Brief research report 275
Effect of home exercise program performance in patients with
osteoarthritis of the knee or the spine on the visual analog
scale after discharge from physical therapy
Hamilton Chena,b and Kentaro Onishia,b
The aim of our study was to assess the effect of the
frequency of home exercise program (HEP) performance
on pain [10-point visual analog scale (VAS)] in patients
with osteoarthritis of the spine or knee after more than
6 months discharge from physical therapy (PT). We
performed a retrospective chart review of 48 adult patients
with a clinical diagnosis of knee or spine osteoarthritis and
had been discharged from PT of the spine or the knee for at
least 6 months with provision of HEP from a physical
therapist. Adult patients who were younger than 50 years
of age, taking more than one medication to control pain,
participating in worker’s compensation, or had a history of
c 2012 Wolters Kluwer Health | Lippincott
drug abuse were excluded from the study. We recorded
patient demographics, pain level (10-point VAS scale), and
the number of days that a HEP was performed per week.
The mean VAS score of patients who performed 0 days of
HEP per week was 6.90. The mean VAS score of patients
who performed HEP 1–3 times per week was 6.36. The
mean VAS score of patients who performed HEP 4–7 times
per week was 5.00. Single-factor analysis of variance
analysis indicated a P-value of less than 0.01. Post-hoc
comparison of the mean VAS using Fisher’s least
significant difference test showed a significant difference
Introduction
According to the Diagnostic and Therapeutic Criteria
Committee of the American Rheumatism Association,
osteoarthritis is defined as a painful progressive degenera-
tive process in heterogeneous joints, which results in bony
changes and articular cartilage defects (Altman et al., 1986).
Osteoarthritis is a common disease worldwide. According
to the Centers for Disease Control and Prevention, osteo-
arthritis affects one in three adults older than 65 years of
age. The prevalence in the USA is an estimated 27 million
individuals, with an estimated 25% of primary care
physician visits for osteoarthritic symptoms. Overall,
osteoarthritis affects 13.9% of adults aged 25 years and
older and 33.6% (12.4 million) of adults aged 65 years and
older (Dekker et al., 1992; McAlindon et al., 1993; Felson
et al., 2000).
One of the main modalities of conservative treatment
of osteoarthritis is physical therapy (PT). The benefits
of PT in patients with osteoarthritis have been well
documented in the literature. Fransen et al. (2002)
showed that a short-term, supervised exercise program
0342-5282
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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
between the mean VAS score of 4–7 days per week of HEP
versus 0 days per week (P < 0.01) and 1–3 days per week
(P < 0.01) of HEP. There was no significant difference in
the mean VAS score between 0 days of HEP and 1–3 days
of HEP (P > 0.05). Patients who performed 4–7 days per
week of HEP had statistically significant lower mean VAS
scores than patients who performed 0 days per week of
HEP and 1–3 days per week of HEP. Therefore, after 6
months of discharge from PT, patients should be
encouraged to perform at least 4 days of HEP per
week. International Journal of Rehabilitation Research
35:275–277
Williams & Wilkins.
International Journal of Rehabilitation Research 2012, 35:275–277
Keyword: home exercise program, knee osteoarthritis, pain, physical
therapy, spine osteoarthritis, visual analog scale score
a
UCI Medical Center, Orange and bVA Long Beach Medical Center, Long Beach,
California, USA
Correspondence to Hamilton Chen, MD, 101 The City Drive, Bldg 53,
Room B-17, Orange, CA 92868, USA
Tel: + 1 714 456 6668; fax: + 1 714 456 6557; e-mail: hchen82@gmail.com
Received 2 December 2011 Accepted 6 May 2012
provided by trained therapists to osteoarthritis patients
resulted in a significant reduction in pain.
Despite the benefits that PT can provide, it is not
convenient or financially feasible for patients to remain in
supervised PT for a prolonged period of time. Therefore,
one of the critical aspects in the treatment of osteoarthritis
patients is the provision of a home exercise program
(HEP).
Previous studies have shown the benefits of HEP for
osteoarthritis. In a study by Thomas et al. (2002), patients
achieved statistically significant reductions in the Western
Ontario and McMaster Universities Osteoarthritis Index,
a measure of osteoarthritic knee pain at 6, 12, 18, and
24 months of HEP compared with patients who performed
no HEP. A study by Ben Salah Frih et al. (2009) compared
HEP with standard PT and found that a home-based
rehabilitation program was as effective as standard PT.
Kawasaki et al. (2009) compared HEP with hyalgan
injections, and found that the two interventions equally
resulted in beneficial improvements in a visual analog
DOI: 10.1097/MRR.0b013e328355a1bd
276 International Journal of Rehabilitation Research 2012, Vol 35 No 3
scale (VAS), the Japanese Knee Osteoarthritis Measure,
and the Outcome Measures in Rheumatology Clinical
Trials and Osteoarthritis Research Society International
criteria.
Prognostic factors for HEP have also been studied. Jansen
et al. (2010) showed that the duration and severity of
symptoms at baseline were a significant prognostic factor
for outcomes in osteoarthritis patients on HEP. Interest-
ingly, the type of HEP may not be a significant prognostic
factor for the outcomes of osteoarthritis patients in
HEP. Chaipinyo and Karoonsupcharoen (2009) investi-
gated the difference in pain improvement between two
knee osteoarthritis groups receiving a strength-focused
HEP and a balance-focused HEP. The results showed no
difference in the pain outcomes in the two groups. A
study by Sled et al. (2010) found that hip abductor
strengthening alone improved the pain and function from
knee osteoarthritis.
A previous review reported that after discharge from PT,
the benefits of HEP on osteoarthritic pain reduced with
time (Pisters et al., 1999). According to the MOVE
consensus, adherence to exercise is the principal predictor
of long-term outcomes in exercise therapy in patients with
osteoarthritis (Roddy et al., 2005). Therefore, one can
postulate that after discharge from PT, adherence is likely
the primary reason why the benefits of HEP reduce.
Pisters et al. (2010) evaluated the effect of HEP adherence
on pain through a 5-year prospective observational follow-
up study of 150 patients with osteoarthritis of the hip or
the knee on HEP. The study showed that long-term
adherence to HEP led to a better treatment outcome on
pain, self-reported physical function, physical performance,
and self-perceived effect. The association between adher-
ence and outcomes was consistent over time. The study
determined adherence through a five-point Likert scale
(almost never, occasionally adherent, regularly adherent,
often adherent, and very often) and divided patients into
two groups: adherent and nonadherent.
To our knowledge, no previous studies have objectively
assessed the relationship between the number of days per
week of HEP performance and its effect on osteoarthritic
pain in patients who have been discharged from PT. The
aim of our retrospective study is to determine the frequency
of HEP performed (in days per week) and assess its effect
on pain [10-point VAS scale] in patients with osteoarthritis
of the knee or the spine who have been discharged from a
formal PT program for more than 6 months.
Methods
An institutional review board approval was not obtained
because of the study design. All previous therapy
interventions were standard of care and data were obtained
from available clinical charts. Patients were not contacted.
Protected health information was not recorded.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
A retrospective chart review of patients who fulfilled
the inclusion criteria was performed. Forty-eight adult
patients with confirmed osteoarthritis of the spine and
knee who had been discharged from PT for over 6 months
with provision of HEP were included in the study. The
exclusion criteria included patients younger than 50 years
of age, taking more than one medication to control pain,
participating in worker’s compensation, or those with a
history of drug abuse.
If a patient fulfilled the criteria upon chart review, available
data (age, sex, number of medications used to control pain,
VAS pain score, number of days HEP performed) were
recorded. After data were recorded, patients were categor-
ized into three groups according to the number of days
HEP performed per week: no HEP (0 days), occasional
HEP (1–3 days), and regular HEP (4–7 days).
Patients were placed in three categories of HEP
performance frequency (0 days per week, 1–3 days per
week, and 4–7 days per week) to account for possible
inconsistencies and recall bias in HEP performance
among patients. A patient who reports that he performs
7 days of HEP per week during a clinic visit may not
consistently perform 7 days of HEP from week to week.
Therefore, a broader range for the frequency of HEP may
account for these inconsistencies and better reflect the
actual amount of therapy the patient performs.
For each of these groups, a mean VAS score with an SD
of VAS score was calculated. Statistical analysis was
performed using the analysis of variance analysis.
Results
The characteristics of the study groups (no HEP, 1–3 days
per week of HEP, and 4–7 days per week of HEP) are
presented in Table 1. The mean VAS score of patients who
performed no HEP was 6.9 (SD = 1.78). The mean VAS
score of patients who performed occasional HEP (1–3 days
per week) was 6.36 (SD = 1.55). The mean VAS score of
patients who performed regular HEP (4–7 days per week)
was 5.00 (SD = 1.30). A single-factor analysis of variance
was used to test for the differences in the VAS score among
the three study groups. VAS scores differed significantly
across the three study groups [F(2,45) = 6.03, P < 0.01].
Post-hoc comparison of the mean VAS using Fisher’s least
significant difference test showed a significant difference
between the mean VAS score of regular HEP versus the no
HEP (P < 0.01) and occasional HEP (P < 0.01) groups.
There was no significant difference in the mean VAS score
between no HEP and occasional HEP (P > 0.05).
Discussion
Our study shows that patients who performed 4–7 days per
week of HEP after at least 6 months of discharge from PT
had a statistically significantly lower mean VAS score than
patients who performed no HEP and 1–3 days of HEP.
There was no significant difference between the mean VAS
 HEP VAS score Chen and Onishi 277

Table 1 Characteristics of the study sample patients who performed 0 days per week of HEP and
Occasional Regular HEP 1–3 days per week of HEP. This suggests a relationship
HEP (1–3 (4–7 days/ between the frequency of HEP performance per week
No HEP days/week) week) Total and a patient’s amount of pain from osteoarthritis.
Number of 20 14 14 48 Therefore, lifestyle modifications to include HEP should
patients
Sex
be encouraged by practitioners, even after patients have
Males 19 13 12 44 been discharged from standard PT. Similar to preventing
Females 1 1 2 4 complications from other chronic illnesses such as
Age (years)
51–60 5 4 7 16
diabetes mellitus, hypertension, or dyslipidemia, perfor-
61–70 12 8 4 24 mance of HEP may prevent progression of osteoarthritis
> 71 3 2 3 8 and the costly treatments that ensue.
Number of pain medications
0 5 0 7 12
1 15 14 7 36
HEP Acknowledgements
Knee 12 9 5 26 The authors thank the editor and the anonymous
Spine 8 5 9 22
reviewers for their contributions in improving the manu-
HEP, home exercise program. script. The authors also thank Naveed Natanzi, OMS IV,
for his contributions.

scores of patients who performed no HEP and 1–3 days of
HEP. These findings suggest that the performance of at
least 4 days per week of HEP in patients with osteoarthritis
of the knee and spine after long-term discharge from PT
has an effect on pain levels from osteoarthritis. Therefore,
patients should be encouraged to perform at least 4 days of
HEP after discharge from PT.
There were inherent limitations in our study. Some of these
limitations include an unequal sex distribution, a small
sample size, the innate subjectiveness of the VAS scale, and
recall bias. In addition, because of the nature of a retrospec-
tive chart review at a single institution, certain confounding
variables could not be standardized without significantly
reducing the sample size. For example, the study could have
been limited to patients taking no pain medication, but our
sample size would have been decreased to 12.
In addition, there was no standardization for patients who
received alternative forms of treatments such as visco-
supplementation, steroid injections, transcutaneous elec-
trical nerve stimulationunits, bracing, etc. as well as
the baseline severity of osteoarthritis. The quality and
accuracy of HEP performed by each study participant was
also not controlled.
Future studies should seek to prospectively determine
the effect of frequency of HEP performance on osteo-
arthritic pain with standardization of confounding factors.
Given our findings in this study, patients should be
encouraged to adhere to home exercise recommendations
even after discharge from PT. Suggestions of improving
adherence to HEP include usage of visual–audio media,
such as DVD videos of HEP, practitioner-driven encourage-
ment of proper and consistent HEP performance, and
HEP diaries.
Conclusion
Patients who performed 4–7 days per week of HEP had
statistically significant lower mean VAS scores than
Conflicts of interest
There are no conflicts of interest.
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