Recommendations for exercise and other treatment interventions for patients with knee osteoarthritis

In the past few months I have seen an increase in clients who have been referred for osteoarthritis (OA), particularly at the knee. Majority of these clients have come in with the intention of building up strength around the knee to reduce their pain levels and improve their day to day function. 

I thought it would be appropriate to discuss some of the guidelines and recommendations regarding treatment for knee osteoarthritis, with reference to the latest research. 

The core treatment for knee OA includes exercise, patient education regarding self management strategies/flare ups and weight loss. According to the evidence less than 40% of patients with knee OA are receiving this as first line treatment, which means that we as clinicians need to do a better job in practice. 

One study by Dantas et al (2021), breaks down education, exercise and weight loss into a checklist that is easily explained to patients that suffer ongoing knee OA. These are especially useful for us as clinicians. Whether it is a hip or knee it is essential that we can breakdown the condition and provide insight into what OA actually is, and what this means for treatment itself. The checklist is situated down below and I have addressed the following with some simple answers that can be used in clinic.

Patient Education Checklist:

• Explanation of knee OA
  • Knee OA is a common degenerative condition of the cartilage within the knee and is influenced by movement/loading/age respectivelly 
• Addressing knee OA beliefs
  • Many people believe that if you have knee OA, you cannot go out for walks, run or participate in regular physical activity or exercise. The evidence says otherwise.
• Importance of weight loss/regular physical activity/lifestyle
  • By addressing weight loss, we can reduce the amount of load that goes through the knees. The presence of synovitis or swelling is prevalent in people who are overweight or obese, which means more inflammation in and around the knee.
• Education on flareups
  • Flare ups are common with any sort of injury, and shouldn’t be feared as a step backwards
• Load Management Principles
  • Progressive loading is essential in building tissue tolerance and capacity around the knees
• Reassurance
  • Knee OA doesn’t mean you can’t do things, it just means that you have to be more mindful of what you do and how often you do it.
• Discuss/manage expectations and goals

Exercise/Physical Activity:

• There is no superior form of exercise for patients with knee OA
• Exercise should be based on factors that are inclusive of patient’s goals, impairments and limitations
• >150 mins of moderate intensity exercise or 2 days per week of moderate to vigorous exercise in bouts >10 minutes.
• >2 days of resistance training targeting the entire lower limb
• Regular exercise for 8-12 weeks 

Weight Loss:

• For individuals with a BMI >25kg/m2
• Weight loss programs should address both diet and exercise.

Other treatment interventions include manual therapy, taping, acupuncture however these are of low quality evidence and if used should be incorporated with first line treatment interventions as identified above. Adjunct therapies that include ice/heat, ultrasound, TENS are not recommended for patients with knee OA.

Due to the complexity of the condition there seems to be a strong relationship between exercise and functional outcomes  which may be mediated by neural mechanisms, increased muscular strength/neuromuscular control, improved cartilage health and reduced systemic and joint inflammation. 

The benefits of exercise in patients with knee OA are due to a variety of these factors rather than one of these factors alone. As knee OA is a complex multi-facted condition, it is important that we gets the basics right and provide exercise, education and weight loss options for anyone who comes into the clinic with OA.

Davis. A, Davis. K, Skou. S & Roos. E (2020) Why is exercise effect in reducing pain in people with osteoarthritis? Current Treatment Options in Rheumatology, 1-14.

Dantas. L, de Fatime Salvani. T & McAlindon. T (2021) Kne osteoarthritis: key treatments and implications for physical therapy. Brazilian journal of physical therapy, 25(2), 135-146

Voinier. D, White. D (2022) Walking, running and recreational sports for knee osteoarthritis: An overview of the evidence. European Journal of Rheumatology. Epub ahead of print.