exercise can improve mobility but cannot reduce pain in obese patients with chronic musculoskeletal problems.
Long-term exercise therapy did not change knee radiographic disease severity, cartilage morphology or synovitis/effusion, but may slightly increase bone marrow lesion severity. There was limited evidence suggesting some protective effects on patellar cartilage. 24 therapeutic exercise sessions and 8- to 12- week durations were observed with large effects by the authors. An exercise frequency of once per week was associated with no effect. 4-6 week durations of care have medium, small or no effect.
NA
CRITICALLY LOW
NA
HIGH
NA
LOW
NA=Not Applicable NSAID=Non-steroidal anti-inflammatory drug *AMSTAR 2 scored consistent with the recommendations presented in Shea BJ et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ (Clinical research ed). 2017;358:j4008
29
Box 1: Areas for Future Rehabilitation Research •
Advance rehabilitation approaches that contribute to long-term weight management in OA.
•
Directly compare dosage, delivery, modality and duration of exercise and lifestyle diet interventions to find the optimal range of intervention parameters.
•
Track and promote adherence to rehabilitation interventions.
•
Identify confounders of treatment response to exercise and lifestyle diet interventions.
•
Identify responders versus non-responders to exercise and lifestyle diet interventions.
•
Build further evidence regarding the impact of long-term exercise on hand, hip and knee structures.
•
Explore quality of life and psychological outcomes as primary outcomes in rehabilitation studies.
30
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Figures Fig. 1. Flow chart documenting the identification of randomized controlled trials and synthesis papers to be included in this review of studies of exercise and diet in osteoarthritis (OA) published between January 1, 2018 and April 1, 2019, from all of the potential titles and abstracts yielded by a search of health-related databases.