Knee osteoarthritis (OA) is a major cause of musculoskeletal disability in older population affecting both men and women1–3 and reported by the World Health Organization on the global burden of disease.4 Knee OA causes pain, joint stiffness, and decreased quadriceps strength resulting in physical disability and disease progression,5–8 with models showing a decrease in Western Ontario and McMaster osteoarthritis (WOMAC) scores by 1.77 units per year in most of knee OA population,9 leading to rapid progression to knee arthroplasty.10
Reduction of pain and improvement of function are the main aims of any treatment approach in the management of knee OA. Combinations of treatment approaches, including both pharmacological and nonpharmacological methods, are often preferred over a single approach.11 The Osteoarthritis Research Society International recommended nonpharmacological methods, including patient education programs, weight reduction, coping strategies, and exercise programs, in the treatment of knee OA.12 Both rehabilitation programs with and without supervised clinic-based exercises have been shown to reduce pain and improve of function in individuals with knee OA.13–15 Although home exercise programs have advantages over supervised clinic-based exercise programs because they are inexpensive and require little to no equipment, concerns arise about long-term compliance of home exercise programs. In a prospective long-term study conducted by Deyle et al,16 the effects of a home exercise program on lower extremity function were almost equal to those of supervised clinic-based exercise programs even at 1-year follow-up. Past studies have consistently shown that a home exercise program is beneficial for improving strength, reducing pain, and improving function in individuals with knee OA.13–20
However, neither a systematic review of the literature nor a meta-analysis has been published on the effectiveness of home exercise programs for the management of individuals with knee OA. Hence, the objectives of this systematic review were to investigate evidence regarding the effectiveness of home exercise programs in the management of individuals with knee OA.
The search was conducted in PubMed, CINAHL, Embase, Scopus, and PEDro using a combination of key words such as pain, exercise, home exercise program, rehabilitation, supervised exercise program, and physiotherapy with “osteoarthritis knee” and the medical subject headings “osteoarthritis, knee” combined with “exercise” or “rehabilitation.” The bibliographical survey was restricted to randomized and case-controlled trials published in English language prior to September 1, 2014. Hand searching of the identified papers was used to find other appropriate papers. The authors were asked to provide full text of potential articles that were not available online. Two evaluators individually selected the studies based on titles, excluding those articles not related to the objectives of this review. After selection, the abstracts of the selected studies were analyzed by evaluators to identify those that met the inclusion criteria.
Inclusion and Exclusion Criteria
Limits were by design as we included only randomized clinical trials (RCTs) and case-controlled trials, published in the English language prior to September 1, 2014. The intervention of interest was home exercise programs for individuals with knee OA. Trials were required to compare home exercise programs with inpatient/outpatient physical therapy, and no intervention. Studies that did not include home exercise programs in their interventions were excluded. The outcome measures of interest were pain and function in patients with knee OA. Randomized clinical trials were excluded if the publication was in the abstract form only.
Assessment of Methodological Quality
The PEDro Scale21 was used to assess the methodological quality of the included studies. It consists of 11 questions that assess the methodological quality of RCTs and focuses on 2 aspects of the study: whether it has internal validity (criteria 2-9) and whether it contains sufficient statistical information to make it interpretable (criteria 10-11). Each question is scored according to its presence or absence in the assessed study. The final score is calculated by the sum of all positive responses.
In accordance with Moseley et al,22 studies with a score of 5 (50%) or greater were considered high-quality. So, in the present review, all randomized studies with scores of 5 (5/10) or greater were considered to be of high methodological quality. The analysis of studies classified with the PEDro Scale was done independently by 2 evaluators.
The Cochrane collaboration's tool for assessing risk of bias was used to assess risk of bias in the domain-based evaluation. The sequence generation, allocation concealment, blinding of participants, therapist and assessors, completeness of outcome data, and selective outcome reporting were the domains assessed. Risk of bias was classified as low, unclear, and high in each domain.23
The selected studies were screened by 2 independent evaluators. The analysis of included studies was performed according to a structured script using the following parameters: author/year, subjects, design, outcomes measurement, intervention, instruments, and effects found. Disagreements between the evaluators were resolved by discussion to reach consensus. Agreement between the 2 evaluators was determined by using unweighted kappa (κ).
The outcome measures of interest were pain and function. The mean and standard deviation of the baseline and final end point scores for pain and function were extracted from included studies. The mean change score (final end point minus baseline score) for each outcome measure was calculated for each intervention. Studies that did not provide estimates of random variability or presented data as medians were excluded from the meta-analysis. The standardized mean difference for the outcomes (pain and function) was computed using Hedges' (adjusted) g (g = M1 − M2/Spooled, where M1 and M2 are the mean change score of groups 1 and 2. Spooled is the estimate of the population standard deviation).24 Cohen's categories were used to evaluate the magnitude of the effect size, calculated by the standardized mean difference, with g < 0.5 as a small effect size; g ≥ 0.5 and ≤0.8, medium effect size; and g > 0.8, large effect size. The random effects meta-analysis was conducted to determine the overall effect size of home exercise program. Ninety-five percent confidence intervals were calculated for effect sizes on the basis of a generic inverse variance outcome model. The z statistic was used to test for significance of the overall effect. The Cochran's Q statistic and the Higgins' I2 statistic24 were used to determine statistical heterogeneity between studies. A low P value (≤.10) for the Q statistic was considered evidence of heterogeneity of treatment effects. All statistics were computed using Comprehensive Meta-Analysis software.25
The initial search resulted in 65 research studies. A total of 34 studies that appeared in more than 1 database or did not meet predetermined inclusion criteria were excluded. A total of 31 studies were assessed for eligibility. Twelve studies were eliminated because they did not match the inclusion criteria or were not available in full text (Figure 1). The final selection, made by consensus, resulted in the inclusion of 19 studies in the quality assessment phase.
Quality Assessment of Study
The 19 included studies had an average PEDro score of 6.78/10, as illustrated in Table 1. These scores represent multiple sources of bias that may skew the results. The most common shortcomings were lack of blinding (patient, therapist, or assessor) and concealed allocation. Three trials failed to meet the randomization criterion,17,20,40 6 trials failed to meet intention-to-treat criterion,18,38–42 and 1 trial failed to meet the baseline comparability41 criterion of PEDro.
Five trials failed to meet the follow-up13,15,18,38,45 and point and variability measures17–19,39,46 criterion of PEDro. However, when these studies were examined together, there was strong scientific evidence from high-quality studies with consistent results that the home exercise programs brought significant improvement in individuals with knee OA.13,15–20,38,39,41,42,44–49
Agreement between evaluators was excellent (unweighted κ = 0.85) in assessing risk of bias across studies. Table 2 details the risk of bias assessment of the included studies. The overall risk of bias assessment indicated that the risk of bias was low in 6 studies,15,16,38,41,44,46 high in 10 studies,13,17–20,39,40,42,43,49 and unclear in the other 3 studies.45,47,48
General Data About the Selected Studies
Table 3 summarizes the studies included in this systematic review using the following information: author, subjects, design, intervention, outcomes, and effects found. All studies were experimental, with 11 studies13,17,19,20,39–41,44,45,47,49 including pre- and postintervention assessments and 8 studies15,16,18,38,42,43,46,48 with long-term treatment evaluation (follow-up). Regarding the effects found in the majority of the studies, a significant effect of home exercise programs was found on pain and function between pre- and postintervention evaluations.
Components of Home Exercise Programs Included in Studies
The interventions used as home exercise programs in the reviewed studies included a combination of open and closed kinematic chain exercises as home exercise programs.13,16–18,38,44,47,49 Three studies used muscle stretching (quadriceps, hamstring, and calf),16,39,48 range-of-motion exercise,16,45,48 and 4 studies used balance exercises38,41,43,44 as home exercise programs. One study used proprioception,19 cold compression,19 neuromuscular electrical stimulation,18 pedometer-driven walking,40 and tai chi exercise46 as home exercise programs.
The outcome measures of interest were pain and function in patients with knee OA. Eight studies used Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score,13,15,16,18,20,40,43,47 7 studies used visual analogue scale,17,19,38,39,45,46,49 and 1 study used present pain intensity index of the McGill Pain Questionnaire,42 for measuring pain. One study used Japanese Knee Osteoarthritis Measure,45 while others used WOMAC for measuring function.
Effect of Home Exercise Program on Pain
Meta-analysis of 11 trials13,15,17,18,20,39,40,42,43,47,49 showed that most study outcomes displayed effect size point estimates that favored home exercise compared with no intervention; the test for an overall effect across the 11 included studies was significant (P < .001), with an overall small effect size point estimate of 0.46 (95% CI, 0.24-0.68) based on a random-effects model (Figure 2). Meta-analysis of 3 trials19,38,45 showed that 1 study had an effect size point estimate that favored the other intervention compared with home exercise; however, 2 studies displayed insignificant effect size point estimate to favor any one intervention (P > .05) (Figure 3). Meta-analysis of 2 trials46,48 showed effect size point estimates that favored the group and home exercise compared with no intervention; the test for an overall effect was significant (P < .001), with an overall large effect size point estimate of 0.80 (95% CI, 0.38-1.22) based on a random-effects model (Figure 4).
Effect of Home Exercise Program on Function
Meta-analysis of 9 trials13,15,17,18,20,40,43,47,49 showed that most studies displayed effect size point estimates that favored home exercise compared with no intervention; the test for an overall effect across the 9 included studies was significant (P < .001), with an overall small effect size point estimate of 0.35 (95% CI, 0.15-0.55) based on a random-effects model (Figure 5). Meta-analysis of 5 trials16,19,38,41,45 showed that 2 studies had an effect size point estimate that favored the other intervention compared with home exercise; however, 3 studies indicated insignificant effect size point estimate to favor any one intervention (P > .05) (Figure 6). Meta-analysis of 2 trials46,48 showed effect size point estimates that favored group and home exercise compared with no intervention; the test for an overall effect was significant (P < .001), with an overall large effect size point estimate of 0.88 (95% CI, 0.45-1.30) based on a random-effects model (Figure 7).
This study is the first systematic review of the literature and meta-analysis investigating the effectiveness of home exercise program on pain and function in patients with knee OA. The present review evaluated 19 studies (15 RCTs and 4 case-controlled studies, 4270 subjects with knee OA) to examine evidence regarding the effectiveness of home exercise program in the management of knee OA. The analysis indicated that home exercise programs with and without supervised clinic-based exercises are used commonly in clinical physical therapy practice for individuals with knee OA. Among the 19 studies evaluated using the PEDro scale,21 17 were considered of high methodological quality. On the basis of the present review, the home exercise programs used in the reviewed literature can be considered as treatment possibilities for individuals with knee OA.
The methodological guidelines of the evaluated studies were properly prepared and described, allowing clinical reproducibility. This systematic review and meta-analysis demonstrated the effectiveness of home exercise program compared with no intervention in individuals with knee OA.13,15,17,18,20,39,40,42,43,47,49 Our findings concur with those obtained in previous systematic reviews that have demonstrated the benefits of exercise programs for reducing pain and disability in individuals with knee OA.50,51 However, in the present review, 4 studies20,40,43,49 failed to achieve a statistically significant effect size of functional score changes and 4 studies40,42,43,49 on pain score changes. The cause of nonsignificant effect size could be due to the methods we adopted to calculate effect sizes. We calculated effect size on the basis of the baseline and final end point scores, which included the potential detraining effect. Brismee et al46 reported significant reduction of pain and functional disability in the tai chi group at weeks 9 and 12 (P = .0089 and P = .0157, respectively). However, no significant difference was found in pain and function scores within tai chi or in comparison with the control group, or between the 2 groups throughout the follow-up detraining period.
In the present review, the home exercise compared with other intervention showed that both interventions demonstrated similar effects on pain in 2 studies19,45 and on function in 3 studies.19,41,45 This is consistent with previous studies that found no difference in functional improvement for older persons with knee OA when comparing clinic-based exercise with home exercise.52,53 Another study demonstrated similar effect of knee exercise as compared to intra-articular hyaluronic acid on functional improvement.54 In the present review, the group education or therapy along with home exercise compared with no intervention demonstrated significant reduction of knee pain and improvement of function in individuals with knee OA.
Regarding the assessed outcomes, the use of reliable and valid instruments in the studies strengthens the quality of outcomes. The WOMAC index and visual analog pain scale were the most widely used assessment tools. The WOMAC consists of 3 subscales consisting of pain (0-20 points), stiffness (0-8 points), and physical function (0-68 points), and a summated total score of the subscales.55,56 The WOMAC and visual analogue scale are the most reliable and valid tools to assess pain and function in individuals with knee OA.55–58
In 7 studies,13,38,43–46,49 the knee OA diagnosis was based on the American College of Rheumatology criteria, which include clinical and radiographic evaluations, in accordance with the Kellgren and Lawrence Scale (grades 1 through 4). In 5 studies,15,17,39,42,47 the diagnosis was made on the basis of radiographic imaging, in 2 studies16,20 based on Altman clinical criteria, in 1 study arthroscopically,18 while 3 studies19,40,41 did not report which diagnostic criteria they used. In clinical trials and observational studies, knee OA is commonly diagnosed according to these criteria. However, of the 19 included studies, only 2 reported the degree of knee OA included in the sample.18,39
Most studies reported a priori sample size calculation to determine the minimum number of subjects necessary for each group for adequate power.13,15,16,20,38,44,46–49 Although wide variation was found in the methods and interventions used in these studies, most reported significant improvements in outcome measures following home exercise with and without supervised exercise program. There was considerable variation in the content and duration of the exercise programs included in our systematic review. Length of intervention ranged from 6 weeks to 2 years, while the home exercise programs included various types of exercises such as isometric quadriceps, isometric hamstrings, isotonic quadriceps, isotonic hamstring, stretching, tai chi, range of motion, and resistance exercise. However, the majority of high-quality studies included a combination of open and closed kinematic chain exercises as a home exercise program with consistent positive outcomes.13,16,18,38,44,47,49 Adherence to home exercise program is a key predictor of response,59 and encouraging patients with knee OA to continue exercise programs beyond a supervised period of instruction is a major challenge.
The validity of the present meta-analysis may be low due to the heterogeneity in the design and choice of outcomes of the included studies. For example, the total intervention duration varied between 6 weeks44,48 and 2 years 15 and the sample size varied from 25 subjects41 to 2216 subjects 49 in the included studies. Another limitation is the variation in outcome measures selected, although pain and physical functions were the main outcomes reported in the majority of studies.13,15,17,19,38–40,44–49 However, no studies focused on the dosimetry of exercise (frequency, intensity, duration, and resistance), which cannot be analyzed in this review. Future high-quality studies are needed to assess which duration, dose, and type of exercise are optimal for patients with knee OA or if lifelong exercises are needed to maintain the benefits of exercises.
Based on the high methodological quality of studies included in this systematic literature review and meta-analysis, it can be concluded that home exercise programs reduced knee pain and improved function in individuals with knee OA. The large evidence base supports the effectiveness of a variety of home programs including open and closed kinematic chain exercises. In addition, small but growing evidence supports the effectiveness of other types of exercise such as tai chi, balance, and proprioceptive training for individuals with knee OA. Even though less is known about the effects of these types of exercise, they provide new alternatives for individuals with OA to modify or vary their exercise program. Further direct comparison is required to investigate the relative efficacies of these exercise programs.
The authors would like to extend their sincere appreciation to the Deanship of Scientific Research at King Saud University for funding this research through the research group NO. RGP-VPP-209.
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