Pelland 2004 - Efficacy of Strength Exercises For OA - Part I - A Meta-Analysis

Physical Therapy Reviews 2004; 9: 77–108
EFFICACY OF STRENGTHENING EXERCISES FOR

OSTEOARTHRITIS (PART I): A META-ANALYSIS
LUCIE PELLAND*, LUCIE BROSSEAU*, GEORGE WELLS†, LYNN MACLEAY*,

JUDITH LAMBERT*, CATHERINE LAMOTHE*, VIVIAN ROBINSON‡
AND PETER TUGWELL‡
*School of Rehabilitation Sciences, †Department of Epidemiology and Community Medicine,

and ‡Institute of Population Health, University of Ottawa, Ottawa, Ontario, Canada
ABSTRACT
Objective: Osteoarthritis (OA) is highly prevalent among older adults and is associated with
increased pain, loss of strength and joint range of motion (ROM), as well as to an overall
decrease in functional status. Therapeutic strength exercises are recommended as part of the
standard intervention programme for the patient with OA in an effort to control pain and
improve functional and health status. The purpose of this meta-analysis is to review the
strength and quality of evidence supporting the effectiveness of therapeutic strengthening
exercises for improving a variety of measured outcomes relevant for OA.
Methods: A systematic review was conducted, following a protocol of methods recommended
by the Cochrane Collaboration. Trials were identified by a literature search of Medline,
EMBASE, and the Cochrane Controlled Trials Register. Only randomised controlled trials
using strengthening exercises as an intervention and treating clients with OA were eligible.
Twenty-two trials were included with 2325 patients undergoing various forms strengthening
exercises (e.g. isometric, isotonic, isokinetic, concentric, concentric/eccentric, dynamic). The
exercises were implemented either in stand-alone format or in combination with other
exercises, such as stretching and ROM. Interventions were either facility-based, home-based or
a combination of the two.
Results: Evidence is provided for the inclusion of strengthening exercises in the rehabilitation
programme for the patient with OA. Improvements were found for strength, pain, function and
quality of life (QOL). Important components of the exercise programme that influence outcome
include: (i) the combination of joint-specific strengthening with general strength, flexibility and
functional exercises; (ii) progression of the exercise programme; and (iii) level of client self-reliance
to sustain the programme. There is no evidence that the type of strengthening (i.e. isometric,
isotonic or isokinetic) has an important impact on programme outcome. However, evidence is
provided that the control of pain may be a dominant mechanism by which strengthening exercise
produces beneficial effects for the patient with OA.
Conclusion: Strengthening exercises alone have some effects on improving pain and functional
outcomes in clients with OA. However, in order to maximise the effectiveness of strengthening
exercise for these clients, it is necessary to combine strengthening exercises with a more complete
exercise programme including ROM, stretching, functional balance and aerobic exercises.
Keywords: Arthritis, efficacy, evidence-based practice, exercise therapy, meta-analysis,

systematic review, range of motion exercises, rehabilitation, rheumatology, osteoarthritis,
stretching exercises, strengthening exercises, therapeutic exercises
© W. S. Maney & Son Ltd 2004 DOI 10.1179/108331904225005052

78 PELLAND ET AL.
INTRODUCTION increased incidence and severity of OA further cor-

roborates the importance of an intervention that pro-
Osteoarthritis (OA) is the most common form of motes strengthening, control of pain and physical
arthritis in humans.1 Based on recent statistics,2 it is activity. Participation in regular exercise regimens has
projected that one in five individuals will develop OA in fact been shown to have a positive corollary effect
at some point in their life-time. OA is an acquired on bone mineralisation,14,15,21 on the maintenance of a
degenerative process of articular cartilage and reac- healthy weight,13,21 as well as on aerobic fitness, blood
tive bone growth that arises from an interaction pressure, cholesterol levels, mood14,15,21 and on overall
between mechanical, biochemical and other endoge- QOL.13
nous influences.3–5 While OA can affect any joint of Interestingly, the positive effects of exercise have
the body, the knee and hip are the most frequently been found with widely differing programmes of
involved joints. In women, OA also frequently affects strengthening that range from isometric therapist-
the hand leading to a progressive loss of alignment supervised programmes to general programmes of
and function, particularly of the proximal and distal stretching, ROM and functional strengthening per-
inter-phalangeal joints. Clinically, OA is characterised formed primarily at home. For example, while Semble
by pain, stiffness and loss of motion at affected joints, et al.13 recommend a progression from isometric to
decreased strength of peri-articular muscles of the isotonic and isokinetic strengthening exercises in an
involved joint, decreased flexibility, weight gain, and effort to reduce the chance of aggravating symptoms
decreased aerobic capacity.6–8 The progressive of OA, other approaches focus on strengthening
mechanical and inflammatory joint changes ulti- through task-specific functional exercises, such as sit-
mately lead to chronic joint pain, impaired function, to-stand, and step-up and step-down activities.24
and limitation in functional mobility, such as stair Where specific information is lacking is in evaluating
climbing, that negatively impact on overall participa- the relative effectiveness of different exercise pro-
tion as well as the quality of life (QOL) of the patient grammes on key outcome measures of OA. As
with OA.9–11 Further, recognising the wide-ranging pointed out over a decade ago by Basmajian,25 the
effects of OA on endurance, balance and co-ordination7 evaluation of programme effectiveness, in terms of
that may place the older patient with OA at an increased both cost and patient benefits, is an important ques-
risk for falling, clinicians consider exercise to be a key tion relating to health policy. The aim of our meta-
component of a proper rehabilitation programme for analysis was to examine the quality and strength of
OA.12 the evidence supporting the effectiveness of different
The general aim of an exercise programme for the strength exercise programs on key rehabilitation-mea-
patient with OA is to improve pain, ROM, joint-spe- sured outcomes of OA (i.e. pain, ROM, strength, flex-
cific strength and flexibility,13–15 as well as general fit- ibility, functional status and QOL) through a
ness, endurance and overall QOL.13,16–19 However, systematic review of existing literature.
despite the inclusion of exercise as a standard compo-
nent of the care plan of the patient with OA,20 rela-
tively little is known about the effects of exercise on METHODS
OA.3 In fact, until recently, the role of exercise in the
management of the patient with OA was a subject of This meta-analysis used the methodology proposed
much controversy. While in the 1970s the consensus by the Cochrane Collaboration.26
among clinical practitioners favoured inactivity,21
with the belief that any form of exercise would cause
undue stress and strain which would potentiate the Literature identification
effects of OA on already compromised joints,21,22 there
has been a gradual shift to recognising the overall A systematic review of the literature, up to and
benefits of exercise to the patient with OA. This shift including December 2002, was completed using the
in clinical approach is a result of research that demon- modified strategy outlined by the Cochrane Colla-
strated a fundamental association between impaired boration for randomised control trials.27,28 Additional
muscle function (i.e. the loss of strength and flexibil- terms for study design were also used to further iden-
ity) associated with OA involvement of a joint23 and tify controlled clinical trials without randomisation,
the potential for increasing abnormal load applica- case-control, cohort and comparative studies. The fol-
tion to the already compromised joint. More recently, lowing databases were searched for relevant articles
joint-specific strengthening exercises have been shown using the keyword and text search strategy outlined in
to improve joint stability.14,15,21 At a more general Table 1: MEDLINE, EMBASE, Healthstar, Sports
level, the association between inactivity, obesity, and Discus, CINAHL, the Cochrane Controlled Trials
EFFICACY OF STRENGTHENING EXERCISES FOR OSTEOARTHRITIS (PART I) 79
Table 1. Keyword and text literature search strategy (part of a global search)
Keywords Text word
1. Exp osteoarthritis 4. Osteoarthritis

2. Arthritis, Juvenile rheumatoid 5. Osteoarthrosis
3. Exp arthritis, rheumatoid 6. Degenerative arthritis
7. Rheumatoid arthritis
8. Rheumatism
9. Caplan’s syndrome
10. Felty’s syndrome
11. Rheumatoid
12. Ankylosing spondylitis
13. Arthrosis
14. Sjogren$
Combined algorithm Or/1–3 Or/4–14
15. Exp Exercise Therapy 17. Mobilizing exercise

16. Passive exercise 18. Strengthening exercise
19. Resistance exercise
20. Aerobic exercise
21. Continuous passive motion or movement device
Combined algorithm And/15–16 And/17–21
22. Clinical trial.pt 26. Random$

23. Randomised controlled trial.pt 27. Placebo$
24. Tu.fs 28. (Sing$ or doubl$ or tripl$) adj (masked or blind$)
25. Dt.fs 29. Sham
Combined algorithm Or/22–25 Or/26–29
Register, the PEDro database, the specialised registry rehabilitation. Acceptable interventions included any
of the Cochrane Musculoskeletal Group (CMSG), form of strengthening exercises, with the majority of
and the Cochrane Field of Physical and Related intervention programmes consisting of a warm-up or
Therapies. In addition, reference lists of included tri- stretching phase followed by a strengthening phase
als were also searched and content experts contacted that may or may not have included a small amount of
for additional studies. aerobic activity. Placebo, untreated, or active inter-
ventions were all acceptable control groups. Concurrent
interventions (e.g. NSAIDs) were accepted only if given
Eligibility criteria to both comparative groups. Lastly, our meta-analysis
included all peripheral joints, while excluding axial
According to a priori protocol, all comparative con- joints and post-surgery intervention such as continuous
trolled trials, including randomised controlled trials passive motion.
(RCTs), controlled clinical trials without randomisa-
tion (CCTs), case-control, and cohort studies were
included with the restriction that abstracts had to be Data extraction
in French or English. Peer-reviewed abstracts were
also accepted. From these, however, trials in which All trials classified as relevant by at least one of the
individuals served as their own control were excluded. reviewers were retrieved and re-examined to ensure they
Trials evaluating the outcome of strengthening pro- met the inclusion criteria (CL, JL). These same two
grammes in individuals with OA were retained and reviewers subsequently extracted the results from each
evaluated by two independent reviewers (VR, LB) for of the included trials using pre-determined extraction
their relevancy according to the following eligibility forms that were developed and pilot-tested, based on
criteria: (i) diagnosis of OA; (ii) participants aged 18 other forms used by the CMSG. The extraction form
years or older; (iii) intervention and control groups documented the following specific information about
that include five or more participants; and (iv) mea- the exercise programme: (i) the type of supervision pro-
sured outcomes of strengthening that are relevant to vided or if unsupervised; (ii) the setting, whether home
80 PELLAND ET AL.
Table 2. Details of included trials
Author BAUTCH et al.32

Sample size RCT Total: 30 Group 1: 15 Group 2: 15
Population details Inclusion: patients who fulfiled the following criteria (clinical and radiographic) for knee OA;
were ≥ 59 years old and living independently, without physical or medical problems for
which an exercise programme would be contra-indicated; were not currently enrolled in a
regular exercise programme; had not received intra-articular or systematic steroids within
the past 2 years; and did not routinely use NSAIDs.
Symptom duration: mean (SD) N/A
Age (years): mean (SD for control) 69
Treatment Group 1: patient education. 1 h/week educational programme consisting of content related to
health, exercise, and arthritis
Comparison group Group 2: same as Group 1 plus exercises. ROM exercises of trunk and of upper and lower
extremities. Then individualised low intensity walking on treadmill, beginning at 3.22 km/h and
grade 0, increasing by 1% each min. Distances increased weekly. Joint protection: good walking
shoes, wood floor in exercise facility, cane on the contralateral side, and chair exercise aimed at
strengthening the quadriceps muscle group
Concurrent therapy N/A
Session/week; No. of weeks 3 times a week for 12 weeks
Follow-up weeks N/A
Quality; R, B, W 1, 0, 0
Author BÖRJESSON et al.33

Population details Inclusion: patients who met the following criteria. Were aged 55–70 years, had medial knee OA
(grade I–III) based on weight-bearing radiographs, were scheduled for surgery, had unilateral
symptoms, and had no symptoms in hip or ankle.
Symptom duration: mean (SD) 7.5 years
Age (years): mean (SD for control) 55–70
Treatment Group 1: exercises. Warm up 10 min on bike. Then knee extension from 90° to maximal
extension, sitting with 1–3 kg around ankle; knee flexion from 90° to maximal flexion, standing
on heel and toes; knee flexion standing with hip straight; hamstrings strength; hip abduction;
hip extension; and passive knee extension. Two sets of 10 repetitions, 10-s isometric hold.
Stretches performed 5 times. Total of 3 times a week, 40 min each time, for 5 weeks
Comparison group Group 2: control
Follow-up weeks N/A
Author DEYLE et al.34

Population details Inclusion: patients who met one of the following criteria: (1) had knee pain, were 38 years old
or younger, and had bony enlargement; (2) had knee pain, were 39 years old or older, and had
morning stiffness for more than 30 min and bony enlargement;(3) had knee pain, crepitus on
active motion, morning stiffness for more than 30 min, and bony enlargement; or (4) had knee
pain, crepitus on active motion, and morning stiffness for more than 30 min and were 38 years
old or older
Age (years): mean (SD for control) Group 1: 59.6 (10.1) Group 2: 62.4 (9.7)
Treatment Group 1: manual therapy and knee exercises. Passive physiological and accessory joint
movements, muscle stretching, and soft-tissue mobilisation, applied primarily to the knee.
Closely supervised standardised knee exercise programme: active ROM for the knee,
strengthening exercises for the hip and knee, muscle stretching for the lower limbs, stationary
bike, and home programme.
Comparison group Group 2: control. Subtherapeutic ultrasound for 10 min at 0.1 W/cm2 and 10% pulsed mode
Session/week; No. of weeks 30 min twice a week for 4 weeks
Follow-up weeks End of treatment at 4 weeks; follow-up at 1 year
Table 2. (Continued) Details of included trials
Author EVCIK and SONEL35

Sample size CCT Total: 81 Group 1: 27 Group 2: 28 Group 3: 26
Population details Inclusion: patients with knee OA
Exclusion: patients who met the following criteria: had participated in a quads exercises
programme during the last 6 months; or had effusion on knees, previous knee replacement,
severe cardiovascular diseases, or grade 4 OA according to Kellgren and Lawrence criteria
Age (years): mean (SD for control) Group 1: 56.3 (6.1) Group 2: 56.9 (6.5) Group 3: 55.8 (6.9)
Treatment Group 1: home exercises programme. Isometric straight leg lifts, isometric quads contraction
and isotonic quads. Exercises progressed by adding weight from 0.5 to 5 kg. Ten repetitions
Group 2: regular walking programme
Comparison group Group 3: control (physical therapist told patients to continue their normal daily activities)
Concurrent therapy None
Session/week; No. of weeks Group 1: twice a day for 3 months
Group 2: 10 min, 3 times a week for 3 months. Gradually increased walking time up to 30 min
Follow-up weeks 6 months
Author FRANSEN et al.36

Sample size RCT First part: Total: 126 Group 1: 43 Group 2: 40 Group 3: 43
Second part: Total: 121 Group 1: 62 Group 2: 59
Population details Inclusion: patients who met the following criteria. Were 50 years and over, had experienced
knee pain most days of the past months, and had evidence of radiographic disease
Exclusion criteria: patients who had one of the following. Intra-articular cortisone injections
within the past 2 months, lower limb joint arthroplasty, unstable cardiac co-morbidity
precluding exercise at 50–60% maximum HR, or other co-morbidity affecting gait.
Age (years): mean (SD for control) First part: Group 1: 68.5 (8.7) Group 2: 65.3 (7.1) Group 3: 66.1 (10.3)
Second part: Group 1: 66.7 (10.1) Group 2: 66.8 (7.5)
Treatment Group 1: individual exercise treatment; choice, frequency, and duration at the discretion of the
treating physical therapist
Group 2: group format programme. Patients were under the supervision of a physical therapist
for 1 h, and the group programme was supplemented with a home exercise programme
Comparison group Group 3: control. Patients were on the waiting list (were offered treatment for the second part
of the study and put in either the individual or group exercise)
Session/week; No. of weeks 8 weeks Group 1: at the therapist’s discretion Group 2: twice a week
Follow-up weeks N/A
Author GUR et al.37

Sample size RCT Total: 23 Group 1: 9 Group 2: 8 Group 3: 6
Population details Inclusion: patients with bilateral complaints of knee OA and who had grade II or III OA, as
judged by criteria of Kellgren and Lawrence, for weight-bearing radiographs; and who
did not have any health problems that might pose a risk during the maximal test and training
Age (years): mean (SD for control) Group 1: 56 (12) Group 2: 55 (12) Group 3: 57 (9)
Treatment Group 1: concentric. Twelve concentric extension, concentric flexion movements; continuous
mode was used, and the patients trained reciprocally for the knee extensors and flexors
Group 2: concentric-eccentric. Six concentric extension, eccentric extension movements, then
6 concentric flexion, eccentric flexion movements.
Comparison group Group 3: control. Patients maintained their normal physical activities and received no training
but were tested twice throughout the 8-week experimental period
Concurrent therapy For Groups 1 and 2: a spectrum of angular velocities ranging from 30°/s to 180°/s at 30°
intervals bilaterally was used. A 2-min rest was given between knee extensors and flexors in
Group 2 and a 5-min rest between the legs in both training groups
Session/week; No. of weeks 3 days a week for 8 weeks
Follow-up weeks N/A
82 PELLAND ET AL.
Author HURLEY and SCOTT24

Sample size CCT Total: 60 Group 1: 44 Group 2: 16
Population details Inclusion: patients had to fulfil the ACR criteria for knee OA. The predominant complaint of
all patients was knee pain: patients who reported co-existent mild symptomatic OA in other
joints were not excluded from the trial unless the pain from these other joints interfered with
the performance of the assessment procedures
Symptom duration: mean (SD) Group 1: 51 months (SD 27.75 months) Group 2: 54 months (SD 42.75 months)
Age (years): mean (SD for control) Group 1: 62 (12.0) Group 2: 61 (11.75)
Treatment Group 1: exercise programme for 5 weeks, twice a week for 30 min: 24 isometric quads muscle
voluntary contractions (4 x 6 repetitions, held 4 s, 2-min rest between sets), 2-min bike, 1-min
isotonic knee extension (concentric quads contractions) and flexion (eccentric quads
contractions) to 90° flexion using therapeutic resistance bands, and 3 functional exercises
(sit-stand, step-ups, step-downs) and 3 balance/co-ordination exercises (unilateral stance,
balance boards) which were each performed for 1 min
Comparison group Group 2: control. Rehabilitation was delayed
Session/week; No. of weeks Twice a week for 5 weeks
Follow-up weeks 6 months
Author KREINDLER et al.16

Sample size RCT Total: 32 Group 1: 8 Group 2: 5 Group 3: 10 Group 4: 9
Population details Inclusion: patients with primary diagnosis of OA of the knee
Age (years): mean (SD for control) 67.42 (8.38)
Treatment Group 2: progressive exercise programme consisting of quadriceps and hamstring strengthening
exercises. Exercises were begun in session 2, monitored 3 times a week, and progressed at
weekly intervals for 6 consecutive weeks
Group 3: same as Group 1, combined with progressive Kinetron programme. Patients worked
at speeds that registered 100–150 psi readings. As patients progressed above the 100–150 psi
level, they progressed to the next higher speed
Comparison group Group 4: Ten quadriceps setting exercises for warm-up before exercising on the Cybex. The
exercise positions on the Cybex matched the evaluation positions. 2-min rest periods were
granted between each test speed
Group 1: control group was evaluated and told to continue normal activities and return for
re-evaluation in 6 weeks
Concurrent therapy Following the 6 weeks’ evaluation, Groups 1–3 were instructed to do the home programme
originally given to Groups 1 and 2
Follow-up weeks 6 weeks
Author MESSIER et al.38

Population details Inclusion: patients who met the following criteria: Were ≥ 60 years; had pain on most days of
the month in one or both knees; showed radiographic evidence of knee OA in the tibiofemoral
compartments of the painful knee; and had difficulty with at least one of the following
activities due to knee pain—walking 0.4 km – climbing stairs, getting in and out of a car, rising
from a chair, lifting and carrying groceries, getting out of bed, getting out of a bathtub,
shopping, cleaning, or self-care
Treatment Group 1: aerobic training. 5-min warm up, 40-min walking phase at an intensity equal to
50–85% of the subjects’ HR reserve, and a 5-min cool down
Group 2: strengthening training. Warm up, 9 upper and lower body exercises using dumbbells
and cuff weights (leg extension, leg curl, step-up, heel raise, chest fly, upright row, military press,
bicep curls, and pelvic tilt) and a cool-down phase. Two sets of 10–12 repetitions were
performed for each exercise
Comparison group Group 3: control. Regularly scheduled contacts similar to those of the two interventions groups.
Patients were divided into groups of 12–15 to participate in monthly on-site health education
sessions during months 1–3. During the transition phase (4–6 months), biweekly telephone
contact was made. The maintenance phase (7–18 months) consisted of monthly phone calls
Concurrent therapy For Groups 1 and 2: 18-months’ period. 3-month facility-based programme followed by a 15-
month home-based programme: (i) 3-month transitory phase of contacts once every 2 weeks
(4 home visits and 6 telephone calls; and (ii) 12-month maintenance phase of telephone contacts
once every 3 weeks during the first 3 months and monthly contact during months 9–18.
Session/week; No. of weeks 3 times a week for 18 months
Follow-up weeks N/A
Author O’REILLY et al.39

Population details Inclusion: patients with ≥ 1 month of pain in or around the knee on most days and any
pain in the past year
Treatment Group 1: exercise programme consisting of the following: (i) isometric quadriceps contraction
in full extension, held for 5 s; (ii) isotonic quadriceps contraction in mid flexion; (iii) isotonic
quadriceps contraction in full flexion; (iv) isotonic quadriceps contraction in full extension; and
(v) dynamic stepping exercise. Exercises increased to a maximum of 20 repetitions and were
performed at home on a daily basis. Subjects were visited at weeks 2 and 6, and at month 3
Comparison group Group 2: control, no treatment
Session/week; No. of weeks Once a day for 6 months
Follow-up weeks N/A
Author PENNINX et al.40

Population details Inclusion: patients who met the following criteria: (i) were aged 60 or older; (ii) had pain in the
knee(s) on most days of the month; (iii) had difficulty with at least one of the following because
of knee pain – walking 0.4 km; climbing stairs; getting in and out of a car, bath or bed; rising
from a chair; or performing shopping, cleaning, or self-care activities; and (iv) showed
radiographic evidence of knee OA
Treatment Group 1: strengthening training. 10-min warm-up and cool-down phase and 40-min phase
consisting of 2 sets of 12 repetitions of 9 exercises: leg extension, leg curl, step up, heel raise,
chest fly, upright row, military press, bicep curls, and pelvic tilt. Home programme
Group 2: aerobic training. 10-min warm-up and cool-down and a 40-min period of walking at
an intensity 50–70% of the HR reserve. During months 4–6, exercise leader visited 4 times and
called 6 times to offer assistance for home programme
Comparison group Group 3: control. During the first 3 months, monthly group sessions on education related to
arthritis management, including time for discussions and social gatherings. Later, participants
were called bimonthly (months 4–6) or monthly (months 7–18) to maintain health updates and
provide support
Session/week 3 times a week.
No. of weeks 3-month supervised facility-based programme, and 15-month home-based programme
Follow-up weeks N/A
84 PELLAND ET AL.

Author PETRELLA 41
Population details Inclusion: patients who were over 65 years old, had pain in one knee on most days, had radio-
graphic evidence of OA in the tibio-femoral compartment, and had difficulties in performing ADL
Treatment Group 1: progressive exercise programme consisting of the following exercises: (i) knee
unloading (joint capsule stretch) with an ankle weight of 1–2 kg; (ii) ROM (knee extension)
with foot elevated, patients push the knee toward the floor; (iii) resistance open kinetic exercises
(straight leg raise with ‘T’ motion) 3 times; and (iv) resistance closed kinetic exercises (eccentric
wall slide to knee flexion of 30° and patients push off on a towel wrapped under the foot, with
the knee bent at 30°). All exercises with progression
Comparison group Group 2: knee unloading (joint capsule stretch), ROM (knee extension), without progression
Concurrent therapy Oxaprozin 1200 mg per os daily
Session/week; No. of weeks Group 1: week 1–2: 3 Week 3–4: 3 Week 5–6: 6 Week 7–8: 15
Group 2: three times a week for 8 weeks
Follow-up weeks N/A
Author REJESKI et al.42

Sample size RCT Total: 357
Population details Inclusion: patients who met the following criteria: (i) were 60 years of age or older; (ii) had pain
on most days of the month in one or both knees; (iii) had difficulty with at least one ADL
(e.g. getting in and out of a car); and (iv) showed radiographic evidence of knee OA
Age (years): mean (SD for control) 68.65 (5.50)
Treatment Group 1: aerobic treatment group. Participants walked at an intensity of 50–75% of t
heir HR reserve
Group 2: resistance training group. They performed 9 different upper and lower body exercises:
leg extensions, leg curls, step-ups, heel raises, chest flies, upright rows, military presses, bicep
curls and pelvic tilts. Participants completed 2 sets of each exercise at a frequency of
10–12 repetitions
Comparison group Group 3: control. Participants were consolidated in groups of 10–15. During months 1–3, they received
a monthly education session which lasted 1.5 h. Patients in this condition were contacted by phone
once every 2 weeks for months 4–6 and then monthly for the remainder of the study
Concurrent therapy Groups 1 and 2: 3-month facility-based exercise followed by a 15-month home-based phase.
Three times a week, 10-min warm-up, 40-min stimulus phase, and 10-min cool down. Home-
based phase: (i) 4 home visits and 6 telephone contacts during the first 3 months; and
(ii) telephone calls every 3 weeks for the second 3 months, then one telephone call each
month for the remainder of the study
Session/week; No. of weeks 3 times a week for the first 3 months 15 months home-based programme
Follow-up weeks N/A
Author RODGERS et al.43

Sample size CCT Total: 20 Group 1: 10 Group 2: 10
Population details Inclusion: patients with unilateral primary TKA for OA
Age (years): mean (SD for control) Group 1: 70 (3.75) Group 2: 65 (8.25)
Treatment Group 1: 6-weeks’ pre-operative PT, 3 times a week; programme individualised according to
baseline physical capacity. Stretching and warm up, heel-slides, isometric quadriceps sets, SLR,
short-arc quad sets, standing squats, step-ups, and bike
Comparison group Group 2: concurrent therapy only
Concurrent therapy Same knee implant, same postoperative therapy including ankle pumps, quad sets, SLR, short-
arc quad sets, heel slides, hamstring-stretching, hamstrings sets, hip abduction, and hip
adduction. Patients started gait training on the first postoperative day. They were discharged
depending on their progress and instructed to begin a home PT programme
Follow-up weeks 6 weeks, 3 months

Author ROGIND et al.44
Population details Inclusion: patients who met the following criteria: ACR criteria for OA in the knee patients
appointed as the most affected knee, the radiograph of this knee rated at least 3 on the Kellgren
scale; and capable of getting down on the floor and up again, of independent walking and
transport, and of taking one flight of stairs unassisted to reach the training facilities
Treatment Group 1: mobility training and venous therapy performed from supine position moving the
joints of the lumbar spine, hips, knees, ankles, shoulders, and elbows. LE and truncal
strengthening: Repetitive exercises for quadriceps, hip adductors and abductors, hamstrings,
gluteus maximus, erector spinae, and abdominal muscles. Stretching: calf quadriceps, hip
adductors, hamstrings, gluteus maximus, lower back, and pectoralis major. Balance and
co-ordination exercises.
Session/week; No. of weeks Twice a week for 3 months
Follow-up weeks 3 and 12 months
Author SASHIKA et al.45

Sample size CCT Total: 23 Group 1: 8 Group 2: 8 Group 3: 7
Population details Inclusion: Patients who had had a THA for hip OA
Symptom duration: mean (SD) Group 1: 26.1 months, SD 8.06 months
Group 2: 23.9 months, SD 14.90 months
Group 3: 29.6 months, SD 7.93 months
Treatment Group 1: ROM exercises of hip flexion and isometric muscle strengthening exercises of
low resistance
Group 2: same as Group 1 plus eccentric muscle contractile exercises of hip abductors in the
standing position on one leg
Comparison group Group 3: Control, no treatment
Concurrent therapy Groups 1 and 2: a physical therapist prescribed a 6-week home programme of PT. Subjects were
usually instructed to perform the exercises twice a day for 15–20 min a session and asked to
keep a daily record of how often they did their exercises. A physical therapist called them every
2 weeks and modified the programme as necessary
Session/week; No. of weeks 6 weeks
Author SCHILKE et al.46

Population details Inclusion: patients who had not participated in a strength-training programme within the
past 6 months
Symptom duration: mean (SD) < 10 years
Age (years): mean (SD for control) Group 1: 64.5 (3.75) Group 2: 68.4 (8)
Treatment Group 1: exercise. Warm-up of 5 min on bike, then isokinetic exercise at 90° per second for 24
sessions. Session 1 comprised 1 set of 5 contractions; session 2, 2 x 5 contractions (1-min rest
between each); session 3, 3 x 5 contractions (1-min rest between each); session 4, 4 x 5
contractions (1-min rest between first 2 sets, 15-min rest between sets 3 and 4); session 5, 5 x 5
contractions (1-min rest between first 2 sets and between sets 4 and 5, 15-min rest between 3
and 4); and sessions 6–24, 6 x 5 contractions (1-min rest between first 3 sets and last 3, 15-min
rest between sets 3 and 4)
Follow-up weeks N/A
86 PELLAND ET AL.
Author STAMM et al.47

Population details Inclusion: patients who met the ACR criteria for hand OA. Medication with analgesics or
NSAIDs was allowed during the study but had to remain stable at least 1 month before and
throughout the study
Treatment Group 1: exercise. Each patient received a 30-min oral and written instruction for joint
protection and a 15-min training in home exercises, which consisted of 7 exercises to
perform with both hands 10 times a day
Comparison group Group 2: control. Oral and written information about hand OA on joint anatomy and pathogenesis
of OA. Patients received a piece of Dycem to open jars for the study period of 3 months
Session/week; No. of weeks 3 months
Follow-up weeks N/A
Author TOPP et al.48

Population details Inclusion: patients with a diagnosis of knee OA and a score of 5 or more on Western Ontario
McMaster Osteoarthritis Index pain subscale
Treatment Group 1: dynamic resistance with Thera-Band elastic bands. Warm up 5 min, strength training
30 min, cool down 5 min
Group 2: standard isometric training techniques. Resistance with Thera-Band elastic bands
that patients were unable to stretch
Both Groups: muscles were ankle plantar/dorsi flexors, knee extensors/flexors, hip
extensors/flexors
Comparison group Group 3: no intervention
Concurrent therapy None
Session/week; No. of weeks Three times a week (twice at home and once under supervision)
Follow-up weeks None
Author VAN BAAR et al.49

Population details Inclusion: patients with OA of the hip or knee according to the clinical criteria of the ACR
Treatment Group 1: exercises for muscle functions (strength and length), mobility, and co-ordination, and
exercises for elementary movement abilities and locomotion abilities. Instructions for the
adaptation of ADL and home exercises were given. Combined with concurrent therapy
Concurrent therapy Treatment by the GP: prescription of medication (patients were instructed to use as little as
possible); and patient education through brochure topics including diagnosis, prognosis, advice
concerning rest, daily activities and diet, use of aids, medical treatment
Session/week; No. of weeks Group 1: 1–3 times a week depending on pain level for 12 weeks
Group 2: patients consulted their GP at least twice, at weeks 0 and 12, and when needed

Author VAN BAAR et al.50
Population details Inclusion: patients with OA of the hip or knee according to the clinical criteria of the ACR
Treatment Group 1: exercises for muscle functions (strength and length), mobility, and co-ordination, and
exercises for elementary movement abilities and locomotion abilities. Instructions for the
adaptation of ADL and home exercises were given. Exercises occurred 1–3 times a week
depending on pain level, 30 min a session
Concurrent therapy GP prescribed paracetamol; prescription of NSAIDs restricted to naproxen, diclophenac
natrium, and ibuprofen. Patients instructed to use as few as possible. Brochure for patient
education covering diagnosis, prognosis, advice about rest, daily activities and diet, use
of aids, medical treatment
Session/week; No. of weeks 1–3 times a week for 12 weeks
Follow-up weeks 24 and 36 weeks
Quality: R, randomisation; B, blinding; W, withdrawals; N/A, not available.

ADL, activity of daily living; AROM, active range of motion; CPM, continuous passive motion; exs, exercise; OA, osteoarthritis; POD,
postoperative day; PROM, passive range of motion; PT, physiotherapy; RA, rheumatoid arthritis; Rx, treatment.
or facility-based, or aquatic; (iii) the type of participa- appropriateness of blinding (B), the rate and accountabil-
tion, whether performed on an individual basis or as ity of dropouts and withdrawals (W). The extent to which
a group; (iv) the nature of the exercises, whether the RCT design, data collection and statistical analysis
strength-specific or functional (including ROM, flexi- minimised or avoided biases in its treatment compar-
bility and strength); (v) the inclusion of an aerobic isons31 was also taken into account. Differences in scoring
component; (vi) the duration, intensity, frequency were resolved by consensus. The final data entry values of
and total number of training sessions; (vii) the type of outcome measures were based on consensus of the two
contractions used for strengthening, whether eccen- reviewers (CL, JL), with a third reviewer (LB) consulted
tric, concentric, isotonic, isometric or isokinetic or when necessary. A final cross-checking of all data entry
combinations of these; (viii) type of equipment used was also performed (VR).
(i.e. free weights or isokinetic machine); and (ix)
safety precautions that were implemented. Outcome
measures included in this meta-analysis were restricted Statistical analysis
to physical measures and included: (i) pain; (ii) health
status including aerobic capacity, blood pressure and Most outcomes were continuous in nature (ROM,
heart rate; (iii) mobility including morning stiffness and pain and strength). Where pooling of data from dif-
tenderness; (iv) strength, flexibility, balance, ROM; (v) ferent trials was possible, these outcomes were
functional status; (vi) medication use; and (vii) quality analysed by a weighted mean difference (WMD)
of activities of daily living (ADL). Psychosocial out- using a fixed effects model.31 According to the WMD
comes were excluded for the purposes of this analysis. model, the effect measured in an individual trial is
The final data entry values were based on consensus of weighted by the amount of variability about the mean
the two reviewers (CL, JL). measured by the standard deviation. In trials where
table data were not available, values from graphical
data were input into the WMD model. The hetero-
Quality assessment geneity of the results across studies was assessed using
a Chi-squared test. Where statistically significant het-
The measured outcomes were weighted according to the erogeneity existed, the trial results were not combined
strength of the research design. The quality of each study and were analysed separately. The contributions of
was assessed by two independent reviewers (CL, JL) using pre-determined hypotheses regarding different popu-
a validated scale developed by Jadad et al.29 and Clark et lations and interventions were examined as possible
al.30 Items pertaining to the strength of the research sources of heterogeneity. For categorical data, relative
design include description of randomisation (R), the risks were used.
88 PELLAND ET AL.
RESULTS general physical activity programme that included other

elements such as stretching, ROM exercises, and general
The systematic review of the literature identified 101 fitness and balance. Interventions were either facility-
studies, 21 of which were RCTs containing strengthen- based, home-based or a combination of the two. The
ing exercises as an intervention and meeting our pre- results from these 21 trials were reviewed to evaluate the
mentioned eligibility criteria (Table 2).16,24,32–50 The strength and quality of evidence supporting the inclu-
remaining 79 studies did not meet our eligibility criteria sion of strengthening exercises in the plan of care for
and were therefore excluded (Table 3).7,8,14,17,21,51–124 The individuals with OA.
21 trials included in the meta-analysis presented data for
2325 individuals with a primary diagnosis of OA under-
going various forms and combinations of strengthening Concentric alone or the combination of concentric and
exercises (isometric, isotonic, isokinetic, concentric, con- eccentric strengthening exercises versus control
centric/eccentric, dynamic whole body, and functional
exercises). These were implemented either as stand- A central issue in the plan of care for the client with
alone interventions or as one component of a more OA is the maintenance or improvement of QOL.
Table 3. Excluded studies (n = 79) for therapeutic exercises
Study Reason for exclusion Study Reason for exclusion
AGS51 Not an RCT Langeland87 No control group

Ahern et al.52 No statistical data for control Lau and Chiu88 Number of patients in each group
group missing
Aubriot et al.53 No SD Leivseth et al.89 Biochemical data
Baker et al.54 Comparative control group is an Lynch et al.90 No SD
active treatment (head-to-head Maloney et al.91 Mixed population
study) Mangione et al.92 Patients as their own control
Balint and Szebenyi55 Not an RCT Mangione et al.93 Wrong intervention
Basso and Knapp56 Not an RCT Marks and Cantin94 No control group
Beaupré et al.57 Mixed population May et al.95 Head-to-head
Belza et al.58 More than 20% dropout rate Mei Hwa and Jin-Shin96 No time period for the outcomes
Beverley59 Review Merchan and de la Corte97 No statistical data
Boardman et al.60 Mixed population Messier et al.98 Nutrition is the main intervention
Bohannon61 Not an RCT Messier et al.99 Healthy subjects
Buchner62 Not an RCT Meyer and Hawley100 No time period for the outcomes
Bunning and Materson63 Review Minor et al.8 Head-to-head
Burke et al.64 No control group Minor et al.101 No control group
Callaghan et al.65 Combined therapies Minor and Brown102 No statistical data for control
Chamberlain et al.66 No statistical data Nicolakis et al.103 No control group
Davis67 Not enough statistical data Nicolakis et al.104 No control group
D’Lima et al.68 Larger proportion of RA patients Nordesjö et al.7 Healthy subjects
Dougados and Ravaud69 Overview Odenbring et al.105 Not TKA subjects
Ettinger et al.70 More than 20% dropout rate Penninx et al.106 No statistical data
Eungpinichpong71 No statistical data Petrella and Bartha107 Review
Fisher et al.72 More than 20% dropout rate Rao and Evans108 No significant data
Fisher et al.73 No control group Rasti and Olsen109 Literature review
Frank et al.74 Head-to-head Rejeski et al.110 The outcome is the compliance
Fransen et al.75 More than 20% dropout rate Rejeski et al.111 More than 20% dropout rate
Frost et al.76 More than 20% dropout rate Simkin et al.112 Not enough statistical data
Gerber21 Review Stenström113 Review
Gettman77 Not an RCT Sullivan et al.114 More than 20% dropout rate
Goletz and Henry78 Not an RCT Sylvester115 Head-to-head
Gose79 Not an RCT Tan et al.116 Healthy subjects
Green et al.80 Head-to-head Thomas et al.117 Not specific to OA
Hall et al.81 No intervention Tork and Douglas118 No control group
Hartman et al.17 Majority spine OA Van Baar et al.14 Systematic review
Haug and Wood82 Combined electrical stimulation Ververeli et al.119 Not an RCT
Hopman-Rock and Westoff83 Education on exercise (wrong Wasilewski et al.120 Not an RCT (retrospective study)
intervention) Weiss et al.121 Multiple conditions
Johnson84 Head-to-head Worland et al.122 Both groups received CPM
Johnson and Eastwood85 No SD Yashar et al.123 Mixed population
Kim and Moon86 Head-to-head Young and Kroll124 Not enough statistical data
Table 4. Clinical relevance: concentric versus control
Study Treatment Outcome No. of Baseline End-of- Absolute Relative difference

group patients mean study benefit in change
mean from baseline
Gur et al.37 Concentric Pain at night (0–10), end tx: 8 weeks 9 4.4 1.4 –3.3 –84%
Control As above 6 3.2 3.5
Gur et al.37 Concentric Pain after inactivity (0–10),end tx: 8 weeks 9 4.1 1.2 –2.9 –73%
Gur et al.37 Concentric Pain sitting (0–10), end tx: 8 weeks 9 3.4 0.9 –2.7 -89%
Gur et al.37 Concentric Pain rising from chair, end tx: 8 weeks 9 5.2 2.0 –3.2 -64%
Gur et al.37 Concentric Pain standing, end tx: 8 weeks 9 4.0 1.4 –2.6 -65%
Gur et al.37 Concentric Pain climbing stairs, end tx: 8 weeks 9 5.8 1.7 –4.3 –80%
Gur et al.37 Concentric Pain descending stairs, end tx: 8 weeks 9 5.8 1.7 –4.1 –75%
Gur et al.37 Concentric Pain total score, end tx: 8 weeks 9 33.9 10.3 –24.3 –78%
LE, lower extremity; METS, Metabolic Equivalent units; ROM, range of motion; tx, treatment; VAS, Visual Analogue Scale;
WOMAC, Western Ontario McMaster Osteoarthritis Index.
Table 5. Clinical relevance: concentric-eccentric versus control

mean from baseline
Gur et al.37 Concentric-eccentric Pain at night (0–10), end tx: 8 weeks 8 3.8 1.5 –2.6 –73%
Gur et al.37 Concentric-eccentric Pain sitting (0–10), end tx: 8 weeks 8 3.5 1.1 –2.6 –85%
Gur et al.37 Concentric-eccentric Pain rising from chair, end tx: 8 weeks 8 5.4 2.5 –2.9 –57%
Gur et al.37 Concentric-eccentric Pain standing, end tx: 8 weeks 8 3.5 1.6 –1.9 –51%
Gur et al.37 Concentric-eccentric Pain climbing stairs, end tx: 8 weeks 8 6.5 3.5 –3.2 –55%
Gur et al.37 Concentric-eccentric Pain, total score, end tx: 8 weeks 8 35.8 16.6 –19.9 –62%
Gur et al.37 Concentric-eccentric 15 m walk (s), end tx: 8 weeks 8 3.9 1.0 –2.9 –78%
Gur et al.37 Concentric-eccentric Stair climbing time (s), end tx: 8 weeks 8 4.6 1.5 –4.1 –97%
Gur et al.37 Concentric-eccentric Stair descending time (s), end tx: 8 weeks 8 5.3 1.8 –4.1 –81%
Gur et al.37 Concentric-eccentric Function, total score, end tx: 8 weeks 8 19.1 6.0 –15.6 –89%
90 PELLAND ET AL.
Table 6. Clinical relevance: hip strengthening + eccentric versus control

group patients mean study mean benefit in change
from baseline
Sashika et al.45 Hip strengthening Maximum isometric torque, 8 12.5 21.0 4 37%
+ eccentric hip abductors,
total hip arthroplasty side,
end tx: 6 weeks
45
Sashika et al. Hip strengthening Maximum isometric torque, 8 15.1 23.3 4.9 35%
+ eccentric hip abductors, opposite side,
end tx: 6 weeks
Table 7. Clinical relevance: lower extremity isometric strengthening versus control

from baseline
Topp et al.48 LE isometric Pain, getting up 32 5.39 2.89 –3 –61%

strengthening from floor (0–16)
Topp et al.48 LE isometric Pain, getting down 32 4.20 1.84 –2.71 -70%
strengthening to floor (0–16)
48
Topp et al. LE isometric Pain, going up stairs (0–16) 32 5.19 2.98 –2.28 –47%
strengthening
Topp et al.48 LE isometric Pain, going down stairs (0–16) 32 4.70 2.78 –1.85 –40%
strengthening
Topp et al.48 LE isometric Pain (WOMAC) 32 11.75 10.38 –1.39 –12%
strengthening
Topp et al.48 LE isometric Time to get down 32 5.56 4.31 –1.6 –30%
strengthening to the floor (s)
48
Topp et al. LE isometric Time to get up off floor (s) 32 8.26 6.37 –2.01 –25%
strengthening
Topp et al.48 LE isometric Time to go up stairs (s) 32 17.99 15.15 –1.52 –8%
strengthening
Topp et al.48 LE isometric Time to go down stairs (s) 32 16.86 13.95 –1.21 –7%
strengthening
Topp et al.48 LE isometric Stiffness (WOMAC) 32 5.13 5.03 –0.37 –7%
strengthening
48
Topp et al. LE isometric Functional limitation 32 38.13 35.97 –2.99 –8%
strengthening (WOMAC)
Intrinsic to this objective is an adequate management

of pain. The beneficial impact of therapeutic strength
exercises in the management of pain for knee OA is
well demonstrated in a study by Gur37 who compared
the effects of concentric extension and flexion exer-
cises of the knee, performed either independently or
in combination, over a period of 8 weeks to a no-
treatment control group of clients with OA of the
knee. Overall, strength exercises provided clinically
important benefits to pain management with
improvements of over 80% on measures of pain at
night, at rest (while sitting), and on stair climbing
(Table 4). The combination of eccentric and concen-
tric strength exercises offered further beneficial effects
on overall functional status (Table 5). The control of
pain, in fact, is one of the dominant mechanisms
through which strengthening exercises produce their
beneficial effects in patients with OA. Acknowledging
this important mechanism, this paper subsequently
concentrated on evaluating the main effect of improv-
ing muscle strength on the key measured outcomes of
strength, ROM, pain, functional status and QOL.
Combination of concentric and eccentric hip

strengthening exercises versus control
The effectiveness of strengthening exercises in the

management of OA was directly addressed by Sashika
et al.45 who compared the effectiveness of two basic
exercise programmes that are commonly part of the
rehabilitation programme for the client with OA of
the hip, to a no-treatment control group: (i) low resis-
tance isometric strengthening of hip abductors and
active ROM for hip flexion, and (ii) combined isomet-
ric and eccentric strengthening of hip abductors and
active ROM for hip flexion. At the end of 6 weeks of
training, neither the isometric or combined isomet-
ric/eccentric programs produced any significant
Fig. 1. Cybex versus control. FU, follow-up; tx, treatment.
improvements on measured outcomes of hip flexion
ROM or maximum isometric hip abductor torque.
The combination of isometric and eccentric strength-
ening did, however, produce clinically important improvements on one outcome measure for pain –
improvements in strength with an increase of 35% decreased pain while getting up from the floor. As
(relative to baseline measure) in maximum isometric found in the study by Sashika et al.,45 isometric
hip abductor torque on the affected side (Table 6). strength training programmes did produce clinically
The effectiveness of isometric strengthening was simi- important improvements in level of pain on stair
larly investigated by Topp et al.48 Isometric strength climbing, as well as improving performance on timed
training for flexion and extension at all three joints of functional tasks that included time to get down on
the lower limb was performed three times a week and up from the floor (see Table 7 for a complete list
(once under supervision and twice as a home pro- of outcomes). These studies provide evidence that the
gramme), and outcomes were measured at the end of clinical benefits associated with isometric strengthen-
the 4-month intervention. Compared to a no-treating could preferentially be mediated through
ment control group, the isometric strength training improved joint-specific strength and function, as well
programme produced statistically significant as through a significant control of pain.
92 PELLAND ET AL.
Fig. 2. Lower extremity strengthening versus control. FU, follow-up; LE, lower extremity; OASI, Osteoarthritis Screening
Index; tx, treatment; VAS, Visual Analogue Scale; WOMAC, Western Ontario McMaster Osteoarthritis Index.
Lower extremity (LE) isometric strengthening vs control pain. As a result, isokinetic training is clinically con-
sidered as the best intervention to achieve strength
In their study, Topp et al.48 further compared the relative gains in OA.77
effectiveness of an isometric strengthening programme
to a dynamic (isotonic) programme on lower extrem-
ity strength, function and pain. Over the same dura- Isokinetic resistance training versus control
tion of 4 months, no statistical or clinical differences
were found between the two strength training Kreindler et al.16 evaluated the comparative effective-
approaches. An important question to consider is ness of isokinetic training (Kinetron-Cybex) to a
whether or not the lack of effectiveness of the cited fixed-resistance strength-training programme in
exercise programmes on strength gains could be clients with a primary diagnosis of OA of the knee.
linked to the type of muscle contraction, a factor that Isokinetic strengthening produced statistically signifi-
may be of specific importance in OA due to the cant improvements solely on one outcome measure at
implicit interaction between joint mechanics and the end of 6-weeks of training – quadriceps torque at
pain. This question is best addressed by examining 120 degree/s (Fig. 1). However, this measured improve-
the effects of isokinetic strength training on measured ment in quadriceps’ strength was not retained through
outcomes of OA.16,46 Isokinetic strength training dif- a 6-week follow-up period. Schilke et al.46 strengthened
fers from fixed-resistance strength training as it the findings by Kreindler et al.16 through a direct com-
respects the changing muscle response over the parison of isokinetic training to a no-treatment control
length–tension curve of the muscle125,126 and is, there- group in clients with OA of the knee. In this study, iso-
fore, considered to facilitate activation of a larger pro- kinetic training consisted of a strength programme for
portion of muscle fibres over a wider ROM. The the quadriceps at a fixed angular velocity of 90 degree/s,
angular velocity of training can also be selected, with with a progression in the number of sets of repetition to a
faster velocities reducing joint compression and hence maximum of 6 sets of 5 repetitions. Over the 24 sessions
Table 8. Clinical relevance: lower extremity strengthening versus control

mean from baseline
Topp et al.48 Exercise Pain, getting up from floor (0–16) 35 6.44 2.67 –4.27 –78%
Topp et al.48 Exercise Pain, getting down to floor (0–16) 35 4.96 2.86 –2.45 –58%
Topp et al.48 Exercise Pain, going up stairs (0–16) 35 5.61 4.03 –1.65 –32%
Topp et al.48 Exercise Pain, going down stairs (0–16) 35 5.30 3.71 –1.52 –31%
Topp et al.48 Exercise Pain (WOMAC) 35 12.40 10.71 –1.71 –15%

Topp et al.48 Exercise Time to get down to the floor (s) 35 4.72 3.89 –1.18 –24%
Topp et al.48 Exercise Time to get up off floor (s) 35 7.16 5.71 –1.57 –21%
Topp et al.48 Exercise Time to go up stairs (s) 35 18.85 16.33 –1.2 –6%
Topp et al.48 Exercise Time to go down stairs (s) 35 19.29 15.96 –1.63 –9%
Topp et al.48 Exercise Functional limitation (WOMAC) 35 41.09 35.30 –6.62 –17%
Schilke et al.46 Exercise Peak torque right knee extensors 10 52.50 67.40 14.5 33%
Schilke et al.46 Exercise OASI mobility 10 11.30 7.64 –3.24 4%

of training, statistically significant improvements were Together, the studies cited above do not provide evi-
noted for peak torque of quadriceps, with an overall dence to support exercise for improving strength in
improvement of 33% relative to baseline, (Fig. 2a) and the patient with OA in the lower extremity joints.
for mobility (Fig. 2b; Table 8). The isokinetic pro- There is evidence, however, to support that the
gramme produced no additional benefits for the control overall format of the programme, in which the
of pain and did not improve joint stiffness or functional strength training is embedded, may be one of the
status (Fig. 2b). These studies, therefore, demonstrate determinant factors influencing the effects produced
the potential equivalency of isometric, isotonic and iso- by strengthening exercises on clinical and functional
kinetic strength training programmes for patients with outcome measures of OA. Hurley and Scott24 evalu-
OA of the knee. ated the effectiveness of a combining standard iso-
metric strengthening of the quadriceps with a general
exercise programme that included isotonic concen-
General LE exercises programme versus control
tric/eccentric strength exercises for the lower limb, as
Börjesson et al.33 investigated the combined effect of well as balance exercises and task-specific functional
isotonic and isometric strengthening in conjunction strengthening for sit-to-stand and step-ups and step-
with stretching and a warm-up on stationary bike on downs. Measured against a no-treatment control
outcome measures of strength (Fig. 3g), pain (Fig. group, this comprehensive programme produced sta-
3f), and functional status. They found statistical and tistically significant benefits not only on quadriceps’
clinical improvement solely for the task of pain dur- strength, (Fig. 3b) but as well on knee proprioception
ing a step-down (Table 9c) after 3 months of training. (Fig. 3e) and functional status (Fig. 3d).
94 PELLAND ET AL.
Fig. 3. (a)
Fig. 3. General lower extremity exercises programme

versus control. ADL, activities of daily living; AFI,
Algofunctional Index; FU, follow-up; HSS, Health Status
Survey; IRLG, Influence of Rheumatic Disease on General
Health and Lifestyle; LE, lower extremity; MVC, muscle
voluntary contractions; QOL, quality of life; ROM, range
of motion; tx, treatment; WOMAC, Western Ontario
McMaster Osteoarthritis Index.
Fig. 3. (b & c)
Manual therapy and exercise versus placebo 4a) and on overall functional status at the end of the 4-
week intervention (Fig. 4b), as well as at the 4-week fol-
In a similar fashion, Deyle et al.34 combined a stan- low-up. Therefore, comprehensive programmes that
dard knee strengthening programme (isometric and include both joint-specific and functional exercises may
isotonic inner range quadriceps, and isotonic ham- provide added benefits to the client with OA of the lower
strings) within a global approach that included manual limb.
therapy (i.e. passive physiological and accessory joint In reviewing results, it is important to consider that
movements, and soft tissue mobilisation), stretching, outcomes will invariably be influenced by the severity
stationary biking, as well as functionally oriented exer- of OA, as well as by the format of the strengthening
cises (standing terminal knee extension, seated-leg press, programme. For example, Rodgers et al.43 evaluated
step-ups, and eccentric quadriceps). The exercises were the effectiveness of a strengthening programme that,
performed under supervision as well as part of a home again, combined isometric strengthening with stretch-
programme that further included walking at a comfort- ing and functional activities (squats and step-ups) in
able pace over a comfortable distance. Compared to a candidates with severe OA of the knee that were on a
control group receiving sub-therapeutic ultrasound, the waiting list for unilateral total knee arthroplasty.
strengthening exercise programme produced statistically Evaluation relative to a no-treatment control group at
significant improvements on the 6-min walk test (Fig. 6-weeks’ and 3-months’ follow-up failed to demon-
Fig. 3. (d,e,f) See previous page for details.
strate any statistically significant benefit of the

strength-training programme on ROM (Fig. 3a), or
on functional status (Fig. 3d). Client-specific charac-
teristics can, therefore, significantly interact with the
design of the strengthening intervention to produce ambulation (Fig. 5a) and transfers from bed (Fig. 5a),
different outcomes of effectiveness. as well as improving various parameters of gait
including increased cadence (Fig. 5c), longer stride
length (Fig. 5d), increased walk velocity (Fig. 5e) and
Whole body functional exercises versus control longer duration of contralateral swing phase (Fig. 5f).
In contrast to the short-term benefits of isokinetic
The wide-ranging effects of a more functional exercise strength training,16 improvements with the pro-
programme for the whole body are well defined in gramme designed by Messier et al.38 were retained
several studies that examined the benefits of incorpo- over an 18-month follow-up period. Rejewski et al.42
rating joint-specific strengthening within a global further reported statistically beneficial effects of a
strength programme for both upper and lower general strengthening programme on timed-perfor-
limbs.38,40,42 The characteristics of each of these pro- mance for stair climbing, climbing self-efficacy score,
grammes are detailed in Table 2. In the study by and general health status, while Penninx et al.40
Messier et al.,38 a free-weight strength programme reported a beneficial outcome on functional capacity
produced statistically significant improvements in the for bathing. Rogind et al.44 designed their training
frequency (Fig. 5a) and intensity of knee pain during programme to emphasise ROM and flexibility
96 PELLAND ET AL.
Fig. 3. (g,h) See caption under Fig.3(a) for details.
Table 9 (a). Clinical relevance: general lower extremity exercises programme versus control

from baseline
Rogind et al.44 Exercises ROM knee flexion 12 130 135 3 2%

(most affected knee),
degrees, end tx: 10–12 weeks
Control As above 13 123 125
44
Rogind et al. Exercises ROM knee flexion (least 12 132 135 4 3%
affected knee), degrees, end tx:
10–12 weeks
Rogind et al.44 Exercises ROM knee flexion (least 12 132 133 6 5%

affected knee), degrees, FU:
12 months
49
Van Baar et al. Exercises Hip muscle strength, change, 93 N/A 0.22 WMD = 0.18
FU: 24 weeks
Control As above 98 N/A 0.04
FU = follow-up; N/A = not available; ROM = range of motion; tx = treatment; WMD = weighted mean difference
Fig. 4. Manual therapy and exercise versus placebo. FU,

follow-up; tx, treatment.
Fig. 3. (i,j) See caption under Fig.3(a) for details.
Table 9 (b). Clinical relevance: general lower extremity exercises programme versus control
from baseline
Fransen et al.36 Exercises WOMAC pain, change 83 N/A 10.6 WMD = 12.1
(0–100), end tx: 8 weeks
Control As above 43 N/A –1.5
Van Baar et al.49 Exercises Pain past week, VAS (0–100), 93 46.9 24.1 –17.1 –38%
change, end tx: 10–12 weeks
Van Baar et al.49 Exercises Pain VAS, (0–100), FU: 24 weeks 93 34.0 23.5 –11.2 –36%
Van Baar et al.50 Exercises Pain VAS, (0–100), FU: 24 weeks 98 34.0 16.8 –11.6 –37%
Rogind et al.44 Exercises Pain at night (0–10), FU: 12 months 12 4.0 2.0 –3 66%
FU = follow-up; N/A = not available; VAS = visual analog scale; tx = treatment; WMD = weighted mean difference; WOMAC = Western
Ontario McMaster Osteoarthritis Index
98 PELLAND ET AL.
Table 9 (c). Clinical relevance: general lower extremity exercises programme versus control
Author Group Outcome Number improved Total N Risk occurrence Risk difference
33
Börjesson et al. Exercises Ability to step down 13 34 38% 26%
Control As above 4 34 12%
Table 9 (d). Clinical relevance: general lower extremity exercises programme versus control

from baseline
Fransen et al.36 Exercises Strength, isometric knee 83 169.45 180.25 13.2 8%

extensors (N), end tx: 8 weeks
Fransen et al.36 Exercises Strength, isometric knee flexors (N), 83 94.65 103.05 9 9%
end tx: 8 weeks
Fransen et al.36 Exercises Fast speed (cm/s), end tx: 8 weeks 83 128.6 135.7 6.7 5%
Fransen et al.36 Exercises Fast cadence (steps/min), end tx: 8 weeks 83 119.9 121.8 1.6 1%
Fransen et al.36 Exercises Fast stride length (cm), end tx: 8 weeks 83 128.2 132.9 4.3 3%
tx = treatment
Table 9 (e). Clinical relevance: general lower extremity exercises programme versus control

from baseline
Fransen et al.36 Exercises WOMAC function, change (0–100), 83 60.8 68.5 7.8 13%
end tx: 8 weeks
Van Baar et al.49 Exercises Self-reported disability (IRLG), 93 –20.00 –1.10 –1.70 8%
FU: 24 weeks
Control As above 98 –20.60 0.00
Fransen et al.36 Exercises SF-36 quality of life, change, 83 32.85 36.45 3.10 9%
end tx: 8 weeks
through stretching exercises, in addition to a general two other determinant factors of the effectiveness of
strength programme for the lower limb and trunk. an exercise programme for OA.
These authors reported further statistically and clini-
cally beneficial effects of a general programme on a
variety of pain measures that included pain at rest Progression versus no progression LE functional
(Fig. 3f), pain on weight-bearing (Fig. 3f), and pain at exercises
night (Fig. 3f; Table 9b). While the programme by
Rogind et al.44 also improved ROM in knee flexion Petrella et al.107 studied the effect of exercise progres-
(Fig. 3a; Table 9a), it failed to produce statistically sion in a general strength programme compared to a
significant changes in gait and stair climbing. Task- non-progressive programme. The progressive pro-
specificity and exercise progression are potentially gramme consisted of knee unloading with ankle
Fig. 5(a-f). Whole body functional exercises versus control.

FU, follow-up; HIKS, hamstrings isokinetic strength; HIS,
hamstrings isometric strength; QIKS, quadriceps isokinetic
strength; QIS, quadriceps isometric strength; tx, treatment;
VAS, Visual Analogue Scale.
100 PELLAND ET AL.
Fig. 6. Progression versus no progression lower extremity functional exercises. LE, lower extremity; tx, treatment; VAS,
Visual Analogue Scale; WOMAC, Western Ontario McMaster Osteoarthritis Index.
weights, ROM, resistance open-kinetic and closed- gramme included general ROM exercises, eccentric
kinetic exercises. All exercises progressed gradually strengthening of the quadriceps, and an individualised
over 8 weeks on the number of repetitions (i.e. walking programme that was progressed on a weekly
increase from 2 to 5 repetitions per session), the dura- basis. Results were compared to a minimal treatment
tion of the training session (i.e. increase for 10–15 group that received the same education session as the
min/session), and on the number of sessions per week exercise group. The progressive exercise programme
(i.e. increase from 3 to 5 sessions). The comparison produced significant decreases in pain (Fig. 5b).
group performed knee unloading and ROM exercises The main effect of exercise progression on mea-
without progression over the same duration of train- sured outcomes is emphasised by the study design of
ing. At the end of the 8-week intervention, statisti- O’Reilly et al.39 who directly compared the effective-
cally significant results favouring a progression in ness of a simple home-based strength programme
exercises were found for overall pain (Fig. 6c), pain at consisting of a combination of isometric and isotonic
rest (Fig. 6c), pain and performance on the self-paced exercises for the quadriceps with dynamic stepping.
walk test (i.e. 2 continuous circuits, each 20 min in All exercises were performed daily at home increasing
length for a total of 40 m following by a 10 min rest to a maximum of 20 repetitions and were measured at
period), as well as improved knee ROM in flexion 6 weeks. Results were then compared to a no-treat-
(Fig. 6b) and overall physical activity. ment control group. Statistically significant outcomes
In a similar fashion, Bautch et al.32 examined the favouring the home-programme of progressive
effects of low intensity weight-bearing exercises on pain, strength exercises were found for pain, quadriceps’
health status, as well as on biological markers in strength (Fig. 3b) and overall QOL. Evidence is,
patients with OA of the knee. The 12-week exercise pro- therefore, available supporting exercise progression as
Table 10. Clinical relevance: home programme strengthening versus control

from baseline
Evcik and Sonel35 Home strengthening WOMAC physical function 27 25.4 10.8 –10.1 –40%
Evcik and Sonel35 Home strengthening NHP physical mobility 27 40.2 29.5 –3.2 –8%
Evcik and Sonel35 Home strengthening WOMAC pain 27 6.6 3.0 –3 –45%
Evcik and Sonel35 Home strengthening Pain VAS 27 7.2 3.5 –3.5 –49%
Evcik and Sonel35 Home strengthening NHP pain 27 40.0 9.8 –9.7 –24%
Evcik and Sonel35 Home strengthening NHP energy 27 53.2 33.4 –16.2 –31%
an important component of a general exercise pro- cally-relevant benefits on pain. Comparison of the
gramme for OA. home exercise group to the supervised exercise group
produced no statistically significant differences. Evcik
and Sonel35 further showed that a simple home pro-
Home programme strengthening versus control gramme of quadriceps’ strengthening could effec-
tively produce wide-ranging effects on QOL measures
A point of clinical interest in the studies by Messier et for the patient with OA of the knee. The home pro-
al.,38 Penninx et al.40 and Rejewski et al.42 is evaluating gramme was comprised of 10 repetitions of isometric
the impact of different levels of supervision provided and isotonic quadriceps’ exercises, initially taught by
to the patient during the exercise programme. For a physiotherapist, and subsequently performed twice
example, these studies38,40,42,44 combined 3 months of daily at home for 3 months, and outcomes were mea-
supervised therapy to a home programme of 15- sured at 6 months. The control group proceeded with
month duration, while Rogind et al.44 used a super- normal activities of daily living with no extra exercise
vised programme for 3 months, with a follow-up or regular walking programmes. This home pro-
evaluation at 3 and 12 months. Callaghan et al.65 gramme produced significant improvements in vari-
investigated the effect of supervision on programme ous dimensions of functional status and QOL
effectiveness by comparing outcome measures for a including pain, physical function, energy level and
home exercise programme for patients with OA of the physical mobility (Table 10).
knee relative to a supervised exercise routine to a no- Fransen et al.36 investigated the benefit of using a
exercise control group. The home exercise programme group setting to reinforce a home exercise pro-
consisted of 10 repetitions of 3 functional activities gramme. In this study, the group under supervised
(sit-to-stand-to-sit, mini-squats, and step-downs) per- care performed an exercise programme that was at the
formed twice daily, and was prefaced by an education discretion of the treating physical therapist and,
session on joint care, medication, pain relief and cop- therefore, differences in the strengthening approach
ing strategies. Outcomes were compared to a group of across supervised and group participants cannot be
patients participating in a 20-min supervised exercise evaluated. The point of interest is the additional ben-
routine consisting of isometric and isotonic inner efits noted in participants of the reinforced home pro-
range strengthening of the quadriceps (3 sets of 10 gramme, particularly on outcome measures of pain
repetitions) and a control group receiving sham elec- and strength at 8 weeks’ post-intervention, compared
trical stimulation. When comparing the home pro- to the control no-treatment group. Statistically signif-
gramme group to the control group at the end of 4 icant improvements were found for pain (Fig. 3f), iso-
weeks of training, statistically significant results were metric strength of quadriceps and hamstrings (Fig.
found for the home exercise group for knee joint 3g), improved gait parameters of speed (Fig. 3h),
swelling and flexion ROM, as well as providing clini- cadence (Fig. 3h) and stride length (Fig. 3h), as well
102 PELLAND ET AL.
Table 11(a). Clinical relevance: grip strength in hand functional strengthening versus control

from baseline
Stamm et al.47 Hand functional Grip strength, change, 20 0.43 0.55 0.09 19%
strengthening right, end tx: 3 months
47
Stamm et al. Hand functional Grip strength, change, 20 0.44 0.55 0.08 16%
strengthening left, end tx: 3 months
Table 11(b). Clinical relevance: pain in hand functional strengthening versus control
Study Group Outcome Number Total No. Risk Risk

observed occurrence difference
Stamm et al.47 Hand functional Pain (Visual Analogue Scale), number 13 20 65% 45%
strengthening improved, end of treatment: 3 months
Control As above 4 20 20%
as overall improvement on functional status (Fig. 3j) home strengthening programme produced statistically
and SF36 QOL measure (Fig. 3i). Comparison of significant improvement on measures of pain and grip
outcomes for the group versus individually supervised strength (Table 11a,b).
intervention did not favour either approach, except
for improved gait speed for the group intervention.
These results underline the possible benefits attribut- DISCUSSION
able to a home-based exercise programme. Similarly,
Van Baar et al.49,50 conducted two RCTs in which There is increasing evidence in the literature for the
strengthening exercises were reinforced by a home benefit of including a programme of increased physi-
programme consisting of an unsupervised exercise cal activity in the management of OA in older
programme including patient education and a adults.14,51,62,127 This evidence is clinically substanti-
brochure. Both studies had participants perform ated by studies that have demonstrated that regular,
strengthening, flexibility, and mobility/co-ordination moderate levels of exercise do not appear to exacer-
exercises, which were incorporated into a home pro- bate OA in the vast majority of patients.32,127 In agree-
gramme. Outcomes measured relative to a control ment with Dekker et al.128 and Van Baar et al.,14 the
group that continued with usual medications at the current systematic review of the existing literature
end of the 12-week intervention and at a 24-week fol- provides evidence of the benefit of strengthening exer-
low-up showed statistically significant improvement cises for improving pain, ROM, strength and func-
for pain (Fig. 3f), muscle strength at the hip (Fig. 3c), tional status in patients with OA. Evidence is not,
and improvement in self-reported disability (Fig. 3j). however, available to favour one type of strengthening
programme (i.e. isometric, isotonic or isokinetic).
Our review does provide moderate evidence of com-
Hand functional strengthening versus control ponents of a general exercise programme that may
have a determinant effect on measured outcomes in
The benefit of a home exercise programme was also OA. These include: (i) the combination of joint-spe-
demonstrated in patients with OA of the hand. Stamm cific strengthening with general strength, flexibility
et al.47 evaluated the effectiveness of combining grip and functional exercises, (ii) progression of the exer-
exercises to be done at home with an education session cise programme; and (iii) level of client self-reliance to
about joint anatomy and protection. Comparing results sustain the programme through a home-based pro-
to a control group that had participated in the same edu- gramme. Optimal parameters of repetition, duration
cation session but were then provided with a piece of and content remain to be defined through future
Dycem to open jars for the study period of 3 months, the research.
Prior to a discussion of results, methodological sured outcomes. This clarification could allow the
issues need to be addressed as they impinge directly optimisation of exercise interventions in terms of
on the interpretation of information. A constant bias time, cost, and overall benefit to the patient and,
to the validity of results is the absence of blinding of thereby, relieve the clinician from relying primarily on
the provider and patient. This is a consequence of the experience in recommending an exercise regimen to
nature of exercise therapy and, therefore, cannot be the patient with OA.13 Evidence could also be
eliminated. However, the lack of standardisation of strengthened in the short-term through care in bal-
exercise reporting and of measured outcomes is an ancing of interventions across experimental and con-
important methodological weakness that could be trol groups. For example, Callaghan et al.65 compared
resolved through research. Researchers also need to the relative effectiveness of a home-based versus facil-
exert scientific rigor in the design of RCTs and assur- ity-based exercise programme, an issue of high rele-
ing, at a minimum, that training and testing protocols vance in terms of health-care cost and patient
have internal validity. For example, in the study by compliance. Their results point to a potential equiva-
Rodgers et al.,43 while the exercise programme evalu- lency between the two programmes. However, the
ating knee OA was comprised of isometric, isotonic strength of this finding is challenged by the lack of
and closed-chain eccentric strengthening, outcome internal equivalency between the two programmes;
for strength improvements was measured on an open- the home exercise programme consisted of 10 repeti-
chain isokinetic task. Knowing the influence of training tions of 3 functional activities (sit-to-stand-to-sit,
specificity on measured strength outcomes,129 the incon- mini-squats, and step-downs) performed twice daily
gruence between the tasks used for training and the task while the supervised exercise routine consisted of iso-
used for testing in the study of Rodgers et al.43 may, in metric and isotonic inner range strengthening of the
part, explain the absence of significant results in this quadriceps. This reinforces the need for applying
study. Another key methodological point is the sensitiv- more rigour in methodological design as a means of
ity of standardised outcome measures that are used to increasing the strength of evidence.
evaluate effectiveness of exercise. D’Lima et al.68 Examining the evidence for potential mechanisms
pointed out this issue, stating that the Arthritis Impact by which exercise produces benefits to the patient
Measurement Scale (AIMS) may not be sensitive with OA, the control of pain emerges as a dominant
enough to measure changes in health status/QOL factor. By combining results from different studies, it
related to an exercise programme in patients with OA. becomes evident that improvements in pain outcomes
Research efforts need to be focused on developing and may not be related specifically to one type of
validating outcome measures that will be disease-spe- strengthening exercises but rather, there is evidence
cific and sensitive enough to adequately reflect poten- that a general increase in physical activity may be the
tial effects of strengthening across different dimensions key factor. For example, while Gur et al.37 reported
of functional status, health status and QOL. Bautch et significant decreases in pain following a supervised
al.32 explored the issue of outcome sensitivity at a fun- programme that combined concentric and eccentric
damental level through a preliminary evaluation of the exercises strengthening for clients with OA of the
concurrent validity of clinical outcome measures in knee, Fransen et al.36 described similar improvements
pain (i.e. visual analogue scale) and health status/QOL following a home programme. The positive effects of
(i.e. AIMS) to changes in biological markers from the exercise on pain are multifactorial in nature and are,
synovial fluid of the OA comprised knee joint of therefore, difficult to delineate clearly. However, it is
patients before and after a progressive walking pro- recognised that improvement in well-being and
gramme. This fundamental research clearly delineates QOL33 will indirectly affect pain, as will more direct
the vast areas of research that are still required in order influences such as enhanced joint protective mecha-
to improve our understanding of the underlying physio- nisms through strengthening.14,15,21 Fundamental
logical, mechanical and behavioural mechanisms by research in metabolism22 has further elucidated the
which exercise supplies benefits to the patient with OA. possibility of exercise having a positive effect on the
An important methodological issue that could be loss of protein, and associated increase in fat linked to
improved upon in the short term is a standardisation chronic inflammation of arthritis. Some evidence is
of exercise reporting. In many studies, the characteris- also provided in our meta-analysis to support the
tics of an exercise programme are not explicitly identi- added benefit of functional activities in the exercise
fied (see Kreindler et al.16 as an example). Without programme in potentiating the positive effects of
this information, the benefit of combining results exercise on pain.38,40,42,44 This advantage may be a by-
from different studies is lost. This is required to product of motor learning,130 which could improve
clearly elucidate the components of an exercise pro- the mechanical and energetic costs of completing a
gramme that exert the most potent influence on mea- functional task, in addition to improved strength.
104 PELLAND ET AL.
In this meta-analysis, a specific effect of the type of ACKNOWLEDGEMENTS

muscle contraction on long-term strength gains was
not identified. This is somewhat curious when one The authors are indebted to Chantal Lavoie, Maxim
considers the results of fundamental research that has Fafard, Judith Robitaille, Magali Scheubel and
shown a selective atrophy of type II (fast-oxidative) Chantelle Garritty for their technical support and
muscle fibres around painful and inflamed joints.7,131 their help in extraction of data. Special thanks are
Based on this knowledge, a clear benefit from isoki- due to Jessie McGowan (MLIS), Institute of
netic strength training16 which out-weighs strength Population Health (University of Ottawa) for her
gains achieved by isometric training would be consultation on the search strategy.
expected.48 The absence of statistical significance This systematic review was completed with the sup-
between different types of strength training may be port of a research grant obtained from the Arthritis
related, in part, to the lack of stratification for the Society (Canada), and two grants for salary support
severity of OA. Sharma1 addressed this issue, suggest- from the Ontario Ministry of Health and Long-Term
ing that the local mechanical environment of the joint Care (Health Research Personnel Development
should be accounted for in the statistical analysis of Program), University Research Chair (salary support
results. The effect of client-specific characteristics is for research personnel), University of Ottawa and the
well shown in the study by Rodgers et al.43 in which results Ministry of Human Resources (Summer Student
indicated the potential of an important interaction Placement Program), Government of Canada.
between the severity of joint damage produced by OA
and the effectiveness of the strengthening programme.
The identified effectiveness of home-based exercise
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LUCIE PELLAND, LUCIE BROSSEAU (for correspondence), LYNN MacLEAY, JUDITH LAMBERT, CATHERINE LAMOTHE,
School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, 451 Smyth Road,
Ottawa, Ontario K1H 8M5, Canada. Tel: +1 613 562 5800 ext.8015; Fax: +1 613 562 5428; E-mail: lbrossea@uottawa.ca
GEORGE WELLS, Department of Epidemiology and Community Medicine, University of Ottawa, Canada
VIVIAN ROBINSON and PETER TUGWELL, Centre for Global Health, Institute of Population Health,
University of Ottawa, Ottawa, Canada

Pelland 2004 - Efficacy of Strength Exercises For OA - Part I - A Meta-Analysis

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Pelland 2004 - Efficacy of Strength Exercises For OA - Part I - A Meta-Analysis

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Physical Therapy Reviews 2004; 9: 77–108

EFFICACY OF STRENGTHENING EXERCISES FOR

LUCIE PELLAND*, LUCIE BROSSEAU*, GEORGE WELLS†, LYNN MACLEAY*,

*School of Rehabilitation Sciences, †Department of Epidemiology and Community Medicine,

Keywords: Arthritis, efficacy, evidence-based practice, exercise therapy, meta-analysis,

© W. S. Maney & Son Ltd 2004 DOI 10.1179/108331904225005052

INTRODUCTION increased incidence and severity of OA further cor-

Keywords Text word

1. Exp osteoarthritis 4. Osteoarthritis

Combined algorithm Or/1–3 Or/4–14

15. Exp Exercise Therapy 17. Mobilizing exercise

Combined algorithm And/15–16 And/17–21

22. Clinical trial.pt 26. Random$

Combined algorithm Or/22–25 Or/26–29

Table 2. Details of included trials

Author BAUTCH et al.32

Author BÖRJESSON et al.33

Author DEYLE et al.34

Table 2. (Continued) Details of included trials

Author EVCIK and SONEL35

Author FRANSEN et al.36

Author GUR et al.37

Table 2. (Continued) Details of included trials

Author HURLEY and SCOTT24

Author KREINDLER et al.16

Author MESSIER et al.38

Table 2. (Continued) Details of included trials

Author O’REILLY et al.39

Author PENNINX et al.40

Table 2. (Continued) Details of included trials

Author REJESKI et al.42

Author RODGERS et al.43

Table 2. (Continued) Details of included trials

Author SASHIKA et al.45

Author SCHILKE et al.46

Table 2. (Continued) Details of included trials

Author STAMM et al.47

Author TOPP et al.48

Author VAN BAAR et al.49

Table 2. (Continued) Details of included trials

Quality: R, randomisation; B, blinding; W, withdrawals; N/A, not available.

RESULTS general physical activity programme that included other

Table 3. Excluded studies (n = 79) for therapeutic exercises

Study Reason for exclusion Study Reason for exclusion

AGS51 Not an RCT Langeland87 No control group

Table 4. Clinical relevance: concentric versus control

Study Treatment Outcome No. of Baseline End-of- Absolute Relative difference

Table 5. Clinical relevance: concentric-eccentric versus control

Study Treatment Outcome No. of Baseline End-of- Absolute Relative difference

Table 6. Clinical relevance: hip strengthening + eccentric versus control

Study Treatment Outcome No. of Baseline End-of- Absolute Relative difference

Table 7. Clinical relevance: lower extremity isometric strengthening versus control

Study Treatment Outcome No. of Baseline End-of- Absolute Relative difference

Topp et al.48 LE isometric Pain, getting up 32 5.39 2.89 –3 –61%

Intrinsic to this objective is an adequate management

Combination of concentric and eccentric hip

The effectiveness of strengthening exercises in the

Table 8. Clinical relevance: lower extremity strengthening versus control

Study Treatment Outcome No. of Baseline End-of- Absolute Relative difference

Topp et al.48 Exercise Pain (WOMAC) 35 12.40 10.71 –1.71 –15%

Schilke et al.46 Exercise OASI mobility 10 11.30 7.64 –3.24 4%

Fig. 3. General lower extremity exercises programme

Fig. 3. (d,e,f) See previous page for details.

LUCIE PELLAND, LUCIE BROSSEAU, GEORGE WELLS†, LYNN MACLEAY*,