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Background Osteoarthritis ( OA ) is a common cause of pain and disability , and is the most common form of arthritis in the Western world . The most common joint to be affected is the knee . Pain and functional disability are common symptoms , which can lead to reduced quality of life and increase the risk of further morbidity . Current treatment aims to educate patients about the management of OA , reduce pain , improve function , decrease disability and reduce the progression of the disease . Education with clients has been described as a set of planned educational activities design ed to improve patients ' health behaviours and /or health status . The purpose of self‐education is to maintain or improve health , or , in some cases , to slow deterioration by increasing participant 's perception of self efficacy defined as an ability to control or manage various aspects of OA . To date , there is no systematic review of the literature undertaken to identify the effectiveness of self‐management educational activities for osteoarthritis of the knee . Objective The objective of this systematic review is to evaluate the effectiveness of  self‐management educational interventions on function and quality of life for adult subjects with OA of the knee . Search strategy A comprehensive search strategy was undertaken on data bases available from University of South Australia from their inception to January 2007 . Selection criteria R and omised controlled trials or clinical controlled trials were sought which evaluated any self management interventions for osteoarthritis knee . Critical appraisal of study quality was undertaken using Joanna Briggs Institute critical appraisal instruments . Data extraction was via the Joanna Briggs Institute st and ard data extraction form for evidence of effectiveness , and Review Manager Software was used to calculate comparative statistics . Results Thirteen trials were included in the review . Trials were clinical ly and method ologically heterogeneous . Pooled results indicate evidence of a beneficial effect from  self management strategies with reducing pain ( SMD ‐0.25 , 95%CI ‐0.36 to ‐0.13 , 11 trials 1379 participants ) . There was no effect on physical function ( SMD 0.13 , 95%CI ‐0.33 to ‐0.08 , eight trials , 1156 subjects ) . No beneficial effects were found from self management interventions with improving quality of life . We also found the exercise component of self management ( four trials ) demonstrated a benefit with reducing pain , improving function and quality of life . Exercise also offered a benefit over no exercise  . Overall method ological quality was moderate . Discussion Pooled results indicate evidence of a beneficial effect from self management strategies with reducing pain and improving function . Significant heterogeneity was found between trials . This was controlled for in the analysis but may be explained by heterogeneity in both the intervention and control group . The exercise component of self management programmes appears to contribute a significant benefit . Conclusion There is encouraging evidence of a small benefit from exercise in self management programs . Clear guidelines can not be provided for practice regarding the exercise content due to heterogeneity but overall benefit suggests this component should be emphasized and implemented in primary care self management programmes Background Osteoarthritis ( OA ) of the knee is one of the leading causes of disability in the United States . One relatively new strategy that could be helpful in the management of OA is the use of mHealth technologies , as they can be used to increase physical activity and promote exercise , which are key components of knee OA management . Objective Currently , no published data on the use of a mHealth approach to comprehensively monitor physical activity in patients with OA are available , and similarly , no data on whether mHealth technologies can impact outcomes are available . Our objective is to evaluate the effectiveness of mHealth technology as part of a tailored , comprehensive management strategy for patients with knee OA . Methods The study will assess the impact of a smartphone app that integrates data from a wearable activity monitor ( thereby both encouraging changes in mobility as well as tracking them ) combined with education about the benefits of walking on patient mobility . The results from the intervention group will be compared with data from a control group of individuals who are given the same Arthritis Foundation literature regarding the benefits of walking and wearable activity monitors but who do not have access to the data from those monitors . Activity monitors will capture step count estimates and will compare those with patients ’ step goals , calories burned , and distance walked . Patients using the novel smartphone app will be able to enter information on their daily pain , mood , and sleep quality . The relationships among activity and pain , activity and mood , and sleep will be assessed , as will patient satisfaction with and adherence to the mobile app . Results We present information on an upcoming trial that will prospect ively assess the ability of a mobile app to improve mobility for knee OA patients who are treated with intra-articular hyaluronic acid . Conclusions We anticipate the results of this study will support the concept that mHealth technologies provide continuous , real-time feedback to patients with OA on their overall level of activity for a more proactive , personalized approach to treatment that may help modify behavior and assist with self-management through treatment support in the form of motivational messages and reminders OBJECTIVE To develop clinical practice guidelines for the use of foot orthotics ( FO ) in the treatment of knee and hip osteoarthritis . METHOD The SOFMER ( French Physical Medicine and Rehabilitation Society ) methodology , associating a systematic review of the literature , input from every day clinical practice and external review by a multidisciplinary expert committee , was used . The selected analysis criteria were  pain , disability , medications used and X-ray evolution of osteoarthritis .  The recommendations are classified according to the level of proof in Grade A , B or C according to the French National Agency for Health Accreditation and Evaluation ( NAHAE ) . RESULTS In medial knee osteoarthritis , foot pronation orthotics -- when there are no contraindications -- can be proposed for their symptomatic impact , especially in the decrease of NSAIDs consumption ( Grade B ) . To this day , there is no evidence of a structural or functional impact on osteoarthritis ( Grade B ) . Outside of this specific clinical framework , there is no vali date d indication for prescribing foot orthotics in the treatment of knee or hip OA ( Grade C ) . CONCLUSION It is necessary to have further r and omized controlled trials to better define the indication of Foot orthotics ( severity of knee OA , genu varum ) , test the efficacy of other orthoses such as cushioning FO . The long-term side effects , mainly on the external femorotibial compartment could also be assessed . A medical and economical assessment of FO prescriptions is also quite necessary OBJECTIVE The purpose of this study was to examine the effect of a preoperative exercise intervention on knee pain , functional ability , and quadriceps strength among patients with knee osteoarthritis before and after total knee arthroplasty ( TKA ) surgery . DESIGN A repeated- measures design was used to compare 2 groups over 4 data collection points . SETTING AND PATIENTS Community-dwelling subjects with osteoarthritis of the knee who were scheduled for a unilateral TKA were recruited from a single orthopedic surgeon 's office and were r and omized into control ( n = 28 ) or prehab groups ( n = 26 ) . INTERVENTIONS The control patients maintained usual care before their TKA . The exercisers performed prehabilitation exercises , which included resistance training , flexibility , and step training , 3 times per week before their TKA . OUTCOME MEASURES Knee pain , functional ability , quadriceps strength , and strength asymmetry were assessed at baseline ( T1 ) , at 1 week before the patients ' TKA ( T2 ) , and again at 1 ( T3 ) and 3 ( T4 ) months after TKA . RESULTS The exercisers improved their sit-to-st and performance at T2 , whereas the control group did not change their performance of functional tasks and had increased pain at T2 . At T3 the exercisers demonstrated improved sit-to-st and performance . The control patients at T3 exhibited decreases in pain , their 6-minute walk , surgical leg strength and an increase in their nonsurgical leg strength and leg strength asymmetry . At T4 the exercisers improved in their performance of 3 of the 4 functional tasks , decreased all of their pain measures , and increased their surgical and nonsurgical quadriceps strength . At T4 the control group improved their performance on 2 of the 4 functional tasks , decreased all of their pain measures , increased their nonsurgical leg strength , and exhibited greater leg strength asymmetry . CONCLUSION These findings appear to indicate the efficacy of prehabilitation among TKA patients and support the theory of prehabilitation Osteoarthritis ( OA ) of the knee leads to restrictions of physical activity and ability to perform activities of daily living . Obesity is a risk factor for knee OA and it appears to exacerbate knee pain and disability . The Arthritis , Diet , and Activity Promotion Trial ( ADAPT ) was developed to test the efficacy of lifestyle behavioral changes on physical function , pain , and disability in obese , sedentary older adults with knee OA . This controlled trial r and omized 316 sedentary overweight and obese older adults in a two-by-two factorial design into one of four 18-month duration intervention groups : Healthy Lifestyle Control ; Dietary Weight Loss ; Structured Exercise ; or Combined Exercise and Dietary Weight Loss . The weight-loss goal for the diet groups was a 5 % loss at 18 months . The intervention was modeled from principles derived from the group dynamics literature and social cognitive theory . Exercise training consisted of aerobic and strength training for 60 minutes , three times per week in a group and home-based setting . The primary outcome measure was self-report of physical function using the Western Ontario and McMaster University Osteoarthritis Index . Other measurements included timed stair climb , distance walked in 6 minutes , strength , gait , knee pain , health-related quality of life , knee radiographs , body weight , dietary intake , and cost-effectiveness of the interventions . We report baseline data stratified by level of overweight and obesity focusing on self-reported physical function and physical performance tasks . The results from ADAPT will provide approaches clinicians should recommend for behavioral therapies that effectively reduce the incidence of disability associated with knee OA OBJECTIVE The purpose s of this pilot study were to determine if a combined dietary and exercise intervention would result in significant weight loss in older obese adults with knee osteoarthritis , and to compare the effects of exercise plus dietary therapy with exercise alone on gait , strength , knee pain , biomarkers of cartilage degradation , and physical function . DESIGN Single-blind , two-arm , r and omized clinical trial conducted for 24 weeks . SETTING A university health and exercise science center . PARTICIPANTS Twenty-four community-dwelling obese older adults aged > or = 60 years , body mass index > or = 28 , knee pain , radiographic evidence of knee osteoarthritis , and self-reported physical disability . INTERVENTION R and omization into two groups : exercise and diet ( E&D ) and exercise alone ( E ) . Exercise consisted of a combined weight training and walking program for 1 hour three times per week . The dietary intervention included weekly sessions with a nutritionist utilizing cognitive-behavior modification to change dietary habits to reach a group goal of an average weight loss of 15 lb ( 6.8 kg ) over 6 months . MEASUREMENTS All measurements were conducted at baseline and 3 and 6 months , except for synovial fluid analysis , which was obtained only at baseline and 6 months . In addition , weight was measured weekly in the E&D group . Physical disability and knee pain were measured by self-report and physical performance was measured using the 6-minute walk and stair climb tasks . Biomechanical testing included kinetic and kinematic analysis of gait and isokinetic strength testing . Synovial fluid was analyzed for levels of total proteoglycan , keratan sulfate , and interleukin-1 beta . RESULTS Twenty-one of the 24 participants completed the study , with one dropout in the E&D group and two in the E group . The E&D group lost a mean of 18.8 lb ( 8.5 kg ) at 6 months compared with 4.0 lb ( 1.8 kg ) in the E group ( P = .01 ) . Significant improvements were noted in both groups in self-reported disability and knee pain intensity and frequency as well as in physical performance measures . However , no statistical differences were found between the two groups at 6 months in knee pain scores or self-reported performance measures of physical function . There was no difference in knee strength between the groups , with both groups showing modest improvements from baseline to 6 months . At 6 months , the E&D group had a significantly greater loading rate ( P = .03 ) and maximum braking force ( P = .01 ) during gait . There were no significant between-group differences in the other biomechanical measures . Synovial fluid sample s were obtainable at both baseline and 6 months in eight participants ( four per group ) . The level of keratan sulfate decreased similarly in both groups from an average baseline of 96.8 + /- 37.1 to 71.5 + /- 23 ng/microg total proteoglycan . The level of IL-1 decreased from 25.3 + /- 9.8 at baseline to 8.3 + /- 6.1 pg/mL. The decrease in IL-1 correlated with the change in pain frequency ( r = -0.77 , P = .043 ) . CONCLUSIONS Weight loss can be achieved and sustained over a 6-month period in a cohort of older obese persons with osteoarthritis of the knee through a dietary and exercise intervention . Both exercise and combined weight loss and exercise regimens lead to improvements in pain , disability , and performance . Moreover , the trends in the biomechanical data suggest that exercise combined with diet may have an additional benefit in improved gait compared with exercise alone . A larger study is indicated to determine if weight loss provides additional benefits to exercise alone in this patient population Lateral wedges were originally proposed to manage medial compartment osteoarthritis of the knee but recent review s suggest that lateral wedges do not affect disease progression . We performed a systematic review to analyse the recent literature and define how effective , if at all , lateral wedges are in the management of medial compartment osteoarthritis of the knee . The inclusion criteria were defined as any study published within the last decade , using a sample size of at least twenty patients , and investigating the effect of insoles or wedges on either unilateral or bilateral knee varus osteoarthritis . The st and ardised keyword term ‘ lateral*wedge*OR insole*OR orthotic * OR medial compartment OR varus OR osteoarthri * OR knee * ’ was used . We identified 10 studies that fitted our inclusion criteria . Although there is not enough evidence in the literature to prove that lateral wedge orthotics are an effective treatment for varus osteoarthritis of the knee  , there is some evidence to suggest that they do have some symptomatic effect .  Patients with early osteoarthritis and higher BMI may benefit to a greater extent than those with a greater extent of degenerative changes and lower BMI . The literature is unclear as to what the optimal duration for the use of lateral wedges is , but does support the prolonged use of the wedges as the benefits at one month are maintained at one year . Future studies should be r and omised controlled trials with a large sample size with long follow-up , and use objective clinical , biomechanical and radiological outcome measures OBJECTIVE This 8 week r and omized , double blind clinical trial compared the effect of a combined home based progressive exercise program and treatment with the nonsteroidal medication oxaprozin to treatment with oxaprozin alone on pain and physical functioning in older community dwelling patients with unilateral knee osteoarthritis ( OA ) . METHODS Efficacy variables measured before and after 8 weeks included ( 1 ) pain using the Western Ontario McMaster ( WOMAC ) pain , physical disability , and stiffness subscales and a 10 point visual analog scale ( VAS ) before and after self-paced walking ( SPW ) and stepping ( SPS ) functional tasks ; ( 2 ) physical function using the time to complete a self-paced 40 m walk ( SPW ) and 20 cycles of 2 steps ( SPS ) : ( 3 ) physical activity level using the Physical Activity Scale for Elderly ( PASE ) ; ( 4 ) clinical measures of knee functioning ( range of motion ) .  One hundred seventy-nine men and women ( mean age 74 + /- 6 yrs ) with radiographic evidence of mild/moderate medial compartment OA were r and omized to either a progressive home based knee exercise program ( n = 88 ) or a control program ( n = 89 ) . All patients were given oxaprozin 1,200 mg per os daily . RESULTS We observed significant reduction from baseline in activity related pain ( VAS ) ; and improvement in SPW and SPS test time , passive range of motion , and PASE after 8 weeks in both groups . These changes were significantly greater ( p < 0.05 ) in the exercise versus sham group . CONCLUSION Addition of a progressive exercise program to nonsteroidal antiinflammatory therapy in patients with knee OA can improve measures of activity and activity related pain more than medication alone OBJECTIVES To examine the efficacy of periosteal stimulation therapy ( PST , osteopuncture ) for the treatment of  chronic pain associated with advanced knee osteoarthritis . DESIGN R and omized , controlled clinical trial . SETTING Outpatient pain clinic . PARTICIPANTS Eighty-eight community-dwelling older adults with moderate knee pain or greater for 3 months or longer and Kellgren-Lawrence ( K-L ) grade 2 through 4 radiographic severity ( 80 % had K-L 4 ) . INTERVENTION Participants were r and omized to receive PST or control PST once a week for 6 weeks . MEASUREMENTS Pain severity and self-reported function ( Western Ontario and McMasters University Osteoarthritis Index ( WOMAC ) ) and physical performance ( Short Physical Performance Battery ( SPPB ) ) were assessed at baseline , after the last PST session ( post ) , and 3 months later ( follow-up ) . Pain severity was also assessed monthly using the multidimensional pain inventory short form . RESULTS Pain was reduced significantly more in the PST group than in the control PST group at post ( P=.003 ; mean WOMAC pain subscale baseline 9.4 vs 6.4 ) and 1 month later ( P<.001 ) , but by 2 months , pain levels had regressed to pre-intervention levels . The group-by-time interaction for the WOMAC function scale was significant at post ( P=.04 ) but not at follow-up ( P=.63 ) . No significant group differences were found for the SPPB . Neither analgesic use nor global improvement differed between groups . There were four treatment dropouts . CONCLUSION PST affords short-term modest pain reduction for older adults with advanced knee OA . Future research should test the effectiveness of booster treatments in sustaining analgesic benefits and of combining PST with therapeutic exercise in ameliorating disability risk UNLABELLED Purpose : To perform a systematic review with best evidence synthesis examining the literature on the relationship between occupational loading tasks and  knee osteoarthritis ( OA ) . METHODS Two data bases were search ed to identify articles published between 1946 and April , 2011 . Eligible studies were those that ( 1 ) included adults reporting on their employment history ; ( 2 ) measured individuals ' exposure to work-related activities with heavy loading in the knee joint ; and ( 3 ) identified presence of knee OA ( determined by X-ray ) , cartilage defects associated with knee OA ( identified by magnetic resonance imaging ) , or joint replacement surgery . RESULTS A total of 32 articles from 31 studies met the inclusion criteria . We found moderate evidence that combined heavy lifting and kneeling is a risk factor for knee OA , with odds ratios ( OR ) varying from 1.8 to 7.9 , and limited evidence for heavy lifting ( OR=1.4 - 7.3 ) , kneeling ( OR=1.5 - 6.9 ) , stair climbing ( OR=1.6 - 5.1 ) , and occupational groups ( OR=1.4 - 4.7 ) as risk factors . When examined by sex , moderate level evidence of knee OA was found in men ; however , the evidence in women was limited . CONCLUSIONS Further high- quality prospect i ve studies are warranted to provide further evidence on the role of occupational loading tasks in knee OA , particularly in women OBJECTIVE To determine the effects of structured exercise programs on  self-reported disability in older adults with knee osteoarthritis . SETTING AND DESIGN A r and omized , single-blind clinical trial lasting 18 months conducted at 2 academic medical centers . PARTICIPANTS A total of 439 community-dwelling adults , aged 60 years or older , with radiographically evident knee osteoarthritis , pain , and self-reported physical disability .  INTERVENTIONS An aerobic exercise program , a resistance exercise program , and a health education program . MAIN OUTCOME MEASURES The primary outcome was self-reported disability score ( range , 1 - 5 ) . The secondary outcomes were knee pain score ( range , 1 - 6 ) , performance measures of physical function , x-ray score , aerobic capacity , and knee muscle strength . RESULTS A total of 365 ( 83 % ) participants completed the trial . Overall compliance with the exercise prescription was 68 % in the aerobic training group and 70 % in the resistance training group . Postr and omization , participants in the aerobic exercise group had a 10 % lower adjusted mean ( + /- SE ) score on the physical disability question naire ( 1.71 + /- 0.03 vs 1.90 + /- 0.04 units ; P<.001 ) , a 12 % lower score on the knee pain question naire ( 2.1 + /- 0.05 vs 2.4 + /- 0.05 units ; P=.001 ) , and performed better ( mean [ + /- SE ] ) on the 6-minute walk test ( 1507 + /- 16 vs 1349 + /- 16 ft ; P<.001 ) , mean ( + /-SE ) time to climb and descend stairs ( 12.7 + /- 0.4 vs 13.9 + /- 0.4 seconds ; P=.05 ) , time to lift and carry 10 pounds ( 9.1 + /- 0.2 vs 10.0 + /- 0.1 seconds ; P<.001 ) , and mean ( + /-SE ) time to get in and out of a car ( 8.7 + /- 0.3 vs 10.6 + /- 0.3 seconds ; P<.001 ) than the health education group . The resistance exercise group had an 8 % lower score on the physical disability question naire ( 1.74 + /- 0.04 vs 1.90 + /- 0.03 units ; P=.003 ) , 8 % lower pain score ( 2.2 + /- 0.06 vs 2.4 + /- 0.05 units ; P=.02 ) , greater distance on the 6-minute walk ( 1406 + /- 17 vs 1349 + /- 16 ft ; P=.02 ) , faster times on the lifting and carrying task ( 9.3 + /- 0.1 vs 10.0 + /- 0.16 seconds ; P=.001 ) , and the car task ( 9.0 + /- 0.3 vs 10.6 + /- 0.3 seconds ; P=.003 ) than the health education group . There were no differences in x-ray scores between either exercise group and the health education group . CONCLUSIONS Older disabled persons with osteoarthritis of the knee had modest improvements in measures of disability , physical performance , and pain from participating in either an aerobic or a resistance exercise program . These data suggest that exercise should be prescribed as part of the treatment for knee osteoarthritis OBJECTIVES To determine whether a home-based pedometer-driven walking program with arthritis self-management education ( Walk + ) would increase physical activity , muscle strength , and functional performance in older adults with osteoarthritis ( OA ) of the knee as opposed to arthritis self-management education alone ( EDU ) . DESIGN A r and omized two-by-three ( group-by-time ) design with participants assigned to  Walk + ( n = 17 , mean age + /- st and ard deviation = 69.6 + /- 6.7 ) or EDU ( n = 17 , age = 70.8 + /- 4.7 ) . SETTING Community located in the Baltimore-Washington area . PARTICIPANTS Thirty-four community-dwelling adults , aged 60 and older with symptomatic knee OA and self-reported functional impairment . INTERVENTIONS Both groups received 12 hours of the Arthritis Self-Management program over 12 weeks and were followed for an additional 12 weeks . In addition , the Walk + group received individualized instruction in the use of a pedometer , with the goal of increasing their step count by 30 % of their baseline step count . MEASUREMENTS The outcome measures were physical activity ( daily step counts and total activity vector magnitude as measured by a pedometer and Tritrac-R3D accelerometer ) , quadriceps femoris strength ( isometric peak torque ) , and functional performance tasks ( 100-foot walk-turn-walk , timed stair climb , timed chair rise , and pain status ) . RESULTS Daily steps walked showed a significant group-by-time interaction ( P = .04 ) after controlling for age . From baseline to completion of training , a 23 % increase in daily steps occurred in the Walk + group and a 15 % decrease in the EDU group . Although steps increased in the Walk + group , total activity vector magnitude was maintained , suggesting a more efficient gait . The Walk + group became quicker than the EDU group in the normal-pace walk-turn-walk ( P = .04 ) . An isometric strength gain of 21 % postintervention was seen in the Walk + group , compared with a loss of 3.5 % in the EDU group . CONCLUSION In older adults with symptomatic knee OA , Walk + appears to increase walking , with improvements in muscle strength and walking performance . The use of a home-based pedometer-driven program to increase physical activity , strength , and function in this population warrants further research Context Despite their established benefit in patients with osteoarthritis , many treatment strategies are underused . Contribution In this r and omized trial , providing treatment recommendations to physicians in addition to telephone-based support to patients with knee or hip osteoarthritis result ed in modest improvements in physical function . Caution The relative contributions of the physician- and patient-based interventions to the observed improvement could not be assessed . Implication A combined physician and patient intervention may be beneficial in patients with knee or hip osteoarthritis . Osteoarthritis is one of the most common chronic health conditions and a leading cause of pain and disability ( 15 ) . Its prevalence is increasing , and this trend is expected to continue ( 6 , 7 ) . In addition to the substantial toll at the individual level ( 8) , osteoarthritis is placing an increasing burden on health care systems ( 9 , 10 ) . Evidence -based guidelines indicate that adequate management of hip and knee osteoarthritis requires both behavioral and clinical strategies ( 1114 ) .  Physical activity  and  weight management  are key behavioral strategies for managing hip and knee osteoarthritis , but most adults with osteoarthritis are physically inactive or overweight ( 15 , 16 ) . Similarly , despite strong evidence supporting several clinical strategies , such as joint injections , physical therapy , and pain medications , some of these treatments are underused , and studies have shown low rates of adherence to osteoarthritis quality indicators ( 1720 ) . Improvement in osteoarthritis management is needed at both the patient and provider levels . The purpose of our study was to examine a combined patient and provider intervention for management of osteoarthritis in primary care . Methods The Institutional Review Board of the Department of Veterans Affairs ( VA ) Medical Center in Durham , North Carolina , approved this study . Detailed methods have been published previously ( 21 ) . Study Design This was a cluster r and omized , controlled trial , with primary care providers ( PCPs ) assigned to an osteoarthritis intervention group or a usual care control group . R and omization was computer-generated , maintained by the study statistician , and stratified on the basis of the providers ' volume of female patients ( < 15 % vs. 15 % ) . We aim ed to enroll 10 patient participants ( 5 white and 5 nonwhite ) from each of 30 PCPs . Providers assigned to the osteoarthritis intervention group received the provider intervention , and their enrolled patient participants received the patient intervention . Patient participants in both groups continued with any usual medical care recommended by their providers . Because all patient participants were enrolled at the Durham VA Medical Center , usual care could include any of the st and ard treatments for osteoarthritis given by a PCP as well as referral to other providers or specialists . Provider and patient participants in the usual care group received no additional intervention during the study . Participants and Recruitment Primary care providers in the Ambulatory Care Service of the Durham VA Medical Center , with patient panels large enough to be likely to enroll 10 participants , were invited to participate . Patients were eligible if they had hip osteoarthritis ( based on radiographic evidence in the electronic medical record [ EMR ] ) , knee osteoarthritis ( based on radiographic evidence in the EMR or clinical criteria from the American College of Rheumatology [ 22 ] ) , or both , along with self-reported joint symptoms ( pain , aching , stiffness or swelling in or around a hip or knee joint with arthritis ) that were present on most days during the past month or for which the patient had used pain medications on most days during the past month ( 23 ) . Participants also had to be overweight ( body mass index [ BMI ] 25 kg/m2 ) and not currently adhering to physical activity recommendations from the U.S. Department of Health and Human Services ( 24 ) . Exclusion criteria are summarized in the Appendix Table . Potential participants were identified from the Durham VA Medical Center EMR , mailed an introductory letter , and called for a screening interview . Eligible patients completed consent and baseline assessment s at the Durham VA Medical Center and were subsequently informed of their group assignment by telephone . Study team members involved in screening and consent were blinded to r and omization . Potential patient participants were blinded to their PCP 's group assignment until after the baseline assessment s. Appendix Table . Exclusion Criteria Interventions Patient Intervention This was a 12-month intervention focusing on physical activity , weight management , and cognitive behavioral pain management strategies ( 21 ) . Telephone calls were scheduled twice per month for the first 6 months and monthly for the last 6 months and were delivered by a counselor with training in osteoarthritis and behavior change . Goal setting and action planning were major components of the intervention . The counselor used motivational interviewing strategies throughout the intervention ( 21 , 25 , 26 ) . Patient participants were given written educational material s corresponding to intervention topics , an exercise video for patients with osteoarthritis , and an audio CD of relaxation exercises . Provider Intervention This intervention involved delivery of the following patient-specific osteoarthritis treatment recommendations to PCPs , based on published treatment guidelines ( 13 , 14 , 27 ) : refer to a physical therapist , refer for an evaluation for a knee brace , refer to MOVE ! ( the VA system 's weight management program that includes physical activity counseling [ 28 ] ) , perform or refer for an intra-articular injection , recommend a topical nonsteroidal anti-inflammatory drug ( NSAID ) or capsaicin , add a gastroprotective agent or remove an NSAID , discuss the possibility of a new or alternate pain medication , or refer to an orthopedic evaluation for joint replacement surgery . We developed algorithms ( Appendix ) to determine when each treatment option might be reasonable for a PCP to consider for a patient ( 21 ) . Study team members collected all information needed to complete the algorithm for each patient participant during baseline assessment s. Patient-specific recommendations were delivered to PCPs via the EMR as a progress note requiring an electronic signature . The study team monitored upcoming visits for participants in the osteoarthritis intervention group , and recommendations were delivered to PCPs about 1 week before the participants ' first routine visit after enrollment . The recommendations remained available to PCPs within the EMR , but no further communications were transmitted to osteoarthritis intervention providers . Outcome Measures Baseline and 12-month follow-up measures were completed in person , except for 36 participants who could not return to the Durham VA Medical Center at 12 months but completed some measures via telephone . The primary outcome was also assessed via telephone at 6 months . Outcomes assessors were blinded to r and omization . Participants were reimbursed $ 25 and $ 10 for completing in-person and telephone assessment s , respectively . Primary Outcome The primary outcome measure was total score on the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) , a self-reported measure of lower extremity pain ( 5 items ) , stiffness ( 2 items ) , and function ( 17 items ) in the previous 2 weeks ( 2931 ) . All items are rated on a 5-point Likert scale ranging from none to extreme ; total scores range from 0 to 96 , with higher scores indicating worse symptoms and function . Secondary Outcomes We examined the WOMAC pain and function subscales separately . We also administered the Short Physical Performance Battery ( SPPB ) ( 32 ) , a commonly used performance measure in older adults that includes 3 tests of balance , a timed 8-foot walk , and 5 chair st and s. The total score ranges from 0 ( worst performance ) to 12 ( best performance ) . Depressive symptoms were assessed with the Patient Health Question naire-8 ( 33 ) , with scores ranging from 0 to 24 . Process Measures We collected additional process measures related to behaviors or outcomes intermediate to changes in symptoms or function . Self-reported physical activity was measured with the Community Healthy Activities Model Program for Seniors ( CHAMPS ) ( 34 , 35 ) , which assesses the frequency and duration of light to vigorous activities in the previous 4 weeks ; we report the weekly frequency and duration of all exercise as well as moderate- or higher-intensity exercise . CHAMPS has established testretest reliability and association with accelerometer-based physical activity among older adults ( 36 ) . Body mass index was calculated using measured height and weight ; when 12-month follow-up measures were administered via telephone , weight was self-reported . For all patient participants , we used the Durham VA Medical Center EMR to examine osteoarthritis-related referrals from PCPs and participants ' actual visits for physical therapy , evaluations for knee braces , joint injections , MOVE ! , and orthopedic consultation during the study . We assessed changes in oral and topical pain medication  by participant self-reports . For oral pain medications , we defined new use during the study as either no pain medication use at baseline but some use at follow-up or use of a different pain medication at follow-up than at baseline . For topical creams , we defined new users as those who reported using any type at follow-up but not at baseline . We acknowledge that use of new oral or topical pain medications may not necessarily have led to better pain control . We also report proportions of osteoarthritis intervention participants whose PCP received each treatment recommendation from the study team and , among those , proportions who had referrals and visits for those treatments . Participant Characteristics We collected patient participantreported information on age , sex , Osteoarthritis is a leading cause of pain and disability ( 13 ) . Already a leading chronic health condition in primary care setting s ( 4 ) , osteoarthritis will become increasingly prevalent ( 58 ) . Treatment involves a combination of behavioral , pharmacologic , and other clinical therapies ( 911 ) ; therefore , both patients and health care providers play key roles in effective management . However , studies have identified gaps in the use of key behavioral strategies , including physical activity and weight management ( 1214 ) , as well as low use of some recommended clinical therapies ( 1520 ) . These studies emphasize the need to improve the use of evidence -based osteoarthritis therapies . It is not known whether interventions focused on health care providers or patients may be more effective for improving osteoarthritis management and outcomes . Most previous osteoarthritis interventions occurred at the patient level , with little attempt to effect provider- or system-level changes . We previously reported that among a group of patients with osteoarthritis receiving care at a single Veterans Affairs medical center ( VAMC ) , a combined patient and provider intervention result ed in statistically significant , modest improvements in physical function ( 21 ) . This study extends this research area by separately examining patient-level , health care providerlevel , and combined osteoarthritis interventions in several primary care clinics . Methods The Institutional Review Board of Duke University Medical Center approved this study . Methods were published previously ( 22 ) . Owing to our lack of awareness , the study was registered at Clinical Trials.gov 15 days after the first participant was enrolled , which met institutional requirements but not the International Committee of Medical Journal Editors ' requirement of registration before participant enrollment . Only 1 participant was enrolled , and no analyses were done before registration . Study Setting and Design This study was conducted within the Duke Primary Care Research Consortium . Ten primary care clinics were r and omly assigned to provider intervention or control conditions , and patients within those clinics were assigned to patient intervention or control , result ing in 4 study groups : patient intervention , provider intervention , patientprovider intervention , and usual care . R and omization schedules for clinics and patients were computer generated by the statistician . Clinic r and omizations were paired on the basis of type ( family or internal medicine ) as well as similarities in practice size ( numbers of patients and providers ) and rural versus urban location ; 1 clinic in each pair was assigned to the provider intervention and 1 to the provider control group . Patient r and omizations were stratified by race ( white vs. nonwhite ) and sex . All participants continued with usual care for osteoarthritis as recommended by their providers , with no restrictions . Participants and Recruitment All primary care providers ( PCPs ) at the study clinics were invited to participate ; only 2 declined . Patients were eligible if they had osteoarthritis of the hip ( based on radiographic evidence in the electronic medical record [ EMR ] ) or knee ( based on radiographic evidence in the EMR or satisfaction of American College of Rheumatology clinical criteria [ 23 ] ) , along with self-reported joint symptoms ( pain , aching , stiffness , or swelling in or around a hip or knee joint with arthritis that was present or for which the patient used pain medications on most days during the past month ) ( 24 ) . Participants had to be overweight ( body mass index [ BMI ] 25 kg/m2 ) and not currently meeting U.S. Department of Health and Human Services physical activity recommendations ( 150 minutes of aerobic activity and 2 sessions of muscle strengthening activity weekly ) ( 25 ) . Exclusion criteria are summarized in Appendix Table 1 . Potential participants were identified from the EMR , were mailed an introductory letter , and were called for screening . Eligible patients gave consent , completed baseline assessment s , and were informed of their r and omization assignment by the study coordinator via telephone . Appendix Table 1 . Exclusion Criteria Interventions Patient Behavioral Intervention for Osteoarthritis The intervention took place over 12 months and focused on physical activity , weight management , and cognitive behavioral strategies for managing  pain  ( 22 ) . Telephone calls were scheduled twice per month for the first 6 months , then monthly for the last 6 months , and were delivered by a counselor with training in osteoarthritis and behavior change . Goal setting and action planning were major intervention components . Motivational interviewing strategies were used throughout the intervention ( 22 , 26 , 27 ) . Participants were given written educational material s , an exercise video , and an audio CD of relaxation exercises . Provider Intervention The study team delivered the following patient-specific osteoarthritis treatment recommendations to PCPs , based on treatment guidelines ( 11 , 28 , 29 ) : refer to physical therapist , refer for evaluation for knee brace , refer to weight management program , refer to physical activity program , perform or refer for intra-articular injection , recommend topical nonsteroidal anti-inflammatory drug or capsaicin , add gastroprotective agent or remove nonsteroidal anti-inflammatory drug in patients at high risk for peptic ulcer disease , discuss new or alternate pain medication , and refer to orthopedic evaluation for joint replacement surgery . We developed algorithms based on patient data ( Appendix Table 2 ) regarding when each treatment option would be reasonable for a PCP to consider for a patient ( 22 ) . However , decisions regarding whether to recommend these treatments to patients were at the discretion of the PCPs . The study team monitored upcoming visits for provider intervention participants , and recommendations were delivered only once per participant , before the first routine visit after enrollment . Most recommendations were delivered via the Duke EMR , but 22 were delivered via secure e-mail during an EMR transition . Appendix Table 2 . Provider Intervention Recommendations and Algorithms Outcome Measures The primary and secondary analyses include measures at baseline through 12 months . Analyses of maintenance effects ( 18 and 24 months ) will be presented separately . All outcomes ( including osteoarthritis treatment use ) were assessed in person at baseline and 12 months , except for 48 participants who could not return at 12 months but completed some measures via telephone . The primary outcome also was assessed via telephone at 6 months . Outcomes assessors were blind to r and omization . Participants were reimbursed $ 25 and $ 10 for in-person and phone assessment s , respectively . Primary Outcomes The primary outcome was the total score on the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) , a self-reported measure of lower-extremity pain ( 5 items ) , stiffness ( 2 items ) , and function ( 17 items ) in the past 2 weeks ( 3032 ) . All items are rated on a 5-point Likert scale ranging from none to extreme ( total range , 0 to 96 ; higher scores indicate worse symptoms and function ) . Secondary Outcomes We examined WOMAC pain and function subscales separately . We also administered the Short Physical Performance Battery ( 33 ) , which includes 3 tests of balance , a timed 8-foot walk , and 5 chair st and s. The total score ranges from 0 ( worst performance ) to 12 ( best performance ) . Depressive symptoms were assessed with the 8-item Patient Health Question naire ( PHQ-8 ) ( 34 ) , with scores ranging from 0 to 24 . Physical Activity and BMI Several exploratory measures were collected ( 22 ) ; here , we focus on physical activity and BMI , because they assess core patient intervention components . Self-reported physical activity was measured with the Community Healthy Activities Model Program for Seniors ( CHAMPS ) ( 35 , 36 ) ; we report the weekly frequency and duration of all exercise , as well as moderate- or higher-intensity exercise , during the past 4 weeks . Height and weight were measured to calculate BMI ; when 12-month follow-up measures were administered via telephone , weight was self-reported . Osteoarthritis Treatment Use and Recommendations We describe the proportions of participants who reported receiving the following treatments during the study period : physical therapy for knee or hip osteoarthritis , new knee brace use , joint injections , a change in oral pain medications , new use of topical creams , and joint replacement surgery . We assessed osteoarthritis treatment use via self-report , because the EMR would not capture care received outside the Duke system . For the provider intervention groups , we also report the proportions of participants for whom each treatment recommendation was given to the PCP by the study team . Data regarding recommendations or referrals given to patients by PCPs were not collected . Participant Characteristics We collected patient-reported characteristics , including age , sex , race/ethnicity ( white vs. nonwhite ) , household financial situation ( with inadequate income meaning just enough or not enough to meet basic expenses ) , education level , marital status , work status ( employed or student vs. other ) , disabled ( positive response to disabled in the work status question ) , general self-rated health ( excellent , very good , or good vs. fair or poor ) , and duration of osteoarthritis symptoms . Adverse Events At each study encounter , we inquired about hip and knee injuries or surgeries . We noted other adverse events that participants reported to the study team during regular contact or that were discovered during study -related EMR review . Sample Size The estimated sample size of 140 participants per group ( 56 per clinic ) was based on detecting a 15 % improvement in WOMAC scores at 12 months for either of 2 primary hypotheses , with 80 % power and a type I error rate of 0.05 . Sample size calculations were based on methods for appropriate INTRODUCTION Physiotherapy is one of the most important components of therapy for osteoarthritis of the knee . The objective of this prospect i ve case series was to assess the efficiency of a guidance manual for patients with osteoarthritis of the knee in relation to pain , range of movement , muscle strength and function , active goniometry , manual strength test and function . METHODS Thirty-eight adults with osteoarthritis of the knee ( > or= 45 years old ) who were referred to the physiotherapy service at the university hospital ( Santa Casa de Misericórdia de São Paulo ) were studied . Patients received guidance for the practice of specific physical exercises and a manual with instructions on how to perform the exercises at home . They were evaluated for pain , range of movement , muscle strength and function . These evaluations were performed before they received the manual and three months later . Patients were seen monthly regarding improvements in their exercising abilities . RESULTS The program was effective for improving muscle strength , controlling pain , maintaining range of movement of the knee joint , and reducing functional incapacity . DISCUSSION A review of the literature showed that there are numerous clinical benefits to the regular practice of physical therapy exercises by patients with osteoarthritis of the knee(s ) in a program with appropriate guidance . This study shows that this guidance can be attained at home with the use of a proper manual . CONCLUSIONS Even when performed at home without constant supervision , the use of the printed manual for orientation makes the exercises for osteoarthritis of the knee beneficial The aim of this study was to evaluate the effects of electrical stimulation program on pain , disability , and quadriceps strength in the patients with knee osteoarthritis . Fifty women diagnosed as knee osteoarthritis were r and omized into two groups as electrical stimulation and biofeedback-assisted isometric exercises . Both of the programs were performed 5 days a week , for a duration of 4 weeks . Outcome measures for pain were visual analogue scale pain score and Western Ontario McMaster osteoarthritis index ( WOMAC ) pain score . Disability and stiffness were assessed with WOMAC physical function and stiffness score . One repetition maximum ( RM ) and 10 RM were used for measuring quadriceps strength . In addition , 50 m walking time and 10 steps stairs climbing up-down time were evaluated . Both groups showed significant improvements in pain , physical function , and stiffness scores after the therapy . There were statistically significant improvements in 50 m walking time and 10 steps stairs climbing up-down time and 1 RM and 10 RM values indicating the improvement in muscle strength . In addition , there were no significant differences between the groups after the therapy . We conclude that electrical stimulation treatment was as effective as exercise in knee osteoarthritis and electrical stimulation treatment can be suggested especially for the patients who have difficulty in or contraindications to perform an exercise program AIM This paper reports a study of the effects of aquatic exercise on physical fitness ( flexibility , strength and aerobic fitness ) , self-reported physical functioning and pain in adults with osteoarthritis of the hip or knee . BACKGROUND Osteoarthritis is a common cause of disability and a primary reason for hip and knee joint replacement . Exercise is important for preventing and /or managing the functional limitations associated with joint disease . Aquatic exercise is thought to be beneficial and is often recommended for people with osteoarthritis ; however , few studies have examined the effects on people with osteoarthritis , and these have yielded inconsistent results . METHODS A two-group r and omized controlled trial with a convenience sample was used . Participants were recruited from community sources and r and omly assigned to a 12-week aquatic programme or a non-exercise control condition . Data for 38 participants were collected at baseline , week 6 , and week 12 during 2003 and 2004 . Instruments were a st and ard plastic goniometer , a h and held dynamometer , the 6-minute walk test , the multidimensional Health Assessment Question naire , and a visual analogue scale for pain . RESULTS Repeated measures analysis of variance showed that aquatic exercise statistically significantly improved knee and hip flexibility , strength and aerobic fitness , but had no effect on self-reported physical functioning and pain . The exercise adherence rate was 81.7 % , and no exercise-related adverse effect was observed or reported . CONCLUSIONS Beneficial short-term effects of aquatic exercise were found in adults with osteoarthritis of the hip or knee . Although the programme may not offer pain relief or self-reported improvements in physical functioning , results suggest that aquatic exercise does not worsen the joint condition or result in injury . Nurses engaging in disease management and health promotion for these patients should consider recommending or implementing aquatic classes for patients BACKGROUND The prevention of disability in activities of daily living ( ADL ) may prolong older persons ' autonomy ( older persons are defined in this study as those aged > or = 60 years ) . However , proved preventive strategies for ADL disability are lacking . A sedentary lifestyle is an important cause of disability . This study examines whether an exercise program can prevent ADL disability . METHODS A 2-center , r and omized , single-blind , controlled trial was conducted in which participants were assigned to an aerobic exercise program , a resistance exercise program , or an attention control group .  Of the 439 community-dwelling persons aged 60 years or older with knee osteoarthritis originally recruited , the 250 participants initially free of ADL disability were used for this study .  Incident ADL disability , defined as developing difficulty in transferring from a bed to a chair , eating , dressing , using the toilet , or bathing , was assessed quarterly during 18 months of follow-up . RESULTS The cumulative incidence of ADL disability was lower in the exercise groups ( 37.1 % ) than in the attention control group ( 52.5 % ) ( P = .02 ) . After adjustment for demographics and baseline physical function , the relative risk of incident ADL disability for assignment to exercise was 0.57 ( 95 % confidence interval , 0.38 - 0.85 ; P = .006 ) . Both exercise programs prevented ADL disability ; the relative risks were 0.60 ( 95 % confidence interval , 0.38 - 0.97 ; P = .04 ) for resistance exercise and 0.53 ( 95 % confidence interval , 0.33 - 0.85 ; P = .009 ) for aerobic exercise . The lowest ADL disability risks were found for participants with the highest compliance to exercise . CONCLUSIONS Aerobic and resistance exercise may reduce the incidence of ADL disability in older persons with knee osteoarthritis .  Exercise may be an effective strategy for preventing ADL disability and , consequently , may prolong older persons ' autonomy PURPOSE To evaluate the influence of exercise on falls and fall risk reduction  in community-dwelling older adults and to present an up date d synthesis of outcome measures for the assessment of fall risk in community-dwelling older adults . METHOD A systematic review was performed , considering English- language articles published from 2000 to 2006 and accessible through MEDLINE , CINAHL , PEDro , EMBASE , and /or AMED . Included were r and omized controlled clinical trials ( RCTs ) that used an exercise or physical activity intervention and involved participants over age 50 . Screening and method ological quality for internal validity were conducted by two independent review ers . RESULTS The search retrieved 156 abstract s ; 22 articles met the internal validity criteria . Both individualized and group exercise programmes were found to be effective in reducing falls and fall risk . The optimal type , frequency , and dose of exercise to achieve a positive effect have not been determined . A variety of outcome measures have been used to measure fall risk , especially for balance . CONCLUSIONS Falls and fall risk can be reduced with exercise interventions in the community-dwelling elderly , although the most effective exercise variables are unknown . Future studies in population s with comorbidities known to increase fall risk will help determine optimal , condition-specific fall-prevention programmes . Poor balance is a key risk factor for falls ; therefore , the best measure of this variable should be selected when evaluating patients at risk of falling Objective : To determine the additional prognostic value of clinical history , physical examination and x-ray findings to a previously derived simple generic model ( age , body mass index , anxiety and pain severity ) in a cohort of older adults with knee pain . Methods : Prospect i ve cohort study in community-dwelling adults in North Staffordshire . 621 participants ( aged ⩾50 years ) reporting knee pain who attended a research clinic at recruitment and were followed up by postal question naire at 18 months . Poor functional outcome was measured by the Physical Functioning Scale of the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) at 18-month follow-up defined in 60 % of participants . Results : Three clinical history variables ( bilateral knee pain , duration of morning stiffness and inactivity gelling ) were independently associated with poor outcome . The addition of the “ clinical history ” model to the “ generic ” model led to a statistical improvement in model fit ( likelihood ratio ( LR ) = 24.84 , p = 0.001 ) . Two physical examination variables ( knee tender point count and single-leg balance ) were independently associated with poor outcome but did not lead to a significant improvement when added to the “ clinical history and generic ” model ( LR = 6.34 , p = 0.50 ) . Functional outcome was significantly associated with severity of knee radiographic osteoarthritis ( OA ) , but did not lead to any improvement in fit when added to the “ generic , clinical history and physical examination ” model ( LR = 1.86 , p = 0.39 ) . Conclusions : Clinical history , physical examination and severity of radiographic knee OA are of limited value over generic factors when trying to predict which older adults with knee pain will experience progressive or persistent functional difficulties BACKGROUND There is limited evidence supporting the hypothesized environment-disability link . The objectives of this study were to ( a ) identify the prevalence of community mobility barriers and transportation facilitators and ( b ) examine whether barriers and facilitators were associated with disability among older adults with functional limitations . METHODS Four hundred and thirty-five participants aged 65 + years old with functional limitations were recruited from the Multicenter Osteoarthritis Study , a prospect i ve study of community-dwelling adults with or at risk of developing symptomatic knee osteoarthritis . Presence of community barriers and facilitators was ascertained by the Home and Community Environment survey . Two domains of disability , ( a ) daily activity limitation ( DAL ) and ( b ) daily activity frequency ( DAF ) , were assessed with the Late-Life Disability Instrument . Covariates included age , gender , education , race , comorbidity , body mass index , knee pain , and functional limitation . Multivariable logistic regression was used to examine adjusted associations of community factors with presence of DAL and DAF . RESULTS Approximately one third of the participants lived in a community with high mobility barriers and low transportation facilitators .  High mobility barriers was associated with greater odds of DAL ( odds ratio [ OR ] = 2.0 , 95 % confidence interval [ CI ] 1.2 - 3.1 ) after adjusting for covariates , and high transportation facilitators was associated with lower odds of DAL ( OR = 0.5 , 95 % CI 0.3 - 0.8 ) but not with DAF in adjusted models . CONCLUSION People with functional limitations who live in communities that were more restrictive felt more limited in doing daily activities but did not perform these daily activities any less frequently Osteoarthritis is the leading cause of persistent knee pain , affecting around one quarter of adults ( 1 , 2 ) , and is a major contributor to global disability ( 3 ) . Knee osteoarthritis causes loss of function , reduced quality of life , and psychological disability ( 4 ) . It has no cure and , given the aging population and increasing obesity rates , disease burden is rapidly increasing ( 5 , 6 ) . The urgent need for effective and accessible models of health service delivery that can be provided on a population level has been recognized as a research priority by key stakeholders ( 7 ) . Such models should take a biopsychosocial approach ; emphasize nondrug , nonsurgical treatment ; and foster self-management , of which appropriate educational information is a core component ( 8) . Exercise has well-established benefits for pain and function in persons with knee osteoarthritis ( 911 ) and is recommended by clinical guidelines as the cornerstone of conservative management ( 12 ) . It is often prescribed by a health professional and can be performed effectively at home ( 9 ) . Evidence also supports  pain-coping skills training ( PCST ) , an approach based on cognitive behavioral principles , to target psychological factors , such as low self-efficacy , poor pain coping , and pain catastrophizing , that are common in persons with chronic pain ( 13 , 14 ) . However , for many , accessing specialist clinicians to prescribe and supervise these treatments may be difficult due to cost , transport issues , or geographic location , particularly in regional and rural areas where services may be limited or nonexistent ( 15 , 16 ) . The Internet is a time-efficient and convenient method to deliver health interventions with broad reach ( 17 , 18 ) . Educational material is often accessed online by persons with chronic pain ( 19 ) . Remotely delivered physiotherapy and exercise can benefit persons with knee pain and osteoarthritis ( 2022 ) and those who have undergone knee joint replacement , albeit often using sophisticated technology ( 23 ) . An Internet-based interactive PCST program ( PainCOACH ) , design ed to translate key therapeutic elements of clinician-delivered face-to-face PCST ( 24 ) , showed improved outcomes in persons with hip or knee osteoarthritis ( 25 ) . An online intervention combining these treatments aligns with a biopsychosocial approach to chronic disease management ( 8) but has not been investigated in this patient population . This study aim ed to evaluate the effectiveness of an innovative Internet-based intervention combining physiotherapist-prescribed home exercise delivered via videoconferencing ( Skype [ Microsoft ] ) and automated PCST in addition to educational material in persons with chronic knee pain . Our primary hypothesis was that the intervention would reduce pain and improve physical function after 3 months compared with educational material only . Supplement . Study Protocol Methods Design Overview We conducted a parallel , 2-group pragmatic r and omized , controlled trial . The protocol has been published ( 26 ) . The trial was prospect ively registered with the Australian New Zeal and Clinical Trials Registry ( ACTRN12614000243617 ) . Initial registration erroneously listed the Depression , Anxiety and Stress Scale ( DASS-21 ) as a secondary outcome rather than an eligibility screening tool . We amended the registry after enrolling 16 participants but before collecting follow-up data . No interim analyses were performed . The Institutional Human Ethics Committee approved the trial , and participants provided informed consent . Recruitment occurred from March 2014 to May 2015 , with follow-up completed in February 2016 . Participants and physiotherapists were unblinded to group allocation and were aware of the alternative treatment components , but study hypotheses were not disclosed to participants . The statistician was blinded . A nested health economic evaluation and a qualitative study exploring patients ' and physiotherapists ' experiences will be published separately . Setting and Participants We recruited community-dwelling participants from Australia via print , radio , and social media advertisements and our data base .  Eligibility was confirmed using an online survey followed by a telephone interview .  Inclusion criteria were age 50 years or older , knee pain for more than 3 months and on most days of the previous month , knee pain during walking ( score of 4 on an 11-point numerical rating scale [ NRS ] , with terminal descriptors of no pain and worst pain possible ) in the previous week , mild to moderate physical dysfunction ( score > 20 out of 68 on the physical function subscale of the Western Ontario and McMaster Universities Osteoarthritis Index [ WOMAC ] ) , and an active e-mail account and a computer with Internet access . Exclusion criteria were joint replacement in the symptomatic knee , awaiting joint replacement surgery , intra-articular corticosteroid injection or knee surgery in the previous 6 months or planned joint surgery in the subsequent 9 months , treatment for knee pain or participation in a strengthening exercise or PCST program in the previous 6 months , systemic arthritic condition , neurologic condition affecting the lower limb or limiting exercise , pain at another site that was worse than knee pain or limited exercise , and high-level depression ( score > 21 on the depression subscale of the DASS-21 [ 27 ] ) . R and omization and Interventions Computer-generated r and omization was conducted by r and om permuted blocks of size 2 to 8 stratified by sex and residence ( metropolitan or regional/rural ) . The r and omization schedule was prepared by an independent biostatistician and concealed from the research er enrolling participants in sequentially numbered , opaque , sealed envelopes . Intervention Participants received 3 Internet-delivered treatments . The first was educational material about exercise and physical activity , pain management , emotions , healthy eating , complementary therapies , and medications ( www.arthritisaustralia.com.au ) . Participants were encouraged to access the material at their leisure . The second was an interactive automated PCST program ( PainCOACH ) ( 24 , 25 ) . Participants were asked to complete eight 35- to 45-minute modules ( 1 per week commencing in week 1 ) and practice pain-coping skills daily ( Appendix Table 1 ) . These skills included progressive relaxation , activityrest cycling , scheduling pleasant activities , changing negative thoughts , pleasant imagery and distraction techniques , and problem solving . The third was 7 Skype sessions with a physiotherapist over 12 weeks ( in weeks 2 , 3 , 4 , 6 , 8 , 10 , and 12 ) . Sessions lasted 45 minutes in weeks 2 and 12 and 30 minutes in the other weeks . Physiotherapists were allocated to participants on the basis of availability , and the same physiotherapist undertook all consultations with any given participant . The physiotherapist performed a brief assessment and prescribed a lower-limbstrengthening home exercise program to be performed 3 times per week ( 26 , 28 ) ( Appendix Table 2 ) . Exercise progression was provided by varying the exercises , repetitions , load , or difficulty to approximate a 10-repetition maximum level and a self-rated effort level of at least 5 out of 10 ( hard ) on a modified Borg Rating of Perceived Exertion scale ( 29 ) . Participants were provided with instructions , video demonstrations , and equipment ( such as resistance b and s and ankle weights ) . They also were encouraged to increase physical activity levels , received written information about how to do so , and were given the option of using a pedometer for motivation ( provided at no cost ) . Appendix Table 1 . Summary of the Internet-Based PainCOACH Content * Appendix Table 2 . Home Exercise Program Protocol * Generic e-mail reminders to complete PainCOACH modules were sent weekly during the first 8 weeks . At week 11 and at monthly intervals from week 13 , participants received e-mails encouraging them to review the final module , revisit useful or meaningful modules , and continue home exercise and pain-coping skills practice .  Eight physiotherapists ( 4 men ) with an average of 16 years ( range , 3 to 28 years ) of clinical musculoskeletal experience were trained to deliver the exercise component . Physiotherapists attended a 1-day training course conducted by the research ers and were given an exercise manual . They also were provided with an overview of PainCOACH and were asked to encourage participants to complete modules and practice skills . Regular telephone and Skype meetings between the physiotherapists and the research ers were held to discuss implementation of the intervention . A brief video showing a mock physiotherapy session is provided in the Supplement Video . Control The control group received access to the same online educational material as the intervention group . Outcomes and Follow-up Participants completed measurements online at baseline , 3 months ( primary time point ) , and 9 months . They received a $ 50AUD gift voucher for completing all question naires . The primary outcomes were valid and reliable self-reported measures of pain and physical function that are recommended for knee osteoarthritis clinical trials ( 30 ) . Overall average pain during walking over the previous week was measured with an NRS , with terminal descriptors of no pain ( score of 0 ) and worst pain possible ( score of 10 ) and a minimum clinical ly important difference ( MCID ) of 1.8 units ( 31 ) . Difficulty with physical function over the previous 48 hours was measured with the WOMAC ( Likert version 3.1 ) physical function subscale ( 32 ) , with total scores ranging from 0 ( no dysfunction ) to 68 ( maximum dysfunction ) and an MCID of 6 units ( 33 ) . Secondary outcomes included knee pain over the previous 48 hours , measured using the WOMAC pain subscale ( 32 ) ( scores range from 0 [ no pain ] to 20 [ maximum pain ] ) ; global change overall , in pain , and in physical function , measured using 7-point Likert scales with terminal descriptors of much worse to much better ( measured at 3 and 9 months ) ; health-related quality of life , Knee osteoarthritis is a major age-related public health problem and a leading cause of long-term pain and disability ( 1 , 2 ) . No effective medical treatments for the disease currently exist . Nonsteroidal anti-inflammatory drugs ( NSAIDs ) and acetaminophen are commonly used to treat osteoarthritis but often fail to relieve symptoms and may cause serious adverse effects ( 3 ) . Physical therapy , a globally recommended element of the st and ard care regimen for knee osteoarthritis , produces moderate benefits for pain and physical functioning , but data on psychological well-being and durability effects are limited ( 4 , 5 ) . Identifying new and effective treatments for patients with knee osteoarthritis is an urgent clinical and public health priority . Tai Chi is a multicomponent traditional Chinese mindbody practice that combines meditation with slow , gentle , graceful movements ; deep diaphragmatic breathing ; and relaxation ( 6 ) . Previous studies have indicated that Tai Chi can reduce pain and improve physical and psychological health among patients with chronic rheumatic disorders , such as rheumatoid arthritis and fibromyalgia ( 713 ) . In our previous r and omized trial , participants with knee osteoarthritis who completed 12 weeks of  Tai Chi showed greater improvements in pain , physical function , depression , and health status compared with an attention control group ( 12 ) . A 2013 up date d meta- analysis of 7 studies that included 348 participants with osteoarthritis showed significant reductions in pain and improvements in physical function after 8 to 24 weeks of Tai Chi training compared with a waiting list , attention control , or usual physical activity ( 14 ) . Those prior trials suggested that Tai Chi could provide a practical exercise regimen with an integrative mindbody approach to manage knee osteoarthritis . The physical component provides exercise benefits that are consistent with recommendations for knee osteoarthritis ( physical function , balance , and muscle strength ) ( 15 ) , and the mind component promotes psychological well-being , life satisfaction , and improved perceptions of health ( 9 , 16 ) . To date , however , no r and omized trials have directly compared Tai Chi and st and ard care treatments . The primary goal of this study was to compare the effectiveness of  Tai Chi  versus a physical therapy regimen among a large sample of patients with symptomatic and radiographic knee osteoarthritis who were seen in the clinical setting and followed for 12 months . Supplement . Study Protocol Methods Design Overview This 52-week , single-blind , r and omized , comparative effectiveness trial recruited participants with symptomatic and radiographic knee osteoarthritis . Patients were r and omly assigned to either Tai Chi ( 2 times per week for 12 weeks ) or physical therapy in a clinical setting ( 2 times per week for 6 weeks , followed by 6 weeks of rigorously monitored home exercise ) . Details of the trial design and conduct have been published ( 17 ) and registered at Clinical Trials.gov ( NCT01258985 ) . The study was approved by the Tufts Health Sciences Institutional Review Board and overseen by an independent data and safety monitoring board . Setting and Participants The trial was conducted at Tufts Medical Center in Boston , Massachusetts , between October 2010 and September 2014 . Participants were recruited through multimodal strategies , including print advertisements , online media , a booth at a senior exposition , and a clinical patient data base . We obtained informed consent before baseline assessment s for eligibility . We enrolled persons aged 40 years or older who met American College of Rheumatology criteria for symptomatic knee osteoarthritis and had radiographic evidence of tibiofemoral or patellofemoral osteoarthritis ( defined as the presence of a definite osteophyte in the tibiofemoral compartment and /or the patellofemoral compartment , as assessed on st and ing anteriorposterior and lateral or sunrise views ) ( 18 ) . All participants were required to have a score of 40 or greater on at least 1 of the 5 questions in the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) pain subscale ( range of 0 to 100 , with higher scores indicating greater pain ) at baseline . A study rheumatologist ( W.H. ) confirmed eligibility of applicants . We excluded persons who had participated in Tai Chi or physical therapy in the past year ; those with current serious medical conditions , such as dementia , symptomatic heart or vascular disease , or recent stroke , that would limit full participation ; those with intra-articular steroid or intra-articular hyaluronic acid injections in the past 3 or 6 months or reconstructive surgery before baseline screening on the most severely affected knee ; and those with a score less than 24 on the Mini-Mental State Examination ( 19 ) . Participants who satisfied eligibility criteria were offered enrollment . R and omization Participants were r and omly assigned in a 1:1 ratio to Tai Chi or physical therapy after the baseline evaluation . R and omization was done in 9 consecutive cycles , comprising about 20 participants each . Within each block of patients r and omly assigned in each cycle , those assigned to Tai Chi were further r and omly assigned to 1 of 3 instructors so that each instructor treated 1 group every 3 blocks . This design allowed for assessment of instructor-level effects . Pseudor and om numbers were generated in advance by the statistician ( C.S. ) using the R statistical package ( 20 ) . Assignments were concealed in sealed , opaque envelopes with date and signature labels . The study coordinator opened the consecutive envelopes individually after obtaining consent and confirming eligibility . Research study nurses , physical function assessors , and sponsor personnel were blinded to the treatment assignments during enrollment . The blinded assessors did not have access to the data until data collection was complete . Interventions Tai Chi and physical therapy ran concurrently to minimize seasonal influences on disease activity . We encouraged participants to maintain routine activities but refrain from new exercises outside the study . Both groups received educational information about the importance of physical activity and home practice . We tracked reasons for missed sessions and asked participants to complete daily logs indicating duration of practice . Participants were encouraged to integrate at least 30 minutes of Tai Chi or physical therapy into their daily routine throughout follow-up . Attendance was monitored during each in-person session by using attendance forms and sign-in sheets . Study staff made monthly calls to monitor adherence throughout the 1-year follow-up . Tai Chi The 60-minute Tai Chi sessions occurred twice per week for 12 weeks . We recruited 3 experienced Tai Chi instructors from the greater Boston area . We developed a st and ardized classical Yang style Tai Chi protocol for knee osteoarthritis that was based on the literature ( 13 ) . Before study initiation , the principal investigator ( C.W. ) and the Tai Chi master ( R.R. , who was also 1 of the 3 instructors ) review ed the concepts of knee osteoarthritis and trained the other instructors ( 17 , 21 ) . In the first session , participants received printed material s on  Tai Chi principles , practice techniques , and safety pre caution s. The instructor explained mindbody exercise theory and procedures . Subsequent sessions started with a warm-up and a review of Tai Chi principles and movement , breathing techniques , and relaxation methods . Participants were instructed to practice Tai Chi at home for at least 20 minutes per day . The principal investigator monitored all sessions by regularly review ing video recordings and providing feedback throughout the study . After completing the 12-week intervention ( 24 sessions ) , participants were instructed to continue Tai Chi practice for 52 weeks with the aid of provided homework material s. Physical Therapy The physical therapy protocol followed U.S. guidelines for knee osteoarthritis treatment ( 15 ) and consisted of two 30-minute outpatient sessions per week for 6 weeks . Before enrollment , the supervising physical therapist ( M.I. ) trained the 3 physical therapists . She observed evaluations and interventions during each treatment cycle to ensure consistency in documentation and provided feedback for program progression ( 17 ) . Depending on the diagnostic findings in the initial musculoskeletal examination , the therapist targeted physical therapy regimens to address specific treatment goals developed collaboratively with the participant . At each session , the physical therapist examined the participant for adverse signs and symptoms before proceeding with manual therapy or exercise . Patients were encouraged to also perform exercises at home . After 6 weeks , participants were instructed to continue exercises in 30-minute sessions 4 times per week for 6 weeks . These were monitored weekly by telephone by using st and ardized forms to ascertain frequency , exercises completed , adverse events , and adherence . Outcomes and Follow-up Knee osteoarthritis outcomes , which were measured at baseline and 12 , 24 , and 52 weeks , were drawn from the core set recommended by the Osteoarthritis Research Society International ( OARSI ) and focused on pain , physical function , and patients ' overall assessment of their disease severity ( 22 ) . Primary Outcome The primary outcome was the change in WOMAC pain subscale score between baseline and 12 weeks . The WOMAC is a vali date d , self-administered visual analogue scale design ed specifically to evaluate osteoarthritis symptoms ( 23 ) . Secondary Outcomes Secondary outcomes were measured at baseline and 12 , 24 , and 52 weeks and included WOMAC physical function and stiffness scores , Patient Global Assessment score , Beck Depression Inventory-II score ( 24 ) , scores on the physical and mental components of the 36-item Short Form Health Survey ( SF-36 ) ( 25 ) , Arthritis Self-Efficacy Scale score ( 26 ) , and results of the 6-minute walk test ( 27 ) and the Background : It has been unclear which training mode is most effective and feasible for improving physical performance in the risk group of prefrail community-dwelling older adults . Objective : The purpose of the present study was to compare the effects of strength training ( ST ) versus power training ( PT ) on functional performance in prefrail older adults . This study was registered at clinical trials.gov as NCT00783159 . Methods : 69 community-dwelling older adults ( > 65 years ) who were prefrail according to the definition of Fried were included in a 12-week exercise program . The participants were r and omized into an ST group , a PT group and a control group . All participants were supplemented with vitamin D3 orally before entering the intervention period . The primary outcome was the global score on the Short Physical Performance Battery ( SPPB ) . Secondary outcomes were muscle power , appendicular lean mass ( aLM ) measured by dual energy X-ray absorptiometry and self-reported functional deficits ( Short Form of the Late-Life Function and Disability Instrument , SF-LLFDI ) . Results : Regarding changes in the SPPB score during the intervention , significant heterogeneity between the groups was observed ( p = 0.023 ) . In pair-wise comparisons , participants in both training groups significantly ( PT : p = 0.012 , ST : 0.009 ) increased their SPPB score ( PT : Δmean = 0.8 , ST : Δmean = 1.0 ) compared to the control group , with no statistical difference among training groups ( p = 0.301 ) . No statistical differences were found in changes in aLM ( p = 0.769 ) , muscle power ( p = 0.308 ) and SF-LLFDI ( p = 0.623 ) between the groups . Muscle power significantly increased ( p = 0.017 ) under vitamin D3 intake . Conclusions : In prefrail community-dwelling adults , PT is not superior to ST , although both training modes result ed in significant improvements in physical performance . With regard to dropout rates , ST appears to be advantageous compared to PT . The high prevalence of vitamin D3 deficiency and the slight improvement of physical performance under vitamin D3 supplementation among study participants underline the relevance of this approach in physical exercise interventions OBJECTIVES To determine the efficacy of a complementary analgesic modality , percutaneous electrical nerve stimulation ( PENS ) , for the treatment of chronic low back pain ( CLBP ) in community-dwelling older adults . DESIGN R and omized , controlled clinical trial . SETTING University of Pittsburgh Pain Evaluation and Treatment Institute . PARTICIPANTS Thirty-four English speaking , community-dwelling adults aged 65 and older with CLBP of at least moderate intensity experienced every day or almost every day . INTERVENTION Subjects were r and omized to receive twice-weekly PENS and physical therapy ( PT ) or sham PENS and physical therapy for 6 weeks . MEASUREMENTS At baseline , immediately after the 6-week intervention period , and 3 months later , the primary outcome measures pain intensity and pain-related disability were assessed . The secondary outcome measures physical performance ( timed chair rise , functional reach , gait speed , static and isoinertial lifting ) , psychosocial factors ( mood , sleep , and life control ) , and cognitive function ( measures of attention , concentration , and mental flexibility ) were also collected . RESULTS Subjects r and omized to PENS plus PT displayed significant reductions in pain intensity measures from pre- to posttreatment ( P < .001 ) , but the sham PENS plus PT group did not ( P = .94 ) . These pain reduction effects were maintained at 3-month follow-up . Similarly , significant reductions in pain-related disability were observed at posttreatment ( P = .002 ) for the PENS plus PT group and were maintained at follow-up , but the sham PENS plus PT group did not show reductions in pain-related disability ( P = .81 ) . Of the secondary outcome measures , psychosocial function , timed chair rise , and isoinertial lifting endurance also improved significantly at posttreatment for the PENS plus PT group , and their improvement was sustained at 3-month follow-up , but the sham PENS plus PT did not display significant changes on these measures after treatment . CONCLUSION This preliminary study suggests that PENS may be a promising treatment modality for community-dwelling older adults with CLBP , as demonstrated by reduction in pain intensity and self-reported disability , and improvement in mood , life control , and physical performance . Larger studies with longer duration of follow-up are needed to vali date these findings and support the use of PENS in clinical practice PURPOSE To evaluate the effectiveness of the Taipei Osteoarthritis Program ( TOAP ) for community elderly persons who suffer from knee OA . METHODS A quasi-experimental study was conducted between January 2008 and December 2008 . Two hundred and five community-dwelling individuals aged 67±10 years with knee OA were recruited from four districts in Taipei City and r and omized . By a clustered r and omization according to the districts , 114 participants were in the intervention group ( IG ) with a 4-week TOAP program and 91 participants were in the control group ( CG ) with routine care . The main outcome measures included health-related quality of life ( HRQOL ) and disability level , which were assessed by the Short Form-36 Taiwan Version ( T-SF36 ) and the Western Ontario McMaster Universities Arthritis Index Taiwan Version ( T-WOMAC ) , respectively , and were repeatedly measured at the baseline , post invention ( 4 weeks after baseline ) , and follow-up ( 8 weeks after baseline ) . RESULTS Subjects in the IG increased their changes of GH scores from baseline to post-intervention and follow-up , which were significantly more than those of subjects in the CG ( p=0.011 and 0.005 , respectively ) . Significant difference of changes was also found at follow-up for the mental component scale between the groups ( p=0.013 ) . There was no change in disability level . CONCLUSIONS The arthritis self-management program improved the psychological outcomes among the participants , but it had no significant effect on a self-reported disability level Question To compare the efficacy of aerobic walking and home based quadriceps strengthening exercises in reducing  pain and disability in knee osteoarthritis . Design Systematic review of r and omised controlled trials . Setting / population People with knee osteoarthritis . Interventions Comparison of aerobic walking or home based quadriceps strengthening exercise with a non-exercise control group . Strengthening exercise was considered to be ‘ home based ' where it was undertaken exclusively in the subject 's home environment or , where exercise was partly supervised , the regimen was intended to be continued at home unsupervised . Outcomes Pain and disability . Results 13 studies were included . One study provided a direct comparison between aerobic walking and home based strengthening exercises and control . Nine RCTs evaluated quadriceps strengthening exercises , and in three studies the exercise intervention was predominantly aerobic walking . Control interventions included education and lifestyle advice , support by telephone calls , and no intervention . When comparing aerobic walking with no exercise interventions , the pooled effect sizes for pain and disability were 0.52 ( 95 % CI 0.34 to 0.70 ) and 0.46 ( 95 % CI 0.25 to 0.67 ) respectively . Corresponding effect size for quadriceps strengthening was 0.32 ( 95 % CI 0.23 to 0.42 ) for both pain and disability . Conclusion Both aerobic walking and home based quadriceps strengthening exercises are effective at reducing pain and disability in subjects with knee osteoarthritis . No advantage of one form of exercise over the other was found on indirect comparison BACKGROUND Osteoarthritis is the most frequent joint disease and is a leading cause of pain and locomotor disability in elderly people . The treatment of osteoarthritis includes non-pharmacological , pharmacological , and surgical therapies . Silver level evidence has been found concerning balneotherapy in osteoarthritis . AIM OF THE STUDY The aim of this study was to evaluate how Lake Hévíz thermal mineral water therapy influences pain , knee function , and quality of life in patients with knee osteoarthritis , compared to the control group . STUDY DESIGN r and omized , controlled , single-blind , follow-up study . SETTING Spa Hévíz and St. And rew Hospital for Rheumatic Diseases POPULATION This study included 77 out patients between 45 and 75 years of age with mild to moderate osteoarthritis of the knee meeting the American College of Rheumatology classification criteria . METHODS Patients were r and omized into two groups . In group I ( n = 38 ) , subjects bathed in Lake Hévíz and in group II ( N.=39 ) , patients were treated in a pool full of tap water . Water temperature was 34 ° C for both groups . Participants underwent 30-minute therapy sessions , five times a week for three weeks . Outcome measures were pain visual analogue scale scores , active flexion degree , knee circumference , stair-climb time , Western Ontario and McMaster Universities osteoarthritis index ( WOMAC ) , and EuroQoL Group 5-Dimension Self-Report Question naire score ( EQ-5D ) . Study parameters were recorded at baseline , immediately after treatment , and after 15 weeks . RESULTS Comparison of the two groups revealed a statistically significant difference in pain visual analogue scale scores ( P<0.01 ) , active flexion degree ( P<0.01 ) , physical function components of WOMAC ( P<0.05 ) , and EQ-5D scores ( P<0.05 ) even after 15 weeks . CONCLUSIONS Balneotherapy  improved pain , function as well as the quality of life in patients with knee osteoarthritis . CLINICAL REHABILITATION IMPACT Balneotherapy is a potentially useful treatment modality for patients with knee osteoarthritis Background Knee osteoarthritis ( OA ) is the most common type of arthritis and imposes a heavy burden on individual welfare among elderly people . There is preliminary evidence that psychological factors play a role in functional ability and pain in knee OA patients , particularly with respect to the surgery outcome . Less is known about psychological factors among community-dwelling patients with knee OA . Objectives We aim ed to determine which psychological factors are associated with pain and functional ability among community-dwelling knee OA patients using a comprehensive set of psychological question naires . Methods In the cross-sectional baseline setting of a prospect i ve , r and omized controlled intervention study , 111 patients aged from 35 to 75 years with clinical symptoms and radiographic grading of knee OA were included . They completed a comprehensive set of psychological question naires , including measures of re sources and coping , fear and catastrophizing , and distress . Results In cross-sectional comparisons , pain self-efficacy , fear of movement , pain catastrophizing , and elevated anxiety were associated with pain and a poorer functional ability . In logistic regression analysis , independent association was seen between pain self-efficacy and poorer functioning . Knee OA patients also reported elevated levels of anxiety . Conclusions The results reveal that both pain self-efficacy and negatively charged emotion and expectations toward pain are important factors when dealing with knee OA patients . Failure to consider these will probably contribute to prolonged disability and further pain . The results call for the routine assessment of multiple psychological factors in knee OA OBJECTIVE The Arthritis , Diet , and Activity Promotion Trial ( ADAPT ) was a r and omized , single-blind clinical trial lasting 18 months that was design ed to determine whether long-term exercise and dietary weight loss are more effective , either separately or in combination , than usual care in improving physical function , pain , and mobility in older overweight and obese adults with knee osteoarthritis ( OA ) . METHODS Three hundred sixteen community-dwelling overweight and obese adults ages 60 years and older , with a body mass index of > or = 28 kg/m(2 ) , knee pain , radiographic evidence of knee OA , and self-reported physical disability , were r and omized into healthy lifestyle ( control ) , diet only , exercise only , and diet plus exercise groups . The primary outcome was self-reported physical function as measured with the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) . Secondary outcomes included weight loss , 6-minute walk distance , stair-climb time , WOMAC pain and stiffness scores , and joint space width . RESULTS Of the 316 r and omized participants , 252 ( 80 % ) completed the study .  Adherence was as follows : for healthy lifestyle , 73 % ; for diet only , 72 % ; for exercise only , 60 % ; and for diet plus exercise , 64 % . In the diet plus exercise group , significant improvements in self-reported physical function ( P < 0.05 ) , 6-minute walk distance ( P < 0.05 ) , stair-climb time ( P < 0.05 ) , and knee pain ( P < 0.05 ) relative to the healthy lifestyle group were observed . In the exercise group , a significant improvement in the 6-minute walk distance ( P < 0.05 ) was observed . The diet-only group was not significantly different from the healthy lifestyle group for any of the functional or mobility measures . The weight-loss groups lost significantly ( P < 0.05 ) more body weight ( for diet , 4.9 % ; for diet plus exercise , 5.7 % ) than did the healthy lifestyle group ( 1.2 % ) . Finally , changes in joint space width were not different between the groups . CONCLUSION The combination of modest weight loss plus moderate exercise provides better overall improvements in self-reported measures of function and pain and in performance measures of mobility in older overweight and obese adults with knee OA compared with either intervention alone Arthritis has been identified as the most common cause of disability in the United States ( 1 , 2 ) . Thirty-three percent of persons 63 to 94 years of age are affected by osteoarthritis of the knee , which often limits the ability to rise from a chair , st and comfortably , walk , and use stairs ( 3 , 4 ) . Acetaminophen and nonsteroidal anti-inflammatory drugs ( NSAIDs ) are commonly used to treat osteoarthritis . Use of NSAIDs can lead to gastric complications , increased risk for hospitalization , and death ( 5 ) . Other treatment options for persons with osteoarthritis of the knee include physical therapy exercise and treatment programs , cortisone injections , and joint replacement surgery . Puett and Griffin ( 6 ) review ed 15 controlled trials of nonmedicinal , noninvasive therapies for hip and knee osteoarthritis from 1966 through 1993 ( 6 ) . The authors concluded that exercise reduces pain and improves function in patients with osteoarthritis of the knee , but the optimal exercise regimen has not been determined . Fitness walking , aerobic exercise , and strength training have all been reported to result in functional improvement in patients with osteoarthritis of the knee ( 6 - 12 ) . Unweighted treadmill walking has not been shown to decrease pain associated with osteoarthritis of the knee ( 13 ) . Other research ers ( 14 , 15 ) have concluded that exercise may benefit patients with osteoarthritis but advise that long-term studies are required to determine the appropriate amounts of exercise to avoid accelerating the underlying process of arthritis . Active and passive range-of-motion exercise is considered an important part of rehabilitation programs for patients with osteoarthritis ( 16 - 18 ) . Physical therapists frequently use manual therapy procedures as part of comprehensive rehabilitation programs to help patients regain joint mobility and function ( 19 ) . We evaluated the effectiveness of manual physical therapy for osteoarthritis of the knee , as applied by physical therapists with formal training in such an approach ( 20 ) . Our hypothesis was that physical therapy consisting of manual therapy to the knee , hip , ankle , and lumbar spine combined with range-of-motion , strengthening , and cardiovascular exercises would be more effective than placebo for improving function , decreasing pain and stiffness , and increasing the distance walked in 6 minutes . Methods Patients Eighty-three patients with osteoarthritis of the knee were r and omly assigned to receive treatment ( n=42 ; 15 men and 27 women [ mean age , 60 11 years ] ) or placebo ( n=41 ; 19 men and 22 women [ mean age , 62 10 years ] ) . All patients were referred by physicians to physical therapy for osteoarthritis of the knee . Physicians at the various clinics in the medical center who normally see patients with osteoarthritis of the knee were informed of the study so that appropriate referrals could be made . If the patients met our inclusion criteria , they were offered the opportunity to participate . The main inclusion criterion was a diagnosis of osteoarthritis of the knee based on fulfillment of one of the following clinical criteria developed by Altman and colleagues [ 21 ] : 1 ) knee pain , age 38 years or younger , and bony enlargement ; 2 ) knee pain , age 39 years or older , morning stiffness for more than 30 minutes , and bony enlargement ; 3 ) knee pain , crepitus on active motion , morning stiffness for more than 30 minutes , and bony enlargement ; or 4 ) knee pain , crepitus on active motion , morning stiffness for more than 30 minutes , and age 38 years or older . Altman and colleagues found this criteria to be 89 % sensitive and 88 % specific ( 21 - 23 ) . Patients were required to be eligible for military health care , have had no surgical procedure on either lower extremity in the past 6 months , and have no physical impairment unrelated to the knee that would prevent safe participation in a timed 6-minute walk test or any other aspect of the study . Patients had to have sufficient English- language skills to comprehend all explanations and to complete the assessment tools . They were also required to live within a 1-hour drive of the physical therapy clinic . Patients who could not attend the required number of visits or had received a cortisone injection to the knee joint within the previous 30 days were not enrolled . Patients were instructed to keep taking any current medications and not to start taking new medications for osteoarthritis during the clinical treatment and 8-week follow-up . Therapy with any osteoarthritis medication must have been initiated at least 30 days before participation in the study . The study was approved by the institutional review board of Brooke Army Medical Center , Fort Sam Houston , Texas . All patients completed an informed consent form and were advised of the risks of the study , including increased symptoms , injuries from falls , and cardiovascular events . No external funding was received for this study . Procedure Patients who met the inclusion criteria were r and omly assigned to one of two groups . Blank folders were numbered from 1 to 100 and were given concealed codes for the group of assignment , determined by a r and om-number generator . When a patient was eligible and gave consent to participate , the treating therapist drew the next folder from the file , which determined the group of assignment . The treatment group received a combination of manual physical therapy and supervised exercise . The placebo group received ultrasound at a subtherapeutic intensity . Neither group was aware of the treatment that the other group was receiving . Demographic data collected for each patient included age , sex , occupation , height , weight , duration of symptoms , presence of symptoms in one or both knees , previous knee surgery , medications , and present activity level . Knee radiographs were obtained and read by a radiologist who assigned a radiographic severity rating for osteoarthritis ( 24 ) . Dependent variables measured in this study were the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) score ( 25 ) and distance covered during a timed 6-minute walk test . The WOMAC Osteoarthritis Index consists of 24 questions , each corresponding to a visual analogue scale . This test has been shown to be a reliable , valid , and responsive multidimensional outcome measure for evaluation of patients with osteoarthritis of the hip or knee ( 26 ) . The timed 6-minute walk test measures the distance a patient walks in 6 minutes and has been demonstrated to be a reliable measurement of functional exercise capacity ( 27 ) . All measurements of dependent variables were obtained by a trained research assistant who was blinded to group assignment . After research assistants obtained pretreatment values for the dependent variables , patients returned to the treating physical therapist for thorough st and ardized clinical examination of the knee , hip , ankle , and lumbar spine . Treatment was initiated according to group assignment . The treatment group received manual physical therapy as indicated by the results of the examination . The manual therapy treatment techniques , consisting of passive physiologic and accessory joint movements , muscle stretching , and soft-tissue mobilization , were applied primarily to the knee . The same treatments were also administered to the lumbar spine , hip , or ankle if these areas showed limitation in active or passive movement , were symptomatic , or were contributing to overall lower limb dysfunction ( 28 - 31 ) . A minimal pain level was not exceeded in any treatment . The treatment group also performed a closely supervised st and ardized knee exercise program at each of the eight treatment sessions . This program consisted of active range-of-motion exercises for the knee , muscle strengthening exercises for the hip and knee , muscle stretching for the lower limbs , and riding a stationary bike . All of the activities were mutually reinforcing , with repeated gentle challenges to the end ranges of movement . An outline of the exercise program is shown in the Appendix Figure . The physical therapist increased the number of strengthening exercise bouts and the stationary bike riding time on the basis of patient tolerance . The current literature provides efficient methods to produce the desired effects of increasing strength , flexibility , and range of motion ( 32 - 35 ) . At each session , the physical therapist examined the patient for adverse signs and symptoms , such as increased pain , joint effusion , and increased skin temperature over knee joints . These signs and symptoms of osteoarthritis had to be stable or decreasing before manual therapy or exercise was progressed . Patients exercised in a painless or minimally painful manner . If any post-treatment or exercise soreness lasted more than a few hours , the regimen was decreased accordingly for that patient . The placebo group received treatment by the physical therapist that consisted of subtherapeutic ultrasound for 10 minutes at an intensity of 0.1 W/cm2 and 10 % pulsed mode ( lowest setting and greatest cycle interruption ) to the area of knee symptoms . The placebo group received the same subjective and h and s-on objective reevaluation before and after each session as the treatment group . The amount of time directly spent with the treating therapist was approximately 30 minutes for both groups . The treatment group required an additional 30 to 45 minutes to perform their exercises in the clinic . Both groups were treated twice weekly for 4 weeks , for a total of eight clinic treatments . Patients in the treatment group also performed the same exercises at home , except for the closed-chain strengthening exercises , on the days on which they were not treated in the physical therapy clinic . They also walked at home each day at a comfortable pace and distance . The treating physical therapist instructed each patient in the performance of the exercises and provided a detailed h and out containing instructions and photographs of the exercises . Each patient maintained a home exercise Objective : To examine the effectiveness of a 12-month community-based water exercise programme on measures of self-reported health and physical function in people aged over 60 years old with knee-hip osteoarthritis ( OA ) . Design : A quasi-experimental design consisting of an exercise group and an age-matched control group . Setting : Public community swimming pool in Sheffield , UK . Subjects : One hundred and six community-dwelling sedentary older people , with confirmed knee-hip osteoarthritis , enrolled in an experimental controlled trial for 12 months . Sixty-six subjects in the exercise group were offered a water-exercise programme .  Forty age-matched , nonexercising , ‘ control ’ subjects received monthly education material and quarterly telephone calls . Interventions : Participants in the exercise group were asked to attend two exercise sessions a week of 1 hour duration led by specially trained swimming instructors . Main measures : Primary outcome measure was the disease-specific Western Ontario and McMaster University Osteoarthritis Index ( WOMAC ) . Secondary outcomes included a battery of performance-based physical function tests . Results : Adherence to exercise averaged 70 % ( ±14 % ) over the year : 77 % of the exercising subjects and 89 % control subjects completed both pre- and post- outcome measures . After one year , participants in the exercise group experienced a significant improvement in physical function ( 4.0 ± 9.1 versus -0.4 ± 7.3 units ; 95 % confidence interval ( CI ) 0.96–7.96 , p < 0.05 ) and reduction in the perception of pain ( 1.3 ± 3.7 versus 0.2 ± 2.5 units ; 95 % CI -0.19 - 2.52 , p < 0.05 ) compared with the control group , as measured by the WOMAC Osteoarthritis Index . In addition , the exercise group performed significantly better in the ascending and descending stairs tests ( p < 0.05 ) , had significantly greater improvements in knee range of movement ( p < 0.01 ) and hip range of movements ( p < 0.005 ) . There were no significant differences in the two groups for quadriceps muscle strength and psychosocial well-being ( Arthritis Impact Measurement Scales 2 question naire ) . Conclusions : Older people with knee/hip osteoarthritis gained modest improvements in measures of physical function , pain , general mobility and flexibility after participating in 12 months of community-based water exercise Background Knee osteoarthritis ( OA ) causes pain and long-term disability with annual healthcare costs exceeding $ 185 billion in the United States . Few medical remedies effectively influence the course of the disease . Finding effective treatments to maintain function and quality of life in patients with knee OA is one of the national priorities identified by the Institute of Medicine . We are currently conducting the first comparative effectiveness and cost-effectiveness r and omized trial of Tai Chi versus a physical-therapy regimen in a sample of patients with symptomatic and radiographically confirmed knee OA . This article describes the design and conduct of this trial . Methods / Design A single-center , 52-week , comparative effectiveness r and omized controlled trial of Tai Chi versus a st and ardized physical-therapy regimen is being conducted at an urban tertiary medical center in Boston , Massachusetts . The study population consists of adults ≥ 40 years of age with symptomatic and radiographic knee OA ( American College of Rheumatology criteria ) . Participants are r and omly allocated to either 12 weeks of Tai Chi ( 2x/week ) or Physical Therapy ( 2x/week for 6 weeks , followed by 6 weeks of rigorously monitored home exercise ) . The primary outcome measure is pain ( Western Ontario and McMaster Universities WOMAC ) subscale at 12 weeks . Secondary outcomes include WOMAC stkiffness and function domain scores , lower extremity strength and power , functional balance , physical performance tests , psychological and psychosocial functioning , durability effects , health related quality of life , and healthcare utilization at 12 , 24 and 52 weeks . Discussion This study will be the first r and omized comparative-effectiveness and cost-effectiveness trial of Tai Chi versus Physical Therapy in a large symptomatic knee OA population with long-term follow up . We present here a robust and well- design ed r and omized comparative-effectiveness trial that also explores multiple outcomes to eluci date the potential mechanisms of mind-body effect for a major disabling disease with substantial health burdens and economic costs . Results of this study are expected to have important public health implication s for the large and growing population with knee OA.Trial registration Clinical Trials.gov identifier : PURPOSE The purpose of this study was to determine , in a r and omized clinical trial of 439 individuals with knee osteoarthritis , the incremental cost-effectiveness of aerobic versus weight resistance training , compared with an education control intervention . METHODS Cost estimates of the intervention were based upon the cost of purchasing from the community similar services to provide exercise or health education . Effect at 18 months was measured using several variables , including : self-reported disability score , 6-min walking distance , stair climb , lifting and carrying task , car task , and measures of pain frequency and pain intensity on ambulation and transfer . RESULTS The total cost of the educational intervention was $ 343.98 per participant . The aerobic exercise intervention cost $ 323.55 per participant , and the resistance training intervention cost $ 325.20 per participant . On all but two of the outcome variables , the incremental savings per incremental effect for the resistance exercise group was greater than for the aerobic exercise group . CONCLUSION The data obtained from this study suggest that , compared with an education control , resistance training for seniors with knee osteoarthritis is more economically efficient than aerobic exercise in improving physical function . However , the magnitude of the difference in efficiency between the two approaches is small Background Osteoarthritis of the knee is a major cause of disability among adults .  Electro-acupuncture is considered a potentially useful treatment for  osteoarthritis .  The purpose of this study is to assess the efficacy of electro-acupuncture on pain control , pain perception , plasma cortisol and beta-endorphin levels , patient-perceived quality of life , and pain medication use in patients with chronic knee pain . Methods / design This study is a placebo-controlled , r and omized , double-blind , parallel design trial . One hundred sixty out- patients who are more than 50 years old and who have osteoarthritis of the knee will be recruited from the isl and of Mallorca , Spain . Each participant will be r and omly placed into one of two groups : ( sham ) electro-acupuncture non-insertion technique and real electro-acupuncture . Acupuncture treatments will be the Traditional Chinese Medicine type . The patients will be evaluated after a period of 1 month ( with two weekly sessions ) , 3 months ( with one monthly session ) , 6 months ( with one session every 45 days ) , and 1 year later with follow-up sessions at the end of the study ( with one session every 2 months).The primary outcomes will be based on the observed changes from the baseline of the visual analogue scale ( VAS ) and the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) for pain measured at 12 weeks after the end of treatment . Also to be included in the study are the possible changes in the secondary efficacy variables from baseline as assessed by the Short Form 36 version 2 health survey ( patient-perceived quality of life ) , patient plasma cortisol and beta-endorphin levels at the different treatment stages , the Goldberg Anxiety and Depression Scale , pain medication use , functional capacity and stiffness ( WOMAC subscales ) , and a VAS . These variables will be assessed at 1 month , 3 months , 6 months , and 1 year after study commencement . Discussion The findings from this study will help to determine whether electro-acupuncture is effective for chronic knee pain management in older people and whether electro-acupuncture can deliver results for the improvement of pain relief , stiffness , and disability . The study will therefore be a major step toward underst and ing the roles of the hypothalamic-pituitary-adrenal axis and the endogenous opioid system in the effectiveness of electro-acupuncture for chronic pain . Trial registration Clinical Trials.gov identifier NCT02299713 ( 11 Nov. 2014 ) Background Total hip or knee replacement is highly successful when judged by prosthesis-related outcomes . However , some people experience long-term pain . Objectives To review published studies in representative population s with total hip or knee replacement for the treatment of osteoarthritis reporting proportions of people by pain intensity . Data sources MEDLINE and EMBASE data bases search ed to January 2011 with no language restrictions . Citations of key articles in ISI Web of Science and reference lists were checked . Study eligibility criteria , participants and interventions Prospect i ve studies of consecutive , unselected osteoarthritis patients representative of the primary total hip or knee replacement population , with intensities of patient-centred pain measured after 3 months to 5-year follow-up . Study appraisal and synthesis methods Two authors screened titles and abstract s. Data extracted by one author were checked independently against original articles by a second . For each study , the authors summarised the proportions of people with different severities of pain in the operated joint . Results Search es identified 1308 articles of which 115 reported patient-centred pain outcomes .  Fourteen articles describing 17 cohorts ( 6 with hip and 11 with knee replacement ) presented appropriate data on pain intensity . The proportion of people with an unfavourable long-term pain outcome in studies ranged from about 7 % to 23 % after hip and 10 % to 34 % after knee replacement . In the best quality studies , an unfavourable pain outcome was reported in 9 % or more of patients after hip and about 20 % of patients after knee replacement . Limitations Other studies reported mean values of pain outcomes . These and routine clinical studies are potential sources of relevant data . Conclusions and implication s of key findings After hip and knee replacement , a significant proportion of people have painful joints . There is an urgent need to improve general awareness of this possibility and to address determinants of good and bad outcomes OBJECTIVE To test the effects of a high intensity home-based progressive strength training program on the clinical signs and symptoms of osteoarthritis ( OA ) of the knee . METHODS Forty-six community dwelling patients , aged 55 years or older with knee pain and radiographic evidence of knee OA , were r and omized to a 4 month home based progressive strength training program or a nutrition education program ( attention control ) .  Thirty-eight patients completed the trial with an adherence of 84 % to the intervention and 65 % to the attention control . The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis ( WOMAC ) index pain and physical function subscales . Secondary outcomes included clinical knee examination , muscle strength , physical performance measures , and question naires to measure quality of life variables . RESULTS Patients in the strength training group who completed the trial had a 71 % improvement in knee extension strength in the leg reported as most painful versus a 3 % improvement in the control group ( p < 0.01 ) . In a modified intent to treat analysis , self-reported pain improved by 36 % and physical function by 38 % in the strength training group versus 11 and 21 % , respectively , in the control group ( p = 0.01 for between group comparison ) . In addition , those patients in the strength training group who completed the trial had a 43 % mean reduction in pain ( p = 0.01 vs controls ) , a 44 % mean improvement in self-reported physical function ( p < 0.01 vs controls ) , and improvements in physical performance , quality of life , and self-efficacy when compared to the control group . CONCLUSION High intensity , home based strength training can produce substantial improvements in strength , pain , physical function and quality of life in patients with knee OA Background Physical activity ( PA ) reduces pain and improves functioning in people with knee osteoarthritis ( OA ) , but few people with the condition meet recommended PA guidelines . Successful intervention strategies to increase PA include goal setting , action planning , self-monitoring , and follow-up feedback from a healthcare professional . Recently developed consumer wearable activity trackers allow users to set activity goals , self-monitor daily goal -progress , and provide feedback on goal attainment . It is hypothesized that a multi-component physiotherapist-led intervention that includes a short ( 40-min ) education module , guided goal - setting and action planning , the use of a wristb and activity tracker , and weekly follow-up phone calls will lead to increased PA outcomes . Methods / design Thirty-six participants will be recruited from the community for a two-group pilot r and omized controlled trial with a stepped-wedge design using an intention-to-treat analysis . Computer-generated block r and omization will be performed using varying block sizes and a 1:1 allocation ratio . The 4-week intervention will be delivered immediately ( immediate-intervention group ) or after a 5-week delay ( delayed-intervention group ) . Outcome measures of pain and disability ( Knee Injury and OA Outcome Score ) , disease self-management ability ( Partners in Health Scale ) , and objective bouted moderate-to-vigorous PA and sedentary time ( BodyMedia SenseWear Mini Armb and ) will be collected at baseline ( week 0 ) and two follow-ups ( weeks 5 and 10 ) , for a total study duration of 11 weeks . Feasibility data relating to process , re source , management , and scientific elements of the trial will be collected . Outcome measure and feasibility data will be summarized , and an estimate of intervention efficacy will be obtained by regression model with planned comparisons . The trial began recruiting in February 2015 . To date , 34 subjects have been recruited . Discussion This study will evaluate the feasibility and preliminary efficacy of a novel intervention to promote  PA in people living with knee OA . The results will provide valuable information to inform a larger r and omized trial to assess intervention effectiveness . Trial registration Clinical Trials.gov Identifier : NCT02313506 ( registration date 8 December 2014 ) . First participant r and omized 20 February 2015 OBJECTIVE To determine whether high exercise adherence improved physical function among older adults with knee osteoarthritis ( OA ) who were overweight or obese . METHODS Associations between  exercise adherence , changes in 6-minute walking distance in meters , and self-reported disability ( Western Ontario and McMaster Universities Osteoarthritis Index function subscale ) after 6 and 18 months were examined among an Arthritis , Diet , and Activity Promotion Trial sub sample ( n = 134 ) using multiple linear regression models . RESULTS Higher exercise adherence was associated with greater improvements in 6-minute walking distance after 6 and 18 months and in disability after 6 months . Pain and body mass index ( BMI ) contributed , to some extent , to explaining the link between exercise adherence  and changes in physical performance and self-reported disability . CONCLUSION Higher exercise adherence is associated with improved physical function in overweight and obese older adults with knee OA . This indicates that promoting adherence is clinical ly relevant when prescribing exercise regimens that also focus on decreasing pain and BMI Context Previous studies of acupuncture for osteoarthritis have had conflicting results . This may have occurred because most studies have included small sample s , a limited number of treatment sessions , or other limitations . Contribution This r and omized , controlled trial compared 24 acupuncture sessions over 26 weeks with sham acupuncture or arthritis education in 570 patients with osteoarthritis of the knee .  Acupuncture led to greater improvements in function but not pain after 8 weeks and in both pain and function after 26 weeks . No adverse effects were associated with acupuncture . Caution s Many participants dropped out of the study , so readers should interpret the findings at 26 weeks with caution . The Editors Osteoarthritis is the most common form of arthritis and is a major cause of morbidity , limitation of activity , and health care utilization , especially in elderly patients ( 1 , 2 ) . Pain and functional limitation are the primary clinical manifestations of osteoarthritis of the knee . Current recommendations for managing osteoarthritis , including guidelines published by the American College of Rheumatology ( 3 ) and European League of Associations of Rheumatology ( 4 ) , focus on relieving pain and stiffness and maintaining or improving physical function as important goals of therapy . No curative therapies exist for osteoarthritis ; thus , both pharmacologic and nonpharmacologic management focus on controlling pain and reducing functional limitation ( 5 ) . Nonpharmacologic therapy , which includes patient education , social support , physical and occupational therapy , aerobic and resistive exercises , and weight loss , is the cornerstone of a multidisciplinary approach to osteoarthritis patient management ( 3 ) . Pharmacologic therapies include nonopioid analgesics ( such as acetaminophen ) , nonsteroidal anti-inflammatory drugs ( NSAIDs ) ( including cyclooxygenase-2 [ COX-2 ] enzyme selective inhibitors ) , topical analgesics ( capsaicin cream ) , opioid analgesics , and intra-articular steroid and hyaluronate injections . Often , these agents are used in combination for additive analgesic efficacy ( 6 ) . Pharmacologic management of osteoarthritis is often ineffective , and agents such as NSAIDs may cause unwanted and dangerous side effects ( 7 , 8) . Complementary and alternative medicine is another approach to treating osteoarthritis ( 9 - 12 ) , particularly in Asian societies ( 13 ) . Many U.S. patients with osteoarthritis also use complementary and alternative medical therapies ( 14 ) . A systematic review of acupuncture and knee osteoarthritis ( 15 ) identified 7 small r and omized , controlled trials published in English . Within the method ologic limitations of the studies , the evidence suggested that acupuncture seemed to alleviate knee pain and function compared with sham acupuncture controls , although 2 trials comparing acupuncture with an active , nonpharmacologic treatment ( physical therapy ) did not indicate such an effect ( 16 , 17 ) . Before conducting our large-scale trial , we completed both a pilot study ( 18 ) and a r and omized , single-blind trial ( 19 ) of the effect of acupuncture on osteoarthritis of the knee . Participants in the uncontrolled pilot study ( n= 12 ) showed statistically significant improvement in both self-reported pain and physical function , as well as performance measures of physical function after 8 weeks of acupuncture treatment and at 12-week follow-up as compared with their baseline ( 18 ) . In our larger r and omized , single-blind trial ( n= 73 ) , which examined the benefit of acupuncture added to st and ard management with NSAIDs , the acupuncture  treatment group experienced statistically significant improvements in self-reported pain and disability scores compared with a st and ard-care control group as late as 4 weeks after the end of treatment ( 19 ) . However , this effect diminished within 18 weeks ( 26 weeks after the beginning of the trial ) after the final acupuncture treatment . Together , however , the previously conducted trials ( both our preliminary studies [ 18 , 19 ] and those referenced in the systematic review [ 15 ] ) have 3 method ologic limitations : lack of credible controls for the placebo effect , inadequate assessment of long-term treatment benefits , and insufficient sample sizes . We tested the hypothesis that an 8-week intensive acupuncture treatment regimen , followed by an 18-week tapering regimen , reduces pain and improves function among patients with knee osteoarthritis as compared with both sham acupuncture and education control groups . Methods Patient Recruitment We recruited patients for this multisite , placebo-controlled trial from March 2000 through December 2003 , primarily through print and radio advertisements . The 3 sites were the Integrative Medicine Clinic of the University of Maryl and School of Medicine , Baltimore , Maryl and ; the Innovative Medical Research Center ( a private research firm ) , Towson , Maryl and ; and the Hospital for Special Surgery , New York City , New York . The institutional review boards of the 3 sites approved the study . We determined the sample size ( n= 570 ) by a power analysis based on our r and omized pilot study ( 19 ) , adjusted by the estimated decrease in effect size result ing from the inclusion of a sham acupuncture group design ed to control for placebo effects . Patients met the following inclusion criteria : age 50 years or older , a diagnosis of osteoarthritis of the knee , radiographic evidence of at least 1 osteophyte at the tibiofemoral joint ( KellgrenLawrence grade 2 ) , moderate or greater clinical ly significant knee pain on most days during the past month , and willingness to be r and omly assigned . Exclusion criteria were the presence of serious medical conditions that precluded participation in study , bleeding disorders that might contraindicate acupuncture , intra-articular corticosteroid or hyaluronate injections ( as well as any knee surgeries or concomitant use of topical capsaicin cream ) during the past 6 months , previous experience with acupuncture , or any planned events ( including total knee replacement ) that would interfere with participation in the study during the following 26 weeks . After a brief telephone screening , patients were scheduled to visit 1 of the 3 participating sites to sign an informed consent statement and undergo a brief rheumatologic examination ( including radiographic examination of affected knees ) by a physician or a nurse practitioner . Because the education course was a group activity , patients were recruited until a cohort of 12 to 21 patients was formed , at which point each cohort at each site was r and omly assigned to 1 of 3 groups by a computer-generated process using r and omly selected blocks of 3 , 6 , and 9 . We assured allocation concealment by using disguised letter codes that were generated and sent to the site coordinators by a central statistical core . We used this procedure to ensure that approximately equal numbers of participants were in each treatment group across the course of the study , to ensure that each cohort would have participants assigned to all 3 treatment groups , and to make the breaking of the group assignment process more difficult . The research assistants who collected assessment s from participants , the participants themselves ( in the true acupuncture and sham acupuncture groups ) , and the statistician were blinded to group assignment . Assessment s were conducted at baseline and 4 , 8 , 14 , and 26 weeks after r and omization . Study Interventions We developed and modified the acupuncture treatment and sham control protocol s from previously reported and vali date d procedures ( 18 - 21 ) . During the trial , 7 acupuncturists were used : 3 at the Integrative Medicine Clinic , 3 at the Innovative Medical Research Center , and 1 at the Hospital for Special Surgery . In general , acupuncturists were assigned to the same participants throughout the 26-week treatment schedule , except for vacation conflicts and staff turnover , and provided approximately the same proportions of true versus sham procedures . All acupuncturists were state-licensed and had at least 2 years of clinical experience . The study 's principal acupuncturist trained and supervised the acupuncturists in performing true or sham procedures and avoiding interactions that could inadvertently communicate group assignment . True Acupuncture The true acupuncture  ( experimental ) group underwent 26 weeks of gradually tapering treatment according to the following schedule : 8 weeks of 2 treatments per week followed by 2 weeks of 1 treatment per week , 4 weeks of 1 treatment every other week , and 12 weeks of 1 treatment per month . We based the acupuncture point selection s on Traditional Chinese Medicine meridian theory to treat knee joint pain , known as the Bi syndrome . These points consisted of 5 local points ( Yanglinquan [ gall bladder meridian point 34 ] , Yinlinquan [ spleen meridian point 9 ] , Zhusanli [ stomach meridian point 36 ] , Dubi [ stomach meridian point 35 ] , and extra point Xiyan ) and 4 distal points ( Kunlun [ urinarybladder , meridian point 60 ] , Xuanzhong [ gall bladder meridian point 39 ] , Sanyinjiao [ spleen meridian point 6 ] , and Taixi [ kidney meridian point 3 ] ) on meridians that traverse the area of pain ( 22 , 23 ) . The same points were treated for each affected leg . If both knees were affected , 9 needles were inserted in each leg . ( The outcome measures were not specifically targeted to whether the patient had osteoarthritis in 1 or both knees , and we observed no differential effects on the basis of the number of knees treated . ) The acupuncturists inserted 1.5-inch ( for local points ) and 1-inch ( for distal points ) 32-gauge ( 0.25-mm diameter ) acupuncture needles to a conventional depth of approximately 0.3 to 1.0 inch , depending on point location . All participants in the treatment group achieved the De-Qi sensation , a local sensation of heaviness , numbness , soreness , or paresthesia that accompanies the insertion and manipulation of needles during acupuncture , at these 9 points . Acupuncturists applied electrical Background : Knee osteoarthritis ( OA ) is the most common musculoskeletal disease among old individuals which affects ability for sitting on the chair , st and ing , walking and climbing stairs . Our objective was to investigate the short and long-term effects of the most simple and the least expensive exercise protocol s in combination to conventional conservative therapy for knee OA . Methods : It was a single blind RCT study with a 12-months follow-up . Totally , 56 patients with knee OA were assigned into 2 r and om groups . The patients in exercise group received exercise for knee muscles in combination with non-steroid anti-inflammatory drugs ( NSAIDs ) and 10 sessions acupuncture and physiotherapy modalities . Non-exercise group received similar treatments except exercise program . The changes in patients ’ pain and functional status were evaluated by visual analog scale ( VAS ) , knee and osteoarthritis outcome score ( KOOS ) question naire and functional tests ( 4 steps , 5 sit up , and 6 min walk test ) before and after treatment ( 1 and 3 months after intervention ) , and 1 year later at the follow-up . Results : The results showed that the patients with knee OA in exercise group had significant improvement in pain , disability , walking , stair climbing , and sit up speed after treatment at first and second follow-up when compared with their initial status and when compared with non-exercise group . At third follow up ( 1 year later ) there was significant difference between groups in VAS and in three items of KOOS question naire in functional status . Conclusion : Non aerobic exercises for muscles around knee can augment the effect of other therapeutic interventions like medical therapy , acupuncture , and modalities for knee OA OBJECTIVES To evaluate the effects of two knee taping techniques , therapeutic tape and neutral tape , on pain and observed disability in symptomatic generalized knee osteoarthritis ( OA ) . METHODS Using a within-subjects study design , 18 participants were tested under three conditions in r and om order : untaped , wearing therapeutic knee tape and wearing neutral knee tape . Outcome measures included assessment of pain during each of four activities ( using a visual analogue scale ) and assessment of observed disability ( walking speed , timed up and go test , and the step test ) . RESULTS Therapeutic tape significantly reduced pain on three of the four activities assessed , when compared with the neutral and untaped conditions ( P<0.017 ) . The only statistically significant change in observed disability was detected in the step test ( P<0.001 ) , in favour of the therapeutic tape . CONCLUSIONS Therapeutic knee tape is a simple , inexpensive strategy that increases the treatment options for therapists and patients in the conservative management of knee OA . Whilst effective in immediately reducing pain , it does not appear to have a significant immediate impact on observed disability associated with the disease . Therapeutic tape may be used as an adjunct to drug and exercise therapies , potentially augmenting the individual benefits of each Background Knee osteoarthritis ( OA ) is one of the most common and costly chronic musculoskeletal conditions world-wide and is associated with substantial pain and disability . Many people with knee OA also experience co-morbidities that further add to the OA burden . Uptake of and adherence to physical activity recommendations is suboptimal in this patient population , leading to poorer OA outcomes and greater impact of associated co-morbidities . This pragmatic r and omised controlled trial will investigate the clinical - and cost-effectiveness of adding telephone coaching to a physiotherapist-delivered physical activity intervention for people with knee OA . Methods / Design 168 people with clinical ly diagnosed knee OA will be recruited from the community in metropolitan and regional areas and r and omly allocated to physiotherapy only , or physiotherapy plus nurse-delivered telephone coaching . Physiotherapy involves five treatment sessions over 6 months , incorporating a home exercise program of 4–6 exercises ( targeting knee extensor and hip abductor strength ) and advice to increase daily physical activity . Telephone coaching comprises 6–12 telephone calls over 6 months by health practitioners trained in applying the Health Change Australia ( HCA ) Model of Health Change to provide behaviour change support . The telephone coaching intervention aims to maximise adherence to the physiotherapy program , as well as facilitate increased levels of participation in general physical activity . The primary outcomes are pain measured by an 11-point numeric rating scale and self-reported physical function measured by the Western Ontario and McMaster Universities Osteoarthritis Index subscale after 6 months . Secondary outcomes include physical activity levels , quality -of-life , and potential moderators and mediators of outcomes including self-efficacy , pain coping and depression . Relative cost-effectiveness will be determined from health service usage and outcome data . Follow-up assessment s will also occur at 12 and 18 months . Discussion The findings will help determine whether the addition of telephone coaching sessions can improve sustainability of outcomes from a physiotherapist-delivered physical activity intervention in people with knee OA.Trial Registration Australian New Zeal and Clinical Trials Registry reference : Background Osteoarthritis ( OA ) is one of the most common joint disorders in the elderly which could be associated with considerable physical disability . Patients and methods In a descriptive , prospect i ve study , 33 patients enrolled in the study from which 15 people were excluded due to incomplete course of treatment , leaving the total number of 18 patients with knee osteoarthritis .  Gal-Al-As diode laser device was used as a source of low-power laser . Patients were performed laser therapy with a probe of LO7 with a wavelength of 810 nm and 50 mW output power in pulse radiation mode ( F = 3,000 , peak power = 80 W , Δt = 200 ns , density = 0.05 W/cm2 , dose = 6 J/cm2 , area = 1 cm2 ) and also a probe of MLO1 K with a power output of 30 mW and a wavelength of 890 nm in pulse radiation mode ( F = 3,000 Hz , peak power = 50 W , Δt = 200 ns , density = 0.017 W/cm2 , total dose = 10 J/cm2 ) , and were given low-level laser therapy ( LLLT ) three times a week with a total number of 12 sessions . Data were analyzed using SPSS ver . 15 , and the obtained data were reported as mean ± SD and frequency ( % ) . To analyze the data , repeated measurement and marginal homogeneity approaches were used . Results In the current study , a significant reduction was observed regarding the nocturnal pain , pain on walking and ascending the steps , knee circumference , distance between the hip and heel , and knee to horizontal hip to heel distance at the end of the treatment course . Conclusions In brief , the current study focuses on the fact that LLLT is effective in reducing pain in knee osteoarthritis OBJECTIVE To examine the effects of aerobic and resistance exercise on self-efficacy beliefs in older adults with knee osteoarthritis ( OA ) and to determine whether self-efficacy and knee pain mediated the effects of the treatments on stair time performance and health perceptions . METHODS Measures of self-efficacy , knee pain , stair climbing performance , and health perceptions were collected prior to r and omization and again at an 18-month followup in older adults with knee OA who were assigned to 1 of 3 treatment conditions : aerobic exercise , resistance training , or health education control .  All analyses were conducted on the intention-to-treat principle . RESULTS Both exercise treatments increased self-efficacy for stair climbing in comparison to the health education control group . Both knee pain and self-efficacy mediated the effect of the treatments on stair climb time , whereas only knee pain mediated health perceptions . CONCLUSIONS The findings suggest that control beliefs and changes in physical symptoms such as knee pain are important outcomes in physical activity programs with patients who have OA of the knee . Moreover , these variables mediate the effects that such programs have on disability and health perceptions BACKGROUND Hip and knee osteoarthritis are frequent causes of primary care consultations . They are considered slowly progressive disorders , often result ing in severe pain or disability and the need for joint replacements . There have been few longitudinal studies of progression to inform individual prognoses in primary care . AIM To describe the degree of progression and investigate predictors of change in hip or knee pain and disability . DESIGN OF STUDY Prospect i ve community-based cohort . SETTING An age-sex stratified survey of 27 000 people registered with 40 general practice s in Avon and Somerset yielded 2437 reporting hip and /or knee symptoms at baseline ( 1992 - 1994 ) . A 25 % r and om sample of 587 individuals was followed up between 1998 and 1999 . METHOD Pain or disability was measured at baseline and followup using the New Zeal and score  . For the worst joint according to the New Zeal and score at baseline , hip and knee problems were analysed separately . Regression models ascertained characteristics of nonresponders and factors associated with change in scores . Seven sociodemographic , seven comorbidity , and two healthcare utilisation variables were considered . RESULTS Generally pain and disability worsened over the 7 years , but 35 % and 29 % of those initially reporting hip and knee pain respectively had improved . Reporting " other health problems " was associated with greater deterioration for both hip and knee disease , as was cardiovascular morbidity for hip disease and lower social class , being retired , hypertension , and higher body mass index for knee disease . Deteriorations in scores were strongly associated with individuals consulting their GP about joint problems . CONCLUSION Osteoarthritis does not invariably deteriorate , but when it does social as well as biological factors appear to be important . These findings may aid outcome prediction . Future research on osteoarthritis should be conducted within a biopsychosocial rather than a purely biological paradigm Objective The objective of this study was to determine whether individualized gait training is more effective than usual care for reducing mobility disability and pain in individuals with symptomatic knee osteoarthritis . Design Adults aged 60 yrs or older with symptomatic knee osteoarthritis and mobility limitations were r and omized to physical therapist – directed gait training on an instrumented treadmill , with biofeedback individualized to optimize knee movements , biweekly for 3 mos or usual care ( control ) . Mobility disability was defined using Late Life Function and Disability Index Basic Lower Limb Function score ( primary ) ; mobility limitations , using timed 400-m walk , chair-st and , and stair-climb tests ; and symptoms , using the Knee Injury/Osteoarthritis Outcome Score at baseline , as well as at 3 , 6 , and 12 mos . The analyses used longitudinal mixed models . Results There were no significant intergroup differences between the  35 gait-training ( 74.3 % women ; age , 69.7 ± 8.2 yrs ) and 21 control ( 57.1 % women ; age , 68.9 ± 6.5 yrs ) participants at baseline . At 3 mos , the gait-training participants had greater improvement in mobility disability ( 4.3 ± 1.7 ; P = 0.0162 ) and symptoms ( 8.6 ± 4.1 ; P = 0.0420 ) . However , there were no intergroup differences detected for pain , 400-m walk , chair-st and , or stair-climb times at 3 mos or for any outcomes at 6 or 12 mos . Conclusions Compared with usual care , individualized gait training result ed in immediate improvements in mobility disability knee symptoms in adults with symptomatic knee osteoarthritis , but these effects were not sustained Objectives : This umbrella review aim ed to determine the effectiveness of exercise interventions , alone or in combination with other interventions , in improving physical function in community-dwelling older people identified as pre-frail or frail . Introduction : Exercise is said to have a positive impact on muscle mass and strength which improves physical function and hence is beneficial for the treatment of frailty . Several systematic review s discuss the effects of exercise interventions on physical function parameters , such as strength , mobility , gait , balance and physical performance , and indicate that multi-component exercise , including resistance , aerobic , balance and flexibility training , appears to be the best way in which to improve physical function parameters in frail older people . However , there is still uncertainty as to which exercise characteristics ( type , frequency , intensity , duration and combinations ) are the most effective and sustainable over the long-term . Inclusion criteria : Participants were adults , 60 years or over , living in the community and identified as pre-frail or frail . Quantitative systematic review s , with or without meta- analysis that examined the effectiveness of exercise interventions of any form , duration , frequency and intensity , alone or in combination with other interventions design ed to alter physical function parameters in frail older people , were considered . The quantitative outcome measures were physical function , including muscular strength , gait , balance , mobility and physical performance . Methods : An iterative search strategy for ten bibliometric data bases and gray literature was developed . Critical appraisal of seven systematic review s was conducted independently by two review ers using a st and ard Joanna Briggs Institute tool . Data was extracted independently by two review ers using a st and ard Joanna Briggs Institute data extraction tool and summarized using a narrative synthesis approach . Results : Seven systematic review s were included in this umbrella review , with a total of 58 relevant r and omized controlled trials and 6927 participants . Five systematic review s examined the effects of exercise only , while two systematic review s reported on exercise in combination with a nutritional approach , including protein supplementations , as well as fruit and dairy products . The average  exercise frequency was 2–3 times per week ( mean 3.0 ± 1.5 times per week ; range 1–7 weekly ) for 10–90 minutes per session ( mean of 52.0 ± 16.5 mins ) and a total duration of 5–72 weeks with the majority lasting a minimum of 2.5 months ( mean 22.7 ± 17.7 weeks ) . Multi-component exercise interventions can currently be recommended for pre-frail and frail older adults to improve muscular strength , gait speed , balance and physical performance , including resistance , aerobic , balance and flexibility tasks . Resistance training alone also appeared to be beneficial , in particular for improving muscular strength , gait speed and physical performance . Other types of exercise were not sufficiently studied and their effectiveness is yet to be established . Conclusions : Interventions for pre-frail and frail older adults should include multi-component exercises , including in particular resistance training , as well as aerobic , balance and flexibility tasks . Future research should adopt a consistent definition of frailty and investigate the effects of other types of exercise alone or in combination with nutritional interventions so that more specific recommendations can be made Background Physical activity can improve health outcomes in people with knee osteoarthritis ( OA ) ; however , participation in physical activity is very low in this population . Objective The objective of our study was to assess the feasibility and preliminary efficacy of the use of wearables ( Fitbit Flex ) and telephone counselling by a physical therapist ( PT ) for improving physical activity in people with a physician-confirmed diagnosis of knee OA , or who have passed 2 vali date d criteria for early OA . Methods We conducted a community-based feasibility r and omized controlled trial . The immediate group ( n=17 ) received a brief education session by a physical therapist , a Fitbit Flex activity tracker , and a weekly telephone call for activity counselling with the physical therapist . The delayed group ( n=17 ) received the same intervention 1 month later . All participants were assessed at baseline ( T0 ) , and the end of 1 month ( T1 ) and 2 months ( T2 ) . Outcomes were ( 1 ) mean moderate to vigorous physical activity time , ( 2 ) mean time spent on sedentary behavior , ( 3 ) Knee Injury and Osteoarthritis Outcome Score ( KOOS ) , and ( 4 ) Partners in Health Scale . Feasibility data were summarized with descriptive statistics . We used analysis of covariance to evaluate the effect of the group type on the outcome measures at T1 and T2 , after adjusting for blocking and T0 . We assessed planned contrasts of changes in outcome measures over measurement periods . Results We identified 46 eligible individuals ; of those , 34 ( 74 % ) enrolled and no one dropped out . All but 1 participant adhered to the intervention protocol . We found a significant effect , with the immediate intervention group having improved in the moderate to vigorous physical activity time and in the Partners in Health Scale at T0 to T1 compared with the delayed intervention group . The planned contrast of the immediate intervention group at T0 to T1 versus the delayed group at T1 to T2 showed a significant effect in the sedentary time and the KOOS symptoms subscale , favoring the delayed group . Conclusions This study demonstrated the feasibility of a behavioral intervention , supported by the use of a wearable device , to promote physical activity among people with knee OA . Trial Registration Clinical Trials.gov NCT02313506 ; https:// clinical trials.gov/ct2/show/NCT02313506 ( Archived by WebCite at http://www.webcitation.org/6r4P3Bub0 Objective Osteoarthritis is a leading cause of disability for which there is no cure . Psychosocial-oriented treatments are underexplored . We developed and tested an intervention to build positive psychological skills ( e.g. , gratitude ) to reduce osteoarthritis symptom severity , including pain and functioning , and to improve psychosocial well-being in patients with knee or hip osteoarthritis . Design Two-arm r and omized design with six-month follow-up . Setting An academic Veterans Affairs Medical Center . Subjects Patients aged 50 years or older with knee or hip osteoarthritis and pain ratings of 4 or higher . Methods Patients ( N = 42 ) were r and omized to a six-week program containing positive skill-building activities or neutral control activities tailored to the patient population . Adherence  was assessed by telephone each week . We assessed osteoarthritis symptom severity ( WOMAC Osteoarthritis Index ) and measures of well-being ( positive affect , negative affect , and life satisfaction ) at baseline and by telephone one , three , and six months after the program ended . We used linear mixed models to examine changes over time . Results The majority ( 64 % ) of patients completed more than 80 % of their weekly activities . Patients in the positive ( vs neutral ) program reported significantly more improvement over time in osteoarthritis symptom severity ( P = 0.02 , Cohen 's d = 0.86 ) , negative affect ( P = 0.03 , Cohen 's d = 0.50 ) , and life satisfaction ( P = 0.02 , Cohen 's d = 0.36 ) . Conclusions The study successfully engaged patients with knee or hip osteoarthritis in a six-week intervention to build positive psychological skills . Improving osteoarthritis symptom severity and measures of psychosocial well-being , the intervention shows promise as a tool for chronic pain management Objective : To investigate whether a four-week walking exercise programme in patients with knee osteoarthritis improves the ability of dual-task performance in older adults with knee osteoarthritis . Design : A r and omized controlled trial with two groups : a walking group and a control group . Subjects : Forty older adults with knee osteoarthritis , 20 participants in each group . Intervention : The walking intervention was design ed to increase the number of steps walked daily . The walking group was instructed to increase their number of steps to 3000 steps more than before the intervention . Main outcome measures : Dual-task performance was computed by an automaticity index : the walking velocity under single-task condition/under dual-task conditions × 100 ( % ) , defined as automaticity . The nearer to 100 % automaticity , the better the dual-task performance . Decrease of the Trail Making Test ( TMT ) performance was defined as ΔTMT . ΔTMT was calculated as the difference between times ( part B – part A ) as a measure of executive function . In addition , functional ability was measured by the Japanese Knee Osteoarthritis Measure . Results : The walking group improved significantly in automaticity ( P < 0.001 , from 75.2 ( 7.6 ) to 86.9 ( 10.4 ) , ΔTMT ( P < 0.001 , from 63.4 ( 43.1 ) to 48.3 ( 29.6 ) ) and Japanese Knee Osteoarthritis Measure score ( P < 0.001 , from 54.4 to 51.9 ) compared with before the intervention , while the control group displayed no significant differences . Conclusions : We found that walking exercise improves executive function and dual-task performance Background Adequate and intensive rehabilitation is an important requirement for successful total knee arthroplasty . Although research suggests that Continuous Passive Motion ( CPM ) should be implemented in the first rehabilitation phase after surgery , there is substantial debate about the duration of each session and the total period of CPM application . A Cochrane review on this topic concluded that short-term use of CPM leads to greater short-term range of motion . It also suggested , however , that future research should concentrate on the treatment period during which CPM should be administered . Methods In a r and omised controlled trial we investigated the effectiveness of prolonged  CPM  use in the home situation as an adjunct to st and ardised PT . Efficacy was assessed in terms of faster improvements in range of motion ( RoM ) and functional recovery , measured at the end of the active treatment period , 17 days after surgery . Sixty patients with knee osteoarthritis undergoing TKA and experiencing early postoperative flexion impairment were r and omised over two treatment groups . The experimental group received CPM + PT for 17 consecutive days after surgery , whereas the usual care group received the same treatment during the in-hospital phase ( i.e. about four days ) , followed by PT alone ( usual care ) in the first two weeks after hospital discharge . From 18 days to three months after surgery , both groups received st and ardised PT . The primary focus of rehabilitation was functional recovery ( e.g. ambulation ) and regaining RoM in the knee . Results Prolonged use of CPM slightly improved short-term RoM  in patients with limited RoM at the time of discharge after total knee arthroplasty when added to a semi-st and ard PT programme . Assessment at 6 weeks and three months after surgery found no long-term effects of this intervention Neither did we detect functional benefits of the improved RoM at any of the outcome assessment s. Conclusion Although results indicate that prolonged CPM use might have a small short-term effect on RoM , routine use of prolonged CPM in patients with limited RoM at hospital discharge should be reconsidered , since neither long-term effects nor transfer to better functional performance was detected . Trial Registration IS RCT Decreases in muscular strength , endurance , and angular velocity have previously been demonstrated in the elderly . Osteoarthritis ( OA ) , especially of the knee , may cause further reductions in these parameters and lead to functional limitations . This study measured the effects of a quantitative progressive exercise muscle rehabilitation program ( QPE ) that was added to a physical therapy ( PT ) program .  Forty subjects ( 20 men and 20 women ) with OA of the knees were r and omly selected from a group of volunteers ( N = 437 ) for the 3-month program . Measurements of strength , endurance , angular velocity , and the Jette Functional Status Index were determined before and after 1 , 2 , and 3 months of the program . The QPE program was composed of isometric , isotonic , isotonic with resistance , endurance , and speed contractions prescribed in a progressive sequence . Muscle strength ( 14 % and 29 % ) and endurance ( 38 % and 43 % ) increased significantly ( p < 0.05 , ANOVA for repeated measures ) for both the quadriceps and hamstrings , respectively , after rehabilitation . There were marked decreases in walking time and the difficulty and pain experienced during functional activities Background The purpose was to conduct systematic review s of the relationship between physical activity of healthy community-dwelling older ( > 65 years ) adults and outcomes of  functional limitations , disability , or loss of independence .  Methods Prospect i ve cohort studies with an outcome related to functional independence or to cognitive function  were search ed , as well as exercise training interventions that reported a functional outcome . Electronic data base search strategies were used to identify citations which were screened ( title and abstract ) for inclusion . Included articles were review ed to complete st and ardized data extraction tables , and assess study quality . An established system of assessing the level and grade of evidence for recommendations was employed . Results Sixty-six studies met inclusion criteria for the relationship between physical activity and functional independence , and 34 were included with a cognitive function outcome . Greater physical activity of an aerobic nature ( categorized by a variety of methods ) was associated with higher functional status ( expressed by a host of outcome measures ) in older age . For functional independence , moderate ( and high ) levels of physical activity appeared effective in conferring a reduced risk ( odds ratio ~0.5 ) of functional limitations or disability . Limitation in higher level performance outcomes was reduced ( odds ratio ~0.5 ) with vigorous ( or high ) activity with an apparent dose-response of moderate through to high activity . Exercise training interventions ( including aerobic and resistance ) of older adults showed improvement in physiological and functional measures , and suggestion of longer-term reduction in incidence of mobility disability . A relatively high level of physical activity was related to better cognitive function and reduced risk of developing dementia ; however , there were mixed results of the effects of exercise interventions on cognitive function indices . Conclusions There is a consistency of findings across studies and a range of outcome measures related to functional independence ; regular aerobic activity and short-term exercise programmes confer a reduced risk of functional limitations and disability in older age . Although a precise characterization of a minimal or effective physical activity dose to maintain functional independence is difficult , it appears moderate to higher levels of activity are effective and there may be a threshold of at least moderate activity for significant outcomes UNLABELLED Knee pain is a common health problem in the elderly population , for which non-invasive treatments are recommended as a first line treatment in the management of knee pain . A r and omized controlled trial was conducted to determine the effects of exercise with or without thermal therapy in community-dwelling elderly women with chronic knee pain . Women over 75 years of age with knee pain ( n=150 ) were r and omly assigned into four groups ; exercise ( Ex ) and heat/steam generating sheet ( HSGS ) ( n=38 ) , Ex ( n=37 ) , HSGS ( n=38 ) , or health education ( HE ) ( n=37 ) . The Ex group attended a 60-min comprehensive training program twice a week for 3-months . The HSGS group placed two sheets on the knee for five hours per day . Functional fitness , visual analog scale ( VAS ) , and Japanese knee osteoarthritis measure ( JKOM ) were assessed at baseline and post-intervention . The results showed VAS improvements in the Ex+HSGS and HSGS groups . Total JKOM score , muscle strength , and functional mobility significantly improved in the Ex+HSGS group compared with the HE group . The odds ratio ( OR ) for VAS and functional mobility improvement was more than eight times as great in the Ex+HSGS group ( OR=8.60 , 95 % confidence interval (CI)=2.82 - 32.73 ) compared with the education group . Ex or HSGS alone were insufficient in enhancing functional fitness or improving pain and quality of life . The combined effects of both Ex and heat therapy seems to have an added benefit of decreasing pain , improving physical function and increasing quality of life . TRIAL REGISTRATION NUMBER JMA-IIA00110 Introduction Osteoarthritis ( OA ) is a chronic joint disease that usually occurs in older people and leads to pain and disabilities . OA treatment ranges from drug therapy to surgery . Drug and rehabilitation therapy are preferred over surgery , and , especially , there is a tendency toward compounds causing regenerative changes in the knee joint . In the present study , the effects of platelet-rich plasma ( PRP ) injection and prolotherapy ( PRL ) were examined on the level of pain and function of the knee joint in patients with OA . Methodology After fulfilling the inclusion criteria and signing the informed consent form , 42 patients with knee OA were scheduled for intra-articular injection in the present r and omized , double-blind , clinical trial . Following admission to the operating pain room , the condition of the patient ’s knee was evaluated first via the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) and , then , ultrasound-guided knee injection was done . Accordingly , patients in the PRP therapy group received 7 mL PRP solution and those in the PRL group received 7 mL 25 % dextrose . Using the WOMAC , levels of pain and knee function were evaluated and recorded for each patient immediately prior to the first injection as well as at 1 month ( immediately prior to the second injection ) , 2 months ( a month after the second injection ) , and 6 months later . Data collected were analyzed using the SPSS v.20 . Results During the first and second months , a rapid decrease in the overall WOMAC score was observed in both groups . The overall WOMAC score increased at the sixth month , but was lower than the overall WOMAC score in the first month . Statistical analysis indicated that the overall WOMAC score significantly decreased in both groups of patients over 6 months . Conclusion Results of the present study suggested a significant decrease in the overall WOMAC score of patients who undergo either PRP therapy or PRL . This positive change in the overall WOMAC score led to an improvement in the quality of life of patients with knee OA shortly after the first injection . PRP injection is more effective than PRL in the treatment of knee OA Early osteoarthritis ( OA ) is increasingly being recognized in patients who wish to remain active while not accepting the limitations of conservative treatment or joint replacement . The aim of this systematic review was to evaluate the existing evidence for treatment of patients with early OA using articular cartilage repair techniques . A systematic search was performed in EMBASE , MEDLINE , and the Cochrane collaboration . Articles were screened for relevance and appraised for quality . Nine articles of generally low method ological quality ( mean Coleman score 58 ) including a total of 502 patients ( mean age range = 36 - 57 years ) could be included . In the reports , both radiological and clinical criteria for early OA were applied . Of all patients included in this review , 75 % were treated with autologous chondrocyte implantation . Good short-term clinical outcome up to 9 years was shown . Failure rates varied from 8 % to 27.3 % . The conversion to total knee arthroplasty rate was 2.5 % to 6.5 % . Although a ( r and omized controlled ) trial in this patient category with long-term follow-up is needed , the literature suggests autologous chondrocyte implantation could provide good short- to mid-term clinical outcome and delay the need for total knee arthroplasty . The use of st and ardized criteria for early OA and implementation of ( r and omized ) trials with long-term follow-up may allow for further expansion of the research field in articular cartilage repair to the challenging population with ( early ) OA AIMS The study aims to compare changes over time among three study groups on the primary outcome , pain , as well as on the secondary outcomes , other symptoms , activities of daily living function , sport and recreation function , knee-related quality of life , knee range of motions and the six-minute walk test and to investigate whether aquatic exercises would be superior compared with l and exercise on pain reduction . BACKGROUND Osteoarthritis is a prevalent musculoskeletal disorder . Appropriate exercise may prevent osteoarthritis-associated disabilities and increase life quality . To date , research that compares the effects of different types of exercise for knee osteoarthritis has been limited . DESIGN The study is a r and omised trial . METHODS Eighty-four participants with knee osteoarthritis were recruited from local community centres . Participants were r and omly assigned to the control , aquatic or l and -based exercise group . Exercise in both groups ran for 60 minutes , three times a week for 12 weeks . Data were collected at baseline , week 6 and week 12 during 2006 - 2007 . The instruments included the Knee Injury and Osteoarthritis Outcome Score , a st and ard plastic goniometer and the six-minute walk test . Generalised estimation equations were used to compare changes over time among groups for key outcomes . RESULTS Results showed statistically significant group-by-time interactions in pain , symptoms , sport/recreation and knee-related quality of life dimensions of Knee Injury and Osteoarthritis Outcome Score , knee range of motions and the six-minute walk test . However , the aquatic group did not show any significant difference from the l and group at both weeks 12 and 6 . CONCLUSIONS Both aquatic and l and -based exercise programmes are effective in reducing pain , improving knee range of motions , six-minute walk test and knee-related quality of life in people with knee osteoarthritis . The aquatic exercise is not superior to l and -based exercise in pain reduction . RELEVANCE TO CLINICAL PRACTICE Similar outcomes could be possible with the two programmes . Health care professionals may consider suggesting well- design ed aquatic or l and -based exercise classes for patients with osteoarthritis , based on their preferences and convenience BACKGROUND Osteoarthritis ( OA ) is a leading cause of disability among adults . Although self-management behaviors such as exercise and weight management can improve pain and function , these behaviors are vastly underutilized . There is a need to implement effective self-management programs among the growing number of adults with OA . OBJECTIVES The Self-Management of OsteoArthritis ( SeMOA ) in Veterans Study examines a 12-month telephone-based OA self-management program in the primary care setting . This manuscript details the design , methodology , and advances of the SeMOA trial . METHODS Participants ( N=519 ) with hip or knee OA are r and omly assigned to one of three groups : OA self-management , health education ( attention control ) , or usual care . The OA self-management group receives written and audio material s regarding OA care ( including health behaviors , medical care , and interacting with health care providers ) . A health educator calls participants monthly to review these material s and provide support for developing individualized goals and action plans related to OA management . The health education group receives written and audio material s and monthly calls from a health educator discussing health issues unrelated to OA . Usual care involves no additional material s or phone calls . The primary outcome is change in the Arthritis Impact Measurement Scales-2 pain subscale from baseline to 12 months . Analysis of covariance models will compare changes in pain across study groups . The cost-effectiveness of the OA self-management program will also be assessed . CONCLUSION SeMOA is one of the first to examine telephone-based delivery of OA self-management and one of few trials to target the primary care setting . This program has the potential for broad dissemination because it reduces both the costs and barriers that accompany in-person programs . This study will provide important information about its feasibility and effectiveness in a real-world clinical setting BACKGROUND Intra-articular hyaluronate sodium is a relatively new therapy for the treatment of osteoarthritis of the knee . This r and omized , double-blind clinical trial was conducted at a large primary care medical center to determine the impact of hyaluronate sodium vs conventional therapy on measures of pain , stiffness , and disability at rest and following functionally relevant walking and stepping activities . METHODS A total of 120 patients ( mean age , 67 years ) with unilateral grade s 1 to 3 medial compartment knee osteoarthritis were r and omized to 1 of 4 treatment groups : group 1 , 2 mL of hyaluronate sodium at a concentration of 10 mg/mL and placebo ( 100 mg of lactose ) ; group 2 , nonsteroidal anti-inflammatory drugs ( NSAIDs ) ( 75 mg of diclofenac and 200 microg of misoprostol ) and hyaluronate sodium ; group 3 , NSAIDs and placebo ( 2 mL of isotonic sodium chloride solution [ saline ] ) ; and group 4 , placebo ( lactose and saline ) . Intra-articular hyaluronate sodium or saline ( 2 mL ) was administered once weekly over 3 weeks while NSAIDs or lactose were administered twice daily over 12 weeks . MAIN OUTCOME MEASURES ( 1 ) Western Ontario McMaster Universities Index ( WOMAC ) global measure of pain , stiffness , and disability ; ( 2 ) visual analog scale ( VAS ) scores for pain at rest and following functional walking and stepping activities ( self-paced walking and stepping ) ; and ( 3 ) functional performance ( exercise time , heart rate , and predicted maximum oxygen uptake ) at baseline and weeks 4 and 12 . RESULTS At week 4 , significant improvement in WOMAC scores for pain and disability and VAS score for resting pain was observed in groups 1 to 3 compared with baseline measures . Groups 1 and 2 showed significantly lower self-paced stepping pain , while no change was observed in group 4 . At week 12 , groups 1 to 3 showed significantly greater improvement in WOMAC pain subscale score and VAS score for resting pain ; however , these differences did not vary from week 4 . Following self-paced walking and stepping , groups 1 and 2 reported significantly less activity pain , while group 1 showed significantly faster self-paced walking and stepping test results . Groups 1 to 3 improved self-paced walking and stepping time at week 12 compared with baseline measures , while predicted maximum oxygen uptake was significantly higher in the hyaluronate sodium groups 1 and 2 at weeks 4 and 12 compared with baseline measures . CONCLUSIONS For resting pain relief , hyaluronate sodium seems to be as effective as NSAIDs . Further , for pain with physical activity and functional performance , hyaluronate sodium may be superior to placebo alone or NSAIDs alone Osteoarthritis ( OA ) is a common chronic and progressive degenerative joint condition . A major consequence of knee OA is physical disability ; especially difficulty with activities requiring ambulation and transfer , which are necessary to maintain independence and a good quality of life . The purpose s of this study were to determine the efficacy of a muscle exercise program along with education about knee care , and investigate the clinical factors which influence its therapeutic efficacy . A prospect i ve study was carried out among elderly Thai people aged 60 years and over , living in an urban community of the Bangkok metropolitan area around Siriraj Hospital , between October 1997 and September 1999 . The number of elderly people with osteoarthritis of the knee was 392 ( male : female=86:306 ) with a mean age of 67.7+/-6 years . They were interviewed for demographic data and information about their symptoms . The range of the knee movement , quadriceps strength and the six-minute walking distance and a knee X-ray were evaluated . Group exercise was arranged twice a week for 8 weeks for the intervention group only . The results of the study revealed that the quadriceps strength in the intervention group had a tendency to increase and the walking distance was significantly improved especially in the first two months but there was a tendency to decline by the sixth and twelfth month after enrollment . On the other h and , there was no statistically significant difference of both important outcomes for the control group when assessed in the second month . The findings at the sixth and twelfth month after enrollment were that the quadriceps strength was slightly increased but the walking distance was decreased when compared with the initial assessment . An exercise frequency of 12 sessions in two months was sufficient to improve muscle strength and walking distance . Group exercise produces a significant improvement in strength and walking ability , especially in the first two months . Deterioration over time could be due to multiple factors , such as lack of regular exercise , lack of motivation , lack of family support or poor economic status , so we should encourage the elderly to exercise regularly OBJECTIVES The American College of Rheumatology ( ACR ) Guidelines for the medical management of osteoarthritis ( OA ) emphasize the use of nonpharmacologic interventions including exercise . Implementation of an exercise program can be difficult for patients , and little is known about the benefits of alternative therapies such as yoga . The aim of this pilot study was to assess the feasibility of using yoga in the tradition of B.K.S. Iyengar to treat the symptoms of osteoarthritis of the knee . DESIGN Participants were instructed in modified Iyengar yoga postures during 90-minute classes once weekly for 8 weeks . SUBJECTS Participants met ACR criteria for osteoarthritis of the knee and completed a medical history and physical examination , Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC  )  , Arthritis Impact Measurement Scale 2 ( AIMS 2 ) , Patient Global Assessment ( GA ) by Visual Analog Scale ( VAS ) , Physician GA by VAS , and 50-foot Walk Time before and following an 8-week course of yoga instruction . Eleven ( 11 ) subjects enrolled , nine completed at least one session and seven ( six of whom were obese ) had data from pre- and post-course time points available for analysis . RESULTS Statistically significant reductions in WOMAC Pain , WOMAC Physical Function , and AIMS 2 Affect were observed when participants ' status were compared to their pre-course status . WOMAC Stiffness , AIMS 2 Symptoms , Social and Role , Physician GA , and Patient GA measured trends in improvement of symptoms . No adverse events from treatment were reported . CONCLUSIONS This pilot study suggests that yoga may provide a feasible treatment option for previously yoga-naive , obese patients > 50 years of age and offers potential reductions in pain and disability caused by knee OA . Future studies should compare yoga to other nonpharmacologic interventions for knee OA , such as patient education or quadriceps-strengthening exercises OBJECTIVE Osteoarthritis ( OA ) is the most common form of arthritis and the second most common cause of long-term disability among middle-aged and older adults in the United States .  Methylsulfonylmethane ( MSM ) is a popular dietary supplement used as a single agent and in combination with other nutrients , and purported to be beneficial for arthritis . However , there is paucity of evidence to support the use of MSM . METHODS A r and omized , double-blind , placebo-controlled trial was conducted . Fifty men and women , 40 - 76 years of age with knee OA pain were enrolled in an outpatient medical center . Intervention was MSM 3 g or placebo twice a day for 12 weeks ( 6g/day total ) . Outcomes included the Western Ontario and McMaster University Osteoarthritis Index visual analogue scale ( WOMAC ) , patient and physician global assessment s ( disease status , response to therapy ) , and SF-36 ( overall health-related quality of life ) . RESULTS Compared to placebo , MSM produced significant decreases in WOMAC pain and physical function impairment ( P<0.05 ) . No notable changes were found in WOMAC stiffness and aggregated total symptoms scores . MSM also produced improvement in performing activities of daily living when compared to placebo on the SF-36 evaluation ( P<0.05 ) . CONCLUSION MSM ( 3 g twice a day ) improved symptoms of pain and physical function during the short intervention without major adverse events . The benefits and safety of MSM in managing OA and long-term use can not be confirmed from this pilot trial , but its potential clinical application is examined . Underlying mechanisms of action and need for further investigation of MSM are discussed Background Osteoarthritis is the most prevalent joint disease and a frequent cause of joint pain , functional loss , and disability . Osteoarthritis often becomes chronic , and conventional treatments have demonstrated only modest clinical benefits without lesion reversal . Cell-based therapies have shown encouraging results in both animal studies and a few human case reports . We design ed a pilot study to assess the feasibility and safety of osteoarthritis treatment with mesenchymal stromal cells ( MSCs ) in humans and to obtain early efficacy information for this treatment . Methods Twelve patients with chronic knee pain unresponsive to conservative treatments and radiologic evidence of osteoarthritis were treated with autologous exp and ed bone marrow MSCs by intra-articular injection ( 40 × 106 cells ) . Clinical outcomes were followed for 1 year and included evaluations of pain , disability , and quality of life . Articular cartilage quality was assessed by quantitative magnetic resonance imaging T2 mapping . Results Feasibility and safety were confirmed , and strong indications of clinical efficacy were identified . Patients exhibited rapid and progressive improvement of algofunctional indices that approached 65 % to 78 % by 1 year . This outcome compares favorably with the results of conventional treatments . Additionally , quantification of cartilage quality by T2 relaxation measurements demonstrated a highly significant decrease of poor cartilage areas ( on average , 27 % ) , with improvement of cartilage quality in 11 of the 12 patients . Conclusions MSC therapy may be a valid alternative treatment for  chronic knee osteoarthritis . The intervention is simple , does not require hospitalization or surgery , provides pain relief , and significantly improves cartilage quality BACKGROUND AND PURPOSE This r and omized clinical trial was conducted to compare the effectiveness of 3 in-hospital rehabilitation programs with and without continuous passive motion ( CPM ) for range of motion ( ROM ) in knee flexion and knee extension , functional ability , and length of stay after primary total knee arthroplasty ( TKA ) . SUBJECTS Eighty-one subjects who underwent TKA for a diagnosis of osteoarthritis were recruited . METHODS All subjects were r and omly assigned to 1 of 3 groups immediately after TKA : a control group , which received conventional physical therapy intervention only ; experimental group 1 , which received conventional physical therapy and 35 minutes of CPM applications daily ; and experimental group 2 , which received conventional physical therapy and 2 hours of CPM applications daily . All subjects were evaluated once before TKA and at discharge . The primary outcome measure was active ROM in knee flexion at discharge . Active ROM in knee extension , Timed " Up & Go " Test results , Western Ontario and McMaster Universities Osteoarthritis Index question naire scores , and length of stay were the secondary outcome measures . RESULTS The characteristics of and outcome measurements for the subjects in the 3 groups were similar at baseline . No significant difference among the 3 groups was demonstrated in primary or secondary outcomes at discharge . DISCUSSION AND CONCLUSION The results of this study do not support the addition of CPM applications to conventional physical therapy in rehabilitation programs after primary TKA , as applied in this clinical trial , because they did not further reduce knee impairments or disability or reduce the length of the hospital stay CONTEXT The findings of systematic review s ( SRs ) and meta-analyses ( MAs ) are used for clinical decision making . The European Association of Urology has committed increasing re sources into the development of high quality clinical guidelines based on such SRs and MAs . OBJECTIVE In this paper , we have summarised the process of conducting SRs for underpinning clinical practice guidelines under the auspices of the European Association of Urology Guidelines Office . EVIDENCE ACQUISITION The process involves explicit methods and the findings should be reproducible . When conducting a SR , the essential first step is to formulate a clear and answerable research question . An extensive literature search lays the foundation for evidence synthesis . Data are extracted independently by two review ers and any disagreements are resolved by discussion or arbitration by a third review er . EVIDENCE SYNTHESIS In SRs , data for particular outcomes in individual r and omised controlled trials may be combined statistically in a meta- analysis to increase power when the studies are similar enough . Biases in studies included in a SR/MA can lead to either an over estimation or an under estimation of true intervention effect size , result ing in heterogeneity in outcome between studies . A number of different tools are available such as Cochrane Risk of Bias assessment tool for r and omised controlled trials . In circumstances where there is too much heterogeneity , or when a review has included nonr and omised comparative studies , it is more appropriate to conduct a narrative synthesis . The GRADE tool for assessing quality of evidence strives to be a structured and transparent system , which can be applied to all evidence , regardless of quality . A SR not only identifies , evaluates , and summarises the best available evidence , but also the gaps to be targeted by future studies . CONCLUSIONS SRs and MAs are integral in developing sound clinical practice guidelines and recommendations . PATIENT SUMMARY Clinical practice guidelines should be evidence based , and systematic review s and meta-analyses are essential in their production . We have discussed the key steps of conducting systematic review s and meta-analyses in this paper BACKGROUND Osteoarthritis ( OA ) is a chronic degenerative joint disease and is considered to be the fourth leading cause of disability and the second cause of inability to work in men . Recently , adipose-derived mesenchymal stem cells ( AD-MSCs ) came into focus for regenerative medicine as a promising tool for the treatment of OA . The administration of stem cells into impaired joints results in pain relief and improves quality of life , accompanied by restoration of hyaline articular cartilage . METHODS In the present study , nine patients ( including two patients with bilateral symptoms ) diagnosed with osteoarthritis ( International Knee Documentation grade B in 5 and grade D in six knees ) were treated using a single injection of AD-MSCs at a concentration of 0.5 - 1.0 × 107 cells and were followed up for 18 months . During follow-up , all the cases were evaluated clinical ly by Knee Society score ( KSS ) , Hospital for Special Surgery knee score ( HSS-KS ) , Tegner-Lysholm ( T-L ) score and visual analogue scale ( VAS ) of pain , as well as by plain radiography and by magnetic resonance imaging visualization with 2D Magnetic Resonance Observation of Cartilage Repair Tissue ( MOCART ) score assessment . RESULTS Significant improvement of all four clinical scores was observed within the first 6 months ( KSS for 41.4 points , HSS-KS for 33.9 points , T-L score for 44.8 points , VAS of pain from 54.5 to 9.3 ) and improvement persisted throughout the rest of the follow-up . MOCART score showed significant cartilage restoration ( from 43 ± 7.2 to 63 ± 17.1 ) , whereas radiography showed neither improvement , nor further joint degeneration . CONCLUSIONS The results obtained in the present study provide good basis for prospect i ve r and omized controlled clinical trials with respect to the use of AD-MSCs in the treatment of osteoarthritis PURPOSE This study was to determine whether the Sun-style 24 forms of Tai Chi exercise improve pain , stiffness , disability , knee joint motion , mobility , balance or falling . METHOD Forty-six community-dwelling elderly subjects ( mean age , 75.46+/-6.28 ) voluntarily participated in an intervention group of either 24 forms of Sun-style Tai Chi for 60 min , 2 times per week for 12 weeks or a control group . A non-equivalent pretest-posttest design was used . Independent t-test and ANCOVA were used to examine group differences by using SPSS12.0 . RESULT The experimental group had significantly less pain ( F=7.60 , p=.008 ) and stiffness ( t=-3.19 , p=.003 ) than the control group . Also there were significant improvements in knee joint motion on the right knee ( t=2.44 , p=.019 ) , left knee ( t=2.30 , p=.026 ) , rising time ( F=8.03 , p=.07 ) , balance on the left single leg test ( t=2.20 , p=.033 ) , and fear of falling ( t=-2.33 , p=.024 ) in the Tai Chi exercise group . No significant group differences were found in disability and falls efficacy . CONCLUSION The Sun-style 24 forms Tai Chi exercise is effective in decreasing pain , stiffness , fear of falling and it improves balance , rising time , and knee joint motion . We suggest a continuing long term intervention to decrease disability and increase efficacy concerning falls BACKGROUND CONTEXT Low back pain ( LBP ) is a prevalent disorder in society that has been associated with increased loss of work time and medical expenses . A common intervention for LBP is spinal manipulation , a technique that is not specific to one scope of practice or profession . PURPOSE The purpose of this systematic review was to examine the effectiveness of physical therapy spinal manipulations for the treatment of patients with low back pain . METHODS A search of the current literature was conducted using PubMed , CINAHL , SPORTD iscus , Pro Quest Nursing and Allied Health Source , Scopus , and Cochrane Controlled Trials Register . Studies were included if each involved : 1 ) individuals with LBP ; 2 ) spinal manipulations performed by physical therapists compared to any control group that did not receive manipulations ; 3 ) measurable clinical outcomes or efficiency of treatment measures , and 4 ) r and omized control trials . The quality of included articles was determined by two independent authors using the criteria developed and used by the Physiotherapy Evidence Data base ( PEDro ) . RESULTS Six r and omized control trials met the inclusion criteria of this systematic review . The most commonly used outcomes in these studies were some variation of pain rating scales and disability indexes . Notable results included varying degrees of effect sizes favoring physical therapy spinal manipulations and minimal adverse events result ing from this intervention . Additionally , the manipulation group in one study reported statistically significantly less medication use , health care utilization , and lost work time . CONCLUSION Based on the findings of this systematic review there is evidence to support the use of spinal manipulation by physical therapists in clinical practice . Physical therapy spinal manipulation appears to be a safe intervention that improves clinical outcomes for patients with low back pain Osteoarthritis ( OA ) is the most common cause of disability in older adults , which , in turn , leads to poor quality of life ( QOL ) . Disability is caused primarily by the joint degeneration and pain associated with OA . A r and omized pilot study was conducted to test the effectiveness of guided imagery with relaxation ( GIR ) to improve health-related QOL ( HRQOL ) in women with OA . A two-group ( intervention versus control ) longitudinal design was used to determine whether GIR leads to better HRQOL in these individuals and whether improvement in HRQOL could be attributed to intervention-associated improvements in pain and mobility .  Twenty-eight women were r and omized to either the GIR intervention or the control intervention group . Using GIR for 12 weeks significantly increased women 's HRQOL in comparison to the women who used the control intervention , even after statistically adjusting for changes in pain and mobility . These findings suggest that the effects of GIR on HRQOL are not limited to improvements in pain and mobility .  GIR may be an easy-to-use self-management intervention to improve the QOL of older adults with OA Abstract Salmon , JR , Roper , JA , and Tillman , MD . Does acute whole-body vibration training improve the physical performance of people with knee osteoarthritis ? J Strength Cond Res 26(11 ) : 2983–2989 , 2012—The purpose of this study was to determine the effects of a single session of whole-body vibration training ( WBVT ) on the physical performance of individuals with knee osteoarthritis ( OA ) in 3 tests design ed to simulate activities of daily living ( ADLs ) . Fifteen individuals with symptomatic knee OA completed the Timed-Up- and -Go Test , step test , 20-m walk test , and visual analog scale ( VAS ) recordings of knee pain intensity . A main effect was detected for time to complete the step test ( F[2,28 ] = 6.243 , p = 0.006 , ) . Post hoc analyses revealed that the time to complete the step test at 5 minutes after WBVT improved significantly ( p = 0.042 ) from that of the pretest . A moderate correlation ( r = 0.465 , p = 0.001 ) was found between the VAS scores and the time to complete the step test across all trials . A main effect was found for time to complete the walk test ( F[2,28 ] = 4.370 , p = 0.022 , ) . Post hoc analyses did not indicate significant improvements from pretest seen at 5 minutes after WBVT ( p = 0.110 ) and 1 hour after WBVT ( p = 0.224 ) . The WBVT was well tolerated in nearly all the participants , and we observed that an acute bout of WBVT was effective in improving the ability of individuals with knee OA  to perform a step test and 20-m walk test . Our findings suggest that WBVT may be an effective nonpharmacologic modality to treat some knee OA symptoms and improve ADLs OBJECTIVE To assess the efficacy and safety of radial extracorporeal shock wave therapy ( rESWT ) for  disabling pain due to primary knee osteoarthritis . DESIGN R and omized , placebo-controlled trial ( level of evidence , 1 ) . SUBJECTS A total of 105 women with disabling pain due to primary knee osteoarthritis lasting for a mean of 103 months ( range 3 - 480 months ) . METHODS Patients received either rESWT ( 3 sessions , each one week apart , 2,000 rESWT impulses per session , positive energy flux density 0.10 - 0.16 mJ/mm2 ) or placebo treatment . Primary outcome measure was pain on movement 3 months after the final treatment session . Secondary outcomes were pain , stiffness and limitations in physical function on the Western Ontario and McMaster Universities Osteoarthritis ( WOMAC ) Index and the level of tolerance to pressure over muscles , tendons , ligaments and skin at both the treated and the untreated side at 1 week and 3 months follow-up examinations . RESULTS Compared with placebo treatment , rESWT led to a statistically significant improvement only in mean WOMAC scores for pain and a few of the pressure measurements . CONCLUSION rESWT , as performed in the present study , is not efficient for treating patients with disabling pain due to primary knee osteoarthritis . Published data indicate that substantially higher energy flux densities are necessary for treatment success in this condition OBJECTIVE To examine the effect of a targeted balance training program on dynamic balance and self-reported physical function in people with medial tibiofemoral osteoarthritis ( OA ) . DESIGN Single-blind r and omized controlled trial . SETTING Exercise gymnasium and community dwellings . PARTICIPANTS Individuals with medial compartment knee OA ( N=40 ) . INTERVENTIONS Ten weeks of partially supervised exercises targeting dynamic balance and strength performed 4 times per week or no intervention ( nonintervention group ) . MAIN OUTCOME MEASURES Dynamic balance was measured using the Community Balance and Mobility Scale ( CB&M ) , and self-reported physical function was measured using the Western Ontario and McMaster Universities Arthritis Index physical function subscale . Secondary outcomes included knee pain , fear of movement , knee joint proprioception , and muscle strength . RESULTS Forty individuals underwent baseline testing , with 36 participants completing follow-up testing .  Adherence to exercise in the training group was high , with 82.2 % of all home-based exercise sessions completed . No significant changes were observed in any outcome in the nonintervention group at follow-up . Significant improvements in self-reported pain , physical function , and fear of movement were observed in the training group when compared with the nonintervention group . No other within- or between-group differences were observed . CONCLUSIONS A 10-week dynamic balance training program for people with knee OA significantly improved self-reported knee pain , physical function , and fear of movement ; however , there was no change in dynamic balance as quantified by the CB&M. Further research is needed to investigate how exercise may result in improvement on objective measures of dynamic balance OBJECTIVE To assess the effect of a home based exercise programme , design ed to improve quadriceps strength , on knee pain and disability . Methods —191 men and women with knee pain aged 40–80 were recruited from the community and r and omised to exercise ( n=113 ) or no intervention ( n=78 ) . The exercise group performed strengthening exercises daily for six months . The primary outcome measure was change in knee pain ( Western Ontario McMaster Osteoarthritis index ( WOMAC ) ) . Secondary measures included visual analogue scales ( VAS ) for pain on stairs and walking and WOMAC physical function scores . Results —WOMAC pain score reduced by 22.5 % in the exercise group and by 6.2 % in the control group ( between group difference p<0.05 , unpairedt test).VAS scores for pain also reduced in the exercise group compared with the control group ( p<0.05 ) . Physical function scores reduced by 17.4 % in the exercise group and were unchanged in controls ( p<0.05 ) . Conclusion —A simple programme of home quadriceps exercises can significantly improve self reported knee pain and function Background The purpose of this report is to provide a succinct but comprehensive summary of the scientific evidence regarding the effectiveness of manual treatment for the management of a variety of musculoskeletal and non-musculoskeletal conditions . Methods The conclusions are based on the results of systematic review s of r and omized clinical trials ( RCTs ) , widely accepted and primarily UK and United States evidence -based clinical guidelines , plus the results of all RCTs not yet included in the first three categories . The strength/ quality of the evidence regarding effectiveness was based on an adapted version of the grading system developed by the US Preventive Services Task Force and a study risk of bias assessment tool for the recent RCTs . Results By September 2009 , 26 categories of conditions were located containing RCT evidence for the use of manual therapy :  13 musculoskeletal conditions , four types of chronic headache and nine non-musculoskeletal conditions . We identified 49 recent relevant systematic review s and 16 evidence -based clinical guidelines plus an additional 46 RCTs not yet included in systematic review s and guidelines .Additionally , brief references are made to other effective non-pharmacological , non-invasive physical treatments . Conclusions Spinal manipulation/mobilization is effective in adults for : acute , subacute , and chronic low back pain ; migraine and cervicogenic headache ; cervicogenic dizziness ;  manipulation/mobilization is effective for several extremity joint conditions ; and thoracic manipulation/mobilization is effective for acute/subacute neck pain . The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration , and for manipulation/mobilization for mid back pain , sciatica , tension-type headache , coccydynia , temporom and ibular joint disorders , fibromyalgia , premenstrual syndrome , and pneumonia in older adults . Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation , or for Stage 1 hypertension when added to an antihypertensive diet . In children , the evidence is inconclusive regarding the effectiveness for otitis media and enuresis , and it is not effective for infantile colic and asthma when compared to sham manipulation . Massage is effective in adults for  chronic low back pain and chronic neck pain . The evidence is inconclusive for knee osteoarthritis , fibromyalgia , myofascial pain syndrome , migraine headache , and premenstrual syndrome . In children , the evidence is inconclusive for asthma and infantile colic Background . This paper aim ed to identify condition-specific patient-reported outcome measures used in clinical trials among people with wrist osteoarthritis and summarise empirical peer- review ed evidence supporting their reliability , validity , and responsiveness to change . Methods . A systematic review of r and omised controlled trials among people with wrist osteoarthritis was undertaken . Studies reporting reliability , validity , or responsiveness were identified using a systematic reverse citation trail audit procedure . Psychometric properties of the instruments were examined against predefined criteria and summarised . Results . Thirteen clinical trials met inclusion criteria . The most common patient-reported outcome was the disabilities of the arm , shoulder , and h and question naire ( DASH ) . The DASH , the  Michigan H and Outcomes Question naire ( MHQ ) , the  Patient Evaluation Measure ( PEM ) , and the  Patient-Reported Wrist Evaluation ( PRWE ) had evidence supporting their reliability , validity , and responsiveness . A post-hoc review of excluded studies revealed the AUSCAN Osteoarthritis H and Index as another suitable instrument that had favourable reliability , validity , and responsiveness . Conclusions . The DASH , MHQ , and AUSCAN Osteoarthritis H and Index instruments were supported by the most favourable empirical evidence for validity , reliability , and responsiveness . The PEM and PRWE also had favourable empirical evidence reported for these elements . Further psychometric testing of these instruments among people with wrist osteoarthritis is warranted OBJECTIVE The purpose of this study was to investigate lower extremity movement and muscle activation patterns in individuals with knee osteoarthritis and healthy age- and gender-matched control subjects . DESIGN This study utilized a non-r and omized case-control design to compare 24 subjects with unilateral symptomatic knee osteoarthritis to 24 age- and gender-matched control subjects without knee osteoarthritis . BACKGROUND It is hypothesized that knee osteoarthritis is associated with altered lower extremity movement and muscle activation patterns . METHODS A gait analysis was performed to determine the lower extremity movement and muscle activation patterns when walking on a level surface at 1.12 to 1.34 m/s and while descending a 20 cm step . Paired t-tests were used to compare the average of five trials between the groups . RESULTS Subjects with knee osteoarthritis demonstrated less excursion of the knee in the sagittal plane from heelstrike to peak flexion before midstance ( i.e. during loading ) . Subjects with knee osteoarthritis also demonstrated reduced peak vertical ground reaction forces relative to body weight . The muscle activity patterns were also different between the groups . The vastus lateralis , medial hamstrings , tibialis anterior and medial gastrocnemius were on approximately 1.5 times longer than the same muscles in the control subjects . Additionally , significant increases in muscle co-activation were also observed in individuals with knee osteoarthritis during walking . Similar findings were observed when the subject descended a 20 cm step OBJECTIVES To describe the relationships between proinflammatory biomarkers and self-reported and performance-based physical function and to examine the effect of weight loss on these markers of inflammation . DESIGN R and omized , longitudinal , clinical study comparing subjects eating an energy-restricted diet and participating in exercise training with a control group . SETTING Community-base participants for the Physical Activity , Inflammation and Body Composition Trial . PARTICIPANTS Eighty-seven obese ( body mass index ( BMI ) > 30.0 kg/m(2 ) ) adults aged 60 and older with knee pain and self-report of osteoarthritis . MEASUREMENTS Inflammatory biomarkers ( interleukin 6 ( IL-6 ) , tumor necrosis factor alpha ( TNFalpha ) , C-reactive protein , and soluble receptors for TNFalpha ( sTNFR1 and sTNFR2 ) ) and self-reported ( Western Ontario and McMaster University Osteoarthritis Index question naire ) and performance-based ( 6-minute walk distance and stair climb time ) measures of physical function at baseline and 6 months . RESULTS Mean ( st and ard error of the mean ) weight loss was 8.7 % ( 0.8 % ) in the intervention group , compared with 0.0 % ( 0.7 % ) in the control group . sTNFR1 was significantly less in the intervention group than in the control group at 6 months . sTNFR1 and sTNFR2 predicted stair climb time at baseline . Change across the 6-month intervention for sTNFR2 was an independent predictor for change in 6-minute walk distance . CONCLUSION These results indicate that an intensive weight-loss intervention in older obese adults with knee pain can help improve inflammatory biomarkers and that changes in these concentrations showed associations with physical function Very few studies tested the effectiveness of spa therapy in older patients with osteoarthritis . Therefore , we aim ed to evaluate the short-term effects of spa therapy in patients aged 65 years and older with generalized , knee , hip , and cervical and lumbar spine osteoarthritis . In an observational retrospective study design at the Medical Ecology and Hydroclimatology Department of Istanbul Medical Faculty , we analyzed the records of 239 patients aged over 65 years with the diagnosis of all types of osteoarthritis who were prescribed a spa therapy course in some spa resorts in Turkey between 7 March 2002 and 31 December 2012 . They travelled to a spa resort where they stayed at a thermal spa hotel and followed the usual therapy packages for 2 weeks . Patients were assessed by an experienced physician within a week before the spa journey and within a week after the completion of the spa therapy . Compared with baseline in whole sample , statistically significant improvements were observed in pain ( visual analog scale , VAS ) , patient and physician global assessment s ( VAS ) , Health Assessment Question naire disability index ( HAQ-DI ) , Lequesne algofunctional index ( LAFI ) for knee , Western Ontario and McMaster Universities index ( WOMAC ) , Waddell disability index ( WDI ) , and Neck Pain and Disability Scale ( NPAD ) . According to Outcome Measures in Rheumatology — Osteoarthritis Research Society International ( OMERACT-OARSI ) Set of Responder Criteria , responder rate were 63.8 % ( 51/80 ) in generalized , 52 % ( 13/25 ) in knee , 50 % ( 2/4 ) in hip , 66.7 % ( 8/12 ) in lumbar , and 100 % ( 6/6 ) in cervical osteoarthritis subgroups . Spa therapy  improved pain and physical functional status in older patients with osteoarthritis , especially generalized osteoarthritis and multiple joint osteoarthritis with involvement of knee . This improvement was clinical ly important in majority of the patients . To confirm the results of this preliminary study , there is a need of a r and omized controlled clinical study comparing spa therapy with usual care in the elderly population with osteoarthritis Global estimates suggest that knee osteoarthritis affects 10 % to 25 % of women and 5 % to 15 % of men aged 60 years or older ( 1 ) . It results in pain , physical dysfunction , and reduced quality of life and is a leading contributor to global disability ( 1 ) . In the United States , osteoarthritis is the second most common nonacute reason for seeking medical advice after skin disorders ( 2 ) . Because it has no cure , advice for self-management is the cornerstone of conservative treatment , along with exercise and weight control ( 3 , 4 ) . Given that abnormal biomechanics are critical to the pathogenesis of knee osteoarthritis ( 5 , 6 ) , clinical guidelines recommend appropriate footwear as part of core treatment ( 3 , 7 ) . However , there is scant evidence from clinical trials to guide footwear choice for this patient group or for any population with chronic musculoskeletal pain . Accordingly , both the European League Against Rheumatism ( 7 ) and the U.K. National Institute for Health and Care Excellence ( 3 ) have identified footwear trials as a research priority . Furthermore , a U.S. stakeholder panel recently identified evaluating the effectiveness of biomechanical strategies for osteoarthritis as a high-priority evidence gap ( 8) . Abnormal knee load is important in the development and progression of knee osteoarthritis ( 5 , 6 ) and probably explains why most tibiofemoral osteoarthritis occurs medially ( 9 ) , given that medial compartment loading is greater than lateral compartment loading during walking ( 10 ) . Wearing shoes increases medial knee load compared with being barefoot ( 11 , 12 ) , so recent research has focused on developing novel unloading shoes for persons with knee osteoarthritis to reduce medial knee load . Unloading shoes with soles that are stiffer laterally than medially significantly reduce medial knee loads via changes in foot and ankle biomechanics ( 1316 ) compared with shoes with conventional soles of uniform stiffness . These types of unloading shoes are now commercially available from footwear retailers ( for example , ABEO SMARTsystem [ The Walking Company ] and GEL-Melbourne OA or GEL-Melo [ ASICS ] ) and are recommended by the manufacturers for persons with knee pain or osteoarthritis . However , whether unloading shoes can reduce pain and physical dysfunction associated with knee osteoarthritis is unclear . In the only r and omized , controlled trial ( RCT ) to date , unloading shoes with soles that were stiffer laterally than medially did not result in between-group differences in the primary pain outcome at 6 months ( 17 ) or 1 year ( 18 ) , but they did lead to more persons achieving a clinical ly important reduction in pain than the control group ( 71 % vs. 35 % at 6 months ) . Given that persons with generally mild pain and radiographic disease were recruited as well as the considerable dropout rate ( 30 % at 1 year ) , further clinical trials are required to definitively evaluate unloading shoes for knee osteoarthritis . The aim of this study was to evaluate the efficacy of unloading walking shoes in alleviating knee osteoarthritis symptoms . We hypothesized that unloading shoes would reduce pain and improve physical function after 6 months compared with conventional walking shoes . Methods Design Overview We conducted a 2-group , parallel-group , comparative effectiveness RCT . The protocol has been published ( 19 ) . The trial was prospect ively registered with the Australian New Zeal and Clinical Trials Registry ( ACTRN12613000851763 ) and was approved by the Institutional Human Ethics Committee . Participants provided informed consent . Setting and Participants We recruited community-dwelling participants from Melbourne , Australia , between August 2013 and May 2015 via print , radio , television , and social media advertisements and our research data base . Participants were included if they were aged 50 years or older , had knee pain on most days in the previous month , reported average pain of at least 4 on an 11-point numerical rating scale ( NRS ) ( with terminal descriptors of no pain and worst pain possible ) in the previous week , had radiographic evidence of osteoarthritis ( KellgrenLawrence grade 2 [ 20 ] ) , and had definite medial tibiofemoral osteoarthritis on radiography ( grade 1 medial osteophytes and grade 1 medial joint space narrowing that was greater than lateral [ 21 ] ) . Exclusion criteria were presence of lateral tibiofemoral osteophytes that were worse than medial ( 21 ) ; intra-articular corticosteroid injection or knee surgery in the prior 3 months ; presence of a systemic arthritic condition ; prior knee arthroplasty or osteotomy or planned knee surgery in the subsequent 6 months ; presence of another condition affecting lower limb function ; current or previous ( prior 6 months ) use of shoe inserts , braces , or customized shoes from a health professional ; inability to walk unaided ; body mass index of 36 kg/m2 or greater ; or self-reported pathology or pain in the ankle or foot . R and omization and Interventions Participants were r and omly assigned in r and om permuted blocks of 6 to 12 , stratified by radiographic severity ( KellgrenLawrence grade 2 , 3 , or 4 ) . The r and omization schedule was prepared by an independent biostatistician ; concealed in consecutively numbered , sealed opaque envelopes by an independent research assistant ; and stored in a central ly accessible and locked location . A research er who was not involved in enrollment or outcome assessment accessed the schedule . Participants were blinded to allocation . Unloading shoes were visually similar to conventional shoes ( Appendix Figure ) , and model names were removed to ensure that the shoes could not be identified . Participants recorded which group they believed they were allocated to ( after being fitted with shoes and at 6 months ) , and the James blinding index was used to assess blinding success ( 22 ) . Because primary and secondary outcomes were participant-reported , assessors were also blinded . In addition , the research assistant overseeing data entry and the biostatistician were blinded . Appendix Figure . Intervention ( unloading ) shoes ( top ) and comparator ( conventional ) shoes ( bottom ) . Participants were provided a pair of appropriately sized shoes on the basis of their r and om assignment and were asked to wear them as much as possible every day ( 4 hours/day ) for 6 months and to avoid changing shoes . Participants were provided the shoes at no cost to themselves and were permitted to keep the shoes regardless of whether they completed the trial . For the intervention , we provided black , commercially available unloading walking shoes ( GEL-Melbourne OA ) ( Appendix Figure , top ) with triple-density midsoles ( stiffer laterally than medially ) and mild ( 5-degree ) lateral-wedge insoles attached to the underside of the sock liners . These shoes significantly reduce indirect measures of load across the medial knee compared with conventional recreational shoes ( 15 , 16 ) . For the comparator group , we provided black , commercially available neutral walking shoes ( GEL-Odyssey [ ASICS ] ) ( Appendix Figure , bottom ) that did not contain the specific design features of the unloading shoes . Adherence was measured by self-reported wear of allocated shoes ( hours per day ) , which was recorded in a logbook for 7 consecutive days each month ; overall self-reported adherence over 6 months using an 11-point NRS ( with the anchors not worn at all and worn completely as instructed ) ; and a shoe-mounted pedometer ( Oregon Scientific PE903 ) for 7 consecutive days during the fourth week of months 2 and 5 to record the number of daily steps in the trial shoes . Outcomes and Follow-up Participants completed self-reported primary and secondary outcome measures at baseline and 6 months , either electronically or on paper at the University of Melbourne . To minimize missing follow-up data , participants were provided a $ 50AUD gift voucher for returning completed question naires at 6 months . Primary outcomes were valid and reliable self-reported pain and physical function measures recommended for knee osteoarthritis clinical trials ( 23 ) . Overall average pain with walking over the previous week was measured via an 11-point NRS , with terminal descriptors of no pain and worst pain possible and a minimum clinical ly important difference ( MCID ) of 1.8 units ( 24 ) . Difficulty with physical functioning over the previous 48 hours was measured by the function subscale of the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC , Likert version 3.1 ) ( 25 ) , with total scores ranging from 0 ( no dysfunction ) to 68 ( maximum dysfunction ) and an MCID of 6 units ( 26 ) . Both primary outcomes were also assessed at 3 months ( secondary time point ) . Secondary outcomes included knee pain over the previous 48 hours , assessed with the WOMAC pain subscale ( 25 ) ( also administered at 3 months , with scores ranging from 0 [ no pain ] to 20 [ maximum pain ] and an MCID of 18 % improvement from baseline [ 27 ] ) ; knee stiffness over the previous 48 hours , evaluated with the WOMAC stiffness subscale ( 25 ) ( also administered at 3 months , with scores ranging from 0 [ no stiffness ] to 8 [ maximum stiffness ] and an MCID of 22 % improvement from baseline [ 27 ] ) ; intermittent and constant knee pain over the previous week , measured by using the Intermittent and Constant Osteoarthritis Pain question naire ( 28 ) ( scores ranging from 0 [ no pain ] to 100 [ maximum pain ] and MCIDs of 18.7 and 18.4 , respectively [ 29 ] ) ; global change in pain and physical function , assessed with 7-point Likert scales ( measured at 3 and 6 months , with terminal descriptors of much worse and much better ) ; health-related quality of life , evaluated with the Assessment of Quality of Life 6D scale ( AQoL-6D ) ( 30 ) ( scores ranging from 0.04 [ lowest quality ] to 1.00 [ highest quality ] and an MCID of 0.06 units [ 31 ] ) ; and physical activity over the previous week , assessed with the Physical Activity Scale for the Elderly ( 32 ) ( scores ranging from 0 [ lowest ] to > 400 [ highest ] ) . Adverse effects of treatment ( any problem believed by the BACKGROUND Osteoarthritis ( OA ) is the most common joint disease encountered throughout Europe . A task force for the EULAR St and ing Committee for Clinical Trials met in 1998 to determine the method ological and logistical approach required for the development of evidence based guidelines for treatment of knee OA . The guidelines were restricted to cover all currently available treatments for knee OA diagnosed either clinical ly and /or radiographically affecting any compartment of the knee . METHODS The first stage was the selection of treatment modalities to be considered . The second stage comprised a search of the electronic data bases Medline and Embase using a combination of subject headings and keywords . All European language publications in the form of systematic review s , meta-analyses , r and omised controlled trials , controlled trials , and observational studies were included . During stage three all the relevant studies were quality scored . The summary statistics for vali date d outcome measures , when available , were recorded and , where practical , the numbers needed to treat and the effect size for each treatment were calculated . In the fourth stage key clinical propositions were determined by expert consensus employing a Delphi approach . The final stage ranked these propositions according to the available evidence . A second set of propositions relating to a future research agenda was determined by expert consensus using a Delphi approach . RESULTS Over 2400 English language publications and 400 non-English language publications were identified . Seven hundred and forty four studies presented outcome data of the effects of specific treatments on knee OA . Quantitative analysis of treatment effect was possible in only 61 studies . Recommendations for the management of knee OA based on currently available data and expert opinion are presented . Proposals for a future research agenda are highlighted . CONCLUSIONS These are the first clinical guidelines on knee OA to combine an evidence based approach and a consensus approach across a wide range of treatment modalities . It is apparent that certain clinical propositions are supported by substantial research based evidence , while others are not . There is thus an urgent need for future well design ed trials to consider key clinical questions Background Hip and knee osteoarthritis is a common cause of pain and disability , which can be improved by exercise interventions . However , regular exercise is uncommon in this group because the low physical activity level in the general population is probably reduced even further by pain related fear of movement . The best method of encouraging increased activity in this patient group is not known . A booklet has been developed for patients with hip or knee osteoarthritis . It focuses on changing disadvantageous beliefs and encouraging increased physical activity . Methods / Design This paper describes the design of a Phase II r and omised controlled trial ( RCT ) to test the effectiveness of this new booklet for patients with hip and knee osteoarthritis in influencing illness and treatment beliefs , and to assess the feasibility of conducting a larger definitive RCT in terms of health status and exercise behaviour . A computerised search of four general medical practice patients ' record data bases will identify patients older than 50 years of age who have consulted with hip or knee pain in the previous twelve months . A r and om sample of 120 will be invited to participate in the RCT comparing the new booklet  with a control booklet , and we expect 100 to return final question naires . This trial will assess the feasibility of recruitment and r and omisation , the suitability of the control intervention and outcome measurement tools , and will provide an estimate of effect size . Outcomes will include beliefs about hip and knee pain , beliefs about exercise , fear avoidance , level of physical activity , health status and health service costs . They will be measured at baseline , one month and three months . Discussion We discuss the merits of testing effectiveness in a phase II trial , in terms of intermediate outcome measures , whilst testing the processes for a larger definitive trial . We also discuss the advantages and disadvantages of testing the psychometric properties of the primary outcome measures concurrently with the trial . Trial registration Current Controlled Trials IS RCT OBJECTIVE : To determine the effect of weight loss and exercise interventions on serum leptin and to investigate the relationship of physical function and osteoarthritis ( OA ) severity with serum leptin in older overweight and obese adults with knee OA . In addition , the study examined if serum leptin predicts weight loss . DESIGN : Longitudinal , controlled clinical trial of weight loss and exercise interventions .SUBJECTS : Community dwelling , older , overweight and obese adults ( n=316 ; > 60 years of age ; body mass index ≥28.0 kg m−2 ) with symptomatic knee OA and self-reported difficulty in performing selected physical activities were recruited . INTERVENTIONS : Participants were r and omized into one of four groups for the 18-month study duration : Healthy Lifestyle Controls , Dietary Weight Loss ( Diet ) , Exercise Training ( Exercise ) , and a combination of Dietary Weight Loss and Exercise Training ( Diet+Exercise ) . The weight loss goal for the two Diet groups was 5 % from baseline at 18 months . Participants in the Exercise groups were trained for 3 days week−1 , 60 min day−1 . MEASUREMENTS : Body weight , body mass index , serum leptin , physical function , and OA severity were measured at baseline , 6 months , and 18 months . RESULTS : Diet and Diet+Exercise groups lost 5.3 and 6.1 % of their weight , respectively , at 18 months with the Exercise group losing 2.9 % . There was a significant main effect of weight loss on serum leptin with a decrease in serum leptin averaged across the 6- and 18-month time points for the Diet and Diet+Exercise groups compared to the other two groups ( β=0.245 ; P<0.01 ) . No main effect  for exercise training was observed . Serum leptin was related to self-reported physical function . In all participants , a mixed model analysis demonstrated that lower levels of baseline serum leptin predict larger weight loss ( β=−2.779 ; P=0.048 ) . CONCLUSION : Decreases in serum leptin may be one mechanism by which weight loss improves physical function and symptoms in OA patients OBJECTIVE To compare the feasibility of blinding and the perceived risk of unblinding in trials evaluating  pharmacologic ( PT ) and nonpharmacologic treatments ( NPT ) of hip or knee osteoarthritis . STUDY DESIGN AND SETTING Two independent review ers assessed the feasibility of blinding  patients , care providers , and outcome assessors , the perceived risk of unblinding , and whether blinding was reported in 110 reports of r and omized controlled trials ( RCTs ) evaluating PT and NPT in patients with hip or knee osteoarthritis . RESULTS Blinding was considered to be possible less often in NPT trials than in PT trials for patients ( 42 vs. 96 % ; P < .001 ) , care providers ( 12 vs. 96 % ; P < .001 ) , and outcome assessors ( 34 vs. 98 % ; P < .001 ) . When blinding was judged feasible , the perceived risk of unblinding was more often considered moderate or important in NPT than PT trials for patients ( 35 vs. 14 % , P=.02 ) and outcome assessors ( 44 vs. 10 % , P=.0004 ) . When blinding was judged feasible , it was reported less often in NPT reports than in PT reports for patients ( 46 vs. 98 % , P < .001 ) , care providers ( 43 vs. 83 % , P=.03 ) , and outcome assessors ( 72 vs. 98 % , P=.0006 ) . CONCLUSION Blinding appears to be more difficult to achieve and unblinding may occur more often in NPT than PT trials OBJECTIVES To determine the effect of newly developed knee pain on general health and physical function of people > or=50 yrs living in the community . METHODS Prospect i ve cohort study of 3907 people aged 50 + registered with three general practice s in North Staffordshire , in the UK . The main outcome measures were self-reported knee pain ; general health and physical function as measured by the Short Form 36 ( SF-36 ) . RESULTS Of those with no knee pain at baseline , 24 % ( n = 501 ) reported it at follow-up . There was a steep decline in physical function in this group ( mean fall in SF-36 score at follow-up 10.3 points ) compared with the 1558 persons who had no knee pain at baseline or follow-up ( mean fall 3.3 ) . Those with knee pain at baseline whose pain had resolved at 3-yr follow-up ( n = 409 ) showed only minor improvements in physical functioning scores at follow-up ( mean improvement -1.3 ) . CONCLUSIONS The onset of knee pain is associated with a substantial and persistent reduction of physical function in older adults living in the community . Since knee pain is common , and reduced physical function in mid to older ages is a strong predictor of future disability and dependency , effective prevention or early treatment of knee pain at these ages is likely to have a major influence on healthy ageing in the population Osteoarthritis is a major contributor to functional impairment and reduced independence in older adults ( 1 - 4 ) . It is the leading cause of arthritis in the United States , affecting an estimated 21 million persons ( 5 ) , and has substantial economic impact ( 6 , 7 ) . History of an injury to a joint , particularly at the knee and hip , is associated with an increased risk for osteoarthritis in cross-sectional and casecontrol studies ( 8 - 11 ) . Such studies , however , may overestimate this relation because persons with symptomatic osteoarthritis may be more likely to recall a past injury or to interpret early symptoms of osteoarthritis as indicative of joint injury . A prospect i ve cohort study can address this weakness by determining exposure status before the outcome develops . To date , prospect i ve studies have examined the relation between history of joint injury and osteoarthritis in middle-aged persons and senior citizens ( 12 , 13 ) , but not in young adults . However , many athletic injuries occur in high school and college . In addition , joint trauma may be a more common cause of osteoarthritis than has been previously recognized ( 14 ) . We performed a prospect i ve cohort study of 1321 young adults to examine the risk for knee and hip osteoarthritis associated with joint injury during young adult life . Methods Study Participants The Johns Hopkins Precursors Study was design ed by the late Caroline Bedell Thomas , MD , to identify precursors of the aging process ( 15 ) . A total of 1337 medical students , members of the graduating classes of 1948 through 1964 at the Johns Hopkins University School of Medicine in Baltimore , Maryl and , enrolled in the study . The cohort was 91 % male and 97 % white ; the mean age was 22 years . At entry , participants underwent a st and ard history and examination , including  assessment of musculoskeletal disorders , history of trauma , level of physical activity , and measurement of weight and height . Body mass index was calculated as weight in kilograms divided by height in meters squared . In addition , participants were asked to categorize their level of physical training during the past month as none , little , moderate , or much , as described elsewhere ( 16 ) . Since graduation , participants have been followed prospect ively with annual self-administered question naires to detect incident disease and to up date risk factor status over time . At the time that baseline data were collected , it was not customary to obtain informed consent . After establishment of the Joint Committee on Clinical Investigation at Johns Hopkins , the follow-up protocol was review ed and approved . Assessment of Injury Injury was defined as a report of trauma to the knee or hip joint , including internal derangement and fracture . During the baseline assessment , knee and hip injuries that occurred before graduation from medical school and the year of their occurrence were recorded . Postgraduation injuries were assessed by annual morbidity question naires . During every 5-year follow-up period , at least 86 % of the living participants responded at least once to the question naires . Injuries were assigned diagnosis codes according to the International Classification of Diseases , Ninth Revision , Clinical Modification ( ICD-9-CM ) ( 17 ) . Diagnoses included torn meniscus ( code 836.2 ) ; torn knee ligament ( code 844.9 ) ; tibial fracture ( code 823.8 ) ; femoral fracture ( code 821.01 ) ; fibular fracture ( code 823.81 ) ; patellar fracture ( code 822 ) ; broken leg , site not otherwise specified ( code 827.0 ) ; knee injury , not otherwise specified ( code 959.7 ) ; gunshot wound ( code 891 ) ; hemarthrosis ( code 844.9 ) ; shin splints ( code 844.9 ) ; and hip dislocation ( code 836.5 ) . Incidence of Osteoarthritis The methods used to determine osteoarthritis incidence in this cohort have been described elsewhere ( 18 ) . Briefly , all participants were mailed annual morbidity question naires . Before 1985 , respondents were queried about the development of physical and musculoskeletal disorders . Since 1985 , follow-up morbidity question naires have contained the specific question , Have you ever had arthritis ? and have asked those who respond affirmatively to provide the type of arthritis , year of onset , and treatment received . An event of osteoarthritis was defined as the self-report of osteoarthritis or degenerative arthritis in response to the question naire . The incidence date was determined by the reported year of osteoarthritis onset . Two rheumatologists review ed each report of osteoarthritis , assigned ICD-9-CM codes ( 17 ) to the most specific arthritis site reported by the respondent , and excluded inflammatory arthritides . For this analysis , only osteoarthritis at the knee ( code 715.96 ) and hip ( code 715.95 ) were included as outcomes . In 1995 , all surviving participants who had previously reported osteoarthritis were mailed a more detailed question naire . They were asked , Have you had pain in or around the knee , including back of the knee , on most days for at least 1 month ? and Have you had pain in or around either hip joint , including the buttock , groin , and side of upper thigh , on most days for at least 1 month ? These symptom-related questions were used to screen for knee and hip osteoarthritis , respectively , in the National Health and Nutrition Examination Survey ( NHANES ) ( 19 ) . Respondents were also asked whether they had undergone  radiographic evaluation of their knees and hips  and whether radiography revealed osteophytes , joint space narrowing , subchondral cysts , or bony sclerosis ( the radiographic hallmarks of osteoarthritis ) ( 20 ) . Statistical Analysis The association between baseline characteristics and injury status was assessed by using the Student t-test for continuous variables and the chi-square test for categorical variables . These data are presented both for the entire cohort and separately by sex . Injury was the independent variable in the survival analysis ; age was the time variable . Knee and hip osteoarthritis were examined as separate outcomes . The relation of a joint injury at baseline to the incidence of osteoarthritis was examined by using KaplanMeier analysis ( 21 ) . The log-rank statistic was used to test whether the cumulative incidence of osteoarthritis differed according to injury status at cohort entry ( 22 ) . In addition , Cox proportional-hazards analysis was used to estimate the independent risk for osteoarthritis associated with a joint injury . Cox models were constructed for injury status at cohort entry and over follow-up , modeled as a time-dependent covariate . We adjusted for age at graduation , sex , body mass index , and level of physical activity , each of which was determined at baseline , to evaluate for possible confounding . In this cohort , body mass index at enrollment was more predictive of future osteoarthritis than average or most recent body mass index during follow-up ( 18 ) . These analyses were performed for all reported events of knee and hip osteoarthritis and for cases confirmed by both characteristic symptoms and radiographic findings . Hazard ratios are reported as relative risks with 95 % CIs . Statistical significance was defined as an level equal to 0.05 using a two-tailed test . We conducted a sensitivity analysis to assess the potential effect of an omitted covariate on the association between joint injury and subsequent osteoarthritis . Role of the Funding Sources The funding sources did not have a role in the collection , analysis , or interpretation of the data or in the decision to su bmi t the study for publication . Results At graduation from medical school , the average age of the 1216 men and 121 women in the cohort was 26 years . Our analysis is based on events reported through 30 November 1995 and represents a median follow-up of 36 years . Information at baseline or during follow-up was available for 1321 participants , who form the basis of our longitudinal analysis . At the end of follow-up in 1995 , the mean age of the cohort SD was 61.4 8.9 years . Overall , 141 participants had a joint injury ( knee alone [ n = 111 ] , hip alone [ n = 16 ] , or injuries at both sites [ n = 14 ] ) before or after graduation . Table 1 shows the baseline characteristics of the cohort according to injury status at the end of follow-up . Proportions of men and women with joint injury were similar ( P > 0.2 , chi-square test ) . Participants were generally lean , 49 % were physically active , and 54 % smoked cigarettes . Men who had a joint injury were heavier at baseline than men who were injury-free , but both groups of men were similar in age , level of physical activity , and smoking status . Women with injury were , on average , 2 years older at baseline than those without injury . Table 1 . Baseline Characteristics of 1321 Men and Women according to Joint Injury at Cohort Entry or during Follow-up At baseline , 47 men ( 3.9 % ) reported a knee injury and 12 men ( 1.0 % ) reported a hip injury . The mean age at which the injuries occurred was 16 years . Knee injuries included 10 tibial fractures , 3 fibular fractures , 4 femoral fractures , 2 patellar fractures , and 9 otherwise unspecified leg fractures . In addition , 8 men incurred trauma result ing in torn knee cartilage , 2 had torn knee ligaments , 2 had knee injuries result ing from gunshot wounds , 1 had traumatic hemarthrosis , 1 had joint dislocation , 1 had shin splints , and 4 had otherwise unspecified knee injuries . Of men with a knee injury , 4 reported that they were injured while playing football , 2 each reported that they were injured while playing basketball or participating in athletics , and 1 each reported that he was injured while horseback riding , bicycling , skiing , playing volleyball , wrestling , playing baseball , or playing tennis . Knee trauma also result ed from motor vehicle accidents ( n =3 ) and falls ( n = 2 ) . At baseline , 4 of the 121 women ( 3.3 % ) had a history of knee injuries and 1 ( 0.8 % ) had a history of hip injuries . Sixty-two men and 7 women developed knee osteoarthritis , and 27 men and 5 women developed hip osteoarthritis . The mean SD ages at onset of OBJECTIVES To investigate the association between baseline physical activity and 1-year functional performance in adults with knee osteoarthritis ( OA ) . DESIGN Prospect i ve cohort study of knee OA development and progression with 1-year follow-up . SETTING Community . PARTICIPANTS Osteoarthritis Initiative public data on adults with knee OA ( n=2274 ; age , 45 - 79y ) who participated in functional performance assessment s ( timed 20-m walk and chair st and test ) at baseline and 1-year follow-up . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURE A good 1-year performance outcome ( separately defined for walk time and chair st and measures ) was improvement from baseline quintile or maintenance in the best quintile . RESULTS Almost 2 in 5 persons with radiographic knee OA improved or maintained high performance at 1 year .  Physical activity  measured by the  Physical Activity Scale for the Elderly  ( PASE ) was significantly associated with good walk rate and chair st and outcomes ( odds ratio per 40 units PASE [ 95 % confidence interval]=1.13 [ 1.13 , 1.17 ] and 1.10 [ 1.05 , 1.15 ] , respectively ) , as were participation in sports/recreational activities ( 1.45 [ 1.23 , 1.71 ] and 1.29 [ 1.09 , 1.51 ] , respectively ) and lifestyle activities ( 1.11 [ 1.06 , 1.16 ] and 1.09 [ 1.04 , 1.14 ] , respectively ) . An independent protective relationship for these physical activity measures approached significance after adjusting for sociodemographic and health factors . Older adults reported the least baseline physical activity and least frequent good 1-year outcomes . CONCLUSIONS These findings support public health recommendations to be physically active in order to preserve function for persons with knee OA .  Physical activity messages should specifically target older adults whose low activity levels may jeopardize their ability to maintain functional performance Background Osteoarthritis ( OA ) is a leading cause of disability in the United States . Although no disease-modifying therapies exist , patients with knee OA who increase walking may reduce risk of functional limitations . Objective The objective of the study is to evaluate the impact of a mobile app ( OA GO ) plus wearable activity monitor/pedometer ( Jawbone UP 24 ) used for 90 days on the mobility of patients with knee OA treated with hylan G-F 20 .  Methods Patients with knee OA aged 30 to 80 years who were eligible to receive hylan G-F 20 and were familiar with smartphone technology were enrolled in this r and omized , multicenter , open-label study . Patients who had a body mass index above 35 kg/m2 were excluded . All patients received a single 6-mL injection of hylan G-F 20 and wore the Jawbone monitor . The patients were then r and omized 1:1 to Jawbone and OA GO ( Group A ; n=107 ) with visible feedback ( unblinded ) or Jawbone only ( Group B ; n=104 ) with no visible feedback ( blinded ) . The primary endpoint was mean change from baseline in steps per day at day 90 between Groups A and B. Results Baseline characteristics were similar between groups . There were significant differences between the increases in least squares ( LS ) mean number of steps per day ( 1199 vs 467 , P=.03 ) and the mean percentage change ( 35.8 % vs 11.5 % , P=.02 ) from baseline in favor of Group A over Group B. There was a greater reduction in pain from baseline during the 6-minute walk test in Group A versus Group B. ( LS mean change : −55.3 vs −33.8 , P=.007 ) . Most patients ( 65.4 % ) and surveys of physicians ( 67.3 % ) reported they would be likely or very likely to use/recommend the devices . Patient Activity Measure-13 scores improved from baseline ( LS mean change for Groups A and B : 5.0 vs 6.9 ) , with no significant differences between groups . The occurrence of adverse events was similar in the 2 groups . Conclusions Use of a novel smartphone app in conjunction with a wearable activity monitor provided additional improvement on mobility parameters such as steps per day and pain with walking in the 6-minute walk test in patients with knee OA who were treated with hylan G-F 20 . Results also highlight the amenability of patients and physicians to using mobile health technology in the treatment of OA and suggest further study is warranted Background Arthroscopic partial meniscectomy ( APM ) is extensively used to relieve pain in patients with symptomatic meniscal tear ( MT ) and knee osteoarthritis ( OA ) . Recent studies have failed to show the superiority of APM compared to other treatments . We aim to examine whether existing evidence is sufficient to reject use of APM as a cost-effective treatment for MT+OA . Methods We built a patient-level microsimulation using Monte Carlo methods and evaluated three strategies : Physical therapy ( ‘ PT ’ ) alone ; PT followed by APM if subjects continued to experience pain ( ‘ Delayed APM ’ ) ; and ‘ Immediate APM ’ .  Our subject population was US adults with symptomatic MT and knee OA over a 10 year time horizon . We assessed treatment outcomes using societal costs , quality -adjusted life years ( QALYs ) , and calculated incremental cost-effectiveness ratios ( ICERs ) , incorporating productivity costs as a sensitivity analysis . We also conducted a value-of-information analysis using probabilistic sensitivity analyses . Results Calculated ICERs were estimated to be $ 12,900/QALY for Delayed APM as compared to PT and $ 103,200/QALY for Immediate APM as compared to Delayed APM . In sensitivity analyses , inclusion of time costs made Delayed APM cost-saving as compared to PT . Improving efficacy of Delayed APM led to higher incremental costs and lower incremental effectiveness of Immediate APM in comparison to Delayed APM . Probabilistic sensitivity analyses indicated that PT had 3.0 % probability of being cost-effective at a willingness-to-pay ( WTP ) threshold of $ 50,000/QALY . Delayed APM was cost effective 57.7 % of the time at WTP = $ 50,000/QALY and 50.2 % at WTP = $ 100,000/QALY . The probability of Immediate APM being cost-effective did not exceed 50 % unless WTP exceeded $ 103,000/QALY . Conclusions We conclude that current cost-effectiveness evidence does not support unqualified rejection of either Immediate or Delayed APM for the treatment of MT+OA . The amount to which society would be willing to pay for additional information on treatment outcomes greatly exceeds the cost of conducting another r and omized controlled trial on APM Background : Short-term and mid-term differences between hamstring and patellar tendon autografts for anterior cruciate ligament ( ACL ) reconstruction are well documented . Systematic review s highlight the lack of long-term results between the two grafts . Hypothesis : Seventeen years after ACL reconstruction , no difference will be found in functional outcome , quality of life , and graft failure between patients with patellar tendon ( PT ) or semitendinosus and gracilis tendon ( STG ) autografts ;  however , a significant difference will be seen in the prevalence of osteoarthritis . Study Design : R and omized controlled trial ; Level of evidence , 2 . Methods : Sixty-four patients were included in this prospect i ve study ( 32 in each group ) . A single surgeon performed primary ACL reconstruction in alternating sequence . Forty-eight patients ( 24 in each group ) were evaluated 17 years after ACL reconstruction :  A clinical assessment was made based on the International Knee Documentation Committee ( IKDC ) form , instrumented laxity was measured with KT-1000 arthrometer , and radiography of the operated knee was conducted and assessed for degenerative disease . The Lysholm question naire and the Short Form–36 version 2 question naire were filled out by the patients . Results : At the 17-year follow-up , no statistically significant differences were seen with respect to graft failure ( 2 reruptures in the semitendinosus and gracilis tendon [ STG ] group [ 6.3 % ] and 3 reruptures in the PT group [ 9.4 % ] ) and functional outcome . Increased instrumented laxity ( > 3 mm ) measured with KT-1000 arthrometer was seen in significantly more patients in the STG group ( 8 in the STG group compared with 2 in the PT group ; P = .03 ) with a mean side-to-side difference of 2.17 ± 1.86 mm in the STG group compared with 1.33 ± 1.93 mm in the PT group . A significant difference was found in frequency of knee osteoarthritis (OA)—100 % in the PT group compared with 71 % in the STG group ( P = .004 ) . Patients in the PT group tended to have higher grade OA according to the IKDC grading system , with an average grade of 1.46 in the PT group compared with 1 in the STG group ( P = .055 ) . The degenerative changes in the PT group were more common in the medial and patellofemoral compartments ( P = .003 and P = .04 , respectively ) . Conclusion : Both autografts provided good to excellent subjective outcomes . No significant differences were noted in graft failure and clinical instability . However , significantly more patients in the STG group had increased instrumented anteroposterior translation measured with KT-1000 arthrometer , and there was a greater prevalence of knee OA at 17 years after surgery in the PT group Background and Purpose — Individuals with chronic stroke often demonstrate a “ plateau , ” or deceleration of motor recovery , which may lead to discharge from physical therapy ( PT ) . However , numerous studies report improvements in motor function when individuals are provided intensive practice of motor tasks . We suggest that reduced task-specific walking practice during clinical PT contributes to limited gains in ambulatory function in those with a perceived plateau poststroke , and suggest that further gains can be realized if intensive stepping , or locomotor training ( LT ) is provided after discharge . Methods — Twenty subjects with chronic stroke completed a repeated baseline measures , r and omized crossover trial in which walking performance was assessed during the last 4 weeks of clinical PT before discharge secondary to reaching a plateau , followed by 4 weeks of intensive LT and 4 weeks of no intervention . Outcome measures included clinical and physiological ( metabolic ) measures of walking overground and on a treadmill , and measures of daily stepping activity in the home and community , including during clinical PT and subsequent LT sessions . Results — Stepping practice was more than 4-fold higher during LT versus clinical PT sessions , with significant improvements in daily stepping and gait efficiency only after LT . Changes in daily stepping after clinical PT and intensive LT were correlated ( P<0.001 ) with the amount of stepping practice received during these interventions . Conclusions — Intensive LT results in improved daily stepping in individuals poststroke who have been discharged from PT because of a perceived plateau in motor function . These improvements may be related to the amount and intensity of stepping practice BACKGROUND pain is the leading symptom of osteoarthritis ( OA ) and is often chronic in nature , leading to significant morbidity and decreased quality of life . Duloxetine , a selective serotonin norepinephrine reuptake inhibitor has been demonstrated to have a central ly acting analgesic effect . OBJECTIVES the aim of the present study was to investigate the efficacy of duloxetine in reducing pain in older adults with knee OA . METHODS totally , 288 patients aged 65 years and above with primary knee OA were enrolled in this study . Patients were r and omised 1:1 . Totally , 144 received 60 mg/day of duloxetine HCL and 144 received placebo for 16 weeks . Outcome measures included pain reduction and improvement in physical functioning scores . Pain was assessed using the visual analogue pain scale ( VAS ; 0 - 100 mm ) . The Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) scores were used to assess function . RESULTS two-hundred and seventy four of the 288 patients completed the study . There was a statistically significant reduction in pain and a significant improvement in WOMAC scores at 16 weeks in the duloxetine group versus the placebo group . No serious side effects were reported . CONCLUSIONS the findings of the present study provide evidence for the efficacy and tolerability of duloxetine in reducing pain and subsequently improving function in older adults with knee OA . TRIAL REGISTRATION NCT01425827 BACKGROUND There are no controlled , prospect i ve studies comparing the 10-year outcomes of anterior cruciate ligament ( ACL ) reconstruction using patellar tendon ( PT ) and 4-str and hamstring tendon ( HT ) autografts . HYPOTHESIS Comparable results are possible with HT and PT autografts . STUDY DESIGN Cohort study ; Level of evidence , 2 . METHODS One hundred eighty ACL-deficient knees that met inclusion criteria underwent ACL reconstruction ( 90 HT autograft , 90 PT autograft ) by one surgeon and were treated with an accelerated rehabilitation program . All knees were observed in a prospect i ve fashion with subjective , objective , and radiographic evaluation at 2 , 5 , 7 , and 10-year intervals . RESULTS At 10 years , there were no differences in graft rupture rates ( 7/90 PT vs. 12/90 HT , P = .24 ) . There were 20 contralateral ACL ruptures in the PT group , compared with 9 in the HT group ( P = .02 ) . In all patients , graft rupture was associated with instrumented laxity > 2 mm at 2 years ( P = .001 ) . Normal or near-normal function of the knee was reported in 97 % of patients in both groups . In the PT group , harvest-site symptoms ( P = .001 ) and kneeling pain ( P = .01 ) were more common than in the HT group . More patients reported pain with strenuous activities in PT knees than in HT knees ( P = .05 ) . Radiographic osteoarthritis was more common in PT knees than the HT-reconstructed knees ( P = .04 ) . The difference , however , was composed of patients with mild osteoarthritis . Other predictors of radiographic osteoarthritis were < 90 % single-legged hop test at 1 year and the need for further knee surgery . An " ideal " outcome , defined as an overall International Knee Documentation Committee grade of A or B and a radiographic grade of A at 10 years after ACL reconstruction , was associated with <3 mm of instrumented laxity at 2 years , the absence of additional surgery in the knee , and HT grafts . CONCLUSIONS It is possible to obtain excellent results with both HT and PT autografts . We recommend HT reconstructions to our patients because of decreased harvest-site symptoms and radiographic osteoarthritis Background : Osteoarthritis ( OA ) is a degenerative joint disease affecting the knee joint of many middle-aged and older adults . As OA symptoms typically involve knee pain and stiffness , individuals with knee OA are often insufficiently physically active , have low levels of physical function , and are at increased risk of other comorbidities and reduced quality of life . While moderate-intensity continuous training ( MICT ) cycling is often recommended , little is known about the feasibility , safety , and benefits of high-intensity interval training ( HIIT ) cycling for this population , even though the feasibility , safety , and benefits of HIIT have been demonstrated in other chronic disease groups . Purpose : The primary objective of this pilot study was to examine the feasibility and safety of home-based HIIT and MICT cycling in middle-aged and older adults with knee OA . A secondary objective was to gain some insight into the relative efficacy of HIIT and MICT for improving health status ( pain , stiffness , and disability ) , muscle function , and body composition in this population . This study protocol is being published separately to allow a detailed description of the research methods , explain the rationale for choosing the method ological details , and to stimulate consideration of the best means to simulate a research protocol that is relevant to a real-life treatment environment . Study Design : R and omized pilot study protocol . Methods : This trial sought to recruit 40 middle-aged and older adults with knee OA . Participants were r and omly allocated to either continuous ( MICT ) or HIIT home-based cycle training programs , with both programs requiring the performance of 4 cycling sessions ( approximately 25 minutes per session ) each week . Participants were measured at baseline and postintervention ( 8 weeks ) . Feasibility and safety were assessed by adherence rate , dropout rate , and number of adverse events . The relative efficacy of the cycling programs was investigated by 2 knee OA health status question naires ( Western Ontario and McMaster Universities Osteoarthritis Index scale[WOMAC ] and the Lequesne Index ) as well as the timed up and go , sit to st and , preferred gait speed , and body composition . Discussion : This pilot study appears to be the first study assessing the feasibility and safety of a home-based HIIT training program for middle-aged and older adults with knee OA . As HIIT has been demonstrated to be more effective than MICT for improving aspects of health status , body composition , and /or muscular function in other chronic disease groups , the current study has the potential to improve patient outcomes and inform the design of future r and omized controlled trials Background and Purpose Aquatic physical therapy is frequently used in the management of patients with hip and knee osteoarthritis ( OA ) , yet there is little research establishing its efficacy for this population . The purpose of this study was to evaluate the effects of aquatic physical therapy on hip or knee OA . Subjects A total of 71 volunteers with symptomatic hip OA or knee OA participated in this study . Methods The study was design ed as a r and omized controlled trial in which participants r and omly received 6 weeks of aquatic physical therapy or no aquatic physical therapy . Outcome measures included pain , physical function , physical activity levels , quality of life , and muscle strength . Results The intervention result ed in less pain and joint stiffness and greater physical function , quality of life , and hip muscle strength . Totals of 72 % and 75 % of participants reported improvements in pain and function , respectively , compared with only 17 % ( each ) of control participants . Benefits were maintained 6 weeks after the completion of physical therapy , with 84 % of participants continuing independently . Discussion and Conclusion Compared with no intervention , a 6-week program of aquatic physical therapy result ed in significantly less pain and improved physical function , strength , and quality of life . It is unclear whether the benefits were attributable to intervention effects or a placebo response OBJECTIVES To examine the effectiveness of shock-absorbing insoles in the immediate reduction of knee joint load , as well as reductions in knee joint load , pain , and dysfunction after 1 month of wear , in individuals with knee osteoarthritis ( OA ) . DESIGN Pre-post design with participants exposed to 2 conditions ( normal footwear , shock-absorbing insoles ) with a 1-month follow-up . SETTING University laboratory for testing and general community for intervention . PARTICIPANTS Community-dwelling individuals ( N=16 ; 6 men , 10 women ) with medial compartment knee OA . INTERVENTION Participants were provided with sulcus length shock-absorbing insoles to be inserted into their everyday shoes . MAIN OUTCOME MEASURES Primary outcome measures included the peak , early stance peak , and late stance peak external knee adduction moment ( KAM ) ; the KAM impulse ( positive area under the KAM curve ) ; and peak tibial vertical acceleration . Secondary outcomes included walking pain , the Western Ontario and McMaster Universities Osteoarthritis Index pain subscale and total score , and a timed stair climb task . RESULTS There was a significant reduction in the late stance peak KAM with shock-absorbing insoles ( P=.03 ) during follow-up compared with the baseline test session . No other immediate or longitudinal significant changes ( P>.05 ) in the other KAM parameters or peak tibial acceleration after use of a shock-absorbing insole were observed . However , significant improvements in all measures of pain and function ( P<.05 ) were observed . CONCLUSIONS Shock-absorbing insoles produced significant reductions in self-reported knee joint pain and physical dysfunction with 1 month of wear in patients with knee OA despite no consistent changes in knee joint load . Further research using r and omized controlled trials , with larger sample sizes and explorations into long-term use of shock-absorbing insoles and their effect on disease progression , is warranted OBJECTIVES To recommend a consensus-derived set of performance-based tests of physical function for use in people diagnosed with hip or knee osteoarthritis ( OA ) or following joint replacement . METHODS An international , multidisciplinary expert advisory group was established to guide the study . Potential tests for consideration in the recommended set were identified via a survey of selected experts and through a systematic review of the measurement properties for performance-based tests . A multi-phase , consensus-based approach was used to prioritize and select performance-based tests by applying decision analysis methodology ( 1000Minds software ) via online decision surveys . The recommended tests were chosen based on available measurement-property evidence , feasibility of the tests , scoring methods and expert consensus . RESULTS Consensus incorporated the opinions of 138 experienced clinicians and research ers from 16 countries . The five tests recommended by the advisory group and endorsed by Osteoarthritis Research Society International ( OARSI ) were the  30-s chair-st and test , 40 m fast-paced walk test , a stair-climb test , timed up- and -go test and 6-min walk test . The first three were recommended as the minimal core set of performance-based tests for hip or knee OA . CONCLUSION The OARSI recommended set of performance-based tests of physical function represents the tests of typical activities relevant to individuals diagnosed with hip or knee OA and following joint replacements . These tests are complementary to patient-reported measures and are recommended as prospect i ve outcome measures in future OA research and to assist decision-making in clinical practice . Further research should be directed to exp and ing the measurement-property evidence of the recommended tests UNLABELLED : Osteoarthritis ( OA ) is the most widespread musculoskeletal disorder in adults . It leads to cartilage damage associated with subchondral bone changes and synovial inflammation , causing pain and disability . The present study aim ed at evaluating the safety of a dose-escalation protocol of intra-articular injected adipose-derived stromal cells ( ASCs ) in patients with knee OA , as well as clinical efficacy as secondary endpoint . A bicentric , uncontrolled , open phase I clinical trial was conducted in France and Germany with regulatory agency approval for ASC expansion procedure in both countries . From April 2012 to December 2013 , 18 consecutive patients with symptomatic and severe knee OA were treated with a single intra-articular injection of autologous ASCs . The study design consisted of three consecutive cohorts ( six patients each ) with dose escalation : low dose ( 2 × 10(6 ) cells ) , medium dose ( 10 × 10(6 ) ) , and high dose ( 50 × 10(6 ) ) . The primary outcome parameter was safety evaluated by recording adverse events throughout the trial , and secondary parameters were pain and function subscales of the Western Ontario and McMaster Universities Arthritis Index . After 6 months of follow-up , the procedure was found to be safe , and no serious adverse events were reported . Four patients experienced transient knee joint pain and swelling after local injection . Interestingly , patients treated with low-dose ASCs experienced significant improvements in pain levels and function compared with baseline . Our data suggest that the intra-articular injection of ASCs is a safe therapeutic alternative to treat severe knee OA patients . A placebo-controlled double-blind phase IIb study is being initiated to assess clinical and structural efficacy . SIGNIFICANCE Although this phase I study included a limited number of patients without a placebo arm , it showed that local injection of autologous adipose-derived stem cells was safe and well tolerated in patients with knee osteoarthritis . This study also provides encouraging preliminary evidence of efficacy . Larger and controlled long-term studies are now m and atory to confirm whether this new strategy of cell therapy can improve pain and induce structural benefit in osteoarthritis Background Osteoarthritis is the most prevalent joint disease and a common cause of joint pain , functional loss , and disability . Conventional treatments demonstrate only modest clinical benefits without lesion reversal . Autologous mesenchymal stromal cell ( MSC ) treatments have shown feasibility , safety , and strong indications for clinical efficacy . We performed a r and omized , active control trial to assess the feasibility and safety of treating osteoarthritis with allogeneic MSCs , and we obtain information regarding the efficacy of this treatment . Methods We r and omized 30 patients with chronic knee pain unresponsive to conservative treatments and showing radiological evidence of osteoarthritis into 2 groups of 15 patients . The test group was treated with allogeneic bone marrow MSCs by intra-articular injection of 40 × 106 cells . The control group received intra-articular hyaluronic acid ( 60 mg , single dose ) . Clinical outcomes were followed for 1 year and included evaluations of pain , disability , and quality of life . Articular cartilage quality was assessed by quantitative magnetic resonance imaging T2 mapping . Results Feasibility and safety were confirmed and indications of clinical efficacy were identified . The MSC-treated patients displayed significant improvement in algofunctional indices versus the active controls treated with hyaluronic acid . Quantification of cartilage quality by T2 relaxation measurements showed a significant decrease in poor cartilage areas , with cartilage quality improvements in MSC-treated patients . Conclusions Allogeneic MSC therapy may be a valid alternative for the treatment of  chronic knee osteoarthritis  that is more logistically convenient than autologous MSC treatment . The intervention is simple , does not require surgery , provides pain relief , and significantly improves cartilage quality BACKGROUND People with osteoarthritis ( OA ) of the knee experience pain and deconditioning that lead to disability . This study challenged the clinical belief that repetitive lower extremity exercise is not indicated in persons with knee OA . The effects of high-intensity and low-intensity stationary cycling on functional status , gait , overall and acute pain , and aerobic capacity were examined . METHODS Thirty-nine adults ( 71+/-6.9 years old ) with complaints of knee pain and diagnosis of OA were r and omized to either a high-intensity ( 70 % heart rate reserve [ HRR ] ) or low-intensity ( 40 % HRR ) exercise group for 10 weeks of stationary cycling . Participants cycled for 25 minutes , 3 times per week . Before and after the exercise intervention they completed the Arthritis Impact Measurement Scale 2 for overall pain assessment , underwent timed chair rise , 6-minute walk test , gait , and  grade d exercise treadmill tests . Acute pain was reported daily with a visual analog scale and the Western Ontario and McMaster Universities Osteoarthritis Index scale . RESULTS Analysis of variance revealed that participants in both groups significantly improved in the timed chair rise , in the 6-minute walk test , in the range of walking speeds , in the amount of overall pain relief , and in aerobic capacity . No differences between groups were found . Daily pain reports suggested that cycling did not increase acute pain in either group . CONCLUSIONS Cycling may be considered as an alternative exercise modality for patients with knee OA .  Low-intensity cycling was as effective as high-intensity cycling in improving function and gait , decreasing pain , and increasing aerobic capacity Knee osteoarthritis is the most common cause of disability among people and it is a common disease of joints that can lead to cartilage damage . In this study the analgesic effects of a herbal ointment containing cinnamon , ginger , mastic ( Saghez ) and sesame oil is compared with Salicylate ointment in patients suffering from knee osteoarthritis . It was a double-blind r and omized controlled trail study . Patients with diagnosed arthritis were involved in the study and they were divided in two groups via block r and omization method . For six weeks , twice a day , intervention group applied herbal ointment and control group used Salicylate ointment . The severity of pain , morning stiffness and limited motion were measured using Visual Analog Pain Scale . In order to analyze the trends of these three indexes , repeated measurement test was used . Ninety two participates with the mean age of 52.2 ( + /- 12.4 ) years and with the mean disease period of 30.45 ( + /- 30.3 ) months were involved in the study . There was no significant difference between two groups regarding the distribution of sex , weight , height , BMI and the duration of illness . No statistical difference was observed between two groups regarding pain relief , morning stiffness and limited motion ; nevertheless in repeated measurements during second , forth and sixth weeks in both groups the decreasing trend of these three indexes had been statistically significant ( p < 0.0001 ) . It seems that using this herbal combination is clinical ly effective for patients suffering from knee osteoarthritis in order to decrease their pain , morning stiffness and limited motion ; its effect is comparable with Salicylate ointment BACKGROUND Non-pharmacological therapies are recommended for the care of knee osteoarthritis patients . Unloader knee braces provide an interesting functional approach , which aims to modulate mechanical stress on the symptomatic joint compartment . We aim ed to confirm the biomechanical effects and evaluate functional benefits of a new knee brace that combines a valgus effect with knee and tibial external rotation during gait in medial osteoarthritis patients . METHODS Twenty patients with unilateral symptomatic medial knee osteoarthritis were included and they performed two test sessions of 3D gait analysis with and without the brace at the initial evaluation ( W0 ) and after 5weeks ( W5 ) of wearing the brace .  VAS-pain , satisfaction scores , WOMAC scores , spatio-temporal gait parameters ( gait speed , stride length , stance and double stance phases , step width ) , and biomechanical data of the ipsilateral lower limb ( hip , knee , ankle and foot progression angles ) were recorded at each session . RESULTS VAS-pain and WOMAC significantly decreased at W5 . Walking speed was not significantly modified by knee bracing at W0 , but increased significantly at W5 . Knee adduction moments and foot progression angles significantly decreased in the terminal stance and push off , respectively , with bracing at W0 and W5 . Lower-limb joint angles , moments and powers were significantly modified by wearing the brace at W0 and W5 . CONCLUSION This new knee brace with distraction-rotation effects significantly alters knee adduction moments and foot progression angles during gait , which might lead to significant functional gait improvements and have carry-over effects on pain at the short term in osteoarthritis patients ( < 2 months ) . LEVEL OF EVIDENCE level IV Background and Purpose : Physical therapists have an important role in the management of clinical knee osteoarthritis ( OA ) through design ing and supervising exercise programs . This study explored whether their current use of therapeutic exercise for patients with this condition is in line with recent recommendations . Subjects and Methods : A cross-sectional survey was conducted with a r and om sample of chartered ( licensed ) physical therapists ( N=2,000 ) practicing in the United Kingdom . This survey included a vignette describing a patient with clinical knee OA as well as clinical management questions relating to the respondents ’ use of therapeutic exercise . Results : The question naire response rate was 58 % ( n=1,152 ) , with 538 respondents stating they had treated a patient with clinical knee OA in the preceding 6 months . In line with recent recommendations , 99 % of the physical therapists stated they would use therapeutic exercise for this patient population , although strengthening exercises were favored over aerobic exercises . Although nearly all physical therapists would monitor exercise adherence , only 12 % would use an exercise diary . Seventy-six percent of physical therapists would provide up to 5 treatment sessions , and only 34 % would offer physical therapy follow-up after discharge . Discussion and Conclusions : The measure of physical therapists ’ current clinical practice was self-reported clinical behavior on the basis of a vignette . Although this is a valid measure of clinical behavior , in practice , physical therapists may use therapeutic exercise differently . There are disparities between physical therapists ’ current use of therapeutic exercise for clinical knee OA and recent recommendations . Identifying potential ways to overcome these disparities is an important step toward optimizing the outcome from therapeutic exercise for patients with clinical knee OA Background Osteoarthritis is the most common reason for pain in older adults , and the individual and economic burden of this disease is immense . The chronic character of osteoarthritis requires a long-term therapeutic treatment . In this regard life-style interventions such as physical exercises that can be carried out by the patient himself are recommended as first line treatment . There is evidence for the short-term benefit of exercise therapy in terms of pain reduction and physical functioning . Nonetheless research agendas highlight the need for multifaceted interventions that incorporate exercise strategies into patient care . Studies should be conducted with appropriate sample sizes and should allow statements on long-term effects as well as cost-utility and safety . These open questions are under the scope of this study . Methods / design This is a controlled study in the context of health services research . The study population consists of n = 1400 subjects with hip or knee osteoarthritis . The  intervention group will be recruited from participants of a country-wide health insurance offer for people with hip or knee osteoarthritis . Potential participants for the control group ( ratio 10:1 ( control vs. intervention ) will be filtered out from the insurance data base according to pre-defined matching criteria and asked by letter for their participation . The final statistical twins from the responders ( 1:1 ) will be determined via propensity score matching . The progressive training intervention comprises 8 supervised group sessions , supplemented by home exercises ( 2/week over 11 weeks ) . Exercises include mobilization , strengthening and training of postural control . Primary outcomes are pain and function measured with the WOMAC Index immediately after the intervention period . Among other things , health related quality of life , self-efficacy , cost utility and safety will be evaluated as secondary outcomes . Participants will be followed up 6 , 12 and 24 month after baseline . Discussion Results of this trial will document the effects of clinical as well as economic outcomes in a regular health care setting on the basis of a large sample size . As such , results of this trial might have great impact on future implementations of group- and home-based exercises in hip or knee osteoarthritis . Trail registration German Clinical Trial Register DRKS00009251 . Registered 10 September 2015 OBJECTIVE To evaluate how an intervention program modifies the clinical course of work disability in musculoskeletal diagnoses . METHODS All patients with temporary work disability related to musculoskeletal disorders ( MSDs ) in 3 health districts of Madrid , Spain were r and omized into st and ard care ( control group ) or the intervention group . Intervention consisted of a specific program , run by rheumatologists , following detailed proceedings . Inclusion and followup lasted 12 months each . According to the cause , every temporary work disability episode was classified into 11 syndrome categories . For each we calculated efficacy , as the difference between groups in the number of days on sick leave per temporary work disability episode ; relative efficacy , or the percentage of days saved in the intervention group ; and time of maximum program effect . Analyses were performed on an intent-to-treat basis . Survival techniques were run and results were expressed as the hazard ratio ( HR ) in the intervention versus control group . RESULTS A total of 13,077 patients were included , generating 16,297 temporary work disability episodes .  The most frequent cause was back pain . Temporary work disability episodes were significantly shorter in the intervention group than in the controls in all syndrome categories except knee pain ( excluding osteoarthritis ) . Program relative efficacy varied from 28 - 72 % . The program was highly efficacious in carpal tunnel syndrome ( HR 2.09 , 95 % confidence interval [ 95 % CI ] 1.17 - 3.75 ) , peripheral osteoarthritis ( HR 1.58 , 95 % CI 1.14 - 2.19 ) , and inflammatory diseases ( HR 1.52 , 95 % CI 1.09 - 2.12 ) . The maximum effect of the program always took place within the first 2 months . CONCLUSION The implementation of this type of specialist-run , protocol -based early intervention program would be very beneficial in the treatment of patients with work disability related to MSDs , except for those with knee pain ( excluding osteoarthritis ) Osteoarthritis of the knee is the most common cause of chronic disability among older persons in the United States [ 1 ] . In persons with symptomatic osteoarthritis of the knee , quadriceps muscle weakness is common and is widely believed to result from disuse atrophy secondary to joint pain . Although exercises to strengthen the quadriceps may relieve joint pain in persons with osteoarthritis of the knee [ 2 - 6 ] , the role of periarticular muscle weakness in the pathogenesis of joint pain and disability in these persons is poorly understood . The basis for the beneficial effect of strengthening exercises is unclear , and the duration of the improvement has not been studied . Furthermore , the possibility that muscle weakness is an etiologic factor underlying the pathologic changes of osteoarthritis has seldom been considered . Elucidation of the role of muscle weakness in osteoarthritis is particularly important given our growing underst and ing of safe and effective methods for increasing strength in elderly persons [ 7 , 8 ] . A substantial proportion of persons who have radiographic evidence of osteoarthritis of the knee have no joint pain [ 9 ] . Because asymptomatic persons with radiographic changes seldom seek medical attention for osteoarthritis , muscle weakness has not been studied previously in this group . Thus , it is not known whether quadriceps weakness precedes or follows joint pain or ( if it follows joint pain ) whether it is mediated by disuse atrophy or by physiologic mechanisms that may inhibit muscle contraction [ 10 ] . To address this issue , we studied the relation among lower-extremity muscle strength , lower-extremity lean tissue mass , and osteoarthritis of the knee in men and women 65 years of age and older . Methods Study Group To obtain a sample of elderly persons living in the community , we conducted brief  telephone interviews with residents of households in central Indiana . Potential participants were selected through modified r and om-digit dialing to increase the sample d proportion of persons 65 years of age and older . Persons were eligible if they met the minimal criteria for participation : They were willing and able to provide informed consent and to undergo the necessary strength assessment s and other evaluations . Persons were excluded if they had had amputations of both lower extremities , had undergone total knee arthroplasty , or had recently had a cerebrovascular accident or myocardial infa rct ion . A total of 462 persons ( approximately 55 % of all who were eligible ) agreed to participate and completed the following evaluations . Evaluations Radiography of the Knee St and ing anteroposterior and lateral radiographs of both knees of each study participant were obtained , and the severity of osteoarthritis in the tibiofemoral compartment was grade d by a musculoskeletal radiologist according to the criteria of Kellgren and Lawrence . Similar criteria , based on the presence of osteophytes and joint space narrowing , were used for the patellofemoral compartment [ 11 ] . The radiologist was blinded to the clinical status and characteristics of all patients . A participant had to have a Kellgren and Lawrence grade of 2 or more in either knee to be classified as having osteoarthritis . Knee Pain and Function The Western Ontario and McMaster Universities Arthritis Index was used to evaluate knee pain and function [ 12 ] . This index assesses the severity of knee pain during 5 activities or situations ( walking on a flat surface , going up or down stairs , at night while in bed , sitting or lying , and st and ing upright ) and the severity of impairment of lower-extremity function during 17 activities . Pain and functional impairment were assessed in each knee separately . Responses to each question about the severity of knee pain and level of impairment were recorded on a categorical scale as none , mild , moderate , severe , or extreme . Each category was assigned a corresponding numeric score from 1 to 5 ( 5 = extreme ) . Hence , the range on the pain scale was 5 to 25 and the range on the physical impairment scale was 17 to 85 ( 85 = greatest functional limitation ) . For the purpose s of analysis , participants who rated the severity of their knee pain as moderate or greater ( 3 ) with any of the 5 activities on more than half of the days in the month preceding the evaluation were considered to have knee pain . Thus , pain in the more distant past that had resolved was not included . Participants were also question ed about current and previous regular ( 5 times per week ) or occasional use of over-the-counter and prescription analgesics and nonsteroidal anti-inflammatory drugs ( NSAIDs ) in the past year . Lower-Extremity Muscle Strength The strength of each leg was evaluated by using an isokinetic dynamometer ( KIN-COM 500H , Chattecx Corp. , Hixson , Tennessee ) . Peak torque was recorded in both the concentric ( contractions during muscle shortening ) and eccentric ( contractions during muscle lengthening ) modes . Participants were allowed several submaximal or maximal practice efforts to familiarize themselves with the operation of the dynamometer . Once formal testing began , the best of three maximal efforts was recorded for flexion and extension at both 60 degrees per second and 120 degrees per second . Aborted efforts were repeated in order to obtain the best possible representation of strength for each participant . Concentric and eccentric testing yielded similar results , but because of greater variability in eccentric testing , only the concentric test results are shown . Lower-Extremity Lean Tissue Mass Total-body dual-energy x-ray absorptiometry was done in all participants by using a Lunar-DPX-L instrument ( Lunar Corp. , Madison , Wisconsin ) . Results were analyzed for total and regional body composition , including body fat , mineral , and lean components ( lean components were components other than fat or mineral ) . The right and left lower extremities were analyzed separately . The lower extremity was defined as all tissue below a diagonal line drawn outward and upward from the groin area through the femoral neck . Statistical Analysis Participants were divided into four groups on the basis of presence or absence of radiographic evidence of osteoarthritis of the knee and presence or absence of knee pain , as defined above . Men and women were compared by using the t-test . Comparisons of Arthritis Index pain and functional impairment scores were done by using nonparametric approaches . For analyses of continuous data involving more than two groups of participants ( for example , osteoarthritis with or without knee pain ) , analysis of variance was used to determine whether an overall difference was present . The Fisher protected least-significant-difference procedure was used for pairwise comparisons . Comparisons within participants ( for example , comparison of the two legs in a person with unilateral osteoarthritis of the knee ) were done by using paired t-tests . Regression models were constructed with the generalized estimating equations approach of Zeger and Liang [ 13 ] . This approach inflates the st and ard errors to adjust for correlations in both independent variables ( such as strength ) and dependent variables ( such as radiographic grade ) within participants . Statistically significant differences ( P < 0.05 ) in the above analyses are specifically noted below . Results The characteristics of the 462 men and women in the cohort are shown in Table 1 . As expected , men were taller , were heavier , and had greater lower-extremity strength and lean tissue mass in the lower extremities compared with women ( P < 0.001 for all comparisons ) . Table 1 . Age , Height , Weight , and Lower-Extremity Strength and Lean Tissue Mass * One hundred forty-five participants ( 31 % ; 33 % of the women and 30 % of the men ) had radiographic evidence of osteoarthritis involving the tibiofemoral compartment , the patellofemoral compartment , or both . In 62 participants ( 43 % ) , the radiographic changes were unilateral . Table 2 shows the association between osteoarthritis and obesity [ 14 - 16 ] . Women in the cohort who had osteoarthritis were approximately 15 % heavier than women with normal radiographs and no knee pain .  Men with osteoarthritis were also slightly heavier than men without osteoarthritis . Table 2 . Body Weight and Summed Arthritis Index Scores for Recent Pain and Function in the Left Knee in Participants with and without Radiographic Evidence of Osteoarthritis * Among those with radiographic evidence of tibiofemoral osteoarthritis , women were slightly more likely than men to report knee pain ( P = 0.10 ; Table 3 ) . Table 3 . Radiography and Recent Pain in the Left Knee Table 2 also shows the mean summed and the distribution of scores for left knee pain and functional impairment ( data for the right knee were similar ) . Among men and women with radiographic evidence of osteoarthritis who reported having knee pain , the mean summed pain score for the knee with osteoarthritis was approximately 12 ( median score , 2 of 5 ) . In comparison , the mean pain score of participants who reported knee pain but did not have radiographic evidence of osteoarthritis in the painful knee was approximately 10 ( median score , 2 of 5)-only slightly lower than the mean pain score of participants with radiographic changes . Consistent with their relatively low pain scores , these community-dwelling participants with osteoarthritis reported moderately low use of NSAIDs ( Table 4 ) . Table 4 . Participants Reporting Regular Current or Previous Use of Analgesics and Nonsteroidal Anti-inflammatory Drugs Related to the Presence of Radiographic Evidence of Osteoarthritis of the Knee and Recent Knee Pain * Arthritis Index scores for functional impairment paralleled those for pain ( Table 2 ) . Participants with osteoarthritis had the greatest functional impairment ( P < 0.001 for the comparison with patients who did not have pain or radiographic evidence of osteoarthritis ) . Functional impairment in participants who had pain but no radiographic evidence of BACKGROUND Knee osteoarthritis ( OA ) is a painful condition causing disability and muscle weakness . Shortwave diathermy ( SWD ) is one of several physical therapy modalities and used predominantly as a pain reduction modality in the clinical practice . However , the efficacy of SWD in knee OA is still inconclusive . AIM The aim of this study was to determine if SWD increase the effectiveness of isokinetic exercise on pain , function , muscle strength , quality of life and depression in patients with OA . DESIGN This was a r and omised , controlled clinical trial . SETTING Inpatient Physiotherapy Department . POPULATION Forty women aged between 42 and 74 years , with a diagnosis of bilateral primary knee OA . METHODS Patients were sequentially r and omized into two groups . Group 1 ( N.=20 ) received SWD and isokinetic muscular strengthening exercises . Group 2 ( N.=20 ) served as control group and they received isokinetic exercises only . Both of the programs were performed three days a week , for a duration of four weeks , and a total of 12 sessions . Patients were assessed before treatment ( BT ) , after treatment ( AT ) , and at a three-month follow-up ( F ) . Outcome measures included visual analogue scale , Western Ontario and McMaster University Osteoarthritis Index , six minute walking distance , isokinetic muscle testing , Short Form 36 and Beck depression index . RESULTS The patients with OA in each group had significant improvements in pain , disability , depression , walking distance , muscle strength , and quality of life AT and F when compared with their initial status ( P<0.05 ) . There was no statistically significant difference between the groups according to all the parameters regarding the change scores between AT-BT test and F-BT test ( P>0.05 ) except some isokinetic peak torque measurements ( F-BT scores of extension right 60 ° , 120 ° and flexion right 60 ° ) . CONCLUSION Use of SWD in addition to isokinetic exercise program seems to have no further significant effect in terms of pain , disability , walking distance , muscle strength , quality of life and depression in patients with knee OA . CLINICAL REHABILITATION IMPACT Considering the time and cost of combination therapy is now , the isokinetic exercise program , as it is efficient , may be preferable for the treatment of knee OA , alone
Several individual RCTs demonstrated clinical ly important improvements in pain and disability with aerobic exercise .
Other PT interventions demonstrated no sustained benefit .
Individual RCTs showed similar benefits with aerobic , aquatic , and strengthening exercise .
Adverse events were uncommon and did not deter participants from continuing treatment .
Low-strength evidence suggested that only a few PT interventions were effective .
BACKGROUND Osteoarthritis is a leading cause of disability .
Nonsurgical treatment is a key first step .
PURPOSE Systematic literature review of physical therapy ( PT ) interventions for community-dwelling adults with knee osteoarthritis .