The Benefits

Exercise Fo
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CONTENTS
01 What is knee OA?

02
Common Physiotherapy Intervention in Knee OA

03 Effect of Aquatic Exer

04 Conclusion
1
 What is knee OA ?
01

2
Anatomy of knee

Knee is the largest and strongest joint in the body.

It is made up of the lower end of the femur, the upper
end of the tibia, and the patella. 

Two wedge-shaped pieces of cartilage called

meniscus act as "shock absorbers" between your
femur and tibia.  
➢ Both are tough and rubbery to help cushion the
joint and keep it stable.
The knee joint is surrounded by a thin lining called
the synovial membrane.
➢ This membrane releases a fluid that lubricates
the cartilage and reduces friction. 3
Department of Research & Scientific Affairs, American Academy of Orthopaedic Surgeons. Rosemont, IL: AAOS; April 2014.
Osteoarthritis
Osteoarthritis is the most
common form of arthritis in the
knee.

It is a degenerative, "wear-and-
tear" type of arthritis that occurs
most often in people 50 years of
age and older.

Joints cartilage wears away protective space between the bones

decreases bone spurs

4
Department of Research & Scientific Affairs, American Academy of Orthopaedic Surgeons. Rosemont, IL: AAOS; April 2014.
Risk Factors
The ability of cartilage Genetic mutations or Involved in soccer, tennis,
to heal decreases as inherited abnormalities in or long-distance running
a person gets older. the shape of the bones that may be at higher risk.
surround the knee joint.
Repetitive
stress Other
Age Gender Heredity Athletics
injuries illnesses

Women ages 55 and Such as kneeling, Rheumatoid

older are more likely than squatting, or lifting arthritis/Metabolic
men to develop knee OA. heavy weights. disorders 

5
Department of Research & Scientific Affairs, American Academy of Orthopaedic Surgeons. Rosemont, IL: AAOS; April 2014.
Symptoms
• Pain that increases when you are active, but gets a little
better with rest
• Swelling
• Feeling of warmth in the joint
• Stiffness in the knee, especially in the morning or when you
have been sitting for a while
• Decrease in mobility of the knee
• Creaking, crackly sound that is heard when the knee moves
6
Department of Research & Scientific Affairs, American Academy of Orthopaedic Surgeons. Rosemont, IL: AAOS; April 2014.
 Common
02 Interven

7
Common Passive Treatments
for Knee Osteoarthritis
• Cold therapy : By reducing circulation, cold therapy can help decrease
swelling.
• Heat therapy : Increase blood flow to decrease stiffness in the knee
joints and muscles surrounding the knee.
• Hydrotherapy

Handout on Health: Osteoarthritis. National Institute of Arthritis and Musculoskeletal and Skin Diseases Web site. 8
http://www.niams.nih.gov/Health_Info/Osteoarthritis/default.asp. Published July 2010. Accessed July 19, 2011.
Common Active Treatments
for Knee Osteoarthritis
• Flexibility exercises : To ease yourself into an exercise program for
knee OA.
• Strengthening exercises : Help build muscles, which act as shock
absorbers and reduce some the impact to knee joints.
• Aerobic exercises : It gets heart pumping and helps keep at a healthy
weight.

Handout on Health: Osteoarthritis. National Institute of Arthritis and Musculoskeletal and Skin Diseases Web site. 9
http://www.niams.nih.gov/Health_Info/Osteoarthritis/default.asp. Published July 2010. Accessed July 19, 2011.
 Effec
03 Exercis

10
 The Benefits of Aquatic Exercises
• Exercise in water can alleviate pain and improve function in people with knee
OA. Barrels EM. et al(2016)
• Aquatic exercise has the additional benefits provided by the properties of water
such as buoyancy, which significantly decreases the stress on weight-bearing
knees, and water resistance, which strengthens the muscles. Lim JL. et al(2010)
• The hydrostatic pressure acts compressing the tissues and, in combination with
the circulatory changes that occur with immersion, reduces swelling, permitting
greater movement to reduce joint and soft-tissue stiffness and, therefore, improve
pain complaints. Hinman RS. et al(2007)
11
Effects of a dance-based
aquatic exercise program in
obese postmenopausal
women with knee
osteoarthritis: a
randomized controlled trial
Jesu ´s Casilda-Lo ´pez, MSc, Marie Carmen Valenza, PhD,
Irene Cabrera-Martos, PhD, Ana Dı´az-Pelegrina, MSc, Maria
Paz Moreno-Ramı´rez, MSc, and Gerald Valenza-Demet, PhD.
2017 by The North American Menopause Society.

12
Methods - Participants
• 34 participants allocated into two groups : experimental group(17) ＆
control group(17)
•

1. Menopausal women over 50 years of age

2. Body mass index (BMI)of at least 30kg/m2
3. Clinical diagnosis of primary knee OA
• Exclusion criteria
•

1. Planned knee replacement

2. Medical contraindications to active exercise
3. Having undergone a total knee replacement
4. Neurological diseases
5. Symptomatic diseases other than knee OA affecting the lower extremities
6. Severe systemic disease that may interfere with the assessments
7. Psychiatric disorder 13
8. Inability to walk
Methods
• In both groups, the intervention program was performed three times
a week for 8 consecutive weeks.
• The intervention programs were implemented in a heated chest high
swimming pool, with a depth of 1.30 m.
• Water temperature was 32ºC.
• Each session lasted 45 minutes, including 12 minutes of warm-up, 21
minutes of exercises, and 12 minutes of cool-down exercises.

14
Methods
Warm up Walking forward, backward, and Aerobic exercise program
sideways

Training sequence 5minutes of slow rhythm music, Cardiovascular exercises

3minutes of fast rhythm music, including forward and backward
5minutes slow, 3minutes fast, and walking, and range of motion
5 minutes slow (total 21minutes) exercises

Cool down After the last rhythm was allowed Walking slowly with breathing
for all participants exercises and stretching of the
main muscles used during the
session

15
Results

16
Results

17
Conclusions
• An 8-week dance-based exercise program compared with control group
•

➢ Improved more function and cardiorespiratory capacity

➢ Decreased post exercise HR and fatigue
• Improvements continued to show significant differences at 3-month follow-up
in participants in the experimental group.
• Observational studies indicate that dance movement can enhance individuals’
range of movement and freedom of total body movement. Belardinelli R. et al(2008)

18
Effects of high intensity
resistance aquatic training
on body composition and
walking speed in women
with mild knee
osteoarthritis: a 4-month
RCT with 12-month follow-
up
B. Wallery, M. Munukkay, T. Rantalainenz, E. Lammentaustax,
M.T. Nieminenxk, I. Kiviranta , H. Kautiainenyyzz, A. Hakkinen ，
U.M. Kujala ， A Heinonen. Osteoarthritis Research Society
International. Osteoarthritis and Cartilage 25(2017) 1238-1246.

19
Methods
• 87 participants allocated into two groups : exercise group(43) ＆ control
group(44)
• Subject recruitment
•

1. Female aged 60-68 years old

2. Body mass index (BMI) <35
3. Experiences knee pain almost daily(not exceeding 5/10 VAS), K/L
grades I or II
4. No medical reason preventing full participation in intensive exercise
20
Methods - Interventions
Type • Lower limb aquatic • Maintained usual care
resistance training • Ask to continue their
• Three levels: barefoot usual leisure time
small fins large activities
resistance boots
• In small groups of 6–8
subjects in a pool heated
to 30–32°

Frequency 1 hr, three times a week for

16 weeks, for a total of 48
training sessions

21
Results
Treatment effects and
maintenance at 12-months

22
Results
Effects of physical activity

23
Conclusions

• A relatively short high intensity aquatic resistance training program decreases

fat mass and improves walking speed in women with mild knee OA.
• Only improvements in walking speed were maintained at 12-months follow-up.
• LTPA appeared more important for controlling body composition than walking
speed.

24
Effectiveness of aquatic
exercises compared to
patient-education on health
status in individuals with
knee osteoarthritis: a
randomized controlled trial
Marcelo Taglietti1, Ligia Maria Facci2, Celita Salmaso Trelha3,
Fernanda Cristiane de Melo3, Daniela Wosiack da Silva3,
Geovane Sawczuk3, Thamires Marques Ruivo3, Thaisley
Barbosa de Souza3, Chiarella Sforza4 and Jefferson Rosa
Cardoso2. Clinical Rehabilitation(2018)

25
Methods – Study design and selection criteria
• 60 participants allocated into two groups : aquatic exercise(31) ＆ educational
program(29)
• A randomized controlled trial lasting eight weeks, with a three-month
follow-up
• Subject recruitment
•

1. Diagnosis of knee OA, K/L grades I-IV

2. Aged from 60 to 85 years
3. Presented adequate clinical and cognitive conditions for carrying
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4. out activities in the pool-MMSE
Methods – Study design and selection criteria
• Exclusion criteria
•

1. Undergoing orthopaedic and neurological surgical procedures

2. Coronary diseases
3. Cancer
4. Uncontrolled hypertension
5. Unable to walk without aid equipment
6. With contraindications to practice exercises or enter the pool
7. Morbid obesity (body mass index > 40 kg/m2)
8. Unable to continue the study due to change of address or
9. scheduled hospitalization
10.

11.
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Methods – Study interventions

28
Type Exercise protocol
➢ 5 minutes of warm-up :
walking, patellar mobilization;
stretching the
leg muscles
➢ 15 minutes of knee and hip
isometric and dynamic
exercises with elastic
bands
➢ 20 minutes of aerobic
exercises (stationary running or
deep
water-running)
➢ 10 minutes of step training and
proprioceptive exercises
➢ 10 minutes of cool down
Frequency Twice a week, for eight weeks,
each session lasting 60 minutes,
total 16 sessions
• Program was designed and
delivered by a multidisciplinary
team
➢ Physician/pharmacist/nurse/
nutritionist/psychologist/
physiotherapist/physical educator
• Home knee osteoarthritis
exercise guidelines for
practice two to three times a
week
➢ warm-up/self-
stretching/isometric and
dynamic
exercises/proprioceptive and
functional exercises/cool down
The classes were weekly (total of
eight), lasting 2 hours
28
29
 Results

It is generally accepted that the WOMAC questionnaire has greater specificity and
consequently better responsiveness for people with osteoarthritis when compared to
Visual Analogue Scale

30
Results

31
Conclusions

• Aquatic exercises
•

➢ Improving function and pain

➢ Quality of life and depressive symptoms presented no differences
• Aquatic exercises were effective in improving pain, function, and quality of
life after treatment, and function at the end of the three-month follow-up period.

32
Is four-week underwater treadmill
exercise regimen compared to
home exercise efficacious for pain
relief and functional improvement
in obese patients with knee
osteoarthritis? A randomized
controlled trial
Vilai Kuptniratsaikul, Phitsanu Suntornpiyapan, Kriangkrai
Kovintaset and Suwicha Inthibal. Clinical Rehabilitaiton(2018).

33
Methods - Participants
• 80 participants allocated into two groups
•

1. Underwater treadmill group(40)

2. Home exercise group(40)
Inclusion criteria
1. Diagnosis of primary knee osteoarthritis
2. Age 50–80 years
3. Mild to moderate knee pain with numeric rating scale ≧5
4. BMI≧ 25 kg/m 2

Exclusion criteria
5. Bowel and/or bladder incontinence
6. Skin ulcer
7. Inability to walk due to a serious medical condition : cardiopulmonary
system, spinal stenosis, or severe back, hip, or ankle joint pain 34
Methods - Intervention
Type UTM exercise with moderate
intensity (NRS 5-6/10), including
warm up and cool down
Frequency 30 minutes, three times per week
for four weeks (12 total sessions)
Brochures : warm compression
for pain relief / regular isometric
quadriceps exercise / avoid
bending the knee more than 90°
10–20 repetitions/set with a 1–2-
minute rest, total session duration
was 30 minutes daily
35
Results

36
Conclusions

• The mean change in outcome scores was greater in the UTM group than in
the home-based quadriceps group, although magnitude of the differences
did not achieve statistical significance.
• More participants in the UTM group than in the home exercise group self-
rated themselves as much improved and satisfied, with no difference
between groups for adverse events.

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 Conclusion
04

38
Effects of a dance-based 1. Functionality- 8-week 3-month
aquatic exercise program WOMAC 1. Improved function 1. Improvements
in obese postmenopausal 2. Cardiorespiratory and cardiorespiratory continued in function,
women with knee capacity-T6MWT capacity post exercise HR,
osteoarthritis: a
3. Heart rate 2. Decreased post fatigue
randomized controlled
trial (2017) 4. Fatigue exercise HR and
fatigue

Effects of high intensity 1. Walking speed-UKK 4-month 12-month

resistance aquatic training 2km walking test 1. Decrease fat mass 1. Improvement
on body composition and 2. Body composition- 2. Improve walking continued in walking
walking speed in women bods mass/BMI/lean speed speed
with mild knee
mass/fat mass
osteoarthritis: a 4-month
RCT with 12-month 3. KOOS-
follow-up (2017) pain/symptoms/ADL/
sports and
recreation/QoL

39
Effectiveness of aquatic 1. Pain-VAS 8-week 3-month
exercises compared to 2. Functional capacity- 1. Improve pain, 1. Improvements
patient-education on WOMAC function, quality of continued in pain,
health status in 3. QoL-SF 36 life function, quality of
individuals with knee
4. Depression - life
osteoarthritis: a
randomized controlled Yesavage scale
trial (2018) 5. Functional mobility-
TUG

Is four-week underwater
treadmill exercise
1. Pain-Numerical 4 week Aquatic exercise can reduce p
rating scale Mean change in
motor function in dai
1.
regimen compared to 2. 6-minute walking outcome scores :
home exercise efficacious distance UTM group ＞ home
for pain relief and
3. Quadriceps strength exercise group
functional improvement
in obese patients with 4. Body weight 2. Global assessment
knee osteoarthritis? A 5. Adverse event-joint ＆ Satisfaction index :
randomized controlled pain/muscle UTM home ＆
trial(2018) pain/others exercise group have
6. Global assessment significant difference
7. Satisfaction index
40
 Reference
• Casilda-López, J., Valenza, M., Cabrera-Martos, I., Díaz-Pelegrina, A., Moreno-Ramírez, M.,
& Valenza-Demet, G. (2017). Effects of a dance-based aquatic exercise program in obese postmenopausal
women with knee osteoarthritis. Menopause, 24(7), 768-773. doi: 10.1097/gme.0000000000000841
• Casilda-López, J., Valenza, M., Cabrera-Martos, I., Díaz-Pelegrina, A., Moreno-Ramírez, M., &
Valenza-Demet, G. (2017). Effects of a dance-based aquatic exercise program in obese postmenopausal
women with knee osteoarthritis. Menopause, 24(7), 768-773. doi: 10.1097/gme.0000000000000841
• Taglietti, M., Facci, L., Trelha, C., de Melo, F., da Silva, D., & Sawczuk, G. et al. (2018). Effectiveness of
aquatic exercises compared to patient-education on health status in individuals with knee osteoarthritis: a
randomized controlled trial. Clinical Rehabilitation, 32(6), 766-776. doi: 10.1177/0269215517754240
• Kuptniratsaikul, V., Kittichaikarn, C., Suntornpiyapan, P., Kovintaset, K., & Inthibal, S. (2018). Is four-week
underwater treadmill exercise regimen compared to home exercise efficacious for pain relief and functional
improvement in obese patients with knee osteoarthritis? A randomized controlled trial. Clinical Rehabilitation,
33(1), 85-93. doi: 10.1177/0269215518792041
• Heywood, S., McClelland, J., Geigle, P., Rahmann, A., Villalta, E., Mentiplay, B., & Clark, R. (2019). Force
during functional exercises on land and in water in older adults with and without knee osteoarthritis:
Implications for rehabilitation. The Knee, 26(1), 61-72. doi: 10.1016/j.knee.2018.11.003

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