Physical therapy for patients with knee and hip osteoarthritis:

supervised, active treatment is current best practice

S.T. Skou1,2, E.M. Roos1

1
Research Unit for Musculoskeletal ABSTRACT fect a person’s joint health (5, 6). This
Function and Physiotherapy, Department Most patients with knee and hip osteo- viewpoint highlights the key role of
of Sports Science and Clinical arthritis (OA) should be treated in pri- active, non-surgical treatments in the
Biomechanics, University of Southern
mary care by non-surgical treatments. management of OA.
Denmark, Odense, Denmark;
2
Department of Physiotherapy and Building on substantial evidence from In many, but not all, health care sys-
Occupational Therapy, Næstved-Slagelse- randomised trials, exercise therapy tems, exercise therapy is typically de-
Ringsted Hospitals, Region Zealand, and education, typically delivered by livered by physical therapists. In this
Slagelse, Denmark. physical therapists, are core first line article, we focus on knee and hip OA,
Søren T. Skou, PT, PhD treatments universally recommended in as evidence concerning treatment of
Ewa M. Roos, PT, PhD treatment guidelines for OA alongside OA in other peripheral joints remains
Please address correspondence weight loss, if needed. Exercise therapy limited. It is likely that the physical
and reprint requests to: provides at least as effective pain relief therapy treatment paradigm for OA in
Dr Søren Thorgaard Skou, as pharmacological pain medications, those joints will shift as new evidence
Research Unit for Musculoskeletal without serious adverse effects; fur- emerges. We use the phrase “knee and
Function and Physiotherapy,
Department of Sports Science
thermore, the treatment effect from ex- hip OA” throughout this manuscript to
and Clinical Biomechanics, ercise therapy is similar, irrespective of refer to patients suffering from OA of
University of Southern Denmark, baseline pain intensity and radiograph- the knee, of the hip, or of both the knee
55 Campusvej, ic OA severity. Exercise therapy should and hip.
DK-5230 Odense M, Denmark. be individualised to the preferences and
E-mail: [email protected] needs of the individual patient, but at Physical therapy as treatment
Received and accepted on September 6, least 12 supervised sessions, 2 sessions of knee and hip OA
2019. per week, are required initially to ob- Exercise, patient education and weight
Clin Exp Rheumatol 2019; 37 (Suppl. 120): tain sufficient clinical benefit. Struc- loss [at a Body Mass Index (BMI) of 25
S112-S117. tured patient education concerning OA or higher] comprise first-line treatment
© Copyright Clinical and and its treatment options, including recommended in treatment guidelines
Experimental Rheumatology 2019. self-management, is important to retain for knee and hip OA. If patient educa-
motivation and adherence to an exer- tion and exercise therapy are unsuc-
Key words: osteoarthritis, knee, hip, cise programme and thereby maintain cessful to improve pain and function,
physical therapy, exercise the effects over the long-term. If treat- the physical therapist may offer sup-
ment effects from exercise therapy and plementary treatments such as knee
patient education are insufficient, the orthoses and manual treatment (7-10).
physical therapist can deliver supple- Also, a supplementary pain-relieving
mentary interventions that include knee treatment such as acupuncture some-
orthoses and manual treatment. times is included initially as an addi-
tional alternative to oral pharmacologi-
Introduction cal pain relievers, to facilitate starting
Joint pain and functional disability are an exercise programme, although evi-
cardinal symptoms of knee and hip dence remains inconclusive concern-
osteoarthritis (OA) (1, 2). It is often ing its effectiveness (Fig. 1) (11, 12).
implied that these symptoms are due Weight loss is rarely offered by the
to structural damage, which must be physical therapist and therefore will
Funding: S.T. Skou is currently funded ‘fixed’ and not treated with non-sur- not be described in detail in this arti-
by a grant from the European Research gical approaches (3, 4). By contrast, cle. However, it should be noted that
Council (ERC) under the European
contemporary evidence demonstrates even modest weight loss of 5% appears
Union’s Horizon 2020 research and
innovation programme (grant agreement that OA is a ‘whole person condition’ in to have a significant impact on symp-
no. 801790). The funders did not have any which different biopsychosocial factors toms (13); therefore, weight loss is an
role in this study other than to provide that modulate inflammatory processes important part of the treatment plan
funding. as well as behavioural responses which for overweight, and especially obese
Competing interests: see page 115. trigger pain and disability interact to af- patients.

S-112 Clinical and Experimental Rheumatology 2019

 Physical therapy for osteoarthritis / S.T. Skou & E.M. Roos

them from participating in an exercise

therapy programme may benefit from
supplementary pharmacological pain
relievers, in consultation with their
general practitioner (30, 31). Once the
patient’s symptoms decrease as a re-
sult of the exercise therapy, the patient
may stop or reduce the intake of phar-
macological pain relievers. According
to recent guidelines, topical NSAIDs
Fig. 1. The universally recommended treatment approach to hip and knee osteoarthritis. The sizes of are preferred over oral pharmacologi-
the blue ovals indicate that fewer patients would need supplementary treatment and even fewer would cal pain relievers in most patients due
need further referral.
to a better safety profile, and acetami-
nophen (paracetamol) is not recom-
First-line treatment • Exercise therapy as a painkiller mended due to the absence of clinical
Exercise therapy in OA irrespective of radiographic effects compared to placebo (25).
Exercise therapy is the most important severity It is good to inform patients that pain
non-surgical treatment of knee and hip The effects of exercise therapy and flares are to be expected with frequent
OA, not only because of the positive physical therapy in general are not as- daily activities such as repeated chair
effect on joint symptoms (14-16), but sociated with radiographic severity of stands (32) and when starting to exer-
also because evidence highlights that knee OA (21, 22) or the degree of pain cise (33). This is not a sign of danger
exercise and physical activity help pre- (21) that the patients experienced before to the cartilage (34, 35), but rather a
vent at least 35 chronic conditions (17) the treatment. The modern diagnosis of sign of exposing the body to a new or
and improve symptoms in at least 26 OA is based on clinical findings with- repeated activity and similar to what
chronic conditions (18). Up to two out out necessarily including radiographic all people (even who do not have any
of three patients with knee and hip OA evidence (2), and the x-ray findings arthritis) would experience when start-
have one or more comorbidities, in- generally do not change the initial clini- ing any new activities. In patients with
cluding hypertension, type 2 diabetes cal management of the patient (23). In knee and hip OA who start exercis-
and depression (19), and therefore ex- patients with moderate to severe knee ing twice weekly, pain flares decrease
ercise and physical activity are crucial or hip OA awaiting total joint replace- with number of exercise sessions and
for maintaining good general health ment, 95% of one-hour twice weekly are gone for most patients after about
and well-being in patients with OA weight-bearing exercise sessions were 5–6 weeks (33). Remarkably, also in
(16). performed with no more than accept- patients with severe knee and hip OA
Over the last 25 years, more than 54 able pain (36). Therefore, the clinician awaiting total joint replacement, 95%
randomised controlled trials evaluating plays an important role in explaining of pre-operative exercise sessions can
the effect of exercise therapy in knee to the patient that OA severity has no be performed with acceptable pain, i.e.
OA patients (14) and more than 12 tri- clinical impact on the potential effect temporary increase of pain intensity to
als evaluating the effect of exercise he or she may expect from the exercise no more than 5 on a 0–10 scale (36).
therapy in hip OA patients (15) have programme.
been reported. The conclusion is un- Strikingly, exercise therapy appears • Individualisation and exercise
questionable: pain and physical func- more effective and safer for relief of dose are important to increase
tion are improved significantly follow- pain than the traditional pharmacologi- the clinical effects
ing a supervised exercise intervention cal pain relievers offered today. On a Unfortunately, existing studies have
in patients with knee and hip OA (14, group level, exercise therapy has at applied a number of different exer-
15). Based on existing evidence, exer- least the same pain-relieving effect as cise programmes that are not detailed
cise therapy appears to have a larger NSAIDs and 2–3 times as large effect enough to be incorporated into clini-
effect on both pain (effect size of 0.49 as acetaminophen in patients with knee cal practice (37). If the exercise pro-
vs. 0.38) and function (effect size of OA (21, 24, 25). At the same time, ex- grammes for knee OA are grouped into
0.52 vs. 0.38) in knee OA patients com- ercise therapy is associated with only three subgroups, aerobic, resistance,
pared with hip OA patients. Although mild side effects such as muscle sore- and performance exercise, effects are
the treatment effect is slightly smaller ness and temporary pain flares(26), similar for these three subgroups (21).
(20), water-based exercise may offer a whereas pharmacological pain reliev- This does not mean that the all patients
viable alternative, if the patient is un- ers may be associated with a consider- should be offered the same exercise
able to perform land-based exercises, able risk of side effects including on the programme. On the contrary, individu-
due to, for example, intolerable symp- stomach, liver and cardiovascular sys- alisation might further increase treat-
toms from loading the joint and/or se- tem (27-29). ment effects, as an increasing number
vere obesity. Patients with severe pain that prevents of studies have shown that effects of

Clinical and Experimental Rheumatology 2019 S-113

Physical therapy for osteoarthritis / S.T. Skou & E.M. Roos

exercise may vary considerably based

on individual patient characteristics
(38-40). For instance, it appears that
patients with varus thrust may benefit
more from a neuromuscular exercise
programme, whereas patients with a
BMI of 30 or more may benefit more
from quadriceps strengthening (38)
(Figure 2 presents examples of neuro-
muscular exercises).
Fig. 2. Examples of neuromuscular exercises for patients with knee and hip osteoarthritis (Photo: Jørn
Supervision and exercise dose are es- Ungstrup; GLA:D®).
sential elements and may have a large
impact on the effect of exercise thera- Table I. Eight exercise recommendations for knee and hip OA.
py. An element sometimes forgotten is
a need for progression of the exercise Number Recommendation
programme. When patients respond 1 Offer the patient supervised, progressive aerobic, resistance or performance exercise
to exercise and improve their muscle tailored to the patient’s needs, preferences and characteristics.
strength and function, the exercises
2 Consider water-based exercises if the patient is unable to perform land-based exercises,
should be made more difficult to ensure especially during the initial part of the programme.
further gains in muscle function. That is
5 After an adjustment period, and if symptoms allow it, consider three weekly sessions to
one reason why supervision is needed, increase the effect.
as individual adjustments will maxim-
6 Offer patient education to improve compliance and long-term effects.
ise benefits of the programme. Another
reason is to coach and reassure the pa- 7 Consider follow-up sessions after the programme to improve compliance and long-term
tient if pain flares are experienced. Pain effects.
during exercise and exercise-induced 8 Consider supplementary treatment such as knee orthoses and manual treatment if the
pain flares are common, especially in intervention shows no effect.
the early phase of a programme (33),
and an individualised and progressive should be applied as summarised in Two recent parallel randomised con-
exercise plan is essential to optimise re- Table I. Some countries already have trolled trials investigated the effect of a
sults (41). Furthermore, patient prefer- evidence-based national individual- tailored 12-week treatment plan consist-
ences is important to consider to ensure ised knee and hip OA programmes ing of neuromuscular exercise, patient
long-term motivation and adherence consisting of education and exercise education, weight loss, pharmacological
(16). supervised by certified physical thera- pain relievers (if indicated), and insoles
It is not yet possible to present any pists, e.g. GLA:D® which is available for knee OA patients (31, 49). One study
strong specific exercise dose recom- in Denmark, Canada, Australia, China found that on a group level, the tailored
mendations. However, it appears that and Switzerland (44, 45). For more treatment plan was more effective in im-
a minimum of 12 supervised sessions information and results, please visit proving pain and function than leaflets
is more effective compared to fewer glaid.dk; gladcanada.ca; gladaustralia. with information and treatment advice
than 12 sessions among knee OA pa- com.au and gladswitzerland.ch. (49). The other study investigated the
tients(21). Also, studies on knee OA effectiveness of total knee replacement
that follow the recommendations from • The combined effect of exercise followed by the tailed treatment plan
the American College of Sports Medi- therapy and other treatment compared with the tailored treatment
cine (ACSM) regarding strength train- modalities plan alone. On a group level, the total
ing (41) provide superior outcomes Exercise therapy combined with pa- knee replacement group had improve-
compared to exercise interventions that tient education appears more effec- ment in pain and function that was
do not follow these recommendations tive than exercise therapy or patient twice as large as the tailored treatment
(42). In hip OA, the same importance education alone in patients with knee plan only group. However, the tailored
has not been established for number of OA (46), and combined treatment is treatment plan group also experienced
supervised sessions; however, pain and also recommended for hip OA patients clinically relevant improvements in pain
physical function appear to improve based on the existing evidence (25, 47). and function, allowing for 3 out of 4 to
more if the exercise intervention fol- A combined treatment plan consisting postpone surgery for one year (31), and
lows the ACSM criteria for strength of exercise and weight loss also is more 2 out of 3 at two years (50). Contrary
training (43). effective in improving pain and physi- to the total knee replacement group, pa-
More research is needed to develop an cal function in overweight knee OA pa- tients following the tailored treatment
optimal, individualised exercise proto- tients than either exercise and weight plan had no knee-related serious ad-
col. Until then, the existing evidence loss alone (48). verse events (31).

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 Physical therapy for osteoarthritis / S.T. Skou & E.M. Roos

A study performed in hip OA patients treatments are described in more de- effect of acupuncture compared with
found that the combination of exercise tail below. In agreement with clinical placebo acupuncture on knee OA symp-
therapy and patient education could guidelines, supplementary treatments toms (12), while the additional effects
reduce total hip replacement by 44% should never be offered as a stand- from acupuncture beyond exercise are
as compared to those patients who re- alone treatments, but always combined questionable (12). There remains insuf-
ceived patient education alone (51). with exercise therapy, patient education ficient evidence to conclude whether or
Based on the presented evidence, exer- and weight loss (if relevant). not acupuncture is an effective treat-
cise combined with other non-surgical Manual treatment in the form of joint ment for OA.
treatments is effective and can postpone mobilisation and manipulation appears Other passive treatment approaches
surgery for a large number of OA pa- to provide moderate benefit for pain such as massage, neuromuscular elec-
tients. If a patient ultimately decides to and function in knee OA patients (7), trical stimulation, transcutaneous
request a total knee or hip replacement, and can be considered in the treatment electrical nerve stimulation (TENS),
having participated in a preceding exer- of hip OA based on previous studies ultrasound and laser cannot be recom-
cise programme will help lead to faster (8, 9). However, the quality of existing mended as part of the treatment plan,
postoperative recovery (52). studies on knee and hip OA is poor, and based on the absence of high-quality
the added effect of manual treatment in supportive evidence (25, 47, 57).
Patient education addition to exercise therapy is uncertain
The effect measured immediately af- (56, 57), Therefore, firm conclusions Acknowledgement
ter a supervised exercise programme concerning this type of treatment re- The authors would like to thank Mette
is favorable, but diminishes over time main a subject for further clinical re- Dideriksen, MSc, for her support pre-
(14, 15), most likely explained by low search. paring the manuscript.
adherence to the exercise regime and Unloader braces for knee OA that shift
lifestyle changes (16, 53). Patient edu- load from the medial compartment ap- Competing interests
cation alone may have only a small pear to result in small-to-moderate E.M. Roos is deputy editor of Osteoarthri-
effect on pain and function (25); how- improvements in pain and function tis and Cartilage, the developer of the Knee
ever, patient education that is combined in patients with medial knee OA (10). injury and Osteoarthritis Outcome Score
with follow-up sessions after the com- However, the effect size was small (KOOS) and several other freely available
pletion of the programme (54), may compared to a control group that used patient-reported outcome measures, and co-
be key to increasing self-efficacy and a neutral knee brace, neoprene knee founder of Good Life with Osteoarthritis in
Denmark (GLA:D®), a not-for profit initia-
retaining motivation and adherence to sleeve, or shoe insert (10). Importantly,
tive hosted at University of Southern Den-
an exercise programme and thus main- compliance ranged from 45% to 100%,
mark aimed at implementing clinical guide-
taining benefit in OA patients (16, 55). and up to 25% of patients reported lines for osteoarthritis in clinical practice.
Patient education should include infor- complications with brace use, includ- S.T. Skou is associate editor of the Journal
mation about causes, risk factors and ing poor fit, swelling and skin irrita- of Orthopaedic & Sports Physical Therapy,
disease mechanisms, the importance tion (10), highlighting the importance has received grants from The Lundbeck
of physical activity and consequences of individual adaptation of the fit of the Foundation, personal fees from Munks-
of inactivity, effective and ineffective brace if needed and supervision of us- gaard, all of which are outside the submit-
treatments and coping strategies and a age, in order to optimise the potential ted work. He is co-founder of GLA:D®.
self-help guide to help patients success- for clinical effects. The authors affirm that they have no finan-
fully manage their disease (16). This Another study has investigated the effi- cial affiliation (including research funding)
information will support the patient in cacy of lateral wedge insoles as a treat- or involvement with any commercial or-
understanding how to manage pain and ment for pain in medial knee OA and ganisation that has a direct financial interest
exercise-induced pain flares and moti- found no significant effect compared in any matter included in this manuscript,
except as disclosed in an attachment and
vate him or her to life-long exercise and with a neutral insole (58), probably be-
cited in the manuscript.
physical activity. cause custom orthotic insoles require
individual adjustments or are helpful
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