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Best Practice & Research Clinical Rheumatology 28 (2014) 93–117

Contents lists available at ScienceDirect

Best Practice & Research Clinical


Rheumatology
journal homepage: www.elsevierhealth.com/berh

Exercise in osteoarthritis: Moving from


prescription to adherence
Kim L. Bennell 1, Fiona Dobson*, Rana S. Hinman 1
Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, University of Melbourne,
Melbourne, VIC, Australia

a b s t r a c t
Keywords:
Exercise Exercise is recommended for the management of osteoarthritis
Osteoarthritis (OA) in all clinical guidelines irrespective of disease severity, pain
Adherence levels, and functional status. For knee OA, evidence supports the
Strengthening
benefits of various types of exercise for improving pain and func-
tion in the short term. However, there is much less research
investigating the effects of exercise in patients with OA at other
joints such as the hip and hand. It is important to note that while
the magnitude of exercise benefits may be considered small to
moderate, these effects are comparable to reported estimates for
simple analgesics and oral nonsteroidal anti-inflammatory drugs
for OA pain but exercise has much fewer side effects. Exercise
prescription should be individualized based on assessment find-
ings and be patient centered involving shared decision making
between the patient and clinician. Given that patient adherence to
exercise declines over time, appropriate attention should be pain
as reduced adherence attenuates the benefits of exercise. Given
this, barriers and facilitators to exercise should be identified and
strategies to maximize long-term adherence to exercise
implemented.
Ó 2014 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: þ61 3 83444171.


E-mail addresses: k.bennell@unimelb.edu.au (K.L. Bennell), fdobson@unimelb.edu.au (F. Dobson), ranash@unimelb.edu.au
(R.S. Hinman).
1
Tel.: þ61 3 83444171.

http://dx.doi.org/10.1016/j.berh.2014.01.009
1521-6942/Ó 2014 Elsevier Ltd. All rights reserved.
94 K.L. Bennell et al. / Best Practice & Research Clinical Rheumatology 28 (2014) 93–117

Introduction

Osteoarthritis (OA) is a chronic joint disease commonly affecting the joints of the knee, hip, and
hand. People with OA report pain, difficulty performing activities of daily living, sleep problems, and
fatigue. They present with a range of physical impairments including joint stiffness, muscle weakness,
altered proprioception, reduced balance, and gait abnormalities. In addition to these, psychological
impairments such as depression and anxiety are common.
Exercise is an integral component of conservative management for OA and is universally recom-
mended by clinical guidelines [1–5], irrespective of patient age, joint involved, radiographic disease
severity, pain intensity, functional levels, and comorbidities. Exercise prescription should be individ-
ualized based on assessment findings and be patient centered involving shared decision making be-
tween the patient and clinician. This chapter reviews the role of exercise in the management of OA. OA
in general is covered, but knee OA is a primary focus given that this is the most common lower limb
joint affected and that the majority of OA exercise research involves the knee joint.
The first section of the chapter highlights the evidence supporting the effectiveness of exercise in
managing symptoms of OA. Following this, practical recommendations are made regarding specific
exercise prescription in terms of type, dosage, and delivery methods as well as ways to assess and
monitor the outcomes of exercise in individual patients. The subsequent sections cover issues related
to implementation of exercise by clinicians and patients. While there is evidence to support the use of
exercise, clinicians are not routinely recommending exercise to patients and potential reasons for this
are explored. Given that patient adherence to exercise declines over time, appropriate attention
should be pain as reduced adherence attenuates the benefits of exercise. Facilitators and barriers to
exercise adherence are discussed and practical strategies to improve patient adherence to exercise are
provided.

Is exercise effective in reducing symptoms of OA?

While considerable research has investigated the effects of exercise for knee OA, 2002 While
considerable research has investigated the effects of exercise for knee OA, there is much less research at
other joints such as the hip and hand. For knee OA, systematic reviews and meta-analyses consistently
support the benefit of exercise for improving pain and physical function in the short term [6–8]. One
recent review incorporating trial sequential analysis and network meta-analysis located 60 trials for
lower limb OA (44 knee, two hip, and 14 mixed) covering 12 different types of exercise interventions
[6]. Results showed that as of 2002, sufficient evidence was available to confirm the significant benefit
of exercise interventions over no exercise control for a range of exercise types. The benefits of exercise
also extend to patients with severe disease with another systematic review showing that exercise
reduced pain and improved activity in those awaiting total joint replacement [9]. However, while
effective in the short term, the benefits of exercise decline over the longer term [10]. Reasons for this
and strategies to improve long-term effects of exercise are discussed in subsequent sections.
There has been much less research investigating the effects of exercise specifically in patients with
hip OA. A 2009 Cochrane review of land-based exercise for hip OA demonstrated a small treatment
benefit for pain but no significant effect for self-reported physical function [11]. Conversely, the results
of a 2008 meta-analysis were more favorable, suggesting that exercise was beneficial for pain relief in
hip OA [12]. Since then, there have been four additional high-quality exercise randomized controlled
trials (RCTs) that provide hip OA specific data [13–16]. In general, these studies found nonsignificant
mean improvements in pain with various types of exercise. In contrast to pain, exercise appeared to
have greater effects on physical function. Therefore, evidence to date suggests that exercise in people
with hip OA has only modest benefits that appear greater for function than pain.
While clinical guidelines recommend exercise for hand OA, this is based largely on expert
consensus. Indeed, the clinical trial evidence is less convincing with conflicting results from a limited
number of trials, most with small sample sizes [17]. In the recently published largest RCT of exercise for
hand OA to date (n ¼ 257), hand exercises were not effective for improving outcomes at 6 months [18].
The program included stretching and strengthening hand and thumb exercises performed daily.
Further research in this OA patient population is clearly needed.
K.L. Bennell et al. / Best Practice & Research Clinical Rheumatology 28 (2014) 93–117 95

What type of exercise should be recommended?

Many types of exercise have been described in the literature for people with OA, Many types of
exercise have been described in the literature for people with OA, including muscle strengthening/
resistance training, stretching/range of motion, cardiovascular/aerobic conditioning (such as cycling
and walking), neuromuscular exercise, balance training, and Tai Chi. Few studies have directly
compared the effects of different types of exercise but systematic reviews suggest clinical benefits from
a range of exercise types [6,19] (Fig. 1). Importantly, although the magnitude of treatment benefits of
exercise may be considered small to moderate, these effect sizes are comparable to reported estimates
for simple analgesics and oral nonsteroidal anti-inflammatory drugs for OA pain [20] (Fig. 1). Impor-
tantly, however, exercise of all types is associated with relatively few side effects compared to con-
servative drug treatments.
Recent clinical guidelines for managing OA published by the American College of Rheumatology in
2012 [2] strongly recommend that people with knee and hip OA participate in cardiovascular and/or
resistance land-based exercise, as well as aquatic exercise. Results of a recent systematic review
support a combined intervention of strengthening, flexibility, and aerobic exercise for improving
limitation in function [6]. For hand OA, both strengthening and range of motion exercises are rec-
ommended [5].
While strengthening exercise is recommended, there is no evidence to suggest that the specific type
of strengthening exercise significantly influences outcome. Similar benefits have been found with
isotonic (through range), isometric (without movement), and isokinetic (performed on specific ma-
chines) strengthening exercise [8] as well as with strengthening exercise performed in weight-bearing
or non-weight-bearing positions [21,22]. In addition, strengthening programs for knee OA have either
focused on the quadriceps muscle or included strengthening of other lower limb muscles in addition to
the quadriceps. A 2008 systematic review revealed small effect sizes for quadriceps strengthening for
both pain and physical function. By contrast, moderate effect sizes were found for muscle strength-
ening that included several lower limb muscles [7]. While the effect sizes were not statistically
different, the trend suggests that it is preferable to use a program that strengthens major lower limb
muscles. Examples of strengthening exercises for knee/hip OA that can be performed at home with
minimal equipment are shown in the Appendix.
Aerobic exercise, such as walking or cycling, is a popular choice for the management of lower limb
OA, although this has not been specifically investigated in people with hip OA. While aerobic exercise is
beneficial for improving pain and physical function, aerobic exercise also has several other potential
benefits. Combined with dietary restriction, aerobic exercise can assist in weight loss in patients who
are overweight/obese and in maintaining weight loss or preventing weight gain. Aerobic exercise has
also been shown in other populations to have positive effects on psychological impairments such as
depressive symptoms [23], which are common in people with OA.

Fig. 1. Effect sizes of different types of exercise (black bars) for pain compared with those for common drug therapies (white bars) in
knee osteoarthritis (Data from Zhang et al., 2010) [20].
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Stretching/flexibility exercise constitutes a logical exercise strategy to maintain or increase joint


range of motion given that reduced joint range is common in OA with a contracture of periarticular soft
tissue and reduced extensibility of nearby muscles, likely contributors to the loss of range observed.
These exercises generally form part of an overall exercise program for OA.
There are no clinical recommendations as yet regarding specific balance exercises (either alone or in
combination with strengthening exercises) for people with OA, due to the limited evidence available
[24]. However, given that people with lower limb OA have impaired balance placing them at increased
risk of falling [25], clinicians should assess balance and prescribe specific balance exercises if appro-
priate. These can include balancing on one leg and increasing the difficulty by closing the eyes, standing
on foam, or adding reaching/arm movement. Attention to safety while performing such exercises is
important.
Participation in Tai Chi programs is conditionally recommended for people with knee OA according
to the latest American College of Rheumatology guidelines [2]. Tai Chi is a style of gentle, low-impact
exercise that involves slow, controlled movements. Although Tai Chi is gaining popularity among
people with OA, there are few well-designed clinical trials of Tai Chi [26], with these suggesting po-
tential symptomatic benefits for knee OA. Tai Chi has also been shown to enhance cardiovascular
fitness, muscular strength, and balance as well as reduce stress and anxiety [27].
Aquatic exercise appears to have smaller effects on pain compared to land-based exercise in people
with hip and/or knee OA [20,28]; however, far fewer aquatic exercise RCTs have been conducted which
may partially explain this finding. Aquatic exercise is an option for patients and may be particularly
useful in those who are overweight/obese or who have severe joint-related symptoms. The buoyancy
and warmth of the water can assist in improving the range of motion and pain with reduced loading to
joints. Aquatic exercise can also improve aerobic capacity, if the exercise specifically targets the aerobic
system with patients working at 50% or greater of their heart rate reserve.
More recently, neuromuscular exercise has been described for people with lower limb OA.
Neuromuscular exercise covers a broad class of exercise programs that are typically performed in
functional weight-bearing positions and emphasize quality and efficiency of movement, as well as
alignment of the trunk and lower limb joints [29]. Studies have shown that neuromuscular exercise can
improve pain and function in people with knee OA, even those with more advanced disease [29–31].
However, the addition of such exercise to a general strengthening program does not confer additional
benefits [32,33].
Increasing overall physical activity levels in addition to structured exercise is also important. People
with OA are not meeting public health physical activity guideline recommendations [34]. Furthermore,
physical activity levels predict functional performance levels in people with knee OA [35]. Thus, pa-
tients should be encouraged to increase general physical activity levels during everyday life. The use of
a pedometer or accelerometer can facilitate this by providing additional motivation. Pedometers/ac-
celerometers can be simple and relatively inexpensive devices worn at the waist, leg, or arm. Pe-
dometers assess the number of steps taken while accelerometers assess the amount of overall
movement. They can be useful in providing patients with feedback as to the amount of daily physical
activity performed and in setting goals to increase activity levels.

How should exercise be delivered?

Global economic austerity along with rising health-care costs necessitates the delivery of exercise in
efficacious but cost-effective ways. Exercise can be broadly categorized into three different delivery
modes including individual (one-on-one) treatments, class-based (group) programs, and home-based
programs. Other common mixed-mode alternatives include combining individual treatment sessions
with home-based exercise and augmenting home exercise with either a class-based program or su-
pervised home visits by a trained health-care professional.
A comprehensive meta-analysis [7] showed that individual, class-based, and home-based programs
all achieved beneficial treatment effects in terms of reduced self-reported pain and improved self-
reported physical function. Treatment effects for pain and function were greatest for individual pro-
grams, (standardized mean differences >0.50), whereas they were smaller for class-based programs
(standardized mean differences <0.40) and even smaller still for home-based programs (standardized
K.L. Bennell et al. / Best Practice & Research Clinical Rheumatology 28 (2014) 93–117 97

Box 1: Recommendations about the type of exercise.

 Similar reductions in pain and improvements in function can be gained with various types of
exercise.
 For lower limb OA, an exercise program to improve muscle strength, aerobic capacity, and
flexibility is recommended.
 For hand OA, a program involving both strengthening and range of motion exercise is advised.
 Strengthening exercise for knee and hip OA should include major lower limb muscles such as
the quadriceps, hip abductors and extensors, hamstrings, and gastrocnemius.
 In addition to benefits for pain and function, aerobic exercises such as walking can assist in
weight loss/prevention of weight gain and in improving mood and anxiety.
 Aquatic exercises may be beneficial for those who are overweight/obese or those with more
severe disease.
 Tai Chi may be a useful exercise option for some patients with lower limb OA.
 Balance exercises should be included if assessment reveals balance impairments or if the
patient has a history of falls.
 Increasing overall general physical activity levels during everyday life is important in addition
to structured exercise.

mean differences <0.30) (Fig. 2). However, as mean differences between the delivery modes were not
statistically significant and some treatment programs also incorporated mixed methods of delivery
modes [36–38], clear superiority of one mode over the other is not evident and needs to be informed by
additional factors, such as cost and the patient’s clinical presentation and preferences. These factors are
further explored below.
Far fewer studies on different exercise delivery modes for people with hip OA have been evaluated
[13–15,39]. While most of these studies incorporated mixed modes of delivery, using individual
treatments combined with either home-based exercise [14,15] or a gym-based program [13], one study
evaluated a class-based program specifically designed for hip OA [39]. Although nonsignificant small
treatment effects were reported for both pain and function in this class-based program, the small
sample size and relatively few treatment sessions (eight sessions in total) may have contributed to
these findings.
Even less evidence is available concerning the effects of different exercise delivery modes for hand
OA. In a recent RCT, where exercise was delivered using a class-based program supplemented by a daily

Fig. 2. Mean effect size for different modes of exercise delivery including individual treatments (black bars), class-based programs
(light gray bars), and home based programs (dark gray bars) on self-reported pain and function. (Data from Fransen et al. 2008 [7]).
98 K.L. Bennell et al. / Best Practice & Research Clinical Rheumatology 28 (2014) 93–117

home program, hand exercises that aimed to improve grip strength and dexterity were not effective for
improving pain and function [18]. Further evaluation of exercise delivery, including individualized
treatments that are patient-centered and targeted to specific impairments, is required.
In clinical practice, patients are usually prescribed a home exercise program even when attending
supervised individual or class-based exercise sessions on a regular basis. Home-based programs can be
either supervised or unsupervised by a health professional with expertise in exercise prescription.
Given that the clinical presentation of patients with OA is varied regarding pain severity, joints affected,
functional ability, and comorbidities, outcomes following exercise treatment are most likely optimized
to meet individual goals, needs, and interests of the patient when they are initially supervised by an
appropriately qualified health professional with expertise in exercise prescription (such as a physio-
therapist) [40].
Although adverse events have not been consistently studied in exercise programs, the risk of
adverse events for group and home programs is considered low once individuals have been appro-
priately assessed for the suitability of the exercises by a trained health professional [3]. Research shows
that supervision, particularly in the initial stages of a class-based or home-based exercise program, can
promote safe and correct exercise technique and ensure the dosage of the exercise is appropriate for
the patient’s physical ability and overall goals of the program. Results from one study [41] showed that
augmentation of a home program with an 8-week physiotherapist-supervised class exercise program
led to greater improvements in pain and walking function at 12 months follow-up, demonstrating that
the short-term addition of exercise classes in the short-term results in significant symptomatic benefits
in the longer term.
While class-based and home-based programs appear to have somewhat smaller treatment effects
than individual programs [7], these types of programs do have the potential to be more cost-effective.
The amount of supervision provided for these programs further impacts on the overall costs. Though
supervision from a health professional incurs more initial direct costs, such supervised programs have
been shown to be cost-effective when compared to unsupervised programs. Economic analyses
demonstrated that additional cost associated with a supervised classed-based exercise to supplement a
home-based program was offset by reduced use of other services in the health-care system [42]. As
such, supervised exercise class supplementation is a relatively cost-effective approach to maximize the
relatively smaller benefits of home exercise programs.
Conversely, evidence shows that taking a “minimalist” approach to exercise intervention is inef-
fective in patients with hip and knee OA [43]. A recipe-based, general-purpose approach to exercises
prescription will be less likely to achieve meaningful benefits as there is less capacity to vary and
progress the content and optimize the dosage of the exercise program as well as an increased likeli-
hood that patients will be less compliant. It is also quite possible that many patients will perform the
exercises incorrectly, further reducing their effectiveness.
As conclusive superiority of one delivery mode over the other remains unclear, the choice between
individual, class-based, or home-based programs should ultimately be informed by patient preference,
with this information forming part of the decision-making process [44]. Furthermore, alternate forms
of delivery modes need to be explored for people with limited access to services, such as those living in
rural and remote areas. Exercises delivered by a health practitioner using the Internet, via video chat
programs like Skype, may offer a more time-efficient and convenient method of exercise delivery and
are currently being explored as an alternative choice of treatment delivery for the future.

What exercise dosage should be prescribed?

Exercise programs can differ greatly in terms of their dosage. Exercise dosage encompasses the total
number of sessions within a program, the frequency (number of sessions per week), duration (time
length of session) or volume (the amount such as number of repetitions/sets), and the intensity
(amount of muscular effort or exertion, typically expressed as a percentage of the individual’s maximal
capacity), all which may affect the outcome [45]. From a clinical perspective, the optimal dosage of
exercise for people with OA is unclear as very few studies have directly compared different factors of
exercise dosage which varies markedly between studies. Furthermore, appropriate indirect compari-
sons are hampered by insufficient detail of exercise dosage between studies.
K.L. Bennell et al. / Best Practice & Research Clinical Rheumatology 28 (2014) 93–117 99

Box 2: Recommendations about the mode of exercise delivery.

 Treatment benefits in terms of reduced pain and improved function can be gained from in-
dividual, class-based, and home-based programs.
 Although individual treatments show the greatest treatment benefits for pain and function,
superiority of one delivery mode over the other remains unclear.
 Group exercise and home exercise are similarly effective and patient preference should be
considered in the decision-making process of preferred delivery mode.
 For lower limb OA, supervised exercise programs that are at least initially supervised by an
appropriately qualified health professional with expertise in exercise prescription (such as a
physiotherapist) are recommended.
 Home-based programs should be supplemented with supervised programs (class or indi-
vidual) to maximize the cost-effective benefits.
 Alternate forms of exercise delivery modes, such as using the Internet, require further
research.
 For hand OA, further research on the delivery mode, including individualized and patient-
centered treatment approaches is required.

The number of sessions provided in exercise programs in the clinic or as home visits for people with
lower limb OA was evaluated in a meta-analysis [7] where studies were divided into those having
either 12 or more or less than 12 occasions of directly supervised exercise sessions. Significant treat-
ment benefits for self-reported pain and physical function were found for both situations; however, the
amount of direct supervision influenced the amount of benefit. Studies evaluating programs providing
<12 directly supervised sessions showed small mean effect sizes for pain and physical function,
whereas those evaluating programs providing at least 12 directly supervised occasions showed
moderate mean effects sizes (Fig. 3). Furthermore, the mean difference between the two categories was
significant for both pain and physical function.
Specific guidelines for flexibility, strengthening, and aerobic exercise in people with OA, derived
from evidence in existing literature and by consensus among a panel of multidisciplinary experts have
been advised by the American Geriatrics Society [45] (Table 1). Other guidelines for physical activity in
older adults provided by the World Health Organization [46] recommend that 150 min of moderate-
intensity aerobic activity should be performed each week, with additional health benefits when
increased up to 300 min per week. People with chronic conditions such as OA are recommended to be

Fig. 3. The treatment effects of exercise on pain and function when divided in to 12 or more (black bars) or less than 12 (gray bars)
supervised sessions. (Data from Fransen et al. 2008 [7]).
100 K.L. Bennell et al. / Best Practice & Research Clinical Rheumatology 28 (2014) 93–117

Table 1
General guidelines for training parameters in people with OA, as developed by the American Geriatrics Society [45].

Exercise type Intensity Volume Frequency


Flexibility:
Static stretching Stretch to subjective sensation 1 stretch/muscle group; Once daily
initially of resistance hold 5–15 s
Flexibility:
Longer term goal Stretch to full range of motion 3–5 stretches/muscle group; 3–5/week
hold 20–30 s
Strengthening:
Isometric Low–moderate: 40–60% MVC 1–10 submax contractions/ Daily
muscle group; hold 1–6 s
Strengthening:
Isotonic Low: 40% 1 RM 10–15 reps 2–3/week
Mod: 40–60% 1 RM 8–10 reps
High: >60% 1 RM 6–8 reps
Endurance:
Aerobic Low–Mod: 40–60% of VO2 max/HRmax Accumulation of 2–5/week
RPE: 12–14 ¼ 60–65% VO2 max 20–30 min/day

1 RM ¼ one repetition maximum; MVC ¼ maximal voluntary contraction; RPE ¼ rating of perceived exertion; HRmax ¼ age-
predicted heart rate maximum; VO2 max ¼ maximal aerobic capacity.

as physically active as their ability and condition allows. The accumulation of a greater volume of
weekly exercise is desirable when obesity is an issue [47].
Although greater strength gains in people with OA might be expected with higher-intensity training
programs, in terms of higher loads/resistance and more repetitions and sets, there have been concerns
that these programs could potentially overload the joint [48] and exacerbate symptoms such as pain,
swelling, and inflammation [49,50]. While evidence is scant, one study that directly compared high-
and low-intensity strengthening programs found that both were similarly beneficial for self-reported
pain and function in people with knee OA [51]. Even though adverse events were reported to be no
more likely for the high-intensity group, three participants from this group discontinued the exercise
intervention due to severe knee pain, whereas all participants were able to complete the low-intensity
program. Further, direct comparisons of exercise intensity are required before strong recommenda-
tions about intensity can be made.
Although experiences of pain when exercising may assist decisions about exercise dosage, patients
should be advised that it is normal to feel some discomfort or pain during exercise and that this does
not necessarily indicate that it is damaging the joint. If necessary, pain medication can be taken 20 min
prior to undertaking exercise and/or ice packs applied to the joint for 15–20 min following exercise.
However, there are some indicators that the exercise program may be too intensive and that alteration
to the type or dosage is required. These indicators are shown in Box 3.

How can clinicians monitor the effects of exercise?

Clinicians should use validated outcome measures to assess the effectiveness of an exercise pro-
gram. These can include patient self-report measures of pain via a 10-cm visual analog scale or a 0–10-

Box 3: Indicators that the exercise program may be too intensive and that dosage may need
to be altered.

 Severe or intense pain during exercise


 Pain that does not subside to usual levels within a few hours after exercise
 Increased night pain following exercise
 Swelling or increased swelling in the hours following exercise or the next morning
 Increased pain the following day
K.L. Bennell et al. / Best Practice & Research Clinical Rheumatology 28 (2014) 93–117 101

numeric rating scale (Fig. 4). In general, changes of at least 2 cm or 2 units on these scales are needed to
represent a clinically relevant amount of change with treatment. A variety of other self-report mea-
sures of pain and physical function are available including the Western Ontario and McMaster Uni-
versities Osteoarthritis Index (WOMAC), the Lower Extremity Functional Scale, the Hip (HOOS) and
Knee (KOOS) Osteoarthritis Outcome Scales, and the Australian/Canadian Osteoarthritis Hand Index
(AUSCAN) [52]. These should be administered prior to commencing the exercise program to gain a
measure at baseline and readministered at regular intervals, such as monthly. Patients can also rate the
amount of change they feel they have had following treatment using a global rating of change scale
(Fig. 5).
In addition to self-report measures, physical performance measures assess what a patient can
actually do rather than what they perceive they can do. It is recognized that these provide separate
information about patient status compared with self-report measures and are seen as complementary.
The Osteoarthritis Research Society International (OARSI) has recently recommended a core set of
physical performance measures for use in patients with hip and knee OA including those with OA and
those following joint replacement [53]. The set comprises the 30-s chair stand test, 40-min fast-paced
walk test, and a stair climb test with additional tests including the timed up and go test and the 6-min
walk test. These are summarized in Table 2 with further information including test manual, videos,
scoring template, and normative values available from the OARSI website (http://www.oarsi.org).

Why is exercise not being prescribed by clinicians for patients with OA?

Despite convincing research evidence demonstrating the beneficial effects of exercise for people
with OA and the numerous clinical guidelines advocating exercise for OA [1–3,5,20,54–59], exercise
prescription for people with OA continues to be underutilized by medical practitioners and allied
health professionals. Underlying differences in a clinician’s knowledge, beliefs, attitudes, and behavior
towards exercise, as well as external influences of the health-care system and the physical environ-
ment, may contribute to why exercise is being under-prescribed for patients with OA.
A UK-based survey of 2000 physical therapists with subsequent semi-structured interviews to a
subsample [60] found that physiotherapists remained uncertain of the benefits of exercise for people
with OA as they were not necessarily familiar with current research. Similarly, in a French study of both
patient and practitioner views of the management of knee OA, general practitioners also reported
being unsure about which exercises were best, including the type and dosage, and reported having
limited awareness of clinical guidelines and available resources [61]. Physicians emphasized the dif-
ficulties they experience when expanding treatment strategies and felt there was a need for well-
developed tools to help with treatment choices.

(a) Place a mark on the following scale to show the average amount of pain felt over the past
week in your knee when you are walking.

NO WORST PAIN
PAIN POSSIBLE

(b) Tick the number that indicates the average amount of pain felt over the past week in your
knee when you are walking.

0 1 2 3 4 5 6 7 8 9 10

no pain worst pain possible

Fig. 4. Example of a (a) visual analog scale and (b) numeric rating scale, for the assessment of pain. These can be administered prior
to commencing exercise treatment and at intervals throughout the treatment.
102 K.L. Bennell et al. / Best Practice & Research Clinical Rheumatology 28 (2014) 93–117

Place an “X” in the box that best represents the overall change in your knee since you began
the exercise program.

much moderately slightly no slightly moderately much


worse worse worse change better better better

Fig. 5. Example of a patient global rating of change scale.

Additional to clinicians’ overall knowledge of the benefits of exercise for people with OA, their own
personal attitudes and beliefs can also impact on exercise prescription. A systematic review of the
attitudes, beliefs, and behaviors of general practitioners regarding exercise for chronic knee pain,
including knee OA [62], found that up to 29% of general practitioners believed that rest was the op-
timum management approach and exercise should not be used for certain patients with chronic knee
pain. Further, a US study evaluating the quality of care of people with arthritis [63] found that among
people for whom exercise was indicated, only 44% were prescribed an individual or supervised exercise
program. Perhaps more alarming, a French survey of general practitioners [64] showed that <15%
would prescribe exercise for knee OA as a first-line therapeutic approach. These disconcerting findings
suggest that part of the reason why exercise is not being prescribed lies with medical and health-care
practitioners failing to recognize the importance of this treatment option.
Differing practitioner’s views of the management of knee OA were found in another French study
using semi-structured interviews [61]. Some practitioners take a “fatalist” view, with a tendency to-
wards trivialization, where OA in general and knee OA specifically were perceived as a natural
degradation of the body with age.
“(Knee OA) is a part of getting older, it’s normal really, not normal, but it makes sense as it is part
of the natural evolution”

(Alami et al., 2011, page 5)

Similar views that knee OA is a progressive degenerative condition which would worsen, irre-
spective of exercise therapy, with the only cure being surgery, were held from UK-based physical
therapists. [60]
“My guess is that, regrettably, long term her knee is only going to get worse, assuming that it is,
sort of, arthritic and, really, a knee replacement is the answer”

(Holden et al., 2009, page 1515).

Table 2
Description of the core set of physical performance measures for hip and knee osteoarthritis as recommended by the Osteo-
arthritis Research Society International [53].

Test Equipment needed Description


30-s chair stand test  Timer/stop watch Maximum number of chair stand
 Straight back chair with a 44-cm (17 inch) repetitions possible in 30 s
seat height, preferably without arms
40-m fast-paced walk test  Timer/stop watch A fast paced walking test that is
 10-m marked walkway with space to safely timed over 4  10 m for a total of
turn around at each end 40 m performed in comfortable footwear
 2 cones placed approximately 2 m beyond
each end of the walkway
 Calculator to convert time to speed
Stair climb test  Timer/stop watch Time in seconds it takes to ascend
 Set of stairs and descend a flight of stairs. The
number of stairs will depend on
individual availability
K.L. Bennell et al. / Best Practice & Research Clinical Rheumatology 28 (2014) 93–117 103

The wider structure of the health-care system also presents barriers to exercise prescription. Cli-
nicians express frustrations about not being able to follow people up sufficiently due to time restraints,
personnel, and cost to the patient [60]. General practitioners also express limited access and avail-
ability of allied health professionals and the relative high costs involved in physiotherapy were major
barriers to referring patients for individual or group exercise. [65] They also express that a lack of
government support impacts on overall management choices.
A list of commonly available clinical guidelines that provide practical recommendations for non-
pharmacological and nonsurgical treatments, including exercise prescription, for people with OA are
provided in Table 3.

Why don’t patients adhere to exercise recommendations?

In order to achieve optimal clinical outcomes with exercise, long-term patient adherence to a
regular exercise program is critical. For example, Ettinger and colleagues [66] demonstrated a dose–
response relationship between adherence and exercise effects in a large 18-month trial involving 439
people with knee OA. With increasing adherence, improvements in pain, walking ability, and disability
significantly increased. A study by van Baar et al. [67] clearly showed that the beneficial effects of
exercise last only as long as the patient with OA continues to participate in exercise. The authors fol-
lowed up 183 patients with hip/knee OA for 6 months after they had completed a 12-week exercise
program and found that the beneficial effects of exercise on pain and disability were lost 6 months after
the exercise program had been completed (Fig. 6) [68].
A complex array of factors influence a person’s decision to commence, and maintain, participation
in exercise and physical activity. Research has evaluated the factors that motivate patients with knee
OA to commence an exercise program. Motivating factors include the presence of social support, the
presentation of an organized exercise opportunity conducted by professionals, having a partner ex-
ercise alongside them, being familiar with the exercise task, and having positive outcome expectations
of exercise. [69] It appears that once people commence an exercise program, adherence is often high in
the early stages of participation, but can wane quite quickly as time passes. Campbell et al. [70]
interviewed 20 patients with knee OA who participated in physiotherapy, involving primarily home-
based strengthening exercises. Patients were most adherent with the physiotherapy regime in the
initial period while still seeing the physiotherapist regularly. However, the adherence dropped off once
contact with the physiotherapist ceased. The patients cited numerous reasons that affected their
motivation to adhere to the exercises (Fig. 7), including attitude towards exercise (e.g., willingness and
ability to accommodate exercises into everyday life), perceived severity of knee symptoms (those with
more severe symptoms were most likely to adhere), ideas about the cause of arthritis (those thinking

Table 3
Clinical guidelines that include recommendations for exercise in people with OA.

International Body Joint Last updated Quick link


American College of Hip, knee, 2012 http://www.rheumatology.org/Practice/
Rheumatology (ACR) [59] and hand Clinical/Guidelines/Osteoarthritis/
Osteoarthritis Research Hip and knee 2010 http://www.oarsi.org/pdfs/part_III_changes_
Society International (OARSI) [20] in_evidence2010.pdf
American Academy of Knee 2008 www.aaos.org/research/guidelines/
Orthopaedic Surgeons [56] OAKguideline.pdf
European League Against Hip and knee 2012 http://www.eular.org/
Rheumatism (EULAR) [1,5] Hand 2007
Royal Australian College of Hip and knee 2009 http://www.racgp.org.au/your-practice/guidelines/
General Practitioners musculoskeletal/hipandkneeosteoarthritis/
(RACGP)/(NHMRC) [57]
National Institute for Health & All 2011 http://www.nice.org.uk/nicemedia/pdf/
Clinical Excellence (NICE) [3] cg59niceguideline.pdf
Royal Dutch Society for Hip and knee 2011 http://nvl002.nivel.nl/postprint/pppp4491.pdf
Physical Therapy [58]
104 K.L. Bennell et al. / Best Practice & Research Clinical Rheumatology 28 (2014) 93–117

Fig. 6. Beneficial effects of exercise (plotted as effect sizes) decline in people with hip and knee OA once they stop exercising
(Reprinted from (Bennell et al., 2011) [68] with permission from Wiley).

arthritis was due to age or “wear and tear” were less adherent), and the perceived effectiveness of the
intervention (high levels of continued compliance were related to perceptions that physiotherapy is
effective and improvement in symptoms).
Factors influencing adherence to exercise can be intrinsic and/or extrinsic to the patient with OA
[71,72] (Fig. 8). Internal factors include attributes of the individual (such as motivation levels, per-
sonality, self-image, health and exercise attitudes, exercise history, and knowledge of OA) and personal
experiences (such as effect of pain, stiffness and fatigue, finding suitable exercise, perceived exercise
benefits, and quality of sleep). External factors include the social environment (including family sup-
port, physical therapists’ care, physicians’ encouragement, training partners, and socioeconomic sta-
tus) and the physical environment (such as weather, availability and accessibility of exercise facilities
and classes, and transportation).
Attitudes and beliefs of older people with OA about the role of exercise for managing their condition
are particularly important in influencing adherence. A recent large-scale survey identified considerable
uncertainty among older adults with knee pain regarding the role of exercise, including uncertainty

Fig. 7. Model depicting factors that influence ongoing adherence to exercise in patients with knee OA. (Reprinted from Campbell
et al. (2001) [70], with permission from BMJ Publishing Group).
K.L. Bennell et al. / Best Practice & Research Clinical Rheumatology 28 (2014) 93–117 105

Fig. 8. Model depicting the internal and external barriers and facilitators to exercising in people with osteoarthritis (Reprinted from
Petursdottir et al., 2010 [71] with permission from American physical Therapy Association and Bennell 2013 [72] with permission
from Elsevier).

around issues of exercise purpose, safety, and effectiveness in managing knee pain [73]. While most
people recognized that it was their own responsibility to continue participation in an exercise program,
and that adherence influences effectiveness of exercise, factors such as laziness, forgetfulness,
boredom, and lack of enjoyment were all identified in semi-structured interviews as barriers to ex-
ercise participation [73]. Attitudes and beliefs about exercise are associated with individual percep-
tions about their knee problems. It is a commonly held belief that knee pain is due to “wear and tear”
within the joint and that the problem will most probably worsen over the long term. Another common
misconception is that participation in physical activity and exercise, in the presence of OA, may cause
damage within the affected joint. The work of Holden et al. [73] also highlights that many people also
incorrectly believe that more severe OA (X-ray damage) is less likely to benefit from exercise. These
findings highlight how critical patient education is in order to maximize patient adherence to exercise
in OA. This is explored further in the next section. Particularly among older adults, confidence in ability
to carry out exercise (known as exercise self-efficacy) may also be an important factor influencing
adherence to exercise, [74] which may partially explain why a past history of exercise participation is
often a facilitator of exercise adherence.

How can patient adherence to exercise be improved?

Given that the barriers to exercise adherence are complex and vary across individuals, and may
change over time within a given individual, a flexible individualized and proactive approach to
exercise prescription by health professionals is required. No single strategy to promoting exercise
adherence will suffice across all people with OA. Health professionals should consider and identify
the barriers to exercise adherence that exist in individual patients when recommending or pre-
scribing exercise for people with OA, and use this information proactively to tailor exercise rec-
ommendations and implement strategies to overcome potential barriers accordingly. Clinicians
may find it useful to incorporate the checklist of barriers and facilitators influencing exercise
106 K.L. Bennell et al. / Best Practice & Research Clinical Rheumatology 28 (2014) 93–117

Table 4
Checklist of facilitators and barriers influencing exercise behavior among people with osteoarthritis that may be useful for
clinicians to complete during an assessment of patients, prior to prescribing an exercise program (Reproduced with permission
from Petursdottir et al. 2010) [70].
K.L. Bennell et al. / Best Practice & Research Clinical Rheumatology 28 (2014) 93–117 107

behavior in people with OA constructed by Petursdottir et al. [71] (Table 4) into their assessment
procedures in order to assist this process. Participants who are influenced mainly by facilitators are
likely to be more successful in integrating exercise into their lifestyle, compared to participants who
are predominantly influenced by barriers. Alternatively, other questions that could also be useful in
identifying potential barriers to exercise adherence and in guiding exercise prescription to promote
adherence are outlined in Box 4 [74]. When barriers to exercise adherence are identified, Table 5
outlines a range of potential strategies that clinicians may consider implementing.

Box 4: Questions that may be used or adapted to assist clinicians in identifying potential
barriers to exercise adherence and in tailoring the exercise program for individuals (Based
on a short survey provided in Marks, 2012). [74]
108 K.L. Bennell et al. / Best Practice & Research Clinical Rheumatology 28 (2014) 93–117

Table 5
Strategies that may be useful in overcoming barriers to exercise in people with osteoarthritis.

Barrier Strategies to consider


Lack of time Identify available time slots in the patient’s weekly routine. Try to
identify 3  30 min slots over the week, or alternatively, more
frequent slots of shorter duration.
Encourage incorporation of exercise into daily routines. For example,
walking to work or the shops, taking the stairs instead of the elevator,
walk the dog, exercising while watching the news on TV, etc.
Recommend exercises that are time-efficient and do not require
complicated set up of equipment. Aim for home–or work-based
exercise programs rather than those that require additional travel
to get to a gym or scheduled class.
Lack of motivation Encourage your patient to plan exercise sessions for the week ahead,
and to make “appointments” for exercise in their weekly schedule.
Write the “exercise appointments” in a diary or on a calendar.
Discuss the benefits of exercise, and set short- and long-term goals
that are tailored to the patient.
Discuss the importance of exercise with your patient’s friends
and/or family members and encourage them to participate in
exercise as well.
Recommend participation in an exercise group or class. Provide
referrals to appropriate group classes in the community.
Lack of access to exercise Recommend exercises that require no travel to specialized facilities.
facilities, transportation Recommend home-based exercises that can make use of body weight
for resistance, or prescribe aerobic exercises such as walking programs.
Identify inexpensive and convenient facilities available in the local
community (such as arthritis exercise groups, walking groups, local
swimming pools, etc.). Provide your patient with written material
with the contact details for these services.
Weather conditions Provide a range of exercise options that will be possible irrespective
of the weather conditions (e.g., indoor cycling, water aerobics,
indoor swimming, etc.)
Perception exercise is Education regarding the benefits of exercise, using scientific evidence
ineffective or will worsen OA delivered in a language that the patient can easily understand.
Provide educational support materials (website links and written
handouts) that describe the pathology of OA. Encourage use of
educational resources provided by national arthritis and
exercise organizations.
Provide tailored exercise advice with specific individualized
exercise prescription and dosage, rather than generic
exercise recommendations.
Referral to commence exercise under the supervision of a
physical therapist initially.
Lack of enjoyment Discuss with the patient their preferred exercise options.
Tailor the exercise program to the patient’s personal preferences
and according to past exercise strategies that have been
successful for them.
Regularly change the exercise program to minimize boredom.
Listen to music or watch television while exercising.
Discuss reward systems, where the patient rewards themselves at
regular intervals for ongoing exercise participation or for
achieving predetermined exercise goals.
Other health problems Tailor the exercise program to consider the impact of other comorbid
conditions, rather than use generic exercise recommendations. Refer
the patient to commence exercise under the supervision of a physical
therapist initially.
Ensure other medical conditions are being adequately and
appropriately managed.
Forgetfulness Discuss strategies to help the patient to remember. For example,
cue cards around the house; schedule exercise appointments into
the calendar or diary; set reminders via email alerts or reminders on
smart phones or computers, place exercise sheets on visible locations.
K.L. Bennell et al. / Best Practice & Research Clinical Rheumatology 28 (2014) 93–117 109

Table 5 (continued )

Barrier Strategies to consider


Lack of energy Discuss that regular exercise will increase energy over the longer
term. While they might feel tired initially, continued exercise will
increase energy. Sleep quality will also improve with ongoing
exercise, so improved sleeping will also result in reduced tiredness.
Discuss about the
vicious cycle of feeling tired, leading to less physical activity, leading
to feeling more tired.
Exercise causes pain Conduct a comprehensive physical assessment to determine the
body positions, movements, and activities that aggravate pain and
use this information to tailor the exercise program.
Supervised exercise sessions initially, with regular monitoring by the
patients and clinician regarding changes in pain.
Reassure the patient that pain is often felt when people with OA
exercise and that this is normal and safe. Explain that this does not
mean that exercise is harming the joint.
Modify exercise program in a timely manner to remove any
exercises that excessively increase pain or to modify the dosage.
Smaller durations of exercise with greater frequency may be
appropriate.
Consider exercise in aquatic environments rather than land-based.
Lack of confidence Referral to a physical therapist in the early stages of exercise.
in exercise ability Supervised exercise sessions or group classes rather than unsupervised
exercise.
Provide written exercise handouts and instructions. Video clips or DVDs
or photos of the patient themselves performing the exercise with the
clinician can be useful.
Spend sufficient demonstrating the exercises and watching the patient
perform the exercises so as to ensure correct technique and to
provide feedback.
More regular monitoring may be required, especially when
the exercise programs are being progressed or the dosage being
increased.

Individualizing exercise recommendations to the unique problems, clinical presentation, goals, and
preferences are of utmost importance to ensure that the exercise program meets the needs of the
patient. Alongside this, the availability of appropriate exercise equipment and facilities (including
transportation requirements and availability) must be considered to ensure a feasible exercise pro-
gram is recommended in order to promote long-term adherence. Health professionals should not
advise exercise programs that are likely to increase pain or pose an injury or falls risk to individuals
with OA. Some exercises may be more pain provoking than others in any given individual, thus it is
very important that pain levels are monitored closely in the early stages of starting a new exercise
program, and that the program is modified in a timely manner when pain is identified as a barrier to
participation. It is important to recognize that pain may be provoked post-exercise, thus careful
monitoring of pain response in the days immediately following a new or changed exercise program is
also important.
Given that patient attitudes to exercise and OA are a major barrier to exercise adherence, and
that a range of misconceptions about the disease and the role of exercise exist (see previous sec-
tion), education about the disease process and benefits of exercise is critical. It is important that
education regarding the role of exercise comes from medical practitioners involved in the primary
care of the patient, as well as from the health professionals prescribing exercise, [75] and that the
advice provided is complementary and not conflicting. Supplementing verbal discussions with
patient resources such as written materials and/or access to publicly available resources (e.g.,
credible and trustworthy websites) may help increase patient knowledge about the benefits of
exercise for OA and thus promote adherence over the long-term. Hurley et al. [76] evaluated an
integrated exercise and self-management program for people with chronic knee pain. Most
110 K.L. Bennell et al. / Best Practice & Research Clinical Rheumatology 28 (2014) 93–117

participants reported improved pain, physical and psychosocial functioning, increased knowledge
and understanding of their condition and treatment options as well as in their ability to use exercise
to control symptoms upon completion of the program. Interestingly, beliefs about cause and
prognosis of knee pain were unchanged; however, concerns regarding potential dangers of exercise
had reduced.
Regular supervision and monitoring of exercise by an appropriately qualified exercise provider can
enhance positive exercise beliefs and self-efficacy in people with OA [76]. Supervision also facilitates
the prescription of a progressive and flexible exercise program that can modified regularly to suit the
changing needs and clinical status of the patient, as well as to maintain patient interest and motivation
for ongoing participation. Regular monitoring from a health-care professional may help promote pa-
tient adherence to exercise over the long term. Other strategies that may promote adherence to ex-
ercise include self-monitoring (e.g., logbooks, diaries for recording exercise session, pedometers, etc.),
reinforcement by other individuals, telephone and/or mail contact from health professionals, as well as
participating in exercise with a spouse or other family member [44]. Integration of behavioral graded
activity principles and “booster sessions” into exercise programs also seems to result in better
adherence and a more physically active lifestyle [77].

Summary

Exercise is an integral component of conservative management for OA and is universally recom-


mended by OA clinical guidelines. While considerable research has investigated the effects of exercise
for knee OA, there is much less research at other joints such as the hip and hand and the optimal dosage
of exercise for people with OA remains unclear. Treatment benefits of exercise of all types may be
considered small to moderate; however, the effects are comparable to those of conservative drug
treatments but associated with relatively fewer side effects. Despite convincing evidence of the ben-
efits of exercise for people with OA, exercise prescription continues to be underutilized by medical
practitioners and allied health professionals. In order to achieve optimal clinical outcomes with ex-
ercise, long-term patient adherence to a regular exercise program is critical. Complex arrays of factors
influence a person’s decision to commence, and maintain, participation in exercise. Barriers and fa-
cilitators to exercise should be identified and strategies to maximize adherence to exercise imple-
mented regular supervision and monitoring of exercise by an appropriately qualified exercise
specialist, such as a physiotherapist, can enhance positive exercise beliefs and self-efficacy in people
with OA as well as provide a relatively cost-effective approach to exercise prescription. As conclusive
superiority of one delivery mode over the other remains unclear, the type and dosage of exercise
should be individualized to the patient based on assessment findings and should ultimately be
informed by patient preferences.

Practice points

 All patients with OA should be undertaking exercise for the management of their con-
dition regardless of their age, disease severity, pain levels, functional ability, and
comorbidities.
 The type and dosage of exercise should be individualized to the patient based on assessment
findings and the patient’s wishes and preferences.
 Patients should be educated as to the benefits of exercise. They should be advised that it is
normal to feel some discomfort/pain during exercise and that this does not indicate
increasing structural damage to the joint.
 Referral to an exercise specialist such as a physical therapist is recommended.
 Barriers and facilitators to exercise should be identified and strategies to maximize adherence
to exercise implemented.
K.L. Bennell et al. / Best Practice & Research Clinical Rheumatology 28 (2014) 93–117 111

Research agenda

 While exercise is effective for managing OA, further research is needed to clearly define the
optimal dosage in terms of type, method of delivery, frequency, and intensity.
 Given the relative dearth of exercise research in patients with hip and hand OA, further
research is needed in these areas.
 Models of care that encourage and facilitate prescription of exercise by clinicians and uptake
of exercise by patients need to be developed and evaluated for their effectiveness.
 The effectiveness of strategies to enhance longer-term adherence to exercise need to be
investigated.

Conflict of interest

All authors state that there are no conflicts of interest.

Appendix. Examples of strengthening exercises for knee and hip OA

Quadriceps strengthening – Sitting knee extension

Starting position
Put the cuff weight around the ankle of the affected leg.
Sit in a firm chair (and one that is higher if possible).

Activity
Slowly straighten the knee until it is fully straight.
Hold for 5 seconds and lower slowly.
Complete 2 to 3 sets of 10 repetitions
112 K.L. Bennell et al. / Best Practice & Research Clinical Rheumatology 28 (2014) 93–117

Standing quadriceps exercises – Partial wall squats

Starting position
Stand with feet approximately one foot (30cm) away from the wall and feet apart.
Slightly turn your feet outwards.
Lean your trunk and buttocks against a wall and keep your back straight.
Activity
Slowly slide down the wall (as if to sit) keeping your trunk and buttocks in
contact with the wall as you do.
Keep your knees moving over your toes.
Stop when your knees are bent to about 60 degrees (or less if it is painful).
Hold the position for 5 seconds.
Slowly slide back up keeping your trunk and buttocks in contact with the wall
as you do.
Complete 2 to 3 sets of 10 repetitions

Sit to stand

Starting position
Sit in a chair of standard height and firm seat. Place the chair back against a wall.
Activity
Slowly stand without using hands for support.
Start by leaning forward over your toes. As your buttocks lift, bring your hips under
your trunk and straighten up.
Sit back down slowly and hold for 3 seconds with the buttocks just off the chair before
touching down.
Complete 2 to 3 sets of 10 repetitions

Standing hip abduction

Starting position
Put looped Thera-band (resistance) around both legs just above the ankle. Ensure that there
is adequate tension on the band before starting the movement.
Use the back of a chair or a wall to provide support. Maintain a good upright posture with
shoulders and hips both facing forwards throughout.
Activity
Keeping body still and knee straight, lift affected leg out sideways leading with the heel.
Do not allow the leg to turn or swing forwards - keep the knee pointing forward and your
heel slightly behind you as you perform the movement.
Hold for 5 seconds, then lower slowly. Do both legs. Complete 2 to 3 sets of 10 repetitions
K.L. Bennell et al. / Best Practice & Research Clinical Rheumatology 28 (2014) 93–117 113

Hamstring strengthening – Seated knee bending

Starting position
Place a looped Thera-band (resistance) around the leg of a heavy table or chair.
Sit in a chair opposite and put your affected leg into the looped rubber band,
so that your knee is slightly bent.

Activity
Slowly pull your leg back into the rubber band until your knee is bent and you
can feel a strong resistance.
Hold for 5 seconds.
Complete 2 to 3 sets of 10 repetitions

Step Ups

Starting position
Stand with the foot of your affected leg on a step. Use the wall
or hand rail for balance if necessary. If you do not have steps,
you can use some phone books.

Activity
Step up slowly keeping your knee pointing forward. Do not push off
with the foot of the unaffected leg.
Return to your starting position slowly.
Complete 2 to 3 sets of 10 repetitions
114 K.L. Bennell et al. / Best Practice & Research Clinical Rheumatology 28 (2014) 93–117

Step Downs

Starting position
Stand on the step facing down stairs and use the hand rail or wall for balance.

Activity
Bend the knee of your affected leg slowly to lower your non-affected leg toward the ground.
Then straighten your affected knee slowly to return to the starting position.
Make sure that you keep the knee of your affected leg pointing forward during the movement.
Complete 2 to 3 sets of 10 repetitions

Standing calf raises

Starting position
Stand on two feet near a wall or table. Hold on gently to maintain balance.

Activity
Keeping the knee straight, rise up on the toes and hold for 3 to 5 seconds then
lower slowly.
Complete 2 to 3 sets of 10 repetitions
Progression: The exercise can be made more difficult by performing the
activity on one leg only
K.L. Bennell et al. / Best Practice & Research Clinical Rheumatology 28 (2014) 93–117 115

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