What exercise type and dose for pain and disability in knee osteoarthritis?


We have seen from previous blogs that many people suffer with osteoarthritis of the knee and that this can be a painful condition. So what exercise programmes are most beneficial for reducting pain and reducing patient reported disability?

Fortunately a team based in Denmark undertook a systematic review to identify the optimal exercise programme, characterized by type and intensity of exercise, length of program, duration of individual supervised sessions, and number of sessions per week, for reducing pain and patient-reported disability in knee osteoarthritis (OA).

Here’s what they did

They searched the literature for studies published up to May 2012 in the following bibliographic databases with no restriction on publication year or language: Medline via PubMed, EMBase via OVID, CINAHL (including preCINAHL) via EBSCO, PEDro, and the Cochrane Central Register of Controlled Trials.

To be included studies must have involved participants with (explicitly stated) OA in either one or both knees, as defined by the American College of Rheumatology (ACR) criteria. Trials that included patients with knee and/or hip OA were included if separate data on the knee were available. The outcomes for evaluation of clinical efficacy were pain and disability, as recommended by Outcome Measures in Rheumatology III.

A meta-analysis of included randomized controlled trials was performed. Standardized mean differences (SMDs) were combined using a random-effects model. Study-level covariates were applied in meta-regression analyses in order to reduce between-study heterogeneity.

Here’s what they found

  • Forty-eight trials were included.
  • Pain reduction:
    • Similar effects were found for aerobic, resistance, and performance exercise (SMD 0.67, 0.62, and 0.48, respectively; P  0.733).
    • These single-type exercise programmes were more efficacious than programmes that included different exercise types (SMD 0.61 versus 0.16; P < 0.001).
    • Aerobic exercise: pain relief increased with an increased number of supervised sessions (slope 0.022 [95% confidence interval 0.002, 0.043]).
    • Quadriceps-specific exercise was more effective than lower limb exercise (SMD 0.85 versus 0.39; P  0.005).
    • Supervised exercise performed at least 3 times a week (SMD 0.68 versus 0.41; P  0.017) gave best improvements.
    • No impact of intensity, duration of individual sessions, or patient characteristics was found.
  • Patient-reported disability: Similar results were found for the effect on patient-reported disability.

The authors concluded

Optimal exercise programmes should have one aim and focus on improving aerobic capacity, quadriceps muscle strength, or lower extremity performance. Such programs have a similar effect regardless of patient characteristics, including radiographic severity and baseline pain.

For best results the programme should be supervised and carried out 3 times a week

For best results the programme should be supervised and carried out 3 times a week

The Musculoskeletal Elf’s view

The Musculoskeletal Elf

This well conducted systematic review and meta-analysis has interesting findings, for best results the exercise programme should be supervised, carried out 3 times weekly, and comprise at least 12 sessions and should focus on single exercise types. Interestingly these results found no support for individualization of exercise programs based on patient characteristics. For example, the effect of exercise therapy in reducing pain was not associated with the severity of knee OA.

Although the methods indicate that no language restrictions were applied it appears that 10 trials were excluded due to language. However, the 8 available abstracts of the excluded trials indicated that those trials showed similar effects of exercise therapy in reducing pain and disability compared to the included trials.

What do you think?

  • Do you precribe single type exercise programmes such as muscle strength, aerobic exercise and strength training or do you combine them?
  • Do you prescribe programmes that are supervised 3 times per week for 12 weeks?
  • Do you prescribe individualised exercise programmes?
  • Will the results of this review alter your practice?
  • So what if patients have poor aerobic capacity? Is it possible to undertake muscle strength, aerobic exercise and strength training on different days in order to achieve the best effect? 

Send us your views on this blog and become part of the ever expanding Musculoskeletal Elf community. Post your comment below, or get in touch via social media (FacebookTwitterLinkedInGoogle+).

Do you know that there is an evidence-based minimum set of items for reporting in systematic reviews and meta-analyses? This is called the Preferred Reporting Items for Systematic Reviews and Meta-Analyses or PRISMA statement and can be accessed through the website of the EQUATOR Network. The Elves use the PRISMA statement for critical appraisal of systematic reviews, although it is not a quality assessment instrument to gauge the quality of a systematic review.


  • Juhl C, Christensen R, Roos EM, Zhang W, Lund H Impact of exercise type and dose on pain and disability in knee osteoarthritis: a systematic review and meta-regression analysis of randomized controlled trials. Arthritis Rheumatol. 2014 Mar;66(3):622-36. doi: 10.1002/art.38290. [abstract]
  • PRISMA statement
  • EQUATOR Network
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Tracey Howe

Hi I am Tracey Howe. I am a Professor of Rehabilitation Sciences at Glasgow Caledonian University, UK and Deputy Chair of Glasgow City of Science. I am also an editor for the Cochrane Musculoskeletal Review Group and a convenor for the Cochrane Health Care of Older People Field. I am a Trustee of the Picker Institute Europe. I started my career as a physiotherapist in the National Health Service in England. I have extensive experience of assessing the quality of research in Universities in the UK and internationally. I enjoy strategic visioning, creative problem-solving, and creating vibrant, multi-disciplinary environments, through collaboration, partnerships, and relationships, that empower others to succeed.

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