physical therapy interventions for knee pain secondary to osteoarthritis

Physical Therapy Interventions for Knee Pain Secondaryto OsteoarthritisA Systematic ReviewShi-Yi Wang, MD, PhD; Becky Olson-Kellogg, PT, DPT, GCS; Tatyana A. Shamliyan, MD, MS; Jae-Young Choi, PhD;Rema Ramakrishnan, MPH; and Robert L. Kane, MD

Background: Osteoarthritis is a leading cause of disability. Nonsur-gical treatment is a key first step.

Purpose: Systematic literature review of physical therapy (PT) in-terventions for community-dwelling adults with knee osteoarthritis.

Data Sources: MEDLINE, the Cochrane Library, the PhysiotherapyEvidence Database, Scirus, Allied and Complementary Medicine,and the Health and Psychosocial Instruments bibliography database.

Study Selection: 193 randomized, controlled trials (RCTs) publishedin English from 1970 to 29 February 2012.

Data Extraction: Means of outcomes, PT interventions, and risk ofbias were extracted to pool standardized mean differences. Dis-agreements between reviewers abstracting and checking data wereresolved through discussion.

Data Synthesis: Meta-analyses of 84 RCTs provided evidence for13 PT interventions on pain (58 RCTs), physical function (36 RCTs),and disability (29 RCTs). Meta-analyses provided low-strength ev-idence that aerobic (11 RCTs) and aquatic (3 RCTs) exercise im-

proved disability and that aerobic exercise (19 RCTs), strengtheningexercise (17 RCTs), and ultrasonography (6 RCTs) reduced pain andimproved function. Several individual RCTs demonstrated clinicallyimportant improvements in pain and disability with aerobic exercise.Other PT interventions demonstrated no sustained benefit. Individ-ual RCTs showed similar benefits with aerobic, aquatic, andstrengthening exercise. Adverse events were uncommon and didnot deter participants from continuing treatment.

Limitation: Variability in PT interventions and outcomes measureshampered synthesis of evidence.

Conclusion: Low-strength evidence suggested that only a few PTinterventions were effective. Future studies should compare com-bined PT interventions (which is how PT is generally administeredfor pain associated with knee osteoarthritis).

Primary Funding Source: Agency for Healthcare Research andQuality.

Ann Intern Med. 2012;157:632-644. www.annals.orgFor author affiliations, see end of text.

Osteoarthritis (OA) is a progressive joint disorder (1,2). Knee OA affects 28% of adults older than 45

years and 37% of adults older than 65 years in the UnitedStates (2, 3). Osteoarthritis is a leading cause of disabilityamong noninstitutionalized adults (2). Its prevalence andhealth impact are expected to increase as the populationages (4).

Osteoarthritis treatments aim to reduce or controlpain, improve physical function, prevent disability, and en-hance quality of life (5). Nonsurgical OA managementcombines pharmacologic treatments with physical therapy(PT) interventions (6–9). Guidelines recommend exerciseas the core treatment of OA (6, 7, 10). The marginal ef-fects of specific exercise types (aerobic, aquatic, strength,and proprioception) have not been systematically reviewed.

This review evaluates the efficacy and comparative ef-fectiveness of available PT interventions for adult patientswith knee OA (11).

METHODS

We developed the protocol for the review followingPRISMA (Preferred Reporting Items for Systematic Re-views and Meta-Analyses) guidelines (12, 13).

Data Sources and SearchesWe searched MEDLINE, the Cochrane Library, the

Physiotherapy Evidence Database, Scirus, Allied and Com-plementary Medicine, and the Health and Psychosocial In-struments bibliography database from 1970 to February 292012. We manually searched reference lists from system-atic reviews and eligible studies. We used relevant MedicalSubject Headings (MeSH) terms and text words, includ-ing osteoarthritis knee, physical therapy modalities, painmeasurement, activities of daily living, and quality of life(Supplement 1, available at www.annals.org). We searchedClinicalTrials.gov for completed trials related to the keyquestions. We did not contact primary investigators, butwe did request additional information from sponsors ofongoing trials.

Study SelectionAt least 2 investigators determined study eligibility

(14). We included original publications of randomized,controlled trials (RCTs) published in English. Eligible tri-als enrolled community-dwelling adults with knee OA andreported pain as an inclusion criterion or outcome. Dis-

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agreements about the appropriateness of an article wereresolved through discussion.

Eligible interventions were those within the scope ofPT practice (regardless of whether the articles clearly de-scribed the involvement of a physical therapist or physicaltherapist assistant) (Appendix Table 1, available at www.annals.org) (15). Eligible comparators included shamstimulation, usual care, and no active treatment for analy-ses of efficacy and PT interventions for the analysis of com-parative effectiveness. Eligible patient-centered outcomesincluded knee pain, disability, quality of life, perceivedhealth status, and global assessments of treatment effective-ness. Eligible intermediate outcomes included gait func-tion, strength, transfers, joint function, or a compositemeasure of functional performance.

We excluded studies involving children, adolescents,hospitalized patients, or patients in long-term care facili-ties. We also excluded studies of surgical or pharmacologictreatments for knee OA and those that examined PT de-livered in rehabilitation programs for adults with knee OAwho had knee arthroplasty within 6 months before thestudy. Because the effects of PT may differ between hipand knee OA, we synthesized the results from studies thatenrolled patients with knee or hip OA only if they reportedthe outcomes separately.

To assess harms of treatments, we included the find-ings of nonrandomized clinical trials, case series, and ob-servational cohort or case–control studies. Possible adverseevents included injuries related to exercise, back or footpain, falls, blisters related to orthotics, or skin burns relatedto diathermy and electrical stimulation. We defined harmsas a totality of all possible adverse consequences of discon-tinuing an intervention or treatment because of adverseevents (16). We included all evidence of adverse eventswith eligible interventions regardless of how authors per-ceived causality of treatments (16).

Data Extraction and Quality AssessmentTwo researchers used standardized forms to extract

data (17). One reviewer abstracted an article, and a secondreviewer checked the data for accuracy. Discrepancies weredocumented, discussed, and resolved by consensus.

For categorical variables, we abstracted the number ofparticipants randomly assigned to each treatment groupand follow-up duration after randomization. For continu-ous variables, we abstracted means and SDs and thefollow-up duration after randomization. For crossover tri-als, we abstracted the outcome levels after randomization ifreported by the authors. We abstracted mean age; meanbody mass index; proportions of women, minorities, andparticipants with disabilities; severity of knee OA; comor-bid conditions; multijoint OA; baseline physical activitylevel; occupation; and concomitant drug and PT interven-tions. We abstracted settings; supervision of treatments byphysical therapists; and dose, length, and intensity of theinterventions when reported by the authors.

We assessed risk of bias in RCTs by using predefinedcriteria from the Cochrane Risk of Bias tool that includedadequacy of randomization, allocation concealment, andintention-to-treat principles (14). We assigned studies ashaving medium risk of bias if at least 1 criterion was notmet and high risk of bias if 2 or more criteria were not met.We abstracted masking information, but we did not in-clude it in the assessment of risk of bias. We abstracted lossof follow-up and used the number of randomly assignedparticipants in calculating mean differences in measure-ment of pain, disability, and other outcomes.

We assessed strength of evidence according to guide-lines from the Evidence-based Practice Center Program atthe Agency for Healthcare Research and Quality (AHRQ)(Table 1) (18). We focused on direct evidence from head-to-head RCTs. We judged the strength of evidence foreach major outcome following the GRADE (Grading ofRecommendations Assessment, Development, and Evalua-tion) criteria according to risk of bias, consistency, preci-sion, and when appropriate strength of association (18).We defined treatment effect estimates as precise whenpooled estimates had reasonably narrow 95% CIs andpooled sample size was greater than 400 (19). We definedstrength of association by using the Cohen criteria of largeeffect corresponding to standardized mean differences(SMDs) greater than 0.8 (20).

Data Synthesis and AnalysisWe focused on patient-centered outcomes, including

pain, disability, and quality of life. We categorized inter-mediate outcomes as measurements of gait function,strength, transfers, or joint function or a composite mea-sure of functional performance. Follow-up duration was

Table 1. Strength of Evidence Grades, Definitions, andOperationalization

Grade Definition Operationalization

High High confidence that theevidence reflects the trueeffect. Further research isunlikely to change ourconfidence in the estimateof effect.

Low risk of bias, consistent,precise, and whenappropriate, large effectsize.

Moderate Moderate confidence that theevidence reflects the trueeffect. Further researchmay change our confidencein the estimate of effectand may change theestimate.

If 1 criterion mentioned abovewas not met.

Low Low confidence that theevidence reflects the trueeffect. Further research islikely to change theconfidence in the estimateof effect and is likely tochange the estimate.

If at least 2 criteria mentionedabove were not met, risk ofbias was high, or evidenceis limited to an individualstudy with low or mediumrisk of bias.

Insufficient Evidence does not permit aconclusion.

Evidence is limited to anindividual study with highrisk of bias.

ReviewPhysical Therapy for Knee Osteoarthritis

www.annals.org 6 November 2012 Annals of Internal Medicine Volume 157 • Number 9 633


categorized as less than 6 weeks, 6 to 13 weeks, 14 to 26weeks, or more than 26 weeks.

We categorized eligible interventions in accordance withthe definitions and hierarchy of interventions found in theGuide to Physical Therapist Practice (15) (Appendix Table 1).

Exercise interventions in eligible RCTs are describedin Appendix Table 2 (available at www.annals.org). Whenwe found more than 1 study from a particular trial, weused the results from the latest published paper.

Pooling criteria required that definitions of PT inter-ventions and outcomes be the same. We categorized instru-ments according to similar domains with respect to pain,disability, quality of life, and composite function (Appen-dix Table 3, available at www.annals.org). We used SMDsto combine effect estimates obtained from quality-of-lifeinstruments or pain scales (14). Negative direction in ab-solute values of measured pain, disability, and other out-comes corresponded to improvement in the outcomes.

We prioritized pooled analyses over nonpooled resultsand longer versus shorter follow-up. We used the Hedgesmethods to calculate SMDs for different continuous mea-sures of the same outcome (21). We evaluated the consis-tency of findings by comparing the direction and strengthof the effect (18) along with the degree of statistical hetero-geneity (based on the chi-square and I2 statistics) in effectsacross studies (22, 23). We used random-effects models topool results to account for inevitable variation in patientpopulations, concomitant treatments, and specific compo-nents of PT interventions (24). We used meta-regressionand subgroup analyses to evaluate the effects of a priori–defined clinical and study characteristics on pain and phys-ical function.

When heterogeneity was significant, we explored theeffects of clinical diversity (age, sex, race, baseline activitiesof daily living, instrumental activities of daily living, co-morbid conditions, inclusion of adults with previous kneearthroplasty, and obesity); exercise type, dose, and dura-tion; specific study quality criteria; and physical therapistsupervision. We investigated heterogeneity with individualquality criteria and crossover design rather than globalquality scores (24–26). We did not use statistical tests forpublication bias (14, 27–29).

We back-transformed SMDs to mean differences withseveral measures. For disability, we used EuroQol-5D (EQ-5D) (14), a multiattribute, preference-based health statusmeasuring instrument (30). For quality of life, we used the36-Item Short Form Health Survey (SF-36) (31). For pain,we used the visual analogue scale (VAS) (32). For compositefunction, we used the Western Ontario and McMaster Uni-versities (WOMAC) Osteoarthritis Index function score (33).For gait function, we used walking speed (32). Pooled SDs ofthese measures were derived from large population-basedstudies of noninstitutionalized adults (30–33).

We multiplied the SMDs by the pooled SDs men-tioned previously to yield an estimate of the difference inmean outcome scores (with vs. without intervention) on

EQ-5D score (SD, 0.38), SF-36 score (SD, 10.9), VASscore (SD, 22 on a scale of 0 to 100), WOMAC physicalfunction score (SD, 18.5), and walking speed (SD, 0.2m/s) (30–33). We categorized treatment effects by theclinical importance of differences in intermediate out-comes. We used definitions of minimum clinically impor-tant differences from published studies and evidence-basedreports (Appendix Table 4, available at www.annals.org)(34). To assess the clinical importance of pain reduction withinterventions, we did subgroup analyses with a subset of thestudies that used the same VAS instrument for pain measures.We then compared mean reduction in pain with the cutoff forminimum clinically important differences in VAS scores, asreported in observational studies (Appendix Table 4).

We used Stata, version 11 (StataCorp, College Station,Texas), for all analyses (35).

Role of the Funding SourceThe study was funded by AHRQ. The questions were

developed with stakeholder input as part of AHRQ’s Ef-fective Health Care Program. The AHRQ provided copy-right release for this manuscript but had no role in theliterature search, data analysis, conduct of the study, prep-aration of the review, or interpretation of the results. Itreviewed and approved the submitted manuscript withoutrevisions.

RESULTS

The 4266 retrieved reports yielded 212 eligible articles(from 193 RCTs) that contributed to the evidence syn-thesis (Figure 1). We excluded 2085 references at screen-ing; 1605 because of ineligible target population, interven-tions, and outcomes or because they were guidelines orreviews; and 154 of the observational nontherapeutic stud-ies that examined the association between intermediateand patient-centered outcomes. No sponsors of ongoingtrials responded to our requests for scientific informationpackages.

Most RCTs demonstrated adequacy of randomization(138 of 193 RCTs). Adequacy of allocation concealmentwas unclear in most studies (129 of 193 RCTs) (AppendixFigure 1, available at www.annals.org). The most commonreason for increased risk of bias was no planned intention-to-treat analyses (118 of 193 RCTs). One third of RCTs(68 of 193) reported open-label design with no masking ofthe outcome assessment. The mean attrition rate was10.3% (SD, 10.6%).

Overall, RCTs had good applicability to our targetpopulation because they primarily recruited older adultswith knee OA. More than 70% of the participants werewomen. Most participants were overweight; body mass in-dex of participants averaged approximately 29 kg/m2. In100 RCTs (52%), participants were taking anti-inflammatory drugs or pain relievers. One half of the stud-ies provided no information about exact pharmacologictreatments. Few studies specified that they excluded pa-

Review Physical Therapy for Knee Osteoarthritis



tients with previous knee surgery. Most studies did notreport participants’ occupation, knee injury, comorbidconditions, or duration of condition or the proportion ofparticipants who had baseline disability or surgery.

Effectiveness of PT InterventionsOnly 84 RCTs met pooling criteria and provided ev-

idence for 13 PT interventions on pain (58 RCTs), phys-ical function (36 RCTs), and disability (29 RCTs). Evi-dence on long-term PT effects was available for 7intervention–outcome pairs. We found few statistically sig-nificant differences in outcomes between active and controltreatments (Supplement 2, available at www.annals.org).We downgraded strength of evidence because of risk ofbias and low precision of the estimated treatment effects.Individual RCTs reported the same direction of the effect,but variations in statistical significance and strength of theeffects contributed to statistically significant heterogeneityin some cases, which we explored according to a priori–defined characteristics of participants and treatments.

Meta-analyses provided low-strength evidence thataerobic exercise (11 RCTs) and aquatic exercise (3 RCTs)improved disability; aerobic exercise (19 RCTs), strength-ening exercise (17 RCTs), and ultrasonography (6 RCTs)reduced pain and improved function; and at short- but notlong-term follow-up proprioception exercise reduced painand Tai Chi improved function. Nonpooled results fromindividual RCTs did not show consistent statistically sig-nificant, strong, or clinically important changes in out-comes. Despite differences in interventions and outcomemeasures, the results from RCTs consistently demonstratedno benefits from specific education programs, diathermy,orthotics, or magnetic stimulation.

Education Program

Two RCTs (511 participants) studied the effectivenessof education programs (36–38). Low-strength evidencesuggested that education programs had no statistically sig-nificant effect on pain relief (36, 37).

Proprioception Exercise

The effects of proprioception exercise were examinedin 4 RCTs (247 participants) (39–42). Proprioception ex-ercise improved pain (SMD, �0.71 [95% CI, �1.31 to�0.11], corresponding to a back-transformed VAS scoredifference of �15.6 on a scale of 0 to 100 [CI, �28.8 to�2.4]), but not composite function or gait function. Theimprovement was clinically important. Strength of evi-dence was low due to a high risk of bias in included trials.

Aerobic Exercise

Aerobic exercise effects were analyzed in 11 RCTs(1553 participants) (36–38, 43–52). Aerobic exercise ledto statistically significant improvements in long-term pain(� 26 weeks) (SMD, �0.21 [CI, �0.35 to �0.08], cor-

responding to a back-transformed VAS score difference of�4.6 [CI, �7.7 to �1.8]) (36, 37, 46–49), and disability(SMD, �0.21 [CI, �0.37 to �0.04], corresponding to aback-transformed EQ-5D score difference of �0.08 [CI,�0.14 to �0.02]) (38, 46–48), but not psychological dis-ability (43–45, 51) or health perception (38, 47, 48).Within 3 months, aerobic exercise also improved compos-ite function (WOMAC function score difference, �15.4[CI, �24.8 to �5.92]) (45, 49, 53) and gait function(walking speed difference, �0.11 m/s [CI, �0.15 to�0.08 m/s]) (43, 45, 51, 53–56). At 12 months, the ben-efits of aerobic exercise continued for gait function (walk-ing speed difference, �0.11 m/s [CI, �0.17 to �0.05m/s]) (46, 52) but not for composite function (37, 46, 49).

Figure 1. Summary of evidence search and selection.

Excluded studies (n = 1605)Noneligible target population: 342Noneligible exposure: 803Noneligible outcomes: 44No hypothesis tested: 69Guideline: 24Review: 323

Studies not in pooled analyses (n = 128)

Included studies in pooled analyses (n = 84)

Included studies for the original report(n = 576)

Included studies in quantitative analysesfrom 193 RCTs (n = 212)

Excluded at screening (n = 2085)

Studies used for associations between intermediate and patient-centered

outcomes (n = 154)

Studies used for qualitative analyses (n = 210)

Total retrieval(n = 4266)

Potentially relevant articles identifiedafter screening for retrieval (n = 2181)

Included studies for effectiveness, comparative effectiveness, and harm after

physical therapy intervention (n = 422)

RCT � randomized, controlled trial.




The pooled results showed that improvement in disability(but not in pain) was clinically important. Strength of ev-idence was low due to high risk of bias of the includedtrials. Several individual RCTs demonstrated clinically im-portant improvements in pain and disability with aerobicexercise.

Effect estimates were statistically homogeneous. Ameta-regression analysis exploring pain relief after approx-imately 3 months of aerobic exercise compared with pla-cebo found no factor that could have consistently modifiedPT effects. Pain relief at approximately 3 months was con-sistent in RCTs that examined aerobic exercise supervisedby a physical therapist. However, improvement in compos-ite function at 3 months with aerobic exercise was greaterin RCTs that reported no supervision of a physical thera-pist. Subgroup analyses with a subset of the studies thatused the VAS instrument for pain measures found that theeffect size of aerobic exercise at 3 months exceeded the mini-mum clinically importance difference; however, the result wasnot statistically significant.

Aquatic Exercise

Three RCTs (348 participants) studied the effective-ness of aquatic exercise (57–59). Aquatic exercise reduceddisability (SMD, �0.28 [CI, �0.51 to �0.05], corre-sponding to a back-transformed EQ-5D score difference of�0.11 [CI, �0.19 to �0.02]), but had no statisticallysignificant effects on pain relief or quality of life (57, 58).

Strengthening Exercise

The effects of strengthening exercise were examined in9 RCTs (1982 participants) (39, 46, 58, 60–65).Strengthening exercise had no statistically significant effecton disability or quality of life (46, 58, 60, 62). However,we saw a persistent improvement in pain relief (SMD,�0.68 [CI, �1.23 to �0.14], corresponding to a back-transformed VAS score difference of �15.0 [CI, �27.1 to�3.1]); composite function (SMD, �1.00 [CI, �1.95 to�0.05], corresponding to a back-transformed WOMACfunction score difference of �18.5 [CI, �36.1 to �0.93]);and gait function (SMD, �0.39 [CI, �0.59 to �0.20],corresponding to a back-transformed walking speed differ-ence of �0.08 m/s [CI, �0.12 to �0.04 m/s]) at 3 to 12months of follow-up (39, 40, 46, 58, 60–64, 66–73). Theimprovements in pain and composite function were clini-cally important. Strength of evidence was low due to me-dium risk of bias and significant heterogeneity.

Magnitude of the effect differed across the studies,with the I 2 statistic greater than 0.64 and the chi-square Pvalues less than 0.004. We used meta-regression to exploreheterogeneity in gait function or composite function at 3months after strengthening exercise compared with pla-cebo, and we found no factor that could explain theheterogeneity. However, meta-regression exploring hetero-geneity in pain relief approximately 3 months after

strengthening exercise indicated that younger participantshad significantly better outcomes (P � 0.020). In contrastwith aerobic exercises, the involvement of a physical ther-apist in strengthening exercise did not demonstrate consis-tent association with outcomes. For example, in compari-son with studies without PT involvement, studies with PTinvolvement demonstrated smaller effect size for gait func-tion 3 months after strengthening exercise, yet the samestudies showed greater effect size in long-term pain reliefafter strengthening exercise.

Subgroup analyses with a subset of the studies usingthe VAS instrument for pain measures found that strength-ening exercise resulted in statistically and clinically signifi-cant long-term pain reduction (transformed mean differ-ence, �12.8 [CI, �22.9 to �2.7], which exceeded thecutoff for minimum clinically important difference).

Tai Chi

Tai Chi effects were analyzed in 3 RCTs (167 partic-ipants) (74–76). Tai Chi improved composite functionmeasures (SMD, �0.44 [CI, �0.88 to 0], correspondingto a back-transformed WOMAC function score differenceof �8.14 [CI, �16.3 to 0]), at approximately 3 monthsbut had no statistically significant effects on pain or dis-ability. The improvement in composite function was notclinically important. Strength of evidence was low due tomedium risk of bias and imprecision.

Massage

Three RCTs (162 participants) studied the effective-ness of massage (77–79). Massage improved compositefunction (SMD, �0.55 [CI, �0.93 to �0.18], corre-sponding to a back-transformed WOMAC function scoredifference of �10.2 [CI, �17.3 to �3.33]) (77, 78). Theimprovement was clinically important. Strength of evi-dence was low due to high risk of bias and imprecision.

Orthotics

The effects of orthotics were examined in 7 RCTs(364 participants) (80–86). Orthotics had no effect onshort-term outcomes of composite function or gait func-tion. Three Japanese studies offered low strength of evi-dence that elastic subtalar strapping improved compositefunction at approximately 3 months (SMD, �0.27 [CI,�0.53 to �0.02], corresponding to a back-transformedWOMAC function score difference of �5.00 [CI, �9.81to �0.37]) (87–89). The improvement was not clinicallyimportant. Strength of evidence was low due to high risk ofbias and imprecision.

Taping

Two RCTs (105 participants) studied the effectivenessof taping (90, 91). Low-strength evidence suggested thattaping did not improve pain, disability, composite func-tion, or gait function (90, 91). Different reporting formats




precluded pooled analyses. Individual studies suggestedthat taping may provide short-term pain relief (90–92).

Electrical Stimulation

Electrical stimulation effects were analyzed in 7 RCTs(390 participants) (69, 93–98). Electrical stimulation ledto statistically significant short-term improvements in pain(SMD, �0.71 [CI, �0.98 to �0.43], corresponding to aback-transformed VAS score difference of �15.6 [CI,�21.6 to �9.5]) (68, 96, 99–103). However, electricalstimulation worsened pain at 6 months (SMD, 0.57 [CI,0.09 to 1.06], corresponding to a back-transformed VASscore difference of 12.5 [CI, 2.0 to 23.3]) (Appendix Fig-ure 2, available at www.annals.org) (93, 97). Low-strengthevidence showed statistically significant improvementsfrom electrical stimulation at 3 months for global assess-ment (95, 96) and muscle strength (measured at 60-degreeextension) (69, 94). Pooled analyses provided moderate-strength evidence of no improvement in disability or jointfunction and low-strength evidence of no improvementin composite or gait functional measures (69, 93–96,102–105).

Subgroup analyses with a subset of the studies usingthe VAS instrument for pain measures found that electricalstimulation resulted in clinically significant short-term painreduction (mean reduction, �17.2 [CI, �23.1 to �11.4],which exceeded the cutoff for minimum clinically impor-tant difference). At 3-month follow-up, however, electricalstimulation tended to worsen pain measured with VAS(effect size, 0.1 [CI, �6.2 to 6.3]).

Pulsed Electromagnetic Fields

The effects of pulsed electromagnetic fields were exam-ined in 4 RCTs (267 participants) (106–109). We found

moderate-strength evidence that pulsed electromagnetic fieldsneither reduced pain nor improved composite function.

Ultrasonography

Six RCTs (387 participants) studied the effectivenessof ultrasonography (94, 110–114). Low-strength evidencedemonstrated that ultrasonography led to statistically andclinically significant reductions in pain (SMD, �0.74 [CI,�0.95 to �0.53], corresponding to a back-transformedVAS score difference of �16.3 [CI, �20.9 to �11.7]).Ultrasonography also resulted in statistically and clinically sig-nificant improvements in composite function (SMD, �1.14[CI, �1.85 to �0.42], corresponding to a back-transformedWOMAC function score difference of �21.2 [CI, �29.8 to�12.8]) and gait function (SMD, �1.48 [CI, �2.08 to�0.89], corresponding to back-transformed walking speeddifference of �0.30 m/s [CI, �0.42 to �0.18 m/s]) (94, 110,111). Ultrasonography did not improve disability (112, 113).Strength of evidence was low due to medium risk of bias andan imprecise estimate of the treatment effect.

Subgroup analyses with a subset of the studies by usingthe VAS instrument for pain measures found that ultra-sonography resulted in statistically and clinically significantshort-term pain reduction (transformed mean reduction,�10.5 [CI, �18.6 to �2.4], which exceeded the cutoff forminimum clinically important difference). At 3-monthfollow-up, however, the effect size of �6.9 (CI, �11.7 to�2.0) no longer exceeded the minimum clinically impor-tance difference despite being statistically significant.

Diathermy

Diathermy effects were analyzed in 5 RCTs (382 par-ticipants) (94, 115–118). Diathermy led to statistically sig-nificant pain reduction at 1 month (SMD, �0.53 [CI,

Table 2. Comparative Effectiveness of Physical Therapy Interventions in Adults With Knee Osteoarthritis*

Outcome (Follow-upTime)

Studies, n(Reference)

Participants,n

Risk ofBias

Directness Consistency† Precision‡ StrengthofEvidence

Pooled Hedges’ SMD(95% CI)

I2

StatisticP ValueFromChi-SquareTest

Electrical stimulationvs. exercise

Pain (�6 wk) 2 (68, 125) 81 High Direct Inconsistent Imprecise Low �1.28 (�2.95 to 0.40) 0.913 0.001Gait function

(�6 wk)2 (69, 125) 81 Medium Direct Inconsistent Imprecise Low 0.20 (�1.15 to 1.55) 0.888 0.003

Aquatic vs. aerobicexercise

Pain (6–13 wk) 2 (58, 126) 110 Medium Direct Inconsistent Imprecise Low �0.44 (�1.22 to 0.35) 0.762 0.044

Laterally vs. neutrallywedged insole

Function composite(6–13 wk)

2 (89, 127) 383 Medium Direct Consistent Imprecise Low �0.01 (�0.25 to 0.25) 0.516 0.083

SMD � standardized mean difference.* The results are from randomized, controlled clinical trials pooled with random-effects model.† We defined inconsistency when statistical heterogeneity existed (based on the chi-square and I2 statistics) in effects across studies.‡ We defined treatment effect estimates as precise when pooled estimates had reasonably narrow 95% CIs and pooled sample size was greater than 400.




�0.96 to �0.10], corresponding to a back-transformedVAS score difference of �11.7 [CI, �21.1 to �2.2])(116–119), but the effect was statistically insignificant at 3months (94, 117, 118). Diathermy had no effect on dis-ability, composite function, joint function, or gait function(94, 116–119). Strength of evidence was low due to me-dium risk of bias and an imprecise estimate of the treat-ment effect. Subgroup analyses with a subset of the studiesusing the VAS instrument for pain measures found thatdiathermy resulted in clinically significant short-term painreduction (mean reduction, �18.4 [CI, �28.0 to �8.8],which exceeded the cutoff for minimum clinically impor-tant difference). At 3-month follow-up, however, the effectsize of �0.7 (CI, �8.2 to 6.8]) no longer exceeded theminimum clinically important difference.

We could not do a pooled analysis to draw meaningfulconclusions about the effects of joint mobilization (120–122), heat (94, 123, 124), or cryotherapy (103, 123) be-cause of differences in outcomes examined, reporting for-mats, and time to follow-up.

Comparative Effectiveness of PT InterventionsIn individual RCTs, PT interventions demonstrated

similar effects on patient-centered outcomes (Table 2).Aerobic and aquatic exercise had the same benefits for dis-ability and pain relief (126, 128), a finding consistent withthe similar effect sizes demonstrated by these interventionsin efficacy studies. One study demonstrated that Tai Chiwas better than stretching exercise for physical disability,psychological disability, global assessment, and transferfunction (129).

Role of Patient Characteristics on OutcomesModerate-strength evidence suggested that with exer-

cise (aerobic and strengthening), high adherence (definedas the percentage of classes attended) was associated withbetter outcomes (Figure 2) (57, 130–133). The higherexercise adherence subgroup had the lowest risk for inci-dent disability in activities of daily living (130), a loweraverage depression score (131), a higher mean Quality of

Well-Being Scale score (57), and greater improvements in6-minute walking distance and disability (131). These re-sults highlight the importance of exercise adherence.

Evidence was inconclusive for the treatment-modifying effects of patient age (46, 107, 134), body massindex (46, 135), race (46), knee malalignment (72, 134),and comorbid conditions (131, 136). Evidence from 5RCTs showed no statistically significant differences in ef-fects between men and women (46, 81, 89, 137, 138).Baseline OA severity may modify the effects of PT inter-ventions on clinical outcomes, but the effect varied de-pending on the treatments, outcomes, or OA severity def-initions (84, 85, 134, 135, 137, 139).

Adverse EventsAdverse events were uncommon and varied across in-

terventions (Table 3). Skin irritation was reported withbraces, insoles, taping, and electrical stimulation; swellingwith braces, diathermy, and exercise; muscle soreness withelectrical stimulation; throbbing sensation with diathermy,electrical stimulation, and pulsed electromagnetic fields; in-creased pain with diathermy, exercise, insoles, and pulsedelectromagnetic fields; falls with insoles; and need for sur-gery with diathermy. Adverse events were not severeenough to deter participants from continuing treatment.

DISCUSSION

Our comprehensive analysis of patient-centered out-comes with PT interventions has implications for clinicalpractice. Our findings reflect previously published guide-lines (7, 10) and systematic reviews (145–147) about corePT interventions. Specifically, interventions that empowerpatients to actively self-manage knee OA (such as aerobic,strength, and proprioception exercise) improved patient-centered outcomes. No single intervention, however, im-proved all outcomes. Pooled analyses provided low-strength evidence of no benefits from diathermy, orthotics,and magnetic stimulation.

Figure 2. Risk for disability in activities of daily living in adherence subgroups.

Adherence Subgroup (Sample Size)

Strengthening exercise

Lowest adherence (28)

Middle adherence (28)

Highest adherence (26)

Aerobic exercise

Lowest adherence (30)

Middle adherence (30)

Highest adherence (28)

0.57 (0.29–1.12)

0.79 (0.42–1.49)

0.43 (0.19–0.97)

0.77 (0.41–1.46)

0.47 (0.23–0.95)

0.38 (0.17–0.82)

0.1 1 10

Relative Risk (95% CI)

The attention control group is used as the reference.




Because of variability in the definitions of outcomes,we had to calculate SMDs. Statistically significant differ-ences in SMDs do not necessarily reflect the clinical im-portance of improvement in outcomes. We evaluated clin-ical importance of improvement in outcomes on the basisof back-transformation of pooled SMDs and whether theresults from individual RCTs met established criteria forclinically important changes. Aerobic, strength, and propri-oception exercise demonstrated consistent effects for painand disability. Yet, we must use caution when inferringclinically important benefits of PT interventions in clinicalsettings.

Our analyses further indicate a possible association be-tween high adherence to exercise and improvement in kneepain and function. Thus, therapeutic exercise programsshould focus on achieving higher adherence rather thanincreasing the amount or intensity of exercise.

Our review was complicated by the discrepancy be-tween the recommended practice of PT and the design ofstudies that examined the interventions. Current practiceguidelines recommend that PT be delivered with a combi-nation of interventions (15). Most notably, current PTpractice would not administer taping or bracing alone, butrather in combination with therapeutic exercise and possi-

Table 3. Adverse Events Reported With Physical Therapy for Knee Osteoarthritis

Treatment Definition of Adverse Events Studies, n(Reference)

Patients,n

Relative Risk(95% CI)

Number Neededto Treat forHarm (95% CI)

Strength ofEvidence

Diathermy vs. placebo Mild pain, mild swelling, feelingof vasodilatation, deteriorationof pain, or needed operation

1 (115) 113 1.13 (0.30–4.31) NA* Low

Electrical stimulation vs. placebo Mild skin reaction 2 (95, 140) 136 1.02 (0.53–1.97) NA* LowInterferential and patterned

muscle stimulation vs.low-current TENS

Skin irritation, skin burns, musclesoreness, electrical shock, andunanticipated effects

1 (141) 109 0.57 (0.20–1.58) NA* Low

Aquatic vs. land-basedexercise†

Increased pain during and afterexercise or swollen knees

1 (58) 52 0.25 (0.08–0.80) 3 (2–10) Low

Aquatic vs. land-based exercise Discontinuation due to effects 1 (58) 52 0.14 (0.01–2.54) NA* LowHome-based progressive vs.

control exerciseNot specified 1 (142) 179 0.60 (0.21–1.78) NA* Low

8-mm vs. 12-mm laterallywedged insole

Popliteal, low back, or foot solepain

1 (143) 41 0.7 (0.13–3.76) NA* Low

8-mm vs. 16-mm laterallywedged insole†


1 (143) 41 0.23 (0.06–0.95) 3 (2–13) Low

12-mm vs. 16-mm laterallywedged insole


1 (143) 42 0.33 (0.10–1.06) NA* Low

Strapped vs. inserted insole Popliteal, low back, or foot solepain

1 (87) 90 5.74 (0.72–45.77) NA* Low

5-degree laterally wedged vs.neutrally wedged insole

Musculoskeletal symptoms 1 (133) 180 0.6 (0.231–1.58) NA* Low


Blisters 1 (133) 180 0.2 (0.02–1.68) NA* Low


Falls 1 (133) 180 1.33 (0.31–5.79) NA* Low

5-degree laterally wedged vs.neutrally wedged insole†

Self-reported problems withinsoles

1 (144) 179 2.02 (1.31–3.12) 4 (3–10) Low


Back pain 1 (144) 179 9.10 (1.18–70.35) 11 (6–42) Low


Foot pain 1 (144) 179 2.31 (1.33–4.03) NA* Low


Uncomfortable or difficultyfitting in shoes

1 (144) 179 3.79 (1.31–10.99) 5 (3–13) Low


Increased knee pain 1 (144) 179 0.40 (0.08–2.031) NA* Low


Felt unstable 1 (144) 179 0.34 (0.01–8.16) NA* Low


Any discomfort 1 (144) 163 1.79 (1.17–2.74) NA* Low

Medial vs. neutrally wedgedinsole

Mild discomfort 1 (144) 30 0.29 (0.01–6.69) NA* Low

PEMF vs. placebo Grumbling or throbbingsensation

1 (107) 90 1 (0.27–3.75) NA* Low

PEMF vs. placebo Warming sensation 1 (107) 90 6 (0.75–47.85) NA* LowPEMF vs. placebo Aggravation of the osteoarthritic

pain in the study knee1 (107) 90 2 (0.19–21.28) NA* Low

Therapeutic vs. control tape† Skin irritation 1 (90) 58 8 (1.07–59.95) 4 (2–15) Low

NA � not applicable; PEMF � pulsed electromagnetic field; TENS � transcutaneous electrical nerve stimulation.* Because the numbered needed to treat was calculated only for statistically significant relative risk.† There was a significant association at 95% CI.




bly other interventions. Published RCTs have focused onthe effects of combining several PT interventions; however,the varied components in these studies preclude meta-analyses (94, 111, 121, 148).

In addition, clinical care for adults with knee OA in-cludes pharmacologic interventions (6–9, 147, 149, 150).Randomized trials equally distribute concomitant treat-ments among treatment groups and, thus, can providevalid estimates of effects of the examined PT interventions.Examined trials rarely reported other treatments that pa-tients may have received, which impeded meta-regressionanalyses, nor did they analyze outcomes separately in pa-tient subgroups by concomitant treatments.

In most cases, strength of evidence was low due toimprecision and risk of bias. Sample sizes were small; totalstudy participants reached 400 with only a few interven-tions (education and aerobic and strengthening exercise).Most trials had moderate risk of bias because they fre-quently excluded patients from the analyses. Many trialsdid not sufficiently describe the nature and intensity ofinterventions or the involvement of physical therapists,which further impeded our ability to conduct meta-analyses (151, 152).

Inconsistent definitions and measurements of the out-comes hampered synthesis of evidence. Validated measure-ments of functional impairments relevant to PT practiceare listed in the Guide to Physical Therapist Practice (15);however, the guide recommends neither clinically impor-tant thresholds for such measures nor monitoring treat-ment effects according to patient-centered outcomes. TheOsteoarthritis Research Society International has recom-mended evaluating treatment success according to patient-centered outcomes and clinically important differences inthe WOMAC scale (153, 154). However, most trials re-ported outcomes as average scores for all patients in eachtreatment group without evaluating how many patientshad clinically meaningful improvement in pain, function,or quality of life.

Our review has limitations. We included only studiespublished in English in journals or reported in ClinicalTrials.gov. Despite a comprehensive review, we do not knowhow many funded but unregistered studies we may havemissed. We assumed publication bias without conductingformal statistical tests for publication bias (29). We did notcontact the principal investigators of the completed regis-tered studies for unpublished data. We relied on publishedinformation about methods and treatment adherence anddid not contact the authors for clarifications of poorly re-ported information (155, 156). We focused on interven-tions applicable to PT practice and did not analyze thebenefits of weight loss in adults who were obese and hadknee OA, which is associated with statistically significantreductions in self-reported disability (157).

Our report has implications for future research. First,consensus is needed about methods to judge the benefits ofPT interventions (158). Benefits should be defined as

rates of clinically important improvements in pain, in-dependence in daily activities, and quality of life.Through meta-analyses of individual-patient data frompreviously conducted RCTs, researchers could categorizepatients according to the clinical importance of anychanges they experienced. Such meta-analyses may alsoprovide good estimates of treatment effects in patient sub-populations by age, comorbid condition, severity of kneeOA, and concomitant treatments. Fully powered trialsshould examine comprehensive and multimodal interven-tions that more closely resemble PT practice.

In conclusion, our analysis suggests that only a few PTinterventions were effective, specifically exercise (aerobic,aquatic, strengthening, and proprioception) and ultra-sonography. Limited direct evidence of comparative effec-tiveness demonstrated similar benefits in disability mea-sures with aerobic, aquatic, and strengthening exercise.Pain relief was consistent with aerobic exercise supervisedby physical therapists. No single PT intervention improvedall outcomes, and some interventions, specifically dia-thermy, orthotics, and magnetic stimulation, demonstratedno benefit. Adverse events were uncommon and did notdeter participants from continuing treatment. Most studiestested single interventions; evidence is sparse on the effec-tiveness of PT interventions delivered in combination, as istypical in practice.

From the University of Minnesota School of Public Health, Universityof Minnesota Medical School, and Minnesota Evidence-based PracticeCenter, Minneapolis, Minnesota.

Grant Support: By AHRQ (under contract 290-2007-10064-I).

Potential Conflicts of Interest: Ms. Olson-Kellogg, Drs. Shamliyan andKane, and Mr. Choi: Grant (money to institution): Agency for HealthcareResearch and Quality. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum�M11-2838.

Requests for Single Reprints: Tatyana A. Shamliyan, MD, MS, Divi-sion of Health Policy and Management, University of Minnesota Schoolof Public Health, D330-5 Mayo (MMC 729), 420 Delaware StreetSoutheast, Minneapolis, MN 55455; e-mail, [email protected].

Current author addresses and author contributions are available at www.annals.org.

References1. Lawrence RC, Felson DT, Helmick CG, Arnold LM, Choi H, Deyo RA,et al; National Arthritis Data Workgroup. Estimates of the prevalence of arthritisand other rheumatic conditions in the United States. Part II. Arthritis Rheum.2008;58:26-35. [PMID: 18163497]2. Dillon CF, Rasch EK, Gu Q, Hirsch R. Prevalence of knee osteoar-thritis in the United States: arthritis data from the Third National Healthand Nutrition Examination Survey 1991-94. J Rheumatol. 2006;33:2271-9. [PMID: 17013996]3. Jordan JM, Helmick CG, Renner JB, Luta G, Dragomir AD, Woodard J,et al. Prevalence of knee symptoms and radiographic and symptomatic kneeosteoarthritis in African Americans and Caucasians: the Johnston County Osteo-arthritis Project. J Rheumatol. 2007;34:172-80. [PMID: 17216685]




4. Bernstein AB, Hing E, Moss AJ, Allen KF, Siller AB, Tiggle RB. Health Carein America: Trends in Utilization. Hyattsville, MD: National Center for HealthStatistics; 2003. Accessed at www.cdc.gov/nchs/data/misc/healthcare.pdf on 10September 2012.5. Imboden J. Chapter 4: Approach to the patient with arthritis. In: Imboden J,Hellmann D, Stone J. CURRENT Rheumatology: Diagnosis & Treatment. 2nded. New York: McGraw-Hill; 2007.6. National Collaborating Centre for Chronic Conditions. Osteoarthritis: Na-tional Clinical Guideline for Care and Management in Adults. London, UK:Royal Coll Physicians; 2008. Accessed at www.nice.org.uk/nicemedia/pdf/CG059FullGuideline.pdf on 10 September 2012.7. American Academy of Orthopaedic Surgeons. Treatment of Osteoarthritis ofthe Knee (Non-arthroplasty). Rosemont, IL: American Acad Orthopaedic Sur-geons; 2008. Accessed at www.aaos.org/research/guidelines/oakguideline.pdf on10 September 2012.8. Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N,et al. OARSI recommendations for the management of hip and knee osteoarthri-tis, part II: OARSI evidence-based, expert consensus guidelines. OsteoarthritisCartilage. 2008;16:137-62. [PMID: 18279766]9. Jordan KM, Arden NK, Doherty M, Bannwarth B, Bijlsma JW, Dieppe P,et al; Standing Committee for International Clinical Studies Including Thera-peutic Trials ESCISIT. EULAR Recommendations 2003: an evidence basedapproach to the management of knee osteoarthritis: Report of a Task Force of theStanding Committee for International Clinical Studies Including TherapeuticTrials (ESCISIT). Ann Rheum Dis. 2003;62:1145-55. [PMID: 14644851]10. Richmond J, Hunter D, Irrgang J, Jones MH, Snyder-Mackler L, VanDurme D, et al; American Academy of Orthopaedic Surgeons. American Acad-emy of Orthopaedic Surgeons clinical practice guideline on the treatment ofosteoarthritis (OA) of the knee. J Bone Joint Surg Am. 2010;92:990-3. [PMID:20360527]11. Shamliyan T, Wang SY, Olson-Kellogg B, Kane R. Physical Therapy forKnee Pain Secondary to Osteoarthritis. Comparative Effectiveness Review no.12-EHC115-EF (Prepared by the University of Minnesota Evidence-based Prac-tice Center under contract 290-2007-10064 I.) Rockville, MD: Agency forHealthcare Research and Quality; 2012.12. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP,et al. The PRISMA statement for reporting systematic reviews and meta-analysesof studies that evaluate health care interventions: explanation and elaboration.Ann Intern Med. 2009;151:W65-94. [PMID: 19622512]13. Agency for Healthcare Research and Quality. Evidence-based Practice Cen-ter Systematic Review Protocol. Comparative Effectiveness of Physical Therapyfor Knee Pain Secondary to Osteoarthritis. Rockville, MD: Agency for HealthcareResearch and Quality; 2011. Accessed at www.effectivehealthcare.ahrq.gov/ehc/products/241/637/Knee%20Pain%20Protocol.pdf on 31 May 2012.14. Higgins JPT, Green S, eds. The Cochrane Handbook for Systematic Re-views of Interventions, version 4.2.5. Chichester, UK: J Wiley; 2005.15. American Physical Therapy Association. Impaired joint mobility, motorfunction, muscle performance, and range of motion associated with localizedinflammation. In: American Physical Therapy Association. Guide to PhysicalTherapist Practice. Second Edition. Phys Ther. 2001;81:9-746. [PMID:11175682]16. Chou R, Aronson N, Atkins D, Ismaila AS, Santaguida P, Smith DH, et al.AHRQ series paper 4: assessing harms when comparing medical interventions:AHRQ and the effective health-care program. J Clin Epidemiol. 2010;63:502-12. [PMID: 18823754]17. Shamliyan TA, Wang S-Y, Olson-Kellogg B, Kane RL. Comparative Effec-tiveness of Physical Therapy for Knee Pain Secondary to Osteoarthritis. DataAbstraction Forms. 2012. Accessed at https://netfiles.umn.edu/xythoswfs/webui/_xy-20731563_1-t_wzpHYqhT on 10 September 2012.18. Owens DK, Lohr KN, Atkins D, Treadwell JR, Reston JT, Bass EB, et al.AHRQ series paper 5: grading the strength of a body of evidence when compar-ing medical interventions—Agency for Healthcare Research and Quality and theEffective Health-Care Program. J Clin Epidemiol. 2010;63:513-23. [PMID:19595577]19. Guyatt GH, Oxman AD, Kunz R, Brozek J, Alonso-Coello P, Rind D,et al. GRADE guidelines 6. Rating the quality of evidence—imprecision. J ClinEpidemiol. 2011;64:1283-93. [PMID: 21839614]20. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed.London, UK: Routledge Academic; 1988.

21. Borenstein DM, Hedges LV, Higgins DJPT, Rothstein HR. Introductionto Meta-Analysis. Statistics in Practice. Chichester, UK: J Wiley; 2009.22. Viechtbauer W. Confidence intervals for the amount of heterogeneity inmeta-analysis. Stat Med. 2007;26:37-52. [PMID: 16463355]23. Knapp G, Biggerstaff BJ, Hartung J. Assessing the amount of heterogeneityin random-effects meta-analysis. Biom J. 2006;48:271-85. [PMID: 16708778]24. Fu R, Gartlehner G, Grant M, Shamliyan T, Sedrakyan A, Wilt TJ, et al.Conducting quantitative synthesis when comparing medical interventions:AHRQ and the Effective Health Care Program. J Clin Epidemiol. 2011;64:1187-97. [PMID: 21477993]25. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistencyin meta-analyses. BMJ. 2003;327:557-60. [PMID: 12958120]26. Herbison P, Hay-Smith J, Gillespie WJ. Adjustment of meta-analyses on thebasis of quality scores should be abandoned. J Clin Epidemiol. 2006;59:1249-56.[PMID: 17098567]27. Dickersin K, Min YI. NIH clinical trials and publication bias. Online J CurrClin Trials. 1993;Doc No 50. [PMID: 8306005]28. Thornton A, Lee P. Publication bias in meta-analysis: its causes and conse-quences. J Clin Epidemiol. 2000;53:207-16. [PMID: 10729693]29. Sterne JA, Sutton AJ, Ioannidis JP, Terrin N, Jones DR, Lau J, et al.Recommendations for examining and interpreting funnel plot asymmetry inmeta-analyses of randomised controlled trials. BMJ. 2011;343:d4002. [PMID:21784880]30. Shaw JW, Johnson JA, Coons SJ. US valuation of the EQ-5D health states:development and testing of the D1 valuation model. Med Care. 2005;43:203-20.[PMID: 15725977]31. Ware JE Jr, Kosinski M, Bayliss MS, McHorney CA, Rogers WH, RaczekA. Comparison of methods for the scoring and statistical analysis of SF-36 healthprofile and summary measures: summary of results from the Medical OutcomesStudy. Med Care. 1995;33:AS264-79. [PMID: 7723455]32. White DK, Keysor JJ, Lavalley MP, Lewis CE, Torner JC, Nevitt MC,et al. Clinically important improvement in function is common in people with orat high risk of knee OA: the MOST study. J Rheumatol. 2010;37:1244-51.[PMID: 20395640]33. Lingard EA, Katz JN, Wright RJ, Wright EA, Sledge CB; Kinemax Out-comes Group. Validity and responsiveness of the Knee Society Clinical RatingSystem in comparison with the SF-36 and WOMAC. J Bone Joint Surg Am.2001;83-A:1856-64. [PMID: 11741066]34. Chou R, Helfand M, Peterson K, Dana T, Roberts C. Comparative Effec-tiveness and Safety of Analgesics for Osteoarthritis. Comparative EffectivenessReview no. 4. AHRQ Publication no. 06-EHC009-EF. Rockville, MD: Agencyfor Healthcare Research and Quality; 2006. Accessed at http://effectivehealthcare.ahrq.gov/ehc/assets/File/AnalgesicsFinal.pdf on 10 September 2012.35. Egger M, Smith GD, Altman D, eds. Systematic Reviews in Health Care:Meta-Analysis in Context. 2nd ed. London, UK: BMJ Books; 2001.36. Farr JN, Going SB, McKnight PE, Kasle S, Cussler EC, Cornett M. Pro-gressive resistance training improves overall physical activity levels in patients withearly osteoarthritis of the knee: a randomized controlled trial. Phys Ther. 2010;90:356-66. [PMID: 20056719]37. Messier SP, Loeser RF, Miller GD, Morgan TM, Rejeski WJ, Sevick MA,et al. Exercise and dietary weight loss in overweight and obese older adults withknee osteoarthritis: the Arthritis, Diet, and Activity Promotion Trial. ArthritisRheum. 2004;50:1501-10. [PMID: 15146420]38. Rejeski WJ, Focht BC, Messier SP, Morgan T, Pahor M, Penninx B.Obese, older adults with knee osteoarthritis: weight loss, exercise, and quality oflife. Health Psychol. 2002;21:419-26. [PMID: 12211508]39. Weng MC, Lee CL, Chen CH, Hsu JJ, Lee WD, Huang MH, et al. Effectsof different stretching techniques on the outcomes of isokinetic exercise in pa-tients with knee osteoarthritis. Kaohsiung J Med Sci. 2009;25:306-15. [PMID:19560995]40. Lin DH, Lin CH, Lin YF, Jan MH. Efficacy of 2 non-weight-bearinginterventions, proprioception training versus strength training, for patients withknee osteoarthritis: a randomized clinical trial. J Orthop Sports Phys Ther. 2009;39:450-7. [PMID: 19531879]41. Tsauo JY, Cheng PF, Yang RS. The effects of sensorimotor training on kneeproprioception and function for patients with knee osteoarthritis: a preliminaryreport. Clin Rehabil. 2008;22:448-57. [PMID: 18441041]42. Jan MH, Tang PF, Lin JJ, Tseng SC, Lin YF, Lin DH. Efficacy of atarget-matching foot-stepping exercise on proprioception and function in patients




with knee osteoarthritis. J Orthop Sports Phys Ther. 2008;38:19-25. [PMID:18357655]43. Peloquin L, Bravo G, Gauthier P, Lacombe G, Billiard JS. Effects of across-training exercise program in persons with osteoarthritis of the knee. A ran-domized controlled trial. J Clin Rheumatol. 1999;5:126-136. [PMID:19078371]44. Keefe FJ, Blumenthal J, Baucom D, Affleck G, Waugh R, Caldwell DS,et al. Effects of spouse-assisted coping skills training and exercise training inpatients with osteoarthritic knee pain: a randomized controlled study. Pain. 2004;110:539-49. [PMID: 15288394]45. An B, Dai K, Zhu Z, Wang Y, Hao Y, Tang T, et al. Baduanjin alleviatesthe symptoms of knee osteoarthritis. J Altern Complement Med. 2008;14:167-74. [PMID: 18315512]46. Ettinger WH Jr, Burns R, Messier SP, Applegate W, Rejeski WJ, MorganT, et al. A randomized trial comparing aerobic exercise and resistance exercisewith a health education program in older adults with knee osteoarthritis. TheFitness Arthritis and Seniors Trial (FAST). JAMA. 1997;277:25-31. [PMID:8980206]47. Yip YB, Sit JW, Wong DY, Chong SY, Chung LH. A 1-year follow-up ofan experimental study of a self-management arthritis programme with an addedexercise component of clients with osteoarthritis of the knee. Psychol HealthMed. 2008;13:402-14. [PMID: 18825579]48. Sullivan T, Allegrante JP, Peterson MG, Kovar PA, MacKenzie CR. One-year followup of patients with osteoarthritis of the knee who participated in aprogram of supervised fitness walking and supportive patient education. ArthritisCare Res. 1998;11:228-33. [PMID: 9791321]49. Hay EM, Foster NE, Thomas E, Peat G, Phelan M, Yates HE, et al.Effectiveness of community physiotherapy and enhanced pharmacy review forknee pain in people aged over 55 presenting to primary care: pragmatic ran-domised trial. BMJ. 2006;333:995. [PMID: 17056608]50. Thorstensson CA, Roos EM, Petersson IF, Ekdahl C. Six-week high-intensity exercise program for middle-aged patients with knee osteoarthritis: arandomized controlled trial [ISRCTN20244858]. BMC Musculoskelet Disord.2005;6:27. [PMID: 15924620]51. Aglamis B, Toraman NF, Yaman H. The effect of a 12-week supervisedmulticomponent exercise program on knee OA in Turkish women. J Back Mus-culoskelet Rehabil. 2008;21:121-8.52. Focht BC, Rejeski WJ, Ambrosius WT, Katula JA, Messier SP. Exercise,self-efficacy, and mobility performance in overweight and obese older adults withknee osteoarthritis. Arthritis Rheum. 2005;53:659-65. [PMID: 16208674]53. Jan MH, Lin CH, Lin YF, Lin JJ, Lin DH. Effects of weight-bearing versusnonweight-bearing exercise on function, walking speed, and position sense inparticipants with knee osteoarthritis: a randomized controlled trial. Arch PhysMed Rehabil. 2009;90:897-904. [PMID: 19480863]54. Peterson MG, Kovar-Toledano PA, Otis JC, Allegrante JP, Mackenzie CR,Gutin B, et al. Effect of a walking program on gait characteristics in patients withosteoarthritis. Arthritis Care Res. 1993;6:11-6. [PMID: 8443252]55. Deyle GD, Henderson NE, Matekel RL, Ryder MG, Garber MB, AllisonSC. Effectiveness of manual physical therapy and exercise in osteoarthritis of theknee. A randomized, controlled trial. Ann Intern Med. 2000;132:173-81.[PMID: 10651597]56. Messier SP, Thompson CD, Ettinger WH. Effects of long-term aerobic orweight training regimes on gait in an older, osteoarthritic population. J ApplBiomech. 1997;13:205-25.57. Patrick DL, Ramsey SD, Spencer AC, Kinne S, Belza B, Topolski TD.Economic evaluation of aquatic exercise for persons with osteoarthritis. MedCare. 2001;39:413-24. [PMID: 11317090]58. Lund H, Weile U, Christensen R, Rostock B, Downey A, Bartels EM, et al.A randomized controlled trial of aquatic and land-based exercise in patients withknee osteoarthritis. J Rehabil Med. 2008;40:137-44. [PMID: 18509579]59. Rooks DS, Huang J, Bierbaum BE, Bolus SA, Rubano J, Connolly CE,et al. Effect of preoperative exercise on measures of functional status in men andwomen undergoing total hip and knee arthroplasty. Arthritis Rheum. 2006;55:700-8. [PMID: 17013852]60. Kuptniratsaikul V, Tosayanonda O, Nilganuwong S, Thamalikitkul V. Theefficacy of a muscle exercise program to improve functional performance of theknee in patients with osteoarthritis. J Med Assoc Thai. 2002;85:33-40. [PMID:12075718]61. Baker KR, Nelson ME, Felson DT, Layne JE, Sarno R, Roubenoff R. Theefficacy of home based progressive strength training in older adults with knee

osteoarthritis: a randomized controlled trial. J Rheumatol. 2001;28:1655-65.[PMID: 11469475]62. Doi T, Akai M, Fujino K, Iwaya T, Kurosawa H, Hayashi K, et al. Effectof home exercise of quadriceps on knee osteoarthritis compared with nonsteroidalantiinflammatory drugs: a randomized controlled trial. Am J Phys Med Rehabil.2008;87:258-69. [PMID: 18356618]63. Topp R, Woolley S, Hornyak J 3rd, Khuder S, Kahaleh B. The effect ofdynamic versus isometric resistance training on pain and functioning amongadults with osteoarthritis of the knee. Arch Phys Med Rehabil. 2002;83:1187-95.[PMID: 12235596]64. Borjesson M, Robertson E, Weidenhielm L, Mattsson E, Olsson E. Phys-iotherapy in knee osteoarthrosis: effect on pain and walking. Physiother Res Int.1996;1:89-97. [PMID: 9238726]65. Thomas KS, Muir KR, Doherty M, Jones AC, O’Reilly SC, Bassey EJ.Home based exercise programme for knee pain and knee osteoarthritis: ran-domised controlled trial. BMJ. 2002;325:752. [PMID: 12364304]66. Schilke JM, Johnson GO, Housh TJ, O’Dell JR. Effects of muscle-strengthtraining on the functional status of patients with osteoarthritis of the knee joint.Nurs Res. 1996;45:68-72. [PMID: 8604366]67. Gur H, Cakin N, Akova B, Okay E, Kucukoglu S. Concentric versuscombined concentric-eccentric isokinetic training: effects on functional capacityand symptoms in patients with osteoarthrosis of the knee. Arch Phys Med Rehabil.2002;83:308-16. [PMID: 11887109]68. Cheing GL, Hui-Chan CW, Chan KM. Does four weeks of TENS and/orisometric exercise produce cumulative reduction of osteoarthritic knee pain? ClinRehabil. 2002;16:749-60. [PMID: 12428824]69. Cheing GL, Hui-Chan CW. Would the addition of TENS to exercise train-ing produce better physical performance outcomes in people with knee osteo-arthritis than either intervention alone? Clin Rehabil. 2004;18:487-97. [PMID:15293483]70. Jan MH, Lin JJ, Liau JJ, Lin YF, Lin DH. Investigation of clinical effects ofhigh- and low-resistance training for patients with knee osteoarthritis: a random-ized controlled trial. Phys Ther. 2008;88:427-36. [PMID: 18218827]71. Lim BW, Hinman RS, Wrigley TV, Sharma L, Bennell KL. Does kneemalalignment mediate the effects of quadriceps strengthening on knee adductionmoment, pain, and function in medial knee osteoarthritis? A randomized con-trolled trial. Arthritis Rheum. 2008;59:943-51. [PMID: 18576289]72. Bennell KL, Hunt MA, Wrigley TV, Hunter DJ, McManus FJ, HodgesPW, et al. Hip strengthening reduces symptoms but not knee load in people withmedial knee osteoarthritis and varus malalignment: a randomised controlled trial.Osteoarthritis Cartilage. 2010;18:621-8. [PMID: 20175973]73. Swank AM, Kachelman JB, Bibeau W, Quesada PM, Nyland J, Malkani A,et al. Prehabilitation before total knee arthroplasty increases strength and functionin older adults with severe osteoarthritis. J Strength Cond Res. 2011;25:318-25.[PMID: 21217530]74. Lee HJ, Park HJ, Chae Y, Kim SY, Kim SN, Kim ST, et al. Tai Chi Qigongfor the quality of life of patients with knee osteoarthritis: a pilot, randomized,waiting list controlled trial. Clin Rehabil. 2009;23:504-11. [PMID: 19389743]75. Brismee JM, Paige RL, Chyu MC, Boatright JD, Hagar JM, McCaleb JA,et al. Group and home-based tai chi in elderly subjects with knee osteoarthritis: arandomized controlled trial. Clin Rehabil. 2007;21:99-111. [PMID: 17264104]76. Song R, Roberts BL, Lee EO, Lam P, Bae SC. A randomized study of theeffects of t’ai chi on muscle strength, bone mineral density, and fear of falling inwomen with osteoarthritis. J Altern Complement Med. 2010;16:227-33.[PMID: 20192907]77. Yip YB, Tam AC. An experimental study on the effectiveness of massage witharomatic ginger and orange essential oil for moderate-to-severe knee pain amongthe elderly in Hong Kong. Complement Ther Med. 2008;16:131-8. [PMID:18534325]78. Ko T, Lee S, Lee D. Manual therapy and exercise for OA knee: effects onmuscle strength, proprioception, and functional performance. Journal of PhysicalTherapy Science. 2009;21:293-9.79. Perlman AI, Sabina A, Williams AL, Njike VY, Katz DL. Massage therapyfor osteoarthritis of the knee: a randomized controlled trial. Arch Intern Med.2006;166:2533-8. [PMID: 17159021]80. Toda Y, Tsukimura N, Segal N. An optimal duration of daily wear for aninsole with subtalar strapping in patients with varus deformity osteoarthritis of theknee. Osteoarthritis Cartilage. 2005;13:353-60. [PMID: 15780649]81. Bar-Ziv Y, Beer Y, Ran Y, Benedict S, Halperin N. A treatment applying abiomechanical device to the feet of patients with knee osteoarthritis results in




reduced pain and improved function: a prospective controlled study. BMC Mus-culoskelet Disord. 2010;11:179. [PMID: 20698991]82. Hinman RS, Bowles KA, Bennell KL. Laterally wedged insoles in kneeosteoarthritis: do biomechanical effects decline after one month of wear? BMCMusculoskelet Disord. 2009;10:146. [PMID: 19939281]83. Maly MR, Culham EG, Costigan PA. Static and dynamic biomechanics offoot orthoses in people with medial compartment knee osteoarthritis. Clin Bio-mech (Bristol, Avon). 2002;17:603-10. [PMID: 12243720]84. Kerrigan DC, Lelas JL, Goggins J, Merriman GJ, Kaplan RJ, Felson DT.Effectiveness of a lateral-wedge insole on knee varus torque in patients with kneeosteoarthritis. Arch Phys Med Rehabil. 2002;83:889-93. [PMID: 12098144]85. Kuroyanagi Y, Nagura T, Matsumoto H, Otani T, Suda Y, Nakamura T,et al. The lateral wedged insole with subtalar strapping significantly reduces dy-namic knee load in the medial compartment gait analysis on patients with medialknee osteoarthritis. Osteoarthritis Cartilage. 2007;15:932-6. [PMID: 17391994]86. Nigg BM, Emery C, Hiemstra LA. Unstable shoe construction and reduc-tion of pain in osteoarthritis patients. Med Sci Sports Exerc. 2006;38:1701-8.[PMID: 17019290]87. Toda Y, Segal N, Kato A, Yamamoto S, Irie M. Effect of a novel insole onthe subtalar joint of patients with medial compartment osteoarthritis of the knee.J Rheumatol. 2001;28:2705-10. [PMID: 11764221]88. Toda Y, Tsukimura N. A six-month followup of a randomized trial compar-ing the efficacy of a lateral-wedge insole with subtalar strapping and an in-shoelateral-wedge insole in patients with varus deformity osteoarthritis of the knee.Arthritis Rheum. 2004;50:3129-36. [PMID: 15476225]89. Toda Y, Tsukimura N. Influence of concomitant heeled footwear whenwearing a lateral wedged insole for medial compartment osteoarthritis of the knee.Osteoarthritis Cartilage. 2008;16:244-53. [PMID: 17693101]90. Hinman RS, Crossley KM, McConnell J, Bennell KL. Efficacy of knee tapein the management of osteoarthritis of the knee: blinded randomised controlledtrial. BMJ. 2003;327:135. [PMID: 12869456]91. Hinman RS, Bennell KL, Crossley KM, McConnell J. Immediate effects ofadhesive tape on pain and disability in individuals with knee osteoarthritis. Rheu-matology (Oxford). 2003;42:865-9. [PMID: 12730546]92. Cushnaghan J, McCarthy C, Dieppe P. Taping the patella medially: a newtreatment for osteoarthritis of the knee joint? BMJ. 1994;308:753-5. [PMID:8142829]93. Talbot LA, Gaines JM, Ling SM, Metter EJ. A home-based protocol ofelectrical muscle stimulation for quadriceps muscle strength in older adults withosteoarthritis of the knee. J Rheumatol. 2003;30:1571-8. [PMID: 12858461]94. Cetin N, Aytar A, Atalay A, Akman MN. Comparing hot pack, short-wavediathermy, ultrasound, and TENS on isokinetic strength, pain, and functionalstatus of women with osteoarthritic knees: a single-blind, randomized, controlledtrial. Am J Phys Med Rehabil. 2008;87:443-51. [PMID: 18496246]95. Garland D, Holt P, Harrington JT, Caldwell J, Zizic T, Cholewczynski J.A 3-month, randomized, double-blind, placebo-controlled study to evaluate thesafety and efficacy of a highly optimized, capacitively coupled, pulsed electricalstimulator in patients with osteoarthritis of the knee. Osteoarthritis Cartilage.2007;15:630-7. [PMID: 17303443]96. Selfe TK, Bourguignon C, Taylor AG. Effects of noninvasive interactiveneurostimulation on symptoms of osteoarthritis of the knee: a randomized, sham-controlled pilot study. J Altern Complement Med. 2008;14:1075-81. [PMID:19055333]97. Gaines JM, Metter EJ, Talbot LA. The effect of neuromuscular electricalstimulation on arthritis knee pain in older adults with osteoarthritis of the knee.Appl Nurs Res. 2004;17:201-6. [PMID: 15343554]98. Kang RW, Lewis PB, Kramer A, Hayden JK, Cole BJ. Prospective random-ized single-blinded controlled clinical trial of percutaneous neuromodulation paintherapy device versus sham for the osteoarthritic knee: a pilot study. Orthopedics.2007;30:439-45. [PMID: 17598487]99. Law PP, Cheing GL. Optimal stimulation frequency of transcutaneous elec-trical nerve stimulation on people with knee osteoarthritis. J Rehabil Med. 2004;36:220-5. [PMID: 15626162]100. Taylor P, Hallett M, Flaherty L. Treatment of osteoarthritis of the kneewith transcutaneous electrical nerve stimulation. Pain. 1981;11:233-40. [PMID:7033891]101. Itoh K, Hirota S, Katsumi Y, Ochi H, Kitakoji H. A pilot study on usingacupuncture and transcutaneous electrical nerve stimulation (TENS) to treat kneeosteoarthritis (OA). Chin Med. 2008;3:2. [PMID: 18312661]

102. Grimmer K. A controlled double-blind study comparing the effects ofstrong burst method TENS and high rate TENS on painful osteoarthritic knees.Aust J Physiother. 1992;38:49-56.103. Pietrosimone BG, Hart JM, Saliba SA, Hertel J, Ingersoll CD. Immediateeffects of transcutaneous electrical nerve stimulation and focal knee joint coolingon quadriceps activation. Med Sci Sports Exerc. 2009;41:1175-81. [PMID:19461552]104. Yurtkuran M, Kocagil T. TENS, electroacupuncture and ice massage: com-parison of treatment for osteoarthritis of the knee. Am J Acupunct. 1999;27:133-40. [PMID: 10729968]105. Law PP, Cheing GL, Tsui AY. Does transcutaneous electrical nerve stim-ulation improve the physical performance of people with knee osteoarthritis?J Clin Rheumatol. 2004;10:295-9. [PMID: 17043536]106. Ay S, Evcik D. The effects of pulsed electromagnetic fields in the treatmentof knee osteoarthritis: a randomized, placebo-controlled trial. Rheumatol Int.2009;29:663-6. [PMID: 19015858]107. Thamsborg G, Florescu A, Oturai P, Fallentin E, Tritsaris K, Dissing S.Treatment of knee osteoarthritis with pulsed electromagnetic fields: a random-ized, double-blind, placebo-controlled study. Osteoarthritis Cartilage. 2005;13:575-81. [PMID: 15979009]108. Trock DH, Bollet AJ, Markoll R. The effect of pulsed electromagneticfields in the treatment of osteoarthritis of the knee and cervical spine. Report ofrandomized, double blind, placebo controlled trials. J Rheumatol. 1994;21:1903-11. [PMID: 7837158]109. Nicolakis P, Kollmitzer J, Crevenna R, Bittner C, Erdogmus CB, Nico-lakis J. Pulsed magnetic field therapy for osteoarthritis of the knee—a double-blind sham-controlled trial. Wien Klin Wochenschr. 2002;114:678-84. [PMID:12602111]110. Huang MH, Lin YS, Lee CL, Yang RC. Use of ultrasound to increaseeffectiveness of isokinetic exercise for knee osteoarthritis. Arch Phys Med Rehabil.2005;86:1545-51. [PMID: 16084806]111. Huang MH, Yang RC, Lee CL, Chen TW, Wang MC. Preliminary resultsof integrated therapy for patients with knee osteoarthritis. Arthritis Rheum. 2005;53:812-20. [PMID: 16342083]112. Ozgonenel L, Aytekin E, Durmusoglu G. A double-blind trial of clinicaleffects of therapeutic ultrasound in knee osteoarthritis. Ultrasound Med Biol.2009;35:44-9. [PMID: 18829151]113. Tascioglu F, Kuzgun S, Armagan O, Ogutler G. Short-term effectivenessof ultrasound therapy in knee osteoarthritis. J Int Med Res. 2010;38:1233-42.[PMID: 20925995]114. Sayers SP, Gibson K, Cook CR. Effect of high-speed power training onmuscle performance, function, and pain in older adults with knee osteoarthritis: apilot investigation. Arthritis Care Res (Hoboken). 2012;64:46-53. [PMID:22012877]115. Rattanachaiyanont M, Kuptniratsaikul V. No additional benefit of short-wave diathermy over exercise program for knee osteoarthritis in peri-/post-menopausal women: an equivalence trial. Osteoarthritis Cartilage. 2008;16:823-8. [PMID: 18178111]116. Fukuda TY, Alves da Cunha R, Fukuda VO, Rienzo FA, Cazarini C Jr,Carvalho Nde A, et al. Pulsed shortwave treatment in women with knee osteo-arthritis: a multicenter, randomized, placebo-controlled clinical trial. Phys Ther.2011;91:1009-17. [PMID: 21642511]117. Laufer Y, Zilberman R, Porat R, Nahir AM. Effect of pulsed short-wavediathermy on pain and function of subjects with osteoarthritis of the knee: aplacebo-controlled double-blind clinical trial. Clin Rehabil. 2005;19:255-63.[PMID: 15859526]118. Akyol Y, Durmus D, Alayli G, Tander B, Bek Y, Canturk F, et al. Doesshort-wave diathermy increase the effectiveness of isokinetic exercise on pain,function, knee muscle strength, quality of life, and depression in the patients withknee osteoarthritis? A randomized controlled clinical study. Eur J Phys RehabilMed. 2010;46:325-36. [PMID: 20926998]119. Callaghan MJ, Whittaker PE, Grimes S, Smith L. An evaluation of pulsedshortwave on knee osteoarthritis using radioleucoscintigraphy: a randomised,double blind, controlled trial. Joint Bone Spine. 2005;72:150-5. [PMID:15797496]120. Pollard H, Ward G, Hoskins W, Hardy K. The effect of a manual therapyknee protocol on osteoarthritic knee pain: a randomised controlled trial. J CanChiropr Assoc. 2008;52:229-42. [PMID: 19066697]121. Deyle GD, Allison SC, Matekel RL, Ryder MG, Stang JM, Gohdes DD,et al. Physical therapy treatment effectiveness for osteoarthritis of the knee: a




randomized comparison of supervised clinical exercise and manual therapy pro-cedures versus a home exercise program. Phys Ther. 2005;85:1301-17. [PMID:16305269]122. Moss P, Sluka K, Wright A. The initial effects of knee joint mobilization onosteoarthritic hyperalgesia. Man Ther. 2007;12:109-18. [PMID: 16777467]123. Denegar CR, Dougherty DR, Friedman JE, Schimizzi ME, Clark JE,Comstock BA, et al. Preferences for heat, cold, or contrast in patients with kneeosteoarthritis affect treatment response. Clin Interv Aging. 2010;5:199-206.[PMID: 20711439]124. Mazzuca SA, Page MC, Meldrum RD, Brandt KD, Petty-Saphon S. Pilotstudy of the effects of a heat-retaining knee sleeve on joint pain, stiffness, andfunction in patients with knee osteoarthritis. Arthritis Rheum. 2004;51:716-21.[PMID: 15478166]125. Durmus D, Alayli G, Canturk F. Effects of quadriceps electrical stimulationprogram on clinical parameters in the patients with knee osteoarthritis. ClinRheumatol. 2007;26:674-8. [PMID: 16897119]126. Wyatt FB, Milam S, Manske RC, Deere R. The effects of aquatic andtraditional exercise programs on persons with knee osteoarthritis. J Strength CondRes. 2001;15:337-40. [PMID: 11710661]127. Maillefert JF, Hudry C, Baron G, Kieffert P, Bourgeois P, Lechevalier D,et al. Laterally elevated wedged insoles in the treatment of medial knee osteo-arthritis: a prospective randomized controlled study. Osteoarthritis Cartilage.2001;9:738-45. [PMID: 11795993]128. Silva LE, Valim V, Pessanha AP, Oliveira LM, Myamoto S, Jones A, et al.Hydrotherapy versus conventional land-based exercise for the management ofpatients with osteoarthritis of the knee: a randomized clinical trial. Phys Ther.2008;88:12-21. [PMID: 17986497]129. Wang C, Schmid CH, Hibberd PL, Kalish R, Roubenoff R, Rones R,et al. Tai Chi is effective in treating knee osteoarthritis: a randomized controlledtrial. Arthritis Rheum. 2009;61:1545-53. [PMID: 19877092]130. Penninx BW, Messier SP, Rejeski WJ, Williamson JD, DiBari M,Cavazzini C, et al. Physical exercise and the prevention of disability in activities ofdaily living in older persons with osteoarthritis. Arch Intern Med. 2001;161:2309-16. [PMID: 11606146]131. Penninx BW, Rejeski WJ, Pandya J, Miller ME, Di Bari M, ApplegateWB, et al. Exercise and depressive symptoms: a comparison of aerobic and resis-tance exercise effects on emotional and physical function in older persons withhigh and low depressive symptomatology. J Gerontol B Psychol Sci Soc Sci.2002;57:P124-32. [PMID: 11867660]132. Rejeski WJ, Brawley LR, Ettinger W, Morgan T, Thompson C. Compli-ance to exercise therapy in older participants with knee osteoarthritis: implicationsfor treating disability. Med Sci Sports Exerc. 1997;29:977-85. [PMID: 9268953]133. van Gool CH, Penninx BW, Kempen GI, Rejeski WJ, Miller GD, vanEijk JT, et al. Effects of exercise adherence on physical function among over-weight older adults with knee osteoarthritis. Arthritis Rheum. 2005;53:24-32.[PMID: 15696558]134. Brouwer RW, van Raaij TM, Verhaar JA, Coene LN, Bierma-ZeinstraSM. Brace treatment for osteoarthritis of the knee: a prospective randomizedmulti-centre trial. Osteoarthritis Cartilage. 2006;14:777-83. [PMID: 16563810]135. Baker K, Goggins J, Xie H, Szumowski K, LaValley M, Hunter DJ, et al.A randomized crossover trial of a wedged insole for treatment of knee osteo-arthritis. Arthritis Rheum. 2007;56:1198-203. [PMID: 17393448]136. Mangani I, Cesari M, Kritchevsky SB, Maraldi C, Carter CS, AtkinsonHH, et al. Physical exercise and comorbidity. Results from the Fitness and Ar-thritis in Seniors Trial (FAST). Aging Clin Exp Res. 2006;18:374-80. [PMID:17167301]137. Mikesky AE, Mazzuca SA, Brandt KD, Perkins SM, Damush T, LaneKA. Effects of strength training on the incidence and progression of knee osteo-arthritis. Arthritis Rheum. 2006;55:690-9. [PMID: 17013851]138. Fisher NM, Gresham G, Pendergast DR. Effects of a quantitative progres-sive rehabilitation program applied unilaterally to the osteoarthritic knee. ArchPhys Med Rehabil. 1993;74:1319-26. [PMID: 8259900]139. Huang MH, Chen CH, Chen TW, Weng MC, Wang WT, Wang YL.The effects of weight reduction on the rehabilitation of patients with knee osteo-arthritis and obesity. Arthritis Care Res. 2000;13:398-405. [PMID: 14635316]140. Zizic TM, Hoffman KC, Holt PA, Hungerford DS, O’Dell JR, JacobsMA, et al. The treatment of osteoarthritis of the knee with pulsed electricalstimulation. J Rheumatol. 1995;22:1757-61. [PMID: 8523357]

141. Burch FX, Tarro JN, Greenberg JJ, Carroll WJ. Evaluating the benefits ofpatterned stimulation in the treatment of osteoarthritis of the knee: a multi-center, randomized, single-blind, controlled study with an independent maskedevaluator. Osteoarthritis Cartilage. 2008;16:865-72. [PMID: 18262443]142. Petrella RJ, Bartha C. Home based exercise therapy for older patients withknee osteoarthritis: a randomized clinical trial. J Rheumatol. 2000;27:2215-21.[PMID: 10990236]143. Toda Y, Tsukimura N, Kato A. The effects of different elevations of later-ally wedged insoles with subtalar strapping on medial compartment osteoarthritisof the knee. Arch Phys Med Rehabil. 2004;85:673-7. [PMID: 15083446]144. Bennell KL, Bowles KA, Payne C, Cicuttini F, Williamson E, Forbes A,et al. Lateral wedge insoles for medial knee osteoarthritis: 12 month randomisedcontrolled trial. BMJ. 2011;342:d2912. [PMID: 21593096]145. Rutjes AW, Nuesch E, Sterchi R, Kalichman L, Hendriks E, Osiri M,et al. Transcutaneous electrostimulation for osteoarthritis of the knee. CochraneDatabase Syst Rev. 2009:CD002823. [PMID: 19821296]146. Rutjes AW, Nuesch E, Sterchi R, Juni P. Therapeutic ultrasound forosteoarthritis of the knee or hip. Cochrane Database Syst Rev. 2010:CD003132.[PMID: 20091539]147. Recommendations for the medical management of osteoarthritis ofthe hip and knee: 2000 update. American College of Rheumatology Sub-committee on Osteoarthritis Guidelines. Arthritis Rheum. 2000;43:1905-15. [PMID: 11014340]148. Bennell KL, Hinman RS, Metcalf BR, Buchbinder R, McConnell J, Mc-Coll G, et al. Efficacy of physiotherapy management of knee joint osteoarthritis:a randomised, double blind, placebo controlled trial. Ann Rheum Dis. 2005;64:906-12. [PMID: 15897310]149. Brand C, Buchbinder R, Wluka A, Jones K, Ruth D, McKenzie S, et al.Guideline for the non-surgical management of hip and knee osteoarthritis. SouthMelbourne, Victoria, Australia: The Royal Australian Coll General Practitioners;2009. Accessed at www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp117-hip-knee-osteoarthritis.pdf on 10 September 2012.150. Mazieres B, Bannwarth B, Dougados M, Lequesne M. EULAR recom-mendations for the management of knee osteoarthritis. Report of a task force ofthe Standing Committee for International Clinical Studies Including TherapeuticTrials. Joint Bone Spine. 2001;68:231-40. [PMID: 11394623]151. Bruckenthal P, Broderick JE. Assessing treatment fidelity in pilot studiesassist in designing clinical trials: an illustration from a nurse practitionercommunity-based intervention for pain. ANS Adv Nurs Sci. 2007;30:E72-84.[PMID: 17299277]152. Doherty M, Jones A. Design of clinical trials in knee osteoarthritis: practicalissues for debate [Editorial]. Osteoarthritis Cartilage. 1998;6:371-3. [PMID:10343768]153. Pham T, Van Der Heijde D, Lassere M, Altman RD, Anderson JJ, Bel-lamy N, et al; OMERACT-OARSI. Outcome variables for osteoarthritis clinicaltrials: The OMERACT-OARSI set of responder criteria. J Rheumatol. 2003;30:1648-54. [PMID: 12858473]154. Pham T, van der Heijde D, Altman RD, Anderson JJ, Bellamy N, Hoch-berg M, et al. OMERACT-OARSI initiative: Osteoarthritis Research SocietyInternational set of responder criteria for osteoarthritis clinical trials revisited.Osteoarthritis Cartilage. 2004;12:389-99. [PMID: 15094138]155. Viswanathan M, Ansari MT, Berkman ND, Chang S, Hartling L,McPheeters LM, et al. Assessing the Risk of Bias of Individual Studies in Sys-tematic Reviews of Health Care Interventions. In: Methods Guide for Compar-ative Effectiveness Reviews. AHRQ Publication no. 12-EHC047-EF. Rockville,MD: Agency for Healthcare Research and Quality; 2012. Accessed at http://effectivehealthcare.ahrq.gov/ehc/products/322/998/MethodsGuideforCERs_Viswanathan_IndividualStudies.pdf on 10 September 2012.156. Keller C, Fleury J, Sidani S, Ainsworth B. Fidelity to theory in PA inter-vention research. West J Nurs Res. 2009;31:289-311. [PMID: 19020266]157. Christensen R, Bartels EM, Astrup A, Bliddal H. Effect of weight reduc-tion in obese patients diagnosed with knee osteoarthritis: a systematic review andmeta-analysis. Ann Rheum Dis. 2007;66:433-9. [PMID: 17204567]158. Fitzgerald GK, Delitto A. Considerations for planning and conductingclinic-based research in physical therapy. Phys Ther. 2001;81:1446-54. [PMID:11509074]




Current Author Addresses: Dr. Wang: Department of Chronic DiseaseEpidemiology, Yale School of Public Health, 60 College Street, Room432, New Haven, CT 06520.Dr. Olson-Kellogg: Program in Physical Therapy, University of Minne-sota Medical School, 398 Children’s Rehab (MMC 388), 420 DelawareStreet Southeast, Minneapolis, MN 55455.Drs. Shamliyan and Kane: Division of Health Policy and Management,University of Minnesota School of Public Health, D330-5 Mayo (MMC729), 420 Delaware Street Southeast, Minneapolis, MN 55455.Dr. Choi: Division of Business, Hallym University, 10314 Dasan Hall,Chuncheon-si, Kangwon-do 200702, Republic of Korea.Ms. Ramakrishnan: University of South Florida, College of PublicHealth, 13201 Bruce B. Downs Boulevard, MDC 56, Tampa, FL33612-3805.

Author Contributions: Conception and design: S.Y. Wang, T.A. Shamliyan,R.L. Kane.Analysis and interpretation of the data: S.Y. Wang, B. Olson-Kellogg,T.A. Shamliyan, R. Ramakrishnan, R.L. Kane.Drafting of the article: S.Y. Wang, B. Olson-Kellogg, T.A. Shamliyan.Critical revision of the article for important intellectual content: S.Y.Wang, T.A. Shamliyan, R.L. Kane.Final approval of the article: S.Y. Wang, B. Olson-Kellogg, T.A. Sham-liyan, R.L. Kane.Statistical expertise: S.Y. Wang, T.A. Shamliyan.Obtaining of funding: R.L. Kane.Administrative, technical, or logistic support: T.A. Shamliyan, R.L. Kane.Collection and assembly of data: S.Y. Wang, B. Olson-Kellogg, T.A.Shamliyan, J-Y. Choi.

159. Ehrich EW, Davies GM, Watson DJ, Bolognese JA, Seidenberg BC,Bellamy N. Minimal perceptible clinical improvement with the Western Ontarioand McMaster Universities osteoarthritis index questionnaire and global assess-ments in patients with osteoarthritis. J Rheumatol. 2000;27:2635-41. [PMID:11093446]160. Angst F, Aeschlimann A, Stucki G. Smallest detectable and minimal clin-ically important differences of rehabilitation intervention with their implicationsfor required sample sizes using WOMAC and SF-36 quality of life measurementinstruments in patients with osteoarthritis of the lower extremities. ArthritisRheum. 2001;45:384-91. [PMID: 11501727]161. Angst F, Aeschlimann A, Michel BA, Stucki G. Minimal clinically impor-tant rehabilitation effects in patients with osteoarthritis of the lower extremities.J Rheumatol. 2002;29:131-8. [PMID: 11824949]162. Stratford PW, Kennedy DM, Woodhouse LJ, Spadoni GF. Measurementproperties of the WOMAC LK 3.1 pain scale. Osteoarthritis Cartilage. 2007;15:266-72. [PMID: 17046290]163. Tubach F, Ravaud P, Baron G, Falissard B, Logeart I, Bellamy N, et al.Evaluation of clinically relevant changes in patient reported outcomes in knee andhip osteoarthritis: the minimal clinically important improvement. Ann RheumDis. 2005;64:29-33. [PMID: 15208174]

164. Tubach F, Wells GA, Ravaud P, Dougados M. Minimal clinically impor-tant difference, low disease activity state, and patient acceptable symptom state:methodological issues. J Rheumatol. 2005;32:2025-9. [PMID: 16206363]165. Eberle E, Ottillinger B. Clinically relevant change and clinically relevantdifference in knee osteoarthritis. Osteoarthritis Cartilage. 1999;7:502-3. [PMID:10489324]166. Salaffi F, Stancati A, Silvestri CA, Ciapetti A, Grassi W. Minimal clinicallyimportant changes in chronic musculoskeletal pain intensity measured on a nu-merical rating scale. Eur J Pain. 2004;8:283-91. [PMID: 15207508]167. Redelmeier DA, Lorig K. Assessing the clinical importance of symptomaticimprovements. An illustration in rheumatology. Arch Intern Med. 1993;153:1337-42. [PMID: 8507124]168. Kennedy DM, Stratford PW, Wessel J, Gollish JD, Penney D. Assessingstability and change of four performance measures: a longitudinal study evaluat-ing outcome following total hip and knee arthroplasty. BMC MusculoskeletDisord. 2005;6:3. [PMID: 15679884]169. Mangione KK, Craik RL, McCormick AA, Blevins HL, White MB,Sullivan-Marx EM, et al. Detectable changes in physical performance measuresin elderly African Americans. Phys Ther. 2010;90:921-7. [PMID: 20395305]170. Khanna D, Maranian P, Palta M, Kaplan RM, Hays RD, Cherepanov D,et al. Health-related quality of life in adults reporting arthritis: analysis from theNational Health Measurement Study. Qual Life Res. 2011;20:1131-40. [PMID:21298347]171. Shakoor MA, Taslim MA, Hossain MS. Effects of activity modification onthe patients with osteoarthritis of the knee. Bangladesh Med Res Counc Bull.2007;33:55-9. [PMID: 18481439]172. Yip YB, Sit JW, Fung KK, Wong DY, Chong SY, Chung LH, et al.Impact of an Arthritis Self-Management Programme with an added exercise com-ponent for osteoarthritic knee sufferers on improving pain, functional outcomes,and use of health care services: an experimental study. Patient Educ Couns.2007;65:113-21. [PMID: 17010554]173. Kovar PA, Allegrante JP, MacKenzie CR, Peterson MG, Gutin B, Charl-son ME. Supervised fitness walking in patients with osteoarthritis of the knee. Arandomized, controlled trial. Ann Intern Med. 1992;116:529-34. [PMID:1543305]174. Bautch JC, Malone DG, Vailas AC. Effects of exercise on knee joints withosteoarthritis: a pilot study of biologic markers. Arthritis Care Res. 1997;10:48-55. [PMID: 9313390]175. Talbot LA, Gaines JM, Huynh TN, Metter EJ. A home-based pedometer-driven walking program to increase physical activity in older adults with osteo-arthritis of the knee: a preliminary study. J Am Geriatr Soc. 2003;51:387-92.[PMID: 12588583]176. Pietrosimone BG, Saliba SA, Hart JM, Hertel J, Kerrigan DC, IngersollCD. Effects of disinhibitory transcutaneous electrical nerve stimulation and ther-apeutic exercise on sagittal plane peak knee kinematics and kinetics in people withknee osteoarthritis during gait: a randomized controlled trial. Clin Rehabil. 2010;24:1091-101. [PMID: 20713439]177. Loyola-Sanchez A, Richardson J, Beattie KA, Otero-Fuentes C, AdachiJD, MacIntyre NJ. Effect of low-intensity pulsed ultrasound on the cartilagerepair in people with mild to moderate knee osteoarthritis: a double-blinded,randomized, placebo-controlled pilot study. Arch Phys Med Rehabil. 2012;93:35-42. [PMID: 22200383]

Annals of Internal Medicine

www.annals.org 6 November 2012 Annals of Internal Medicine Volume 157 • Number 9 W-205


Appendix Table 1. Physical Therapy Interventions Eligible for Review*

General Method Specific Intervention Definition

Patient- or client-related instructionInstruction, education, and training

of patients or clients andcaregivers

Current conditionEnhancement of performanceHealth, wellness, and fitnessPlan of careRisk factors for pathology or pathophysiology,

impairments, functional limitations, ordisabilities

Therapeutic exercise Aerobic capacity or endurance conditioning orreconditioning

Increased workload over time, walking programs, aquatic therapy

Flexibility exercises Muscle lengthening, range of motion, stretchingGait and locomotion training Gait training, implement and device trainingStrength, power, and endurance training for

limb musclesActive assistive, active, and resistive exercises; quadriceps

strengthening; aquatic programs; standardized, programmatic,and complementary exercise approaches; task-specificperformance training; body mechanics and posturalstabilization; body mechanics training

Balance, coordination, and agility training Neuromuscular education or reeducation, posture awarenesstrainingMuscle relaxation technique for pain

managementFunctional training in self-care, home

management, work, community,and leisure integration orreintegration (including ADL,IADL, work hardening, andwork conditioning)

ADL trainingDevices and equipment use and training Assistive and adaptive device or equipment training during ADL

and IADL; orthotic, protective, or supportive device orequipment training during ADL and IADL

Functional training programs Simulated environments and tasks, task adaptationIADL trainingInjury prevention or reduction Injury prevention education and safety awareness training during

self-care, home management, work, community, and leisureintegration or reintegration; injury prevention or reduction withuse of devices and equipment

Manual therapy techniques(including mobilization ormanipulation)

Detailed examination to reveal impairedmovements

Manual techniques with reinforcing exerciseto improve movement

Manual tractionMassage Connective tissue massage, therapeutic massageMobilization or manipulation Soft tissue, knee joint, other jointsPassive range of motion

Prescription and application ofdevices and equipment

Adaptive devices Raised toilet seatsOrthotic devices Braces, shoe inserts, splintsProtective devices Braces, protective patellar tapingSupportive devices Supportive taping

Electrotherapeutic interventions Electrical stimulation Electrical muscle stimulation, functional electrical stimulation,high-voltage pulsed current, neuromuscular electricalstimulation, TENS

Physical agents and mechanicalinterventions

Nonthermal agents Pulsed electromagnetic fieldsAquatic therapy PoolsSound agents UltrasoundThermotherapy Dry heat, hot packs, diathermy, cold methodsCryotherapy Cold packs, ice massage

ADL � activity of daily living; IADL � instrumental activity of daily living; TENS � transcutaneous electrical nerve stimulation.* Information from the American Physical Therapy Association (15).

W-206 6 November 2012 Annals of Internal Medicine Volume 157 • Number 9 www.annals.org


Appendix Table 2. Types of Exercise Interventions

Exercise Therapies Frequency, n (%)*

Aerobic (21 studies)†Multicomponent 12 (57.1)Walking 6 (28.6)Movement-based‡ 1 (4.8)Weight-bearing 1 (4.8)Not specified 1 (4.8)

Aquatic (3 studies)Aquatic-based 2 (66.7)Aquatic- and land-based 1 (33.3)

Strengthening (17 studies)†Knee extensor and flexor muscles 5 (29.4)Quadricep muscles 4 (23.5)Not specified 1 (5.9)Other§ 7 (41.2)

Proprioception (4 studies)Computer game–based training 2 (50)Proprioceptive neuromuscular facilitation

stretching and isokinetic exercises1 (25)

Sensorimotor training 1 (25)

* Percentages may not sum to 100 due to rounding.† Studies with short follow-ups are included. Effect estimates were based onpooled results from randomized, controlled trials that provided outcomes at thelongest follow-up.‡ Baduanjin set of exercises.§ Include upper and lower extremities, hip abductor and adductor muscle, kneeand whole leg, knee extension, knee flexion, hip extension, hip abduction, and hipadduction, leg muscles (ankle plantar flexors and dorsiflexors, knee extensors andflexors, and hip extensors and flexors), lower body, and multicomponent.

Appendix Table 3. Measurement and Frequency ofOutcomes in Pooled Analyses

Outcome Patients, %*

DisabilityWOMAC: Total 30KOOS: Daily activities subscale 12AIMS 16ASE 4SF-36: Physical function 16HAQ: Disability 12AIMS2: Family or friend 2Self-report of physical disability 4Functional incapacity score (modified Bandi’s criteria) 2Fear of falling 2

Psychological disabilitySF-36: Mental health, emotional well-being 47AIMS 12Anxiety, Hospital Anxiety and Depression Scale 9Center for Epidemiologic Studies Depression Scale 9Depression, Anxiety and Stress Scale 5Geriatric Depression Scale 2Marital adjustment (Dyadic Adjustment Scale) 2Nottingham Health Profile 4Motivation scale for health behavior 2Other scales 8

PainVAS 40.8WOMAC: Pain 28.0Borg Scale 0.8Pain rating index 4.8OASI: Pain 0.8Pain intensity score 1.6AIMS: Arthritis pain 7.2AIMS2: Pain subscale 1.6NRS: Pain 1.6HAQ: Pain 0.8Ambulation intensity† 4.8Combination of pain VAS, Lattinen test, and ROM 0.8Subjective pain 6.4

Quality of lifeQWB 25SF-36 25KOOS 50

Function compositeWOMAC: Physical function 49.3Lequesne Index 37.3KOOS: Symptoms subscale 9.0Lift and carry task‡ 3.0Functional performance(s) 1.5

AIMS � Arthritis Impact Measure Scale; ASE � Arthritis Self-Efficacy Scale;HAQ � Health Assessment Questionnaire; KOOS � Knee Injury and Osteo-arthritis Score; NRS � numerical rating scale; OASI � Osteoarthritis ScreeningIndex; QWB � Quality of Well-Being Scale; ROM � range of motion; SF-36 �36-Item Short Form Health Survey; VAS � visual analogue scale; WOMAC �Western Ontario and McMaster Universities Osteoarthritis Index.* Percentages may not sum to 100 due to rounding.† 1 represents no pain on this scale, and 6 represents excruciating pain.‡ Task involved the timed lifting, picking up, and carrying of a 10-lb weight.



Appendix Table 4. MCIDs in Scales Measuring Pain and Function in Adults With Knee Osteoarthritis

Instrument Relative Value(Change From Baseline), %

Absolute Difference in Valueof the Total Score FromScales

Study, Year (Reference)

Strict MCID Lax MID

WOMACPain 17.97 14.90 9.7* Ehrich et al, 2000 (159)

Angst et al, 2001 (160)Angst et al, 2002 (161)Stratford et al, 2007 (162)

Physical function 17.28 13.93 9.3* Ehrich et al, 2000 (159)Angst et al, 2001 (160)Angst et al, 2002 (161)Tubach et al, 2005 (163)Tubach et al, 2005 (164)

Stiffness 21.72 15.62 10* Ehrich et al, 2000 (159)Angst et al, 2001 (160)Angst et al, 2002 (161)

Total 17.71 13.96 8.2* Angst et al, 2001 (160)Angst et al, 2002 (161)

SF-36Body pain 28.78 7.8* Angst et al, 2001 (160)PCS 6.99 2* Angst et al, 2001 (160)Physical function 8.80 3.3* Angst et al, 2001 (160)

VAS pain 40.80 Published range: 8.4–19.9* Eberle and Ottillinger, 1999 (165)Tubach et al, 2005 (163)

Lequesne Index 0.7† Eberle and Ottillinger, 1999 (165)NRS pain 15 1‡ Salaffi et al, 2004 (166)Global assessment, patient 39 16.81 Published range: 11.7–18.3* Ehrich et al, 2000 (159)

Tubach et al, 2005 (163)HAQ 25.56 20.65 Redelmeier and Lorig, 1993 (167)6-min walk test distance 25.19 m 14.89 m Published range: 61–65 m Kennedy et al, 2005 (168)

Mangione et al, 2010 (169)EQ-5D 0.10 0.01 0.03§ Khanna et al, 2011 (170)

EQ-5D � EuroQol-5D; HAQ � Health Assessment Questionnaire; MCID � minimum clinically important difference; MID � minimally important difference; NRS �numerical rating scale; PCS � physical component summary; SF-36 � 36-Item Short Form Health Survey; VAS � visual analogue scale; WOMAC � Western Ontario andMcMaster Universities Osteoarthritis Index.* Scale of 0 to 100, 0 being the best and 100 being the worst.† Scale of 0 to 24, 0 being the best and 24 being the worst.‡ Scale of 0 to 10, 0 being the best and 10 being the worst.§ Scale of 0 to 1, 1 being the best and 0 being the worst.



Appendix Figure 1. Risk of bias in 193 randomized, controlled trials (RCTs) that examined physical therapy in adults with kneeosteoarthritis.

Unclear

No

Yes

0 100

32 23 138

200

Allocation Concealment

Intention to Treat

Adequacy of Randomization

4

118 71

129 22 42

Double-blind

Single-blind

Open-label

0 100

36 89 68

200

Masking of the Treatment

Status for Outcome Assessors

Unclear

High

Medium

Low

RCTs, n

RCTs, n

RCTs, n

0 100

28

2

107 56

200

Risk of Bias



Appendix Figure 2. Associations between the time of follow-up and intermediate or patient-centered outcomes after electricalstimulation.

Stan

dard

ized

Eff

ect

Size

Follow-up, wk

Disability

0 6 12 18 24–2

–1

0

1

2

Stan

dard

ized

Eff

ect

Size

Follow-up, wk

Composite Function

0 6 12 18 24–2

–1

0

1

2

Stan

dard

ized

Eff

ect

Size

Follow-up, wk

Pain

–2

–1

0

1

2

Stan

dard

ized

Eff

ect

Size

Follow-up, wk

Gait Function

–2

–1

0

1

2

0 6 12 18 24 0 6 12 18 24–2



physical therapy interventions for knee pain secondary to osteoarthritis

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