Exercise For Knee Osteoarthritis

UNIVERSITI TEKNOLOGI MARA (UiTM)
PUNCAK ALAM CAMPUS
FACULTY OF HEALTH SCIENCE
BACHELOR OF PHYSIOTHERAPY (Hons.)
HS 244
EXERCISE PHYSIOLOGY
PHT 485
PREPARED BY:
1. HANANI BINTI KAMALUDIN (HS2446C/2017662136)
2. NUR HALIANA ERNA BINTI OTHMAN (HS2446C/2017662166)
3. SITI FARHANA BINTI ISHAK (HS2446C/2017662198)
4. SITI NABILA BINTI MOHD SHA’ARI (HS2446C/2017662176)
5. UMMU TSARA’ BINTI MUSTAFA (HS2446C/2017662172)
PREPARED FOR:
DR MARIA JUSTINE @ STEPHANY
SUBMISSION DATE:
10TH MAY 2019

A. INTRODUCTION TO OSTEOARTHRITIS
i. Introduction of osteoarthritis (OA)
According to Guilak, Nims, Dicks, Wu, and Meulenbelt (2018), osteoarthritis is an ongoing
process of articular cartilage degeneration, accompanied with pain and changes of its
surrounding structure which are subchondral bone, synovium, and joint tissues.
Osteoarthritis or simply termed as OA is one type of joint disease that characterized with
bone hypertrophy. It occurs as a result of cartilage degeneration which responsible to absorb
shocks between two bones. Pain, crepitus, swelling, locking-joint and approximately 30
minutes joint stiffness in early morning are common features of this condition caused by two
bones scrubbing each other (Azad, Singh, Singh, & Tia, 2015). Iolascon et al. (2017) in his
study concluded that there are specific criteria to identify acute osteoarthritis. As stated in his
study, to be diagnosed with acute osteoarthritis, patients must present with at least 2
episodes of pain for more than 10 days. When patient undergoing Magnetic Resonance
Imaging (MRI), there must be changes of cartilage structure, associated with lesions of
meniscus and subchondral bone marrow as assessed according to the Whole Organ
Magnetic Resonance Imaging Score (WORMS) and Boston Leeds Osteoarthritis Knee
Score (BLOKS) scales. Besides, there must be formation of osteophyte proved via
radiograph and there are cartilage lesions either grade I–IV in at least 2 compartments or
grade II–IV in 1 compartment. The surrounding cartilage is swollen and softens.
ii. Prevalence of osteoarthritis
World Health Organization (WHO) agreed that osteoarthritis is in 6th ranks among the cause
of disability of population universally. In Malaysia, Foo et al., (2017) inferred that 10% to 20%
of older adult aged from 40 years and above develops osteoarthritis with knee pain
especially among Indian society. Besides, as stated in the article, the study conducted in
Malaysia by the Community Oriented Program for the Control of Rheumatic Diseases
(COPCORD) comes out with 64.8% population comes with nee pain complaints and half of it
present with clinical features of osteoarthritis. This results increases to 23% and 39% in 55
year-old subject and 65 year-old subject respectively. Furthermore, in the same article, there
are prevalence for another Asia country such as Japan and Korea. In Japan, over 90% of
patient present with radiographic osteoarthritis and the data increase with mean of 66 year-
old age patient. Whereas, in Korea, The Fifth Korean National Health and Nutrition
Examination Survey (KNHANES, 2010) discovered difference of hip, knee and spine
osteoarthritis features based on sex. The data recorded are 0.2%, 19%, and 16% in women
and 0.1%, 4.5%, and 5.6% occur in men. 11% of men and 23% of women had at least two
painful osteoarthritis joints and 30% of women and 9% men present with at least one joint
involved. However in one country in northern part of North America which is Canada,
Arthritis Alliance of Canada predicted that 26% of osteoarthritis case has been reported from
2010 to 30 years ahead.
iii. Etiology and Risk factor
Clear etiology of osteoarthritis is still unknown. However, Ashkavand, Malekinejad, and

Vishwanath (2013) in their study has identified there are two subgroup of contributing factors
for osteoarthritis which are systemic factor and local factors. Systemic risk factors are age,
gender, genetic and diet while local risk factors are joint trauma, obesity, occupation and
daily physical activity. As mentioned in the article, aging process will deteriorates the
accumulation of glycation that responsible to prevent cartilage breakdown by maintaining its
tensile. Greene and Loeser (2015) has stated that aging adipose tissue production will be
increased thus, that result it is also increased the cytokines production including such as
interleukin (IL)-6 and tumor necrosis factor-α (TNFα) which has been proved that may
increase the development of knee OA. Aside from that, they proposed that one hospital
study shows osteoarthritis cases in older women are higher than older men specifically with
age 65 year-old and above. This happens as a result of high demand used of osteocalcin for
bone resorption in menopause women which also worsens with osteoathritis. However,
Hame & Alexander (2013) claimed that differences in anatomy of women who have narrower
femurs, thinner patellae, larger Q-angles, and larger tibial condylar may also play a role.
Besides, men have larger volume of tibial and patella cartilage compared to women.
Moreover, Ashkavand, Malekinejad, and Vishwanath (2013) also presented that 48 to 70
year-old monozygotic twins aged with identical genes have 65% probability to develop
osteoarthritis. This is because, identical twins have been found to share 100% of their genes
while non-identical twins share 50% of their genes (Magnusson et al., 2017). Diets also play
an important role of osteoarthritis development. Rayman, (2015) declared that poor
management of diet and nutrition such as high cholesterol intake will lead to high body mass
index and obesity. As a result, excessive fats will promote the degeneration of cartilage. The
degenerative process occur prior to the excessive body mass index provide the additional
mass which will increase the stressful towards the articular cartilage beyond its biological
capabilities. Study on gait analysis has shown that with weight loss up to 0.5 kg, it will
reduce the load towards the knee joint and for every 1 kg increase in body fat mass, there is
also increased risk of cartilage defects. As mentioned before, OA develops when the
breakdown of cartilage occur in faster rate than their production. Excessive fat mass added
with biological skeletal muscle mass will lead to higher risk of cartilage degeneration
(Kulkarni, Karssiens, Kumar, & Pandit, 2016). In addition, patient who presented with history
or current joint trauma will significantly develop OA as a result of daily activities loading
worsens the injury. Besides, it is well-known that history of knee trauma will usually leave
sufficient damage towards the joint structures. As results, there will be changes on structural
integrity, alter biomechanics and increase joint tissue stress. By time, the cartilage will lose
its flexibility and eventually will kill the chondrocyte surrounding them. Occupation such as
construction workers that usually lifting heavy loads and climbing stairs will ultimately
develop OA as high loading stress to their knee joint in a long duration and repetitively. In
addition, one study by reported that Verbeek et al. (2017) workers that involving repetitive
and long term kneeling or squatting at work has 1.70 times greater than those workers who
do not involve squatting or kneeling in their daily works. Other than occupation, sport such
as gymnastic are also at risk of OA occurrence due to the same reason of high loading
stress towards the knee joint especially during landing phase as it is the key importance of
success in the gymnastic sports.
B. THE IMPORTANCE OF EXERCISES
i. Physiological basis of exercise
The most common non-pharmacologic therapy prescribed to patients with osteoarthritis is

exercise. By performing low-impact exercise, there is reducing in pain and fatigue as well as
increasing the muscle strength. In additional, there is also an improvement in reducing the
body weight and metabolic abnormalities after performing exercises such as stretching
exercise, strengthening exercise, aerobic exercise, and aquatic exercise (Uthman et al.,
2013).
Effect of exercises on muscle activation.
There is also the effect of exercise on muscle activation for OA patients. The abnormal
afferent information from sensitized articular receptors in damaged joints may lead to
quadriceps activation failure. This will cause reduction of motor drive to the quadriceps
muscle. Prior to this problem, exercise might improve proprioception and improved
quadriceps activation through an exercise (Tagliaferri, Wittrant, Davicco, Walrand, & Coxam,
2015). The combination of greater quadriceps inhibition and greater muscle weakness may
limit the degree to which voluntary exercise that restore quadriceps strength and alter
physical function. The activation of specific muscles can lead to improvement of temporal
and spatial features of muscle activation. Then, it will transfer into untrained tasks. In
additional, these interventions will train the organization of the motor regions of the brain
cortex and these changes are related to developed muscle activation patterns (Tsao, Druitt,
Schollum, & Hodges, 2010).
Effect of strengthening exercise on strength and pain.
There are various systemic and local effects of exercises among people with knee OA. The
main goal of exercise is to improve muscle strength because weakness is seen to be
common among OA patients. By performing strength training exercise with proper dosage
can help to alleviate muscle weakness because there is an improvement in recruitment and
muscle mass. Pain is the main issue for OA patients. So, by improving strength of lower
extremity it help in decreasing the pain by reducing the knee forces and improve physical
function. There is an alteration of biomechanics resulting in a reduced joint loading rate or
localised stress in the articular cartilage as a result of improvement in muscle strength. This
play a crucial role in both initiation and progression of knee OA (B Sun, 2013).
Effect of strengthening exercise on skeletal muscle.
The physiology of strengthening exercise is on the alterations of skeletal muscle. Skeletal

muscle produce myokines that consist of cytokines, peptides and growth factors. Then they
regulated by muscle contraction and have effects on metabolism. (Krishnasamy, Hall, &
Robbins, 2018). The skeletal muscle interfere with surrounding structures and provide a
missing link to improve in muscle strength.The myokines that had been released during
muscle contraction interact with structures such as synovial tissue, cartilage, fat and bone
and also have autocrine and endocrine functions (Pedersen & Febbraio, 2012).
Effect of aerobic exercise on physical fitness.
Another impairment present by people with knee OA is poor physical fitness. Increasing
muscle oxidative capacity will enhance physiological reserve for aerobic capacity. There is
an increase in proteoglycan content with aerobic and weight-bearing exercises.
Proteoglycan content is one of the major components of the cartilage extracellular matrix.
Aerobic exercise such as walking and cycling with sufficient intensity improves muscle
capillarisation and muscle oxidative enzymes, therefore increasing peak oxygen uptake.
Morbidity and mortality is inversely related higher oxygen uptake and provide every
submaximal daily task easier. Thus, there is enhancement in quality of life by improving
physical fitness. A greater range of available daily task will improve physical function
(Bennell, Hinman, Wrigley, Creaby, & Hodges, 2011).
Effect of hydrotherapy in reducing the workload to joint, reduce pain and enhance the
functional activity.
Hydrotherapy is the aquatic exercise, water’s temperature around 32°C to 36°C and can be
counted as the most applicable management for knee osteoarthritis as it will reduce the
workload to joint, reduce pain, enhance the functional activity (Barker et al., 2014) (Waller et
al., 2014) (Bartels et al., 2016). Physiological impact of immersion in the aquatic setting and
principles of hydrotherapy are the factor that contribute to the effectiveness for aquatic
exercise. As mentioned by Becker (2009), buoyancy effect in the aquatic environment will
reduce the compressive load to the knee joint, decreased the gravity force thus enhance the
functional activity and increase the muscle strength and knee range of motion. Through
buoyancy force, it capable to reduce the weight bearing and compressive force to knee able
to prevent the knee joint from more damage hence increase the improvement in exercise
therapy (Multanen et al., 2013). In addition, hydrotherapy can also reduce the sympathetic
nervous system action and combining immersion in water and the impact of hydrostatic
pressure capable to lessen the knee pain and swelling for patient with knee osteoarthritis.
(Barker et al., 2014).
Effect of stretching exercise on joint flexibility.
The physiology of stretching exercise is improve the joint flexibility. There is a limitation in
ROM when the joints are inflamed or damaged by arthritis. When muscles, tendons and
ligaments shorten, people with OA may experience extreme pain as they move.. When
motion is loss, functional activities become more difficult to perform. The individual’s overall
activity level decreases because the joints that are not involved with arthritis also may lose
normal motion. Static stretching exercises will increased the length of muscle and also
improve ease of movement. Static stretching involves stretching a muscle to a point of
muscle tension and holding that position for 20-30 seconds (Bennell, Hinman, Wrigley,
Creaby, & Hodges, 2011).
ii. Benefits of exercise towards knee OA patient
a. Benefit Exercise helps to relieve pain among knee osteoarthritis patient
According to International Association for the Study of Pain (IASP), pain is defined as
unpleasant emotional or sensory characterised with actual or potential damage of the tissue,
or described in terms of such damage. In osteoarthritis, pain may be described as burning,
aching or stiffness sensation especially in the morning as results of inflammation.
Furthermore, pain may pronounce as intermittent or constant in presentation. It is still not
clear for the root of pain sources either from biological, social or psychological factor.
However, the severity of pain known might have relation with the stage of osteoarthritis itself.
In acute stage, pain may present frequently and constantly compared to the late stage as it
present intermittently yet intense in nature. In this stage, OA patient will tend to avoid the
activity that aggravate the pain, thus reduce their functional daily activities (Neogi, 2013). A
lot of studies have been done to determine the effect of exercise as one of the conservative
management in reducing pain. As mentioned by Allen et al. (2013), individual or group based
of exercise involving daily stretching exercise of hamstring, calf, hip, quadriceps and back,
followed by 3 times per week with 5 repetition of functional strengthening exercise including
sit to stand, step up, single leg stand and others may lead to pain reduction after 12 to 24
weeks. Nejati, Farzinmehr, and Moradi-Lakeh (2015) also come with the same prove of
beneficial effect of stretching and strengthening exercise in reducing pain but with the
combination of NSAIDs, modalities and acupuncture while Molgaard et al. (2018) discussed
the positive effect of stretching and strengthening exercise in easing the pain with
combination of orthoses. Besides, Beckwee et al. (2016) added 18 weeks of 40 minutes
walking training for 3 times per week, with 14-17 Borg scale other than stretching and
strengthening exercise has also been proved to reduce pain in knee osteoarthritis. In
addition, Olagbegi, Adegoke, and Odole (2016) proposed in their study that both 10
repetition of open and closed kinetic chain done 3 times per week for 12 week may help a lot
in reducing the level of pain. Moreover, 60 minutes of functional, proprioceptive training,
endurance and strengthening exercise with 10 minutes warm-up and cool down, 2 sessions
per week for 8 weeks has also been confirmed by Holsgaard-Larsen et al. (2017) to ease the
pain intensity.
Authors / Objective Study Interventions control Outcome Findings Conclusion Level
Years design measure of
evide
nce
1. Allen et al. To examine RCT Group-based Individual Western At 12 weeks, Both group or Level
(2015) effectiveness of exercise exercise Ontario and group based individual exercise II
group-based intervention of intervention, McMaster exercise get 2.7 therapy shows
exercise and daily quads, calf same Universities scores lower in reducing knee
individual exercise hamstring, hip intervention Osteoarthritis WOMAC and 0.1 pain and improve
for veterans with and back Index points lower in in knee function at
knee OA. stretching and (WOMAC) SPPB compared 12 and 24
3x/week with 5 to individual Weeks
reps of exercise
Short Physical
functional programmed.
Performance
strengthening
Battery
exercise At 24 weeks,
(SPPB)
(half squat, group based
single leg stand, exercise get 1.3
chair stand, toe score lower in
stand, hip WOMAC
abduction, and compared to
step up) individual
exercise
programmed.
2. Beckwee To investigate either RCT Strength Walking Intermittent 5 patients quit Large Level
et al. the existence of training training, 40 and Constant the training improvement in II
(2016) bone marrow for 3 times/week minutes, Osteoarthritis earlier and all of ICOAP pain
lesions influence for 18 weeks Borg Scale Pain (ICOAP) them present reduce in both
the effect of walking including 14-17, for 3 with bone groups with and
questionnaire
or strengthening functional and times/week marrow lesion without bone
programmed of strength for 18 weeks but 19 patient marrow lesions
Global
OA patients improved in GPE
training of knee Perceived
extensors, Effect (GPE)
hamstring, hip No difference in
abductor and pain scores did
adductor . not differ
between both
group (p > 0.05)
or between
patients with or
without bone
marrow lesions
(p > 0.05)
3. Olagbegi, To investigate the RCT Open kinetic- Closed Visual Combined chain Combined kinetic- Level
Adegoke, effectiveness of chain exercises kinetic-chain Analogue exercise(CCE) chain exercises II
& Odole combined open -Quadriceps exercises or Scale (VAS) group demonstrated
(2016) kinetic and close setting combined demonstrated more
kinetic chain -SLR kinetic-chain Ibadan significantly benefits in
exercises on pain exercises Knee/Hip more reductions average daily pain
-Full arc
and function for extension Osteoarthritis (p < 0.05) in reduction and for
knee OA patients. Outcome average daily pain before and
-Air cycling 10 repetition,
pain (ADP), pain after
3 x/week for Measure
(IKHOAM) before
12 week walking than open
10 repetition, 3
and after walking kinetic-chain
x/week for 12
(PBW and PAW) combine with
week OKCE : SLR
than combination closed
+
exercise group . kinetic-chain
Full-arc
study. exercises
extension.
CKCE :
Quadriceps
setting +
Wall slides
4. Nejati, To assess the RCT 12 months NSAIDs, 10 VAS pain In first and Combination of Level
Farzinmeh effects of the Lower limb sessions second follow aerobic exercise II
r, & combination of strengthening acupuncture Knee Injury up, EG shows Protocol
Moradi- conventional and stretching and and significant with non-invasive
Lakeh conservative exercise with physiotherap Osteoarthritis reduce in pain, techniques helps
(2015) therapy with the NSAIDs, 10 y modalities Outcome disability, to improve pain
simplest and the sessions without Score walking, stair and knee function.
cheapest acupuncture exercises. (KOOS) climbing, and sit
exercise protocols and up speed
for knee OA. physiotherapy compared to CG
6MWT
modalities.
After 12 months,
4 Steps
3 times
significant
5 Sits up difference of
VAS and KOOS
between EG and
CG
5. Molgaard To determine the RCT Knee exercise Foot KOOS Knee exercises 12 weeks Level
et al. impact of knee 3x/week for 12- exercise2x/w combined with targeted-foot II
(2018) exercises alone week with HEP eek for 12 foot exercises exercises with
compared to knee ( squats, semi weeks under and orthoses were
exercises combined squat, lunges, PT Orthoses shows better
with foot exercises knee extensions supervisionw significant than targeted-
and foot orthoses in with rubber ith HEP improvement in knee exercises
knee pain patients. band sitting) (squats, semi KOOS pain alone in reducing
squat, compared to OA knee pain.
lunges, knee exercise
knee alone (95%CI).
extensions
with rubber
band sitting)
6. Holsgaard To investigate the RCT NEMEX: PHARMA: KOOS no significant No significant Level
-Larsen et outcomes of Total 60 mins Danish different between differences in II
al. (2017) neuromuscular functional, Guideline, both groups in active daily living
exercise (NEMEX) proprioceptive video and ADL KOOS (P = but NEMEX
compared to training, pamphlet on 0.216). groups shows
analgesic endurance and acetaminoph significant
(PHARMA) on strengthening en and oral However, in improvement in
patients with early exercise with 10 NSAIDs KOOS knee symptoms
knee OA. mins warm-up prescriptions. Symptoms, compared to
and cool down, NEMEX groups PHARMA group.
2 shows significant
sessions/week improvement (P
for 8 weeks. = 0.004)
compared to
PHARMA group
7. Huang, To evaluate the RCT Quadriceps Local Visual Analog After 1 month Isometric Level
Guo, Xu, influence of isometric physiotherap Scale (VAS) training, VAS quadriceps II
& Zhao isometric y with oral score and WOMAC training provides
(2017) quadriceps exercise NSAIDs questionnaire more advantage
for patients with WOMAC score in for knee OA
knee OA. questionnaire intervention patient compared
group shows to NSAIDs
significant combined
increase (P< with physical
0.05) compared therapy.
to control group
However, there
are more
significant
increase in joint
function
(P < 0.05) of
control group
compared to
intervention after
1 month
After 3 months,
intervention
group shows
more significant
increase in pain
reduction, joint
function and
WOMAC
Questionnaire
(P < 0.05).
b. Exercise helps improving muscle strength among knee osteoarthritis patients
Muscle strength is defined as the ability of a single or group of muscle to produce maximal
force against any load. Strengthening exercise has been proven has a lot of beneficial
effects on development of muscle strength. Among knee osteoarthritis population, one of the
clinical features of the condition is declining of muscle strength or simply term as muscle
weakness. This impairment could elicit a lot of difficulties in functional active daily living
among those with knee osteoarthritis. For instance, difficulties to squat while using toilet and
difficulties to stand from sitting. Therefore, a lot of studies have been done to prove the
beneficial effect of resistance exercise towards enhancement of muscle strength among
knee osteoarthritis population. As stated by Anwer and Alghadir (2014), performing
isometric quadriceps exercise, straight leg raising, and isometric hip adduction for 5 days per
week for 5 weeks, the muscle strength of the muscle can be enhance while it simultaneously
improve the functional activity, while reduce knee pain due to knee osteoarthritis. Strength of
quadriceps can also be improved via quadriceps resistance exercise with or without the use
of 12 session of neuromuscular electrical stimulation (NMES)(Laufer, Elboim-Gabyzon, &
Shtarker (2014). Furthermore, Jorge et. al (2014) mentioned that muscle strength can be
improved with consistent strength training for 12 weeks with the intensity of 50%-70% 1RM
of knee extensor, flexor, hip abductor and adductor. Besides, one studies has shown
squatting exercise with frequency of 3 times per week for 8 weeks can helps to increase
knee flexion motion strength among knee osteoarthritis patient (Lai, Zhang, Lee, & Wang,
2018). Home based and supervised low intensity aerobic exercise involving isotonic and
isometric leg exercise with balance (tandem and single leg stand) 40–45 min a day, rest 30-
60s between sets, 3 times per week for 18 sessions has also been proved has a significant
positive effect on muscle strength (Kuru Colak et al., 2017). In addition, step-aerobic
exercise with frequency of 3 times per weeks for 55 minutes in 12 month boost the maximal
force extension up to 11% higher and 4% higher of aerobic capacity while providing
sufficient stimuli on knee cartilage (KOLI et al., 2015).
evide
nce
1. Anwer & To investigate the RCT Isometric No Numerical After 5 weeks, Isometric Level
Alghadir effects of isometric quadriceps, exercise Rating Scale intervention quadriceps II
(2014) quadriceps exercise straight leg programm (NRS) group shows exercise enhance
on raising, and ed greater its strength and
muscle strength, isometric hip improvement functional activity,
Isometric
pain, and function in adduction for 5 quadriceps compared to while reduce knee
knee osteoarthritis days per week,5 control group in pain due to
weeks pain reducing, osteoarthritis.
WOMAC
quadriceps
strength function
(p<0.05)
2. Jorge et To evaluate the RCT 50%-70% 1RM Waiting list 1 Repetition There is Progressive Level
al. effect of a of knee , no Maximum (1RM) significant resistance II
(2014) progressive extensor,flexor, interventio improvement of exercise helps to
resistance exercise hip abductor n WOMAC pain reduction, reduce pain,
(PRE) for knee OA and adductor function improve hip, knee
women resistance (p<0.001) and muscle strength
exercise some aspect of and some aspect

quality of life of quality of life in
for 12 weeks.
(p<.002) in women with knee
intervention OA.
group compared
to control group.
In muscle
strength,
extensors
(p<0.001),
flexors (p=0.002)
and abductors
(p<0.001).
3. Lai, To determine the RCT Squatting, Education Ankle and knee There is Squatting training Level
Zhang, proprioception of 3x/week for 8 programm proprioception significant for 8 weeks helps II
Lee, & knee and ankle after week e increase in to improves knee
Wang 8-week Visual analog passive motion flexion motion
(2018) strengthening scale (VAS) pain sense knee strength for
exercise for knee flexion strength patients with knee
OA patient. of EG OA.
(p = 0.033) but
no improvement
in knee
extension and
ankle strength.
4. Laufer, The assess the RCT Quadriceps NMES on Visual Analog There is NMES provides Level
Elboim- impact of exercise exercise for 12 quadricep Scale (VAS) significant immediate effect II
Gabyzon, and neuromuscular weeks s, 10 pain increase of knee of knee pain
& Shtarker electrical stimulation contractio WOMAC pain reduction reduction,
(2014) on pain, functional ns at each after NMES whereas,
performance, and session, at therapy. combination with
10m Walk Test
muscle maximal 12 week exercise
(10 MWT)
tolerated training helps to
strength for patient But, both groups
with knee intensity, show equal improve muscle
The Timed Up- strength and
OA for 12 improvement of
And-Go test functional abilities.
sessions. muscle strength
(TUG)
and functional
abilities after 12
Stair Test weeks
programme.
5. Kuru To evaluate the RCT Supervised low- Home- 6-minute There were also Both home-based Level
Çolak et effects of intensity aerobic based low walk test significant and supervised II
al. (2017) supervised and exercise intensity (6MWT) differences in the has beneficial
home-based low- aerobic reduction of effect on lower
intensity aerobic exercise lower limb limb joint pain and
Isotonic and International
exercise on lower isometric leg pain and muscle muscle strength,
Physical Activity
limb pain, strength, exercise with strength in the however
Same Questionnaire
balance and the balance protocol supervised group supervised low
(IPAQ)
hemodynamic (tandem and (p=0.0041) intensity aerobic
But at
parameters of knee single leg stand) compared to exercise shows
home
OA subjects. Non-invasive home-based more improvement
40–45 min a 3x/weeks
hemodynamic group especially in
day, rest 30-60s followed
parameters. balance.
between sets, by
3x/week for 18 Supervised
telephone
sessions group also
follow-up
call Pain visual significant
1x/week analog scale increase in
(VAS) balance scores
(p = 0.009)
The Commander compared to
Muscle Tester home-based
dynamometer group.
(JTECH
Medical) No significant
change was
determined in
hemodynamic
parameters of
either group.
6. KOLI et al. To assess the RCT Aerobic/step- Healthy Cartilage There is 7% Gradual high- Level
(2015) effects of exercise aerobic Lifestyle measurement greater in the impact exercise II
on patellar cartilage 3x/weeks for 55 education using MRI exercise group creates sufficient
in postmenopausal mins, in group compared with stimuli on patellar
women with 12 month meeting the control group cartilage and
KOOS
and in patellar physical function
mild knee OA.
stretching Isometric cartilage in postmenopausal
exercise ( thickness women with mild
knee
knee OA
1 every 3 extension
month) There is 8%
greater
difference in the
exercise group
compared with
controls for the
deep half of
tissue
Force of
extension was
11% higher
whereas,
maximal aerobic
capacity was
4% higher in the
exercise group,
than in controls.
Both groups
shows same
score for Knee
Injury and
Osteoarthritis
Outcome Score
(KOOS)
c. Exercise improves functional activity and quality of life among knee osteoarthritis patients
According to Medical Dictionary for the Health Professions and Nursing, functional activity is
defined as the essential activity that benefits the physical, social, and psychological well-
being of an individual and allowing them to participate in society. Quality of life has been
described by World Health Organization (WHO) as perceptions of individual regarding their
state of life interconnected with the goals, expectations and standards concerning the culture
and value systems in the living environment. It is well known that exercise has a lot of
beneficial impact towards the individual’s quality of life. Hence, number of studies has been
carried out to further prove the facilitation of exercise in alleviate the quality of life. For
instance, De Rooij et al. (2016) stated that lower limb strength training and aerobic exercise
done 30 to 60 minutes per weeks for 2 sessions supervised by therapist may efficacious in
improving physical function. Besides, 12 weeks of leg strengthening exercises include yoga
poses such as squats and lunges confirmed by Chopp-Hurley et al. (2017) to alleviate
working ability and function while lessen the level of pain and depressive symptom.
Furthermore, Focht et al. (2017) verified that 3 months of cognitive behavioural (GMCB)
group training involve 30 to 40 minutes walking with moderate intensity combined with lower
limb strengthening exercise (leg extension, leg curl, step-up, and calf raise) 1-3 sets with 8-
12 repetitions for 60 minutes followed by 20 min of counselling may elevate the cognitive
social outcomes, physical activity and mobility of knee osteoarthritis population. Ability to
perform 6 Minute Walk Test (6MWT), Timed Up and Go (TUG) test and sit to stand has also
been shown by Kabiri, Halabchi, Angoorani, and Yekaninejad (2016) to be improve among
knee osteoarthritis individual after done 8 weeks of treadmill resistance training, cycle
ergometer and combination of resistance training with arm ergometer aerobic training. In
addition, as proved by Lai, Wang, Lee, Hou, and Wang (2017), 5 day per week for 24 weeks
quadriceps resistance exercise combined with whole body vibration (WBV) and education
improved symptoms, physical function, ADL, and quality of life in knee OA patient. Apart
from that, 60 minutes sessions of Tai Chi done for 2 times per weeks in 12 weeks and Tai
Chi home-based exercise at least 20 minutes per day have benefits on depression and
component of quality of life such as walking distance measure by 6MWT and 20-metre walk
test (Wong, Chung, Price, & Wang, 2018). Pilates training and conventional therapeutic
exercises (CTE) are also been approved by Mazloum, Rabiei, Rahnama, and Sabzehparvar
(2018) in increasing the level of functional activity, and reduction of pain and disability
compared to daily routines lifestyle.
Author Objective Study Interventions control Outcome Findings Conclusion Level
s/ design measure of
Years eviden
ce
1. De To assess the RCT Lower limb Usual care WOMAC, NRS Significant Tailored exercise Level
Rooij effectiveness of strength training pain, difference in therapy is II
et al. physical functioning and aerobic physical improvement of efficacious
(2016) and safety of tailored Exercise, 30 to activity, pain and function improving physical
exercise in patients 60 between both functioning and
fatigue, GPE
with knee minutes/weeks 2 groups safe in patients
osteoarthritis with sessions with KOA and
comorbidities. supervised by severe
PT. comorbidities.
2. Chopp To estimate the work RCT 12 weeks leg No exercise Intermittent and Significant Exercise Level
- ability, performance, strengthening Constant improvements in intervention helps II
Hurley and patient-reported exercises Osteoarthritis work ability, to improve work
et al. symptoms in older include yoga Pain (ICOAP) patient-reported ability, self-reported
(2017) university employees poses such as outcomes include pain, physical
with knee and/or hip squats and Knee Injury and pain, function, function, and
osteoarthritis after a lunges Osteoarthritis depressive depressive
12-week workplace Outcome symptoms of symptoms.
exercise program. RPE: 5-7 intervention group
Score (KOOS)
compared to
control group.
Hip Disability
existed in the
and
exercise group.
Osteoarthritis
Outcome Score
(HOOS)
Center
for
Epidemiologic
Studies
Depression
Scale (CES-D)
3. Focht To determine the Pilot 3 months GMCB 3 months Mobility-related The GMCB group The GMCB
et al. effectiveness of RCT group training : TRAD group self-efficacy shows significant intervention shows
(2017) mediated cognitive Walking 30-40 training: increase in SRSE more beneficial
behavioral (GMCB) mins moderate Same and SPF after 12 effects on cognitive
Self-Regulatory
physical activity intensity and exercise months compared social outcomes,
Self-Efficacy
programme without to TRAD groups physical activity
lower limb (SRSE)
compared to counselling with d =0.95 and and mobility than
strengthening
traditional exercise therapy d=0.58 TRAD in knee OA
exercise (leg Satisfaction
respectively. patients.
therapy (TRAD) on extension, leg with Physical
select social curl, step-up, Function
cognitive outcomes and calf raise) 1-
(SPF)
knee OA patients 3 sets with 8-12
reps for 60 mins
+
20 min of
counseling
4. Kabiri, To evaluate the RCT 8 weeks - VAS pain All groups show Combination of Level
Halab impacts of different programme significant resistance exercise II
chi, mode of aerobic improvement in with different types
KOOS
Angoo exercise for lower KOOS, VAS pain of aerobic exercise
Group 1 :
rani, & limbs and upper limb and functional benefit pain
Resistance 6 Minute Walk
Yekani with or without load ability after 8 reduction and
training with Test (6MWT)
nejad for knee OA patients. weeks. functional activity.
treadmill
(2016) However, treadmill
Timed Up and may provide larger
Group 2 : However, in arm
Go improvement in
Resistance ergometer shows
(TUG) test TUG and
training with significant
increase in VAS arm ergometry
cycle ergometer
Chair stand test higher than provide more pain
treadmill group relief and sport
Group 3 : performance.
(P=0.03)
Resistance
whereas, TUG
training with arm
score were higher
ergometer
in
aerobic training
treadmill than arm
ergometer
(P=0.02)
KOOS score was

significantly
greater in arm
ergometer
compared to
treadmill group
(P=0.04).
5. Lai, To evaluate the RCT 5 day/week for Quadriceps VAS pain Both intervention WBV exercise in Level
Wang, effect of a 12-week 24 weeks resistance and control combine II
Lee, WBV exercise quadriceps exercise groups shows with quadriceps
WOMAC
Hou, & compared to resistance significant strength exercise
Wang strengthening exercise improvement in improved
Quality of life
(2017) exercise alone on combined with symptoms, symptoms,
individuals with knee whole body physical function,
physical function,
OA. ADL and quality ADL, and quality of
vibration (WBV)
with education of life. life in knee OA
patient.
6. Wong, To differentiate the RCT Tai Chi sessions 30-minute WOMAC At 12 weeks, Tai Tai Chi and Level
Chung effectiveness of Tai 60 minutes outpatient Chi group’s physical II
, Chi and physical 2x/weeks for 12 sessions per WOMAC score therapy shows
Patient Global
Price, therapy among weeks week for reduced to improvements in
Assessment
& patient with 6 weeks score 167 points while pain and related
Wang symptomatic physical therapy, health outcomes
And Tai Chi
(2018) knee osteoarthritis home-based 143 points after exercise
Beck
for 12 exercise at least Depression however, Tai Chi
months. 20 mins/day Inventory-II Both groups also have more benefits
score on depression and
showed similar
component of
clinically
quality of life.
36-item Short significant
Form Health improvement in
Survey (SF-36) physical
function,
Arthritis Self- depression,
Efficacy medication use,
and quality of life.
Scale
6-minute walk Depression and
test the physical

component score
higher in Tai Chi
20-meter walk
group.
Test
7. Mazlo To evaluate RCT CTE group : Maintain Biodex system There is Pilates training and Level
um, effectiveness of 3 days/week for daily (Joint position significant CTE are better in II
Rabiei conventional 8 weeks. routines, no sense (JPS), increase of all improvement of
, therapeutic exercises Training start 30 exercise or functional outcome functional, pain and
Rahna and Pilates on knee minutes, sporting performance, measured of EG disability compared
ma, & pain and function proceed to 60 activities pain, and compared to CG to daily routines
Sabze towards knee OA minutes disability) (P<0.001). lifestyle.
hparva population.
r
Pilates groups: Time required Pilates groups However, Pilates
(2018) to shows more training are more
1 hour/session,
including 10 complete four improvement effective than CTE
minutes warm- functional compared to CTE in reducing pain
up and cool activities (15m- on pain reduction and disability.
down. walk with sit to and disability
stand and (P=0.003).
40 minutes
Pilates 15m-walk with
exercises, 5x/set climbing stairs)
gradually
increased. Lequesne index
for pain
d. Exercise helps to improve balance in knee osteoarthritis patient
Balance is defined as the ability of individual to keep steady or upright in position or motion
with the introduction of different challenges such as different type of surfaces, environment
or perturbation. In knee osteoarthritis patient, it is common presentation of impaired balance
even after the surgical management of total knee replacement. The elderly involve in risk
factor of osteoarthritis may worsen the situation and lead to high risk of fall. Therefore, these
studies show the importance of exercise in improving balance and reduce risk of fall among
knee osteoarthritis population. As declared by Bressel, Wing, Miller, and Dolny (2014),
balance training and high intensity training on aquatic treadmill using water jets may
increase the balance ability and reducing the risk of fall among this individual. Strengthening
exercise involving sitting knee extension with weight from 0 kg to 2 kg progress to 4 kg
performed 2 times per day for 15 minutes in each session for 6 weeks and stand training on
unstable mat for one week followed by on an air cushion for 2 times per day for 15 minutes
in each session for 6 weeks has also been confirmed to increase the ability of single leg
standing for both leg in individual with knee osteoarthritis (Kim, Lee, & Lim, 2016). Besides,
Rhon, Deyle, Gill, and Rendeiro (2014) suggested that combination of manual therapy 2
times per week for 8 weeks include joint and soft tissue, stretching, range of motion,
strengthening exercises with home exercise program followed by perturbation challenge
exercise and single leg standing helps to improve the ability to maintain the balance of knee
OA patient especially during stepping up and down. Furthermore, Mat, Ng, and Tan (2018)
recommended that Otago home based balance training and lower extremities strengthening
exercise has positive effects on reducing fear of falls, postural control, gait and balance in
elderly knee OA. In addition, Ojoawo, Olaogun, and Hassan (2016) offered that both
proprioceptive exercises involving single leg balance eyes open and closed for 1 minutes
holds, 10-20s, 2 repetitions for 6 weeks and isometric quadriceps exercise with dorsiflexion
10s hold, 6s rest, 10 repetitions for 6 weeks will help to alleviate the postural control and
balance among knee OA patient. Braghin, Libardi, Junqueira, Nogueira – Barbosa, and De
Abreu (2018) also demonstrated in their study that stretching, strengthening and aerobic
exercise focusing on walking helps asymptomatic patient to regain their balance and
postural control.
evide
nce
1. Bressel, To investigate the Cross- balance training - Pain visual Patients shows Patients with knee Level
Wing, value of high section and high- analog scales improvement of OA gets benefit II
Miller, & intensity training of al intensity interval (VAS) post-test from 6 weeks
Dolny aquatic treadmill on study training (HIT) in compared to high intensity
(2014) pain, balance, an aquatic pre-test on pain training on aquatic
Posturography
treadmill using reducing, treadmill
function, and
mobility for knee OA water jets balance,
Sit to stand by shows
patient. function and improvement of
test
mobility after reduced joint pain
completed the and increase
10-m walk test exercise balance, function,
programmed.
and mobility.
Knee Injury
and
Osteoarthritis
Outcome
Score (KOOS)
2. Kim, Lee, To evaluate the Cross- Strengthening Unstable One-legged There were no Knee extensor
& Lim benefit of knee section group (SEG) exercise standing significant strengthening
(2016) extensor al performed group (UEG) (OLS) test differences exercises and
strengthening study sitting knee stand on between the balance exercise
exercise and extension unstable mat VAS SEG, and UEG had beneficial
balance exercises with for one week GROUP. effects on balance
ability through weight from 0 and then on ability and pain
standing exercise kg to 2 kg an air Each group reduction.
on an unstable base progress to 4 cushion showed
of support with kg. (TOGU, significant
regards of pain in Prien am increase in one-
OA patient. Chiemsee, legged standing
2x/day for 15
Germany). (OLS) for both
minutes in each
session for 6 legs and a
weeks. 2x/day for 15 significant
minutes in decrease in
each session VAS.
for 6 weeks.
3. Rhon, To investigate the Observ Manual therapy - WOMAC Mean Manual therapy Level
Deyle, Gill, effects of manual ational 2x/week for 8 total WOMAC and balance III
& therapy and balance cohort- weeks include shows perturbation
Global Rating
Rendeiro exercise on knee study joint and Of Change significant exercises in
(2014) OA soft tissue, (GROC) improvement knee OA has
patient-centered stretching, (46%) after 6 beneficial effects
outcome measures range of motion, months on pain, function,
Numeric Pain
with goal of and and balance.
Rating Scale
reducing fall risks. strengthening
exercises with (NRPS) The total
HEP. WOMAC score
Step-up test was significantly
Patient also improved
prescribe with p=0.001 and
perturbation p=0.009 after 4
challenge week and 6
exercise, single week treatment
leg standing. respectively.
The GROC
score showed
marked
improvement
After 1 months
and 3-months
follow-up with
80% and 60%
respectively.
Functional squat
test had
significant
improvement in
both mean
NPRS
and ROM from
initial to 4
weeks.
The mean step-

up test improved
significant 4-5
seconds steps
during 15s test
after 4 weeks
4. Mat, Ng, & To investigate the RCT EG received CG only Modified EG showed Otago home- Level
Tan improvement of education on received Clinical Test of significant based balance II
(2018) postural balance, falls and education on Sensory increase in the and lower
fear of falling, risk of intervention on health and Interaction on Modified Clinical extremities
falls, gait and home hazards conventional Balance Test of Sensory strengthening
balance problems in cardiovascular, treatment. (mCTSIB) to Interaction on training has
elderly knee OA Visual, exercise measure Balance positive effects on
after home-based and medication postural sway. (mCTSIB), reducing fear of
exercise program. review. Limits of Stability falls,postural
(LOS), and short control, gait and
FES-I scores balance in elderly
Exercise
emphasis on after 6 months knee OA.
Otago Exercise compared to
Program (OEP) CG.
home-based
balance and
strength training
involve knee,
hip and ankle.
The balance
training involve
multilevel knee
bends,
backwards
walking, walking
and turning
around,
sideways
walking, tandem
stance and
walks, single
leg stand,
heel walking,
toe walking,
heel-toe
walking
backward, and
sit to stand.
All exercise
performed for
3x/weeks for 30
minutes, 6
months.
5. Ojoawo, To evaluate the RCT Proprioceptive Isometric WOMAC Proprioceptive Proprioceptive Level
Olaogun, difference effect exercises quadriceps exercises exercises reduced II
& Hassan between isometric -single leg Exercise with reduced more pain and physical
(2016) quadriceps exercise balance dorsiflexion pain (F = 4.76; p difficulty better
and proprioceptive 10s hold, 6s = 0.00) and than isometric
-single leg
exercise on pain, balance with rest, 10 reduced physical exercises.
joint stiffness eyes closed repetitions difficulty (F =
and physical for 6 weeks 3.69; p < 0.04)
Knee extensor
difficulties towards compared to
1 minutes holds, strength and
patient with knee isometric
10-20s, 2 proprioception
OA exercises.
repetitions for 6 additionally
weeks important postural
Control and
balance in knee
OA patient.
6. Braghin, To assess the RCT Group Group 3, no WOMAC Group 1 showed Both group 1 and Level
Libardi, balance and symptomatic intervention significant 2 shows II
Junqueira, function in and Questionnaire difference in improvement in
Nogueira symptomatic and asymptomatic of Falls WOMAC score difference aspect.
– Barbosa, asymptomatic (pain and
& De knee osteoarthritis warm-up (10 function) Asymptomatic
Abreu patients and to find minutes) group improved in
(2018) out the impact of stretching the Group 2 pain and function
physical activity. lower limbs showed shorter in WOMAC score
strengthening time taken to while
exercises for perform Step Up asymptomatic
the lower limbs test and shows
(20 improvement in
postural sway
increased step up test and
minutes) with 3
sets of 15 postural control.
repetitions :
- straight leg
raises (SLR)
- isometry of the
quadriceps
aerobic exercise
on a stationary
bicycle (20
minutes), 65%-
70% MHR
walking while
changing
direction,
walking with
transposition of
4 obstacles,
walking on a
thin mattress,
balance
training with
one-leg support,
balance board
support
e. Exercise among knee osteoarthritis in improving aerobic capacity and cardiorespiratory
fitness
Cardiovascular fitness and aerobic capacity is defined as the ability of vascular system,
heart and respiratory system to take up and deliver oxygen towards the contract muscle
(Marcus, 2013). Exercise may help to improve cardiovascular fitness or aerobic capacity
among knee osteoarthritis patient by improving the myocardial contraction of heart and
maintaining optimum level of diastolic and systolic blood pressure. As introduced by Casilda-
López et al. (2017), 8 weeks of dance-based aquatic exercise may improve cardiorespiratory
fitness, post exercise heart rate, and level of fatigue in obese and postmenopausal women
with knee osteoarthritis. Furthermore, self-management and 90 minutes exercise
programme, performed twice a week for 12 weeks may help to alleviate the functional level
of strength of lower limb and aerobic level capacity in knee osteoarthritis patient. Aquatic
exercise with 1.40 cm height and 37–39°C temperature included warm up, stretching 5
repetitions, 10s hold and strengthening exercises with 8-12 repetitions for 45–60 minutes
has been proved to reduce systolic and diastolic blood pressure, heart rate and rating
perceived exertion post exercise (Sahin, Kunduracilar, Sonmezer, & Ayas, 2018). Moreover,
12 months of high impacts multidirectional aerobic and step aerobics jumping exercise
program for 3 times per week has been confirmed by Multanen et al. (2016) to increase the
femoral neck strength, muscle strength, and cardiovascular fitness among women with mild
knee osteoarthritis.
Authors / Objective Study Interventions Control Outcome Findings Conclusion Level of
Years design measure evidenc
e
1. Casilda- To assess the RCT 8-week dance- Global Western Ontario There are There are Level II
López et al. functionality, based aquatic aquatic and McMaster significant improvement of
(2017) cardiorespiratory exercise exercise Universities difference functionality,
capacity, post- program. Osteoarthritis between both cardiorespiratory
exercise heart Index (WOMAC) group on capacity, post-
rate, and fatigue functionality exercise heart
in obese WOMAC score, rate, and level of
6-minute
postmenopausal cardiorespiratory fatigue in obese
walk test
women with capacity, postmenopausal
knee post-exercise women with
osteoarthritis Post-exercise heart rate, level of knee
after undergone heart rate and fatigue and osteoarthritis
dance-based function. after doing 8-
aquatic exercise Fatigue Visual week dance-
programmed. Analog Scale based exercise
program
2. Marconcin et To evaluate the RCT Self- Three VAS A significant Functional level Level II
al. (2017) effectiveness of management education improvement of muscle
a 12-week self- and exercise programm KOOS shows in EG strength of lower
management programme, 90- e with communication limb and aerobic
and exercise minute books, with the physicians level capacity
Aerobic capacity
intervention (the intervention telephone (P=0.048), aerobic can be improved
PLE2NO twice a week for Calls. capacity, by self-
program) in 12weeks Communication (P=0.035), and management
elderly With Physician functional lower and exercise
individuals with (CWP) scales limb strength programme.
knee (P=0.015)
osteoarthritis. Functional compared to CG.
Lower Limb
Strength
Assessed
Sit-To-Stand
Test (FRSTST).
3. Sahin, To determine RCT Aquatic exercise Conventio Systolic and All groups show Lower limb Level II
Kunduracilar, the impact of with 1.40 cm nal diastolic blood improvement in aquatic training
Sonmezer, & different aquatic height and 37– therapy pressure systolic BP, is more effective
Ayas, (2018) exercise on 39 ◦C (hotpack, walking distance in increasing the
cardiopulmonary temperature. ultrasound and HAD score. exercise
Heart rate
endurance and , capacity and
emotional status TENS and depression
Warm up, Perceived Group 1 showed
in knee stretching 5 HEP) more significant levels in
exertion Borg
osteoarthritis reps, 10s hold improvements in compared to
Scale
patient. and diastolic BP, heart upper limb
strengthening rate and Borg training and

Hospital Anxiety conventional
exercises, 8-12 and Depression Scale (p<0.05) therapy.
reps for Scale (HAD) and Group 2
45–60 minutes. showed
Walking significant more
Group 1 distance improvements in
performed only Borg Scale only
lower limb (p<0.05)
exercise
training.
Group 2
performed
combination of
upper limb, trunk
and lower limb
training.
4. Multanen et To assess RCT High impacts, Attention Cartilage There is significant Femoral Level II
al. (2016) progressive multidirectional control for measure MRI increase in neck strength,
high-impact aerobic and every 3 femoral muscle strength,
exercise on months WOMAC neck bending and
step-aerobic
femoral neck strength of both cardiovascular
jumping exercise
structural group fitness among
program Isometric
strength in after the 12month women with mild
postmenopausal 12 month knee
(p < 0.01). knee OA
women with mild 3 times per extension improved with
knee week high intensity
There is significant
OA. Cardiorespirator training without
increase in
y fitness harming the
isometric strength
(VO2max, and cardiovascular knee cartilage in
ml/kg/min) with fitness in EG women.
2km Walk Test compared to CG
(p<0.01)
There is no effect
on knee cartilage
post 12 month
exercise.
iii. Rationalizes of the principle of training
In this condition, osteoarthritis of the knee, there were some considerations for the principles
of training which are the specificity, overload and the progression (Claire Minshull and Nigel
Gleeson, 2016).
Specificity
Specificity means by the development of the training intervention will obtain improvements in
specific outcome. This specific also can be towards the individual abilities like tolerance to
training stress and recovery. There is whereby like doing the aerobic exercise like having a
brisk walking can improve the cardiovascular fitness instead of improves strength.
Overload
Overload is assigning a greater regimen of training than the individual adapted to achieve
the target outcome. There were principle for overload, FITT which are the frequency that
explain how often do the exercise, intensity about the how hard the exercise, time about how
long or duration doing the exercise and lastly type which is mode of activity.
Progression
While for the progression means by the intensity must be increase progressively as
improvement achieved in the intervention. It still using the same principle, which are FITT but
do the progression for it, FITT Pro. They stated that using the principles appropriately certain
the load that had been given are sufficient to the muscle involved to become stronger, faster
or not easily fatigue.
The uses of the principles of the training must be specific and reliable to make the muscles
that we emphasize on to become more muscular and more resistant which not easily fatigue.
Using of the principle also able to make the precise decision about the effect of the
intervention that had been done like the dosage of the exercise and the acceptance of the
individual towards the regimen of the exercise (Claire Minshull and Nigel Gleeson, 2016).
iv. Health screening and fitness test for OA
According to UK National Screening Committee, screening is the process of identifying

healthy people who may be at increased risk of disease or condition. Nowadays, a lot of
screening provider offers information, further tests and treatment. This is to reduce
associated risks or complications of any disease. According to WHO screening refers to the
use of simple tests across an apparently healthy population in order to identify individuals
who have risk factors or early stages of disease, but do not yet have symptoms. A health
screening test is a medical test or procedure performed on members of an asymptomatic
population or population subgroup to assess their likelihood of having a particular disease
(Givler, 2019).
The function of health screening is to assess a person who might have high risk of any
diseases, with the goal of keeping ailment or passing from that disease. There are several
characteristics of a good screening test which included the diseases that are suitable for
screening are those that are predominant in the population and cause large number of
morbidity and mortality. Next, the illness must have an asymptomatic period amid which
treatment will lessen morbidity and mortality significantly more than waiting before the sign
and symptom is shown. Other than that, the screening test should have the highest possible
sensitivity and specificity. The perfect screening test should be 100% sensitive and 100%
specific, able to identify all patients with the illness and none misdiagnose. The screening
test should also be affordable, convenient, safe, easy and universally available.
OBSERVATION
The primary goal of health screening for this population is to distinguish osteoarthritis (OA)
from other forms of arthritis and causes of joint pain and stiffness as well as to monitor the
side effects of various treatments. It has been suggested that biomechanical changes
resulting from abnormal alignment may influence joint loads, mechanical efficiency of
muscles, and proprioceptive orientation and feedback from the hip and knee.(Bello, Danso,
Bonney, & Bertha, 2015) During objective evaluation of knee OA, it is often necessary to
assess the alignment of the component bones of the lower extremity. According to Bello et al
(2015), the tibiofemoral joint space narrowing is often unsymmetrical, leading to angular
deformity of the lower extremity, more commonly of the varus type. An abnormal to
tibiofemoral alignment has important role in progression of knee OA
PALPATION
In acute stage there might be warmness upon palpation around knee joint in which suggest
inflammation. Through inspection patient will came out with mild to moderate swelling
around the joint (Rannou et al., 2014). Patient will complain about crepitus on the affected
knee and upon moving the knee joint, the feeling of bone rubbing on bone is present. Patient
also presented with reduce active range of motion due to pain especially towards the end of
its range of motion. According to Turcot et al (2015), patients with symptomatic and severe
knee OA tend to flexed posture at all joint levels. It has been reported that patients with end-
stage and symptomatic knee OA have to adapt their postural strategy to achieve a stable
upright posture and attempt to move their body forward their centre of gravity to locate the
load on a less painful knee joint area. Moreover, patient also demonstrated with overloading
their body weight on the contralateral side to avoid pain on affected knee.
GAIT ANALYSIS
As knee OA characterized by pain thus it is much related with abnormal knee moments
during walking. These will later cause gait alteration (Parveen & Noohu, 2017). The
difference in knee adduction moments during stance phase between knee OA patients and
healthy subjects is the most commonly reported. There is evidence of differences in the knee
adduction moment, flexion moment and flexion angle during walking between non-OA
individuals and patients with medial knee OA (Henriksen et. al,2010). Favre & Jolles (2016)
stated in their study that disease progression was associated with larger knee flexion angle
during heel-strike and larger knee adduction and flexion moment during mid-stance. Thus
suggested a sort of amplification mechanism, where the disease can produce specific gait
alterations and, in the reverse direction, the same gait alterations can contribute to disease
development.
IMAGING TEST
Images of the affected joint can be obtained during imaging tests. From these non-laboratory
test, osteoarthritis can be seen not just involves in joints degradation, including articular
ligament and subchondral bone yet in addition affect ligaments, capsule and the synovial
membrane degenerate (Tiulpin et. al, 2018). X-Ray can be utilized to look for joint
variations from the norm and loss of cartilage although it does not indicate significant
changes right off the bat in the ailment. The essential X-ray is utilized to explore breakdown
of cartilage, narrowing of joint space, formation of bone spur, bone damage as well as to rule
out other causes of pain on affected joint area (Blair et. al, 2018). Attractive reverberation
imaging (MRI) may likewise be utilized to look at affected joints. MRI use radio waves and a
solid strong magnetic field to deliver clear images of bone, soft tissues, including cartilage. A
MRI isn't regularly expected to diagnose osteoarthritis but it may help give more data in
complex cases (Bandak et. al, 2014)
BLOOD TEST, ARTHROCENTESIS, ARTHROSCOPY
Generally, blood tests will probably be performed to assess general wellbeing and are not
viewed as useful in diagnosing osteoarthritis. In any case, tests might be requested to
preclude other conditions and to assess the individual's wellbeing incorporate RA.
Examining and testing the fluid from joint can decide whether there's irritation and if torment
is brought about by gout or an infection. (Ahmed et. al, 2018). Arthrocentesis is a method
done by physician utilizing sterile needle to sample tests of joint fluid which would then be
able to be analysed for cartilage fragments, disease or gout. Joint fluid investigation is useful
to rule out gout, infection, and other cause for incendiary joint pain. Expulsion of joint fluid
and infusion of corticosteroids into the joints amid arthrocentesis may help ease torment,
swelling, and aggravation of symptom. Arthroscopy is a surgical technique where a camera
is embedded in the affected joint to get visual data about the damage caused to the joint by
the osteoarthritis.
HEALTH SCREENING
Before participate in any exercise regime, all patient are ought to be screened for health
risks prior to begin any activity. One of the screening tool that can be use is the Pre Activity
Readiness Questionnaire (PAR-Q). PAR-Q is a simple self-screening apparatus that can be
utilized by any individual who want to begin an exercise program. Patients with knee OA
may experience unbearable pain on knee and might limiting themselves to participate in
exercise program however exercise testing are safe to use among this population. The
American College of Sports Medicine (ACSM) had prescribes suitable exercise testing for
muscle strength, aerobic endurance, flexibility, balance and gait. Method that can be used
for strength is isometric knee extension while method to assess endurance are 6- min walk
and aerobic capacity test to determine the heart rate and RPE. To test for joint flexibility and
range of motion, goniometer is used to measure joint range of motion as well as asymmetry
of knee joint. Balance can also be tested by using Berg Balance Test. Last but not least, gait
analysis may be necessary for knee OA patient who have severe disease, altered
biomechanics (Type, Joints, & Lupus, 2009)
v. FITT-PRO of exercise recommendation
According to Bitton (2009), it is the chronic stage in osteoarthritis if may cause disability for
patient and exercise therapy capable to slow down the occurrence of disability in patient with
osteoarthritis. Exercise for osteoarthritis patient consists of aquatic exercise, strengthening
exercise and aerobic exercise. As mentioned by Bennell et al. (2014), purpose of the
exercise therapy for this patient are to enhance muscle strength, improve knee control,
enhance sensorimotor and improve functional activity.
AEROBIC EXERCISE
As suggested by The American College of Sports Medicine and the Centres for Disease
Control and Prevention, aerobic exercise for osteoarthritis patient should be at least 150
minutes per week for moderate intensity and with vigorous aerobic for 75 minutes. For
elderly, are not allowed for moderate intensity more than 150 minutes and beyond their
abilities as they have knee osteoarthritis (Bennell & Hinman, 2011).
Aerobic exercise start with short period for about 10 to 15 minutes, and steadily add 5
minutes for every 2 weeks of aerobic exercise. Intensity of aerobic exercise should be 60-
80% of maximal heart rate or 40-60% of VO2 max. Intensity can enhance the vo2 max.
Decrease the length and intensity, if pain is more than 2 hours after exercise and more
worse than previous aerobic training. Minimise the vigorous activity and repetitive activity as
it will increase workload and compressive force for joint.
Swimming, cycling and jogging are the example for aerobic exercise. Walking is the most
common aerobic exercise that always perform by patient, as it is easy and capable to reduce
pain. Walking usually for 20 to 60 minutes, two to three times per week and combine with
stretching exercise and patient education (Dadabo, Fram, & Jayabalan, 2018).
EXAMPLE OF AEROBIC EXERCISE: CYCLING
Components Description
Frequency For cycling consider as moderate exercise, 5 days per week
Intensity High to low intensity exercise. High intensity: 70% reserve heart rate.
Low intensity: 40% reserve heart rate.
Time For moderate exercise, duration exercise for 39-60 minutes per day
(150 min/week).
Type Involve major muscle group such as quadriceps and hamstring.
Stationary group cycling.
Progression Progression capable to decrease the risks injury, and progress of
exercise through altered the duration, frequency and intensity.
Volume Suggested volume for aerobic exercise is around 500-1000 MET min
per week.
Adapted from Rausch Osthoff, A., Juhl, C. B., Knittle, K., Dagfinrud, H., Hurkmans, E.,
Braun, J., Niedermann, K. (2018). Effects of exercise and physical activity promotion: meta-
analysis informing the 2018 EULAR recommendations for physical activity in people with
rheumatoid arthritis, spondyloarthritis and hip/knee osteoarthritis. RMD Open, 4(2), e000713.
doi:10.1136/rmdopen-2018-000713.
EXAMPLE OF AEROBIC EXERCISE: AEROBIC DANCE IN SITTING
Frequency For moderate exercise, 5 days per week.
Intensity 60-80% of maximal heart rate or 40-60% of VO2 max.
(150 min/week.
Type Involve all major muscle group, continuous and rhythmic.
per week.
doi:10.1136/rmdopen-2018-000713
EXAMPLE OF AEROBIC EXERCISE: SWIMMING
Frequency Vigorous exercise 3 times per week.
Intensity Vigorous intensity: 70% or 85% of maximal heart rate.
Time For vigorous and combination for 20 to 60 minutes per day for adults.
For sedentary, suggested for more than 20 minutes per day. (75
min/week)
Type Involve muscle group such as shoulder, back, abdominal, leg and
triceps. Continuous and rhythmic.
per week.
doi:10.1136/rmdopen-2018-000713.
EXAMPLE OF AEROBIC EXERCISE: WALKING
Frequency For moderate exercise, 5 days per week
Intensity Moderate intensity: 60-80% of maximal heart rate or 40-60% of VO2
max.
(150/week).
Type Involve all major muscle group such as lower leg ( soleous,
gastrocnemius) and thigh muscle ( hamsting and quadriceps),
continuous
per week. It is more benefit if add 2000 steps per day until reach more
than 7000 per day.
doi:10.1136/rmdopen-2018-000713.
STRENGTHENING EXERCISE
Strengthening exercise is the exercise that use the external load such as use machines
(quad bench), theraband or body weight to influence the muscle to actively contract and it is
capable to improve the joint and muscle firing patterns in patient with knee osteoarthritis
(Vincent & Vincent, 2012). As stated by. Wortley et al. (2013) and Foroughi, Smith, Lange,
Singh, and Vanwanseele (2011), it is also decrease the pain for pain with osteoarthritis and
strengthening exercise can perform in variety way.
Strengthening exercise for osteoarthritis patient focus more to the quadriceps muscle.
According to Bennell, Wrigley, Hunt, Lim, and Hinman (2013), weakness on quadriceps are
the commonest problem for knee OA patient. Other than quadriceps, hamstring and hip
abductors also weak for patient with osteoarthritis that impaired the functional activity
(Alnahdi, Zeni, & Snyder-Mackler, 2012).
The American College of Sports Medicine and the Centers for Disease Control and
Prevention recommended that strengthening exercise should be two times per week. This
has been supported Cadore (2014), two times per week capable to increase power and
muscle hypertrophy in geriatric patient. Intensity for strengthening exercise should be light to
moderate intensity, that patient able lift up for 15 to 20 times for light intensity while for
moderate intensity patient need to elevate for 10 to 15 repetitions. For times, repeat all
exercise for three sets. Type of exercise can be use theraband, dumbbell or use machine
such as quad bench.
Strengthening exercise can be completed whether under supervision in physiotherapy

department or just performed it at home (Jan, Lin, Lin, Lin, & Lin, 2009), (Lin, Lin, Lin, & Jan,
2009). According to Fransen & McConnell (2009), supervised or not supervised during
exercise did not significant effect for knee osteoarthritis but it is able to encourage the patient
to accomplish the exercise if they been supervised.
In addition, strengthening exercise also consist of squatting, isometric contraction of

quadriceps while patient in supine lying and steps up. Do all strengthening exercise about
two to three times per week, hold for 10 seconds over 6 to 12 weeks. According to Li et al.
(2016), 12 weeks of strengthening exercise are effective for joint stiffness, and stiffness at
the joint are the common problem for knee osteoarthritis.
STRENGTHENING EXERCISE FOR QUADRICEPS: STATIC QUADRICPES EXERCISE
(SQE)
Components Descriptions
Frequency Train quadriceps muscle groups for two to three days per week.
Intensity Light intensity that 40%–50% of the 1RM in order to enhance the
muscle strength.
Time In adults repeat for 8–12 repetition and 10–15 repetitions for middle
age person. Hold for 10 seconds.
Type Isometric contraction of quadriceps.
Progression Gradually increase the repetitions, intensity, holding time
doi:10.1136/rmdopen-2018-000713
STRENGTHENING EXERCISE: HAMSTRING: perform at quad bench and do knee

flexion.
Frequency Trained hamstring muscle groups for two to three days per week.
Intensity For moderate to high intensity, it should be 60%–70% of the 1RM and
for elderly, use the light intensity that 40%–50% of the 1RM in order to
enhance the muscle strength.
Time Based in repetitions and holding time. In adults repeat for 8–12
repetition and 10–15 repetitions for middle age person.
Type Uses equipment such as theraband or spring
Progression Gradually increase the repetitions, intensity and theraband that has
greater resistance.
doi:10.1136/rmdopen-2018-000713
STRENGTHENING EXERCISE: HIP ABDUCTOR: perform in side lying and actively hip
abduction.
Frequency Trained gluteus medius muscle groups for two to three days per week.
Intensity Light intensity that 40%–50% of the 1RM in order to enhance the
muscle strength.
Time Based in repetitions and holding time. In adults repeat for 8–12
repetition and 10–15 repetitions for middle age person.
Type Uses equipment such as theraband or movement against gravity.
Progression Gradually increase the repetitions, intensity and weight.
doi:10.1136/rmdopen-2018-000713
STRETCHING EXERCISE
For osteoarthritis patient, they tend to have tightness on iliopsosas and vastus of quadriceps
muscle due to increase varus at the knee (Lucha-López et al., 2018). Functional sit and
reach test are the commonest test to evaluate the flexibility of hamstring and lower back
muscle and it shows reduction in patient with knee osteoarthritis (Carvalho, Bittar, Pinto,
Ferreira, & Sitta, 2010).
As mentioned by Dekker, Van Dijk, & Veenhof (2009), due to knee osteoarthritis it can
contribute to the limitations range of motion of the knee. Increase hamstring activity more
than normal, will reduce the knee extensors range of motion and cause the restriction at
knee. Osteoarthritis patient also has over activity of hip muscle as a compensation to the
weak of knee extensor muscle (Suzuki et al., 2018).
Example of stretching exercise for patient with knee osteoarthritis are chair-sitting stretch for
the hamstring muscle and for quadriceps muscle, perform in side-lying stretch. Hold for 30
seconds for each muscle (Suzuki et al., 2018). Repeat each exercise for two to four times. In
order to increase the effectiveness of stretching exercise start with warm up through light
aerobic exercise or use hot pack (Niedermann, 2018).
STRETCHING EXERCISE: HAMSTRING: perform in long sitting and use towel.
Frequency For increasing the joint range of movement, do stretching exercise
more than two to three days per week.
Intensity Do stretching exercise until feel discomfort such as pain or tightness on
the targeted muscle
Time For adult, static stretch are suggested to hold up to 30 seconds
Type For stretching it can be static stretching of hamstring by using towel.
Volume Perform 60 seconds of total stretching time.

doi:10.1136/rmdopen-2018-000713
STRETCHING EXERCISE: QUADRICEPS; in standing and do knee flexion.
the targeted muscle
Time For adult, static stretch are suggested to hold up to 30 seconds.
Type For stretching it can be static stretching and hold by using hand.
Volume Perform 60 s of total stretching time.
doi:10.1136/rmdopen-2018-000713
STRETCHING EXERCISE: ERECTOR SPINAE: child pose position.
the targeted muscle
Time For adult, static stretch are suggested to hold up to 30 seconds.
Type For stretching it can be static stretching, child pose position on mat.
Volume Perform 60 s of total stretching time.
doi:10.1136/rmdopen-2018-000713.
HYDROTHERAPY
As recommended by Bartels et al. (2016), aquatic therapy are more beneficial for patient
with knee osteoarthritis compared to the land exercise. This is support by evidence that
stated by Becker (2009), improvement in blood circulation to the active muscles during
exercise from 1.8 mL/min/ 100 g tissue to 4.1 mL/min/100 g tissue in hydrotherapy. In
addition, as reported by Lund (2008), only three person that showed adverse effect during
aquatic exercise and able to continue the treatment, but for land exercise, three person has
shown the adverse effect but all of the unable to continue the treatment. Aquatic exercise
capable to speed up the strength of muscle and early active mobilise the knee joint even
though in severe pain Peter, Jansen, & Hurkmans (2011) (Gill, McBurney, & Schulz, 2009)
Hydrotherapy management start with motor coordination and agility training that consist of
gait training in sideways, walk to front and back and step up and down at the ladder pool, 30
seconds each sets, repeat for 4 sets and rest for 30 seconds and repeat for two to three
times per week .
In addition, for stretching exercise for triceps, pectoralis major, quadriceps, hamstring,
adductors and gastrocnemius for hold 10 seconds for each muscle, repeat for 6 sets and
rest for 10 seconds and repeat for two to three times per week.
For space perception, speed of action and time the exercise is throwing the ball to therapist
in different direction such as side to side, front and back and its perform at the shallow part
of pool, 1 minute for each set, repeat for 3 sets and rest for 30 seconds and repeat for two
to three times per week .
Moreover, balance training start with standing in board then proceed to eyes closed and
single leg standing for 1 minutes and repeat for 4 sets and rest for 30 seconds and repeat for
two to three times per week.
Furthermore, strengthening training start with trained the quadriceps muscle (squat), hold for
6 seconds and repeat for 40 repetitions. For abdominal muscle, hand support at the bar at
pool and do kicking movement, put both leg at wall pool and return to ground, hold for 10
seconds, repeat for 10 times and repeat for two to three times per week (Alcalde et al.,
2017).
Aquatic aerobic also one of the subtype of hydrotherapy in physiotherapy management.

Aerobic exercise such as walking in the water that temperature around 32°C to 36°C, for 30-
60 minutes, three times per week for 6 to 8 weeks (Dadabo, Fram, & Jayabalan, 2018).
C. SAFETY AND PRECAUTION
Do’s
Move inflamed joints daily and gently through its range of motion.
The joints should be move daily because to maintain the range of motion and to avoid the
joint from becoming stiff. Prolong immobilization of the joints can lead to reduce in range of
motion and joint contractures.
Begin all exercise with a warm-up of slow exercises to minimize joint stress.
Therapist must follow the guideline of training consideration for OA patients by using low
intensity and duration during the initial phase of programming. Before warm-up, take a warm
shower or applying heat (hot pack) just prior to exercise to help make exercise more
comfortable, as heat relaxes joints and muscles and helps to relieve pain. Perform exercises
with a slow, steady rhythm without bouncing. Allow muscles time to relax between
repetitions.
Attempt to achieve full range of motion to the point of a mild discomfort but not pain.
While the exercises may not improve range of motion, they can help prevent further
restriction. Furthermore, must avoid any exercise that can causes the client to experience
worsening pain. Muscle soreness and discomfort is a normal response to exercise. The
indication to reduce intensity of exercise is production of any joint pain that lasts for two or
more hours after exercising.
Choose exercises that minimize stress on the joints.
High-resistance exercises should be done only under the supervision of a physical therapist.
Progressive training beginning with minimal overload is most effective and exercises in a
pool or partial-weight-bearing exercises often are better tolerated than full weight-bearing
exercises. It is important to educate patients to avoid exercises that may be harmful to
injured joints such as high impact activities.
Choose suitable time to perform exercise.
Exercise is best accomplished at times of the day when joints are the least stiff, energy is the
highest, and any medication the clients takes is at its maximal effectiveness. It is also
acceptable for clients to divide an exercise program into short bouts throughout the day
rather than an extended training session at one time.
(Johnsen & Weinblatt, 2009)

Don’ts
Practice sedentary lifestyle (Being inactive)
When someone avoids performing physical activity or exercise it can lead to weakening of
the muscles and can worsen joint pain. Do practices regular exercise that is safe for your
knees and perform the exercise daily.
Expose to the risk a fall.
Therapist must be aware of the slippery or uneven surface because people with knee OA
have high risk of fall due to painful and unstable knee. This will cause more knee damage.
Gain weight. (Being obese)
If a person is obese or overweight, there is more stress put on the knee joint. A person with
a BMI>30 kg/m2 were 6.8 times more likely to develop knee OA than normal-weight
controls.
(Johnsen & Weinblatt, 2009)

D. BARRIER TO EXERCISES
Physical Barrier
Physical barriers such as pain must be considered and may be a barrier to OA patients
because pain is stressful, aversive and inherent. Patients will tend to reduce in adherence to
perform exercises because of the pain. The presentation of pain are either at rest or at the
time of performing the exercises make the patients felt discomfort and intolerence towards
exercises. These symptoms reduce the ability to engage in physical activity together with
fatigue and stiffness (Kanavaki et al., 2017).
Intrapersonal or psychological factors.
Intrapersonal or psychological factors such as the patients belief that exercise is ineffective,
harmful, bring them pain and doubtful. They also belief that physical activity and exercise will
worsen their condition and that is the reason why they neglect to perform an exercise. They
should be encourage and motivated on the importance of exercise for OA. This will lead to
an awareness about the advantages of exercise (Kanavaki et al., 2017).
Emotional factor.
Next is emotional factor which is OA-related distress. People with OA have to adjust their
condition to a reality of decreased physical performance. There is feeling of distressing or
embarrassing about their condition and being unable to meet life roles and daily demands.
Patients keep to be distress that lead to extreme unhappiness, feeling broken, mentally
depressed, weakness and paralysing fatigue. With all these feelings they tend to neglect
about the importance to perform exercise that have been prescribed by physical therapist
because keep thinking negatively about current condition (Kanavaki et al., 2017).
Lack of motivation.
Lack of motivation also become a barrier to exercise. OA patients have lack of motivation or
goal, laziness and also boredom towards exercise. Patient have lack of motivation to
perform exercise because lack of understanding about the importance and effectiveness of
exercise. Sometimes maybe patients are not truly understand about the way to perform
exercise and felt it is difficult to them (Kanavaki et al., 2017).
Lack of behavioural regulation.
Lacking of behavioural regulation such as life roles and a busy schedule, especially family
related and also inactive participants. Family members also play an important role to support
and motivate OA patients about the exercise. They have to spend their time to send patients
for a physio or finding another solution such as by having personal trainer at home
(Kanavaki et al., 2017).
E. CONCLUSION
Globally, knee osteoarthritis or also known as degenerative joint disease, is a well-known as

the leading sources of disability. It usually takes place among the population older ages and
obesity. This disability make person who having it encounter with the pain at joint. This joint
pain also can be vary based on in each person that leading to the limitation in the functional
and quality of life. Knee osteoarthritis can be diagnosed from health screening when certain
criteria have been made. The main objective for plan of intervention in knee osteoarthritis
are focus to relieve pain, improve function and limit disability as well as improving the quality
of life of patients. Nowadays, patient with knee osteoarthritis can be treated either operative
or conservative management that based on their preferences and age. However, a surgery
is recommended if in severe case such as dysfunction of the knee. For conservative
management, patient can consume medicines that help to reduce pain and improve
functions. Other than that, patient can also undergo physical therapy technique such as
therapeutic exercise, joint manual therapy, and pain reduction through modalities. Patients
are also provided with patient education programme as an important part in management of
knee osteoarthritis.
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Exercise For Knee Osteoarthritis

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UNIVERSITI TEKNOLOGI MARA (UiTM)

PUNCAK ALAM CAMPUS

FACULTY OF HEALTH SCIENCE

BACHELOR OF PHYSIOTHERAPY (Hons.)

1. HANANI BINTI KAMALUDIN (HS2446C/2017662136)

2. NUR HALIANA ERNA BINTI OTHMAN (HS2446C/2017662166)

3. SITI FARHANA BINTI ISHAK (HS2446C/2017662198)

4. SITI NABILA BINTI MOHD SHA’ARI (HS2446C/2017662176)

5. UMMU TSARA’ BINTI MUSTAFA (HS2446C/2017662172)

DR MARIA JUSTINE @ STEPHANY

10TH MAY 2019

i. Introduction of osteoarthritis (OA)

ii. Prevalence of osteoarthritis

iii. Etiology and Risk factor

Clear etiology of osteoarthritis is still unknown. However, Ashkavand, Malekinejad, and

i. Physiological basis of exercise

The most common non-pharmacologic therapy prescribed to patients with osteoarthritis is

Effect of exercises on muscle activation.

Effect of strengthening exercise on strength and pain.

The physiology of strengthening exercise is on the alterations of skeletal muscle. Skeletal

Effect of aerobic exercise on physical fitness.

Effect of stretching exercise on joint flexibility.

a. Benefit Exercise helps to relieve pain among knee osteoarthritis patient

exercise some aspect of and some aspect

KOOS score was

6-minute walk Depression and

test the physical

The mean step-

Otago Exercise compared to

Program (OEP) CG.

strengthening rate and Borg training and

Walking significant more

Group 1 distance improvements in

performed only Borg Scale only

lower limb (p<0.05)

According to UK National Screening Committee, screening is the process of identifying

BLOOD TEST, ARTHROCENTESIS, ARTHROSCOPY

Strengthening exercise can be completed whether under supervision in physiotherapy

In addition, strengthening exercise also consist of squatting, isometric contraction of

STRENGTHENING EXERCISE: HAMSTRING: perform at quad bench and do knee

Volume Perform 60 seconds of total stretching time.

STRETCHING EXERCISE: QUADRICEPS; in standing and do knee flexion.

Aquatic aerobic also one of the subtype of hydrotherapy in physiotherapy management.

Choose exercises that minimize stress on the joints.

Choose suitable time to perform exercise.

(Johnsen & Weinblatt, 2009)

Practice sedentary lifestyle (Being inactive)

Expose to the risk a fall.

Gain weight. (Being obese)

(Johnsen & Weinblatt, 2009)

Intrapersonal or psychological factors.

Lack of behavioural regulation.

Globally, knee osteoarthritis or also known as degenerative joint disease, is a well-known as

Alnahdi, A. H., Zeni, J. A., & Snyder-Mackler, L. (2012). Muscle Impairments in

Ashkavand, Z., Malekinejad, H., & Vishwanath, B. S. (2013). The pathophysiology of

B Sun, H. (2013). Osteoarthritis – Why Exercise? Journal of Exercise, Sports &

Becker, B. E. (2009). Aquatic Therapy: Scientific Foundations and Clinical

Bitton, R. (2009). The economic burden of osteoarthritis. The American Journal of

Casilda-Lopez, J., Valenza, M. C., Cabrera-Martos, I., Díaz-Pelegrina, A., Moreno-

Greene, M., & Loeser, R. (2015). Aging-related inflammation in osteoarthritis.

Neogi, T. (2013). The epidemiology and impact of pain in osteoarthritis. Osteoarthritis

Niedermann, K. (2018). SP0086 The development and purpose of the eular

Ojoawo, A. O., Olaogun, M. O., & Hassan, M. A. (2016). Comparative effects of