Effectiveness and clinical applicability of integrated rehabilitation programs for knee osteoarthritis : Current Opinion in Rheumatology

Secondary Logo

Journal Logo

Rehabilitation medicine in rheumatic diseases: Edited by Kent Kwoh

Effectiveness and clinical applicability of integrated rehabilitation programs for knee osteoarthritis

Hurley, Michael Va; Walsh, Nicola Eb

Author Information
Current Opinion in Rheumatology 21(2):p 171-176, March 2009. | DOI: 10.1097/BOR.0b013e3283244422
  • Free



On the surface, osteoarthritis seems a fairly simple condition resulting from a lifetime of (ab)using our joints which causes wear and attrition of bone and cartilage, causing pain and leading to disability. However, the aetiology of osteoarthritis is much more complex, with no direct association between biological changes (radiographic joint damage), symptoms (pain) and consequences (impaired functioning). Osteoarthritis is a complex interaction of biopsychosocial and economic effects, and effective management requires recognizing this complexity and understanding these interactions. This article reviews the developments of integrated rehabilitation programmes based on a biopsychosocial philosophy to address the complexity of osteoarthritis management.

(In)effective physiotherapy modalities

Physiotherapy utilizes relatively safe, nonpharmacological, conservative modalities (electrotherapy, manipulation, acupuncture, etc.) to reduce pain and disability. These modalities are popular with patients and have very powerful placebo effects, but evidence demonstrating their efficacy is limited. In addition, interventions requiring a therapist or specialized equipment or both create patients who are passive recipients of healthcare and reliant on others, which is an inefficient, expensive and impractical way to manage chronic conditions in the long term. However, these modalities may be useful adjuncts to core strategies that have good evidence supporting their effectiveness, such as exercise and self-management [1–4].

The biomedical model and rationale for exercise

The biomedical model views illness as a pathological change in our biological system that gives rise to symptoms. Correcting the underlying disease eliminates the symptoms and cures the patient. In osteoarthritis, biochemical, anatomical and biomechanical changes cause bone and cartilage damage, giving rise to pain that leads to disability. The effectiveness of exercise in knee osteoarthritis [5] is attributed to its ability to reverse muscle sensorimotor dysfunction (weakness, fatigue, poor control) preventing abnormal movement and restore normal biomechanics, effecting better gait, relieving pain and improving function.

The biopsychosocial model and the complexity of osteoarthritis

However, most health problems are more complex than the biomedical model posits [6]. Often there is no identifiable cause or the cause cannot be eliminated, so we cannot cure the condition, and people have to live with chronic illness. Moreover, an individual's emotional and cognitive reaction to symptoms and consequences is frequently unrelated to extent of their underlying problem. The effects of illness are a complex interaction between biological (joint damage, muscle dysfunction, altered biomechanics), psychological (pain, health beliefs, cognitions, perceptions, fears, experiences, impaired functioning), socioeconomic (social support, occupation, relationships) and environmental (climate, safety, availability of required facilities) factors. The biopsychosocial model of illness enables better understanding and management of complex conditions. It acknowledges the important influence of biological, psychological, socioeconomic and environmental factors on how people perceive, react to and cope with their problems, and in acknowledging these influences allows us, indeed forces us, to address them.

The psychosocial effects of osteoarthritis can be profound. Chronic pain that has no discernable cause with an episodic variable and unpredictable course is bewildering and gives rise to health beliefs and behaviours that can exacerbate the problems and interfere with effective management. For example, people with knee osteoarthritis usually associate activity with onset and increase in pain which is relieved by rest. Fearing that the pain is signalling joint damage, to minimize pain and prolong the life of their joints people reduce their activity – ‘fear-avoidance behaviour’ [7]. Challenging erroneous beliefs and reassuring people about the safety, physical and psychosocial benefits of physical activity are vital to promote better understanding and more ‘appropriate’ behaviour.

Self-management interventions

Inappropriate health beliefs can be challenged in patient education/self-management interventions (SMIs), which help people understand and cope with their condition, minimize its effects and adopt healthy lifestyles and behaviours [8–12]. The content of SMIs varies but generally includes advice and education about healthy lifestyles (regular exercise/physical activity, healthy eating, weight control), simple pain-management techniques, joint protection, problem solving and planning skills. They aim to promote behavioural change and overcome barriers to implementation, encourage adherence to treatment and reduce healthcare utilization thereby minimizing the economic burden of chronic ill health. For osteoarthritis, the disease-specific Arthritis Self-Management Programme (ASMP) [13] and more generic Chronic Diseases Self-Management Programme (CDSMP) [14] have been used.

Integrated rehabilitation programmes

Exercise and SMIs are frequently delivered separately. Many SMIs describe the benefits of exercise and encourage exercise but do not have a participatory exercise component, whereas the patient education element of exercise regimens focuses narrowly on getting people to exercise rather than wider aspects of self-management. Theoretically, the individual effects of exercise and SMIs might be additive, so programmes combining exercise with SMI could maximize the benefits from both physical and educational approaches. In particular, skills learnt during SMIs may encourage regular exercise to sustain its short-term benefits [15].

A systematic review of rehabilitation programmes that integrated exercise and SMIs [16•] highlighted wide variation in duration, delivery format and content [17–24,25•,26]: most regimens lasted 6–8 weeks, some lasted 10–12 weeks, one lasted 18 months; interventions were delivered to small groups or individuals, at home or in community centres, clinics or hospitals; the exercises generally aimed to improve strength, flexibility, mobility and balance/coordination; the self-management component generally included the elements described above, and two studies based their intervention on the ASMP. In spite of this heterogeneity, meta-analyses demonstrated significant improvement in pain and function following intervention, similar to meta-analyses of exercise-only [5] and self-management-only [8,27] interventions (Table 1) [28]. Interestingly, though a meta-analysis of drug studies demonstrates greater pain relief, this does not translate into better function (Table 1).

Table 1:
Summary of meta-analyses of pain and physical function for studies investigating exercise and self-management interventions, delivered separately or as integrated programmes, and drug trials

Excess body weight is a major risk factor for knee osteoarthritis [29]. The systematic review included one of the few trials, and arguably the best to date, showing the benefits of reducing excess body weight and exercise, the Arthritis Diet and Activity Promotion Trial (ADAPT) [25•]. It showed that moderate exercise and modest weight loss improved pain and function better than exercise or diet alone. Its success is encouraging but clinical application may be limited by the effort and burden involved in such a long (18 months) and complex intervention.

Since the systematic review was prepared and published, several other integrated rehabilitation programmes have been reported.

Hay et al.[30•] reported an intervention consisting of home-based exercises and patient education (delivered in three to six sessions over 10 weeks) that found improvements in pain and function, 3 months after the intervention.

The community-based intervention ‘Fit and Strong!’ compared an exercise and a behavioural change programme (90-min sessions held three times a week for 8 weeks) with the Arthritis Handbook and exercise advice. Improvements were found in pain and function, self-efficacy, exercise adherence and performance measures [31•]. The programme is described as ‘low cost’, but no cost data are presented. High loss to follow-up weakens the findings and may indicate unacceptability of the programme questioning its clinical applicability.

An intensive in-patient programme of exercise, SMI and several other physiotherapy modalities (delivered for at least 7 h a week over 3–4 weeks) [32] showed short-term improvements in pain and physical function, and pain improvements were maintained for 2 years; functional improvements were lost within 2 years. No cost data are presented, but the resource implications (personnel, facilities and financial) may be significant and preclude application. Moreover, the burden of participation may limit its acceptability by many people.

Improvements in pain, function and arthritis self-efficacy were evident following a supervised intervention that integrated exercise into an adapted version of the ASMP (2-h sessions, held once a week for 6 weeks, and home exercises) [33] and sustained for 1 year [34•]. Again, high loss to follow-up detracts from the results. Similarly, the CDSMP was adapted to include a participatory exercise component (one 90-min session each week for 6 weeks) for people with severe osteoarthritis [35•]. They found that pain and function and self-efficacy improved in all patients. Although the study was not powered to determine whether there were differences between people who had been referred for knee arthroplasty and people who had not, the authors found people who had been referred for surgery had less improvement and speculate that surgical referral may lower compliance with exercise and advice, undermining their response to conservative management.

Activity strategy training involves active coping techniques such as rest–activity cycling to help control symptoms and encourage physical activity. Murphy et al.[36•] integrated exercise with activity strategy training (eight 90-min sessions, over 4 weeks, and two follow-up sessions over 6 months) and compared it with exercise and patient education. Physical activity increased and pain decreased in both groups, and though improvements in the exercise and activity strategy training were greater, these differences were not significant, probably because the study was insufficiently powered to investigate between-group differences in very similar interventions.

Veenhof et al.[37•] compared a ‘behavioural-graded activity’ programme (maximum of 18 sessions in first 12 weeks, then seven sessions over 40 weeks) with usual physiotherapy care for 200 people. Both groups showed similar improvements in subjective and objective measures of pain and function, though behavioural-graded activity showed slightly greater (but not significantly greater) increases and less cost (but not significantly less) −€773 (−€2360 to €772) [38].

Enabling Self-management and Coping of Arthritic knee Pain through Exercise (ESCAPE-knee pain) is an integrated programme which was delivered to either groups of eight to 10 participants or individually and compared with usual primary care (45–60 min sessions, twice a week for 6 weeks) [39••]. Improvements in physical function, pain, subjective and objective psychosocial outcomes were sustained for 6 months after completing the programme, and a parallel economic evaluation indicated healthcare costs were lower making it more cost-effective than usual primary care [40•].

Clinical applicability of integrated rehabilitation programmes

To be clinically applicable, healthcare interventions must be safe, acceptable and clinically effective for patients, deliverable by clinicians, implementable and affordable by healthcare providers. Integrated rehabilitation programmes need to be considered against these criteria.


SMIs have no reported adverse events. Exercise programmes may be unsuitable for people with unstable medical conditions, but controlled exercise is beneficial for most people with few adverse effects apart from mild transient muscle soreness that is commonly reported for a few days after performing unusual activities. Consequently, integrated rehabilitation programmes are comparatively safe, and few adverse events have been reported.


All the programmes involve significant time and effort, and the high loss to follow-up evident in some studies [16•,25•,31•,32,34•,41,42] suggests their complexity and burden may be unacceptable to less committed participants and may limit uptake.


As discussed above, all of the interventions were efficacious, improving pain, physical function and other variables under ideal controlled research conditions. Although the effects of some programmes appear to be small and unimpressive, this is often because the experimental and control interventions were very similar (in content, delivery, etc.) and both were likely to have benefits [36•,37•]. These trials were too small and statistically ‘underpowered’ to detect meaningful differences between the interventions. Programmes that used ‘usual care’ as the control intervention [43] had comparatively greater effects [39••].

Affordability, costs and healthcare utilization

Although knee osteoarthritis is very costly, it is regarded as a nonurgent, benign condition, ‘competing’ for finite healthcare resources with other more ‘urgent’ problems. Self-management-only interventions do not reduce healthcare costs [44,45,46•,47], suggesting people are not dissuaded from using healthcare simply by telling them they do not need them. As healthcare providers are unlikely to commission programmes without evidence of clinical and cost-effectiveness, an important aspect of integrated rehabilitation programmes would be to show they can reduce healthcare utilization. Unfortunately, most studies of integrated rehabilitation programmes have not evaluated costs or healthcare utilization, but given the lengthy, complex nature of some programmes their costs are likely to be substantial. Programmes that have carried out economic evaluation demonstrate they are relatively inexpensive [30•,38,40•] and without the direct and indirect hidden costs associated with adverse side effects of prolonged drug therapy [48]. This confirms exercise-based rehabilitation as a relatively cheap, cost-effective intervention that reduces healthcare utilization, justifying their description as a ‘best buy’ in public health [49].

Clinical implementation

Complex and unwieldy programmes are difficult to implement, and efficacious research programmes are often not as effective when applied in clinical practice. A recent evaluation of the implementation of the ‘People with Arthritis Can Exercise (PACE)’ programme (16, 45-min sessions delivered twice a week over 8 weeks) which has been around for some time [41,42] has highlighted problems with implementation [50••]. The evaluation was performed against the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework [51] that assesses whether a healthcare programme reaches the target population (an individual or organization), effectively helps them and is adopted, implemented and maintained long term. Although healthcare providers were convinced about the need and usefulness of the PACE programme and sent people to be trained to deliver it (i.e. adoption was good), few people with arthritis enrolled when the programme was offered to them (reach was low), and, consequently, the providers discontinued it (maintenance was poor) [50••].

Wider implementation has been achieved by the ASMP [52•] and CDSMP [53] but only after frequent, prolonged and intensive dissemination strategies. To facilitate their implementation further, innovative ways have been devised to deliver these programmes to people who cannot or do not want to attend a programme. A mailed variant of the ASMP over 12–18 months was shown to be as effective as attendance on an ASMP course [54•], and internet-based versions of the ASMP [46•] and CDSMP [45] (accessing internet 1–2 h three times a week for 6 weeks) improve health status and self-efficacy outcomes. These studies emphasize the substantial effort and commitment needed to get these programmes ‘on the streets’. With their participatory exercise component, implementation of integrated rehabilitation programmes may require even greater effort.

One integrated rehabilitation programme included in the systematic review [17] has been successfully implemented on a larger scale [55•], but its ability to reduce healthcare utilization seems limited [56]. Wide implementation of integrated rehabilitation programmes needs to be justified by studies that show these interventions have better clinical and cost-effectiveness and reduced healthcare utilization compared with other forms of management. Although preliminary evidence suggests they may be better in these areas, better and closer evaluation is still required.


To address the complexity of osteoarthritis, rehabilitation programmes integrating exercise and SMIs have been devised that reduce pain, improve physical function and other physical and psychosocial variables. Earlier programmes were long, complex, burdensome and expensive. More recently, programmes have been devised that are safer, more effective, acceptable, deliverable and affordable. Information regarding their ability to reduce healthcare utilization is needed. Although implementation of these programmes will require great effort, commitment and resources, they have the potential to help reduce the personal suffering and socioeconomic burden of the large and increasing number of people with chronic knee pain.


The authors have been funded by the Arthritis Research Campaign, a registered, nonprofit-making charity. They have no commercial affiliations or sources of funding sources.

References and recommended reading

Papers of particular interest, published within the annual period of review, have been highlighted as:

• of special interest

•• of outstanding interest

Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 196).

1 Conaghan PG, Dickson J, Grant RL, on behalf of the Guideline Development G. Care and management of osteoarthritis in adults: summary of NICE guidance. BMJ 2008; 336:502–503.
2 Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis. Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage 2008; 16:137–162.
3 Jordan KM, Arden NK, Doherty M, et al. EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis 2003; 62:1145–1155.
4 Altman RD, Hochberg MC, Moskowitz RW, Schnitzer TJ. Recommendations for the medical management of osteoarthritis of the hip and knee. Arthritis Rheum 2000; 43:1905–1915.
5 Fransen M, McConnell S, Bell M. Therapeutic exercise for people with OA of the hip and knee: a systematic review. J Rheumatol 2002; 29:1737–1745.
6 Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977; 196:129–136.
7 Keefe FJ, Kashikar-Zuck S, Opiteck J, et al. Pain in arthritis and musculoskeletal disorders: the role of coping skills training and exercise interventions. J Orthop Sports Phys Ther 1996; 24:279–290.
8 Warsi A, LaValley MP, Wang PS, et al. Arthritis self-management education programs: a meta-analysis of the effect on pain and disability. Arthritis Rheum 2003; 48:2207–2213.
9 Buszewicz M, Rait G, Griffin M, et al. Self management of arthritis in primary care: randomised controlled trial. BMJ 2006; 333:879–883.
10 Heuts PHTG, de Bie RA, Dijkstra A, et al. Assessment of readiness to change in patients with osteoarthritis: development and application of a new questionnaire. Clin Rehabil 2005; 19:290–299.
11 Heuts PH, de Bie R, Drietelaar M, et al. Self-management in osteoarthritis of hip or knee: a randomized clinical trial in a primary healthcare setting. J Rheumatol 2005; 32:543–549.
12 Lorig KL, Holman H. Patient self-management: a key to effectiveness and efficiency in care of chronic disease. Public Health Rep 2005; 119:239–243.
13 Lorig KR, Mazonson PD, Holman HR. Evidence suggesting that health education for self-management in patients with chronic arthritis has sustained health benefits while reducing healthcare costs. Arthritis Rheum 1993; 36:439–446.
14 Lorig K, Sobel DS, Stewart AL, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalisation: a randomised trial. Med Care 1999; 37:5–14.
15 Pisters MF, Veenhof C, van Meeteren NLU, et al. Long-Term effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review. Arthritis Care Res 2007; 57:1245–1253.
16• Walsh NE, Mitchell HL, Reeves BC, Hurley MV. Effectiveness of rehabilitation programmes combining exercise and self-management interventions for hip and knee osteoarthritis: a systematic review. Phys Ther Rev 2006; 11:289–297. A review of integrated rehabilitation programmes of up to 2004 that discusses heterogeneity, weaknesses and strengths.
17 Hopman-Rock M, Westhoff MH. The effects of a health education and exercise program for older adults with osteoarthritis of the hip or knee. J Rheumatol 2000; 27:1947–1954.
18 van Baar ME, Dekker J, Oostendorp RAB, et al. Effectiveness of exercise therapy in patients with osteoarthritis of knee and hip: a randomised clinical trial. J Rheumatol 1997; 25:2432–2439.
19 Talbot LA, Gaines JM, Huynh TN, Metter EJ. A home-based pedometer-driven walking program to increase physical activity in older adults with osteoarthritis of the knee: a preliminary study. J Am Geriatr Soc 2003; 51:387–392.
20 Quilty B, Tucker M, Campbell R, Dieppe P. Physiotherapy, including quadriceps exercises and patellar taping, for knee osteoarthritis with predominant patello-femoral joint involvement: randomized controlled trial. J Rheumatol 2003; 30:1311–1337.
21 Kovar PA, Allegrante JP, MacKenzie CR, et al. Supervised fitness walking in patients with osteoarthritis of the knee: a randomised controlled trial. Ann Intern Med 1992; 116:529–534.
22 Fransen M, Crosbie J, Edmonds J. Physical therapy is effective for patients with osteoarthritis of the knee: a randomised controlled trial. J Rheumatol 2001; 28:156–164.
23 Corrêa Dias R, Domingues Dias JM, Ramos L. Impact of an exercise and walking protocol on quality of life for elderly people with OA of the knee. Physiother Res Int 2003; 8:121–130.
24 Kuptniratsaikul V, Tosayanonda O, Nilganuwong S, Thamalikitkul V. The efficacy of a muscle exercise program to improve functional performance of the knee in patients with osteoarthritis. J Med Assoc Thai 2002; 85:33–40.
25• Messier SP, Loeser RF, Miller GD, et al. Exercise and dietary weight loss in overweight and obese older adults with knee osteoarthritis: the Arthritis, Diet, and Activity Promotion Trial. Arthritis Rheum 2004; 50:1501–1510. To date, the above is the best designed trial describing intensive input comparing exercise and weight separately and in combination on pain and function.
26 Hughes SL, Seymour RB, Campbell R, et al. Impact of the fit and strong intervention on older adults with osteoarthritis. Gerontologist 2004; 44:217–228.
27 Chodosh J, Morton SC, Mojica W, et al. Meta-analysis: chronic disease self-management programs for older adults. Ann Intern Med 2005; 143:427–438.
28 Superuio-Cabuslay E, Ward MM, Lorig KR. Patient education interventions in osteoarthritis and rheumatoid arthritis: a meta-analytic comparison with nonsteroidal antiinflammatory drug treatment. Arthritis Care Res 1996; 9:292–301.
29 Messier SP. Obesity and osteoarthritis: disease genesis and nonpharmacologic weight management. Rheum Dis Clin N Am 2008; 34:713–729.
30• Hay EM, Foster NE, Thomas E, et al. Effectiveness of community physiotherapy and enhanced pharmacy review for knee pain in people aged over 55 presenting to primary care: pragmatic randomised trial. BMJ 2006; 333:995–998. A pragmatic trial of home-based programmes.
31• Hughes SL, Seymour RB, Campbell RT, et al. Long-term impact of Fit and Strong! on older adults with osteoarthritis. Gerontologist 2006; 46:801–814. The above study describes a potentially practicable community-based programme.
32 Weigl M, Angst F, Stucki G, et al. Inpatient rehabilitation for hip or knee osteoarthritis: 2 year follow up study. Ann Rheum Dis 2004; 63:360–368.
33 Yip YB, Sit JWH, Fung KKY, et al. Effects of a self-management arthritis programme with an added exercise component for osteoarthritic knee: randomized controlled trial. J Adv Nurs 2007; 59:20–28.
34• Yip Y-B, Sit JW, Wong DYS, et al. A 1-year follow-up of an experimental study of a self-management arthritis programme with an added exercise component of clients with osteoarthritis of the knee. Psychol Health Med 2008; 13:402–414. One of the few long-term evaluations of rehabilitation programmes.
35• Lamb SE, Toye F, Barker KL. Chronic disease management programme in people with severe knee osteoarthritis: efficacy and moderators of response. Clin Rehabil 2008; 22:169–178. The above study demonstrates even people with severe osteoarthritis can improve, but referral for surgery may interfere with conservative treatment.
36• Murphy SL, Strasburg DM, Lyden AK, et al. Effects of activity strategy training on pain and physical activity in older adults with knee or hip osteoarthritis: a pilot study. Arthritis Care Res 2008; 59:1480–1487. Programme included follow-up sessions to improve long-term adherence to regular exercise and motivation.
37• Veenhof C, Köke AJA, Dekker J, et al. Effectiveness of behavioral graded activity in patients with osteoarthritis of the hip and/or knee: a randomized clinical trial. Arthritis Care Res 2006; 55:925–934. A pragmatic comparison with physiotherapy which included strategies to maintain long-term effects.
38 Coupe VMH, Veenhof C, van Tulder MW, et al. The cost effectiveness of behavioural graded activity in patients with osteoarthritis of hip and/or knee. Ann Rheum Dis 2007; 66:215–221.
39•• Hurley MV, Walsh NE, Mitchell HL, et al. Clinical effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain: a cluster randomized trial. Arthritis Rheum 2007; 57:1211–1219. A large trial comparing a brief, practicable programme with usual primary care.
40• Hurley MV, Walsh NE, Mitchell HL, et al. Economic evaluation of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain. Arthritis Rheum 2007; 57:1220–1229. A full economic evaluation of the ESCAPE-knee pain programme.
41 Suomi R, Collier D. Effects of arthritis exercise programs on functional fitness and perceived activities of daily living measures in older adults with arthritis. Arch Phys Med Rehabil 2003; 84:1589–1594.
42 Schoster B, Callahan L, Meier A, et al. The People with Arthritis Can Exercise (PACE) Program: a qualitative evaluation of participant satisfaction. Preventing Chronic Dis 2005; 2:A11.
43 Ganz DA, Chang JT, Roth CP, et al. Quality of osteoarthritis care for community-dwelling older adults. Arthritis Rheum 2006; 55:241–247.
44 Gately C, Rogers A, Sanders C. Re-thinking the relationship between long-term condition self-management education and the utilisation of health services. Soc Sci Med 2007; 65:934–945.
45 Lorig KR, Ritter PL, Laurent DD, Plant K. Internet-based chronic disease self-management: a randomized trial. Med Care 2006; 44:964–971.
46• Lorig KR, Ritter PL, Laurent DD, Plant K. The internet-based arthritis self-management program: a one-year randomized trial for patients with arthritis or fibromyalgia. Arthritis Care Res 2008; 59:1009–1017. A variant of the ASMP, devised to reach a greater number of people.
47 Foster G, Taylor SJ, Eldridge SE, et al. Self-management education programmes by lay leaders for people with chronic conditions. Cochrane Database Syst Rev 2007:CD005108.
48 Solomon DH, Glynn RJ, Bohn R, et al. The hidden cost of nonselective nonsteroidal antiinflammatory drugs in older patients. J Rheumatol 2003; 30:792–798.
49 Munro JF, Nicholl JP, Brazier JE, et al. Cost effectiveness of a community based exercise programme in over 65 year olds: cluster randomised trial. J Epidemiol Commun Health 2004; 58:1004–1010.
50•• Gyurcsik NC, Brittain DR. Partial examination of the public health impact of the People with Arthritis Can Exercise (PACE®) program: reach, adoption, and maintenance. Public Health Nurs 2006; 23:516–522. An evaluation of the implementation of a well known programme which suggests the reach and maintenance of such programmes are problematic.
51 Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health 1999; 89:1322–1326.
52• Bruce B, Lorig KL, Laurent DD. Participation in patient self-management programs. Arthritis Care Res 2007; 57:851–854. A self-management-only programme that has been successfully implemented but only after prolonged and intensive implementation strategies.
53 Lorig KR, Hurwicz M-L, Sobel D, et al. A national dissemination of an evidence-based self-management program: a process evaluation study. Patient Educ Couns 2005; 59:69–79.
54• Lorig KL, Ritter PL, Laurent DD, Fries JF. Long-term randomized controlled trials of tailored-print and small-group arthritis self-management interventions. Med Care 2004; 42:346–354. Another innovative variant of the ASMP, devised to reach a greater number of people.
55• de Jong ORW, Hopman-Rock M, Tak ECMP, Klazinga NS. An implementation study of two evidence-based exercise and health education programmes for older adults with osteoarthritis of the knee and hip. Health Educ Res 2004; 19:316–325. Evidence that integrated rehabilitation programmes can be implemented on a wider scale.
56 de Jong R, Tak E, Klazinga N, Hopman-Rock M. The impact on health services utilization in a replication study of two self-management programmes for osteoarthritis of the knee and hip. Primary Healthcare Res Dev 2008; 9:64–74.

exercise; integrated rehabilitation programmes; knee osteoarthritis; self-management interventions

© 2009 Lippincott Williams & Wilkins, Inc.