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Effect of Home Exercise Program in Patients With Knee Osteoarthritis - A Systematic Review and Meta-Analysis.
Effect of Home Exercise Program in Patients With Knee Osteoarthritis - A Systematic Review and Meta-Analysis.
long-term compliance of home exercise programs. In a information to make it interpretable (criteria 10-11). Each
prospective long-term study conducted by Deyle et al,16 the question is scored according to its presence or absence in
effects of a home exercise program on lower extremity func- the assessed study. The final score is calculated by the sum
tion were almost equal to those of supervised clinic-based of all positive responses.
exercise programs even at 1-year follow-up. Past studies In accordance with Moseley et al,22 studies with a score
have consistently shown that a home exercise program of 5 (50%) or greater were considered high-quality. So, in
is beneficial for improving strength, reducing pain, and the present review, all randomized studies with scores of
improving function in individuals with knee OA.13-20 5 (5/10) or greater were considered to be of high method-
However, neither a systematic review of the literature ological quality. The analysis of studies classified with the
nor a meta-analysis has been published on the effective- PEDro Scale was done independently by 2 evaluators.
ness of home exercise programs for the management of The Cochrane collaboration’s tool for assessing risk of
individuals with knee OA. Hence, the objectives of this bias was used to assess risk of bias in the domain-based
systematic review were to investigate evidence regarding evaluation. The sequence generation, allocation conceal-
the effectiveness of home exercise programs in the manage- ment, blinding of participants, therapist and assessors,
ment of individuals with knee OA. completeness of outcome data, and selective outcome
reporting were the domains assessed. Risk of bias was clas-
METHODS sified as low, unclear, and high in each domain.23
(n = 65) (n = 35)
Studies included in
Included
qualitave synthesis
(n = 19)
(Maximum = 10) design, intervention, outcomes, and effects found. All stud-
16/19
12/19
18/19
10/19
14/19
13/19
18/19
14/19
5/19
9/19
6.78
Cumulative Score ies were experimental, with 11 studies13,17,19,20,39-41,44,45,47,49
including pre- and postintervention assessments and 8
Yes
studies15,16,18,38,42,43,46,48 with long-term treatment evalua-
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Ravaud et al49
7
tion (follow-up). Regarding the effects found in the majority
of the studies, a significant effect of home exercise programs
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Bezalel et al48
was found on pain and function between pre- and postint-
8
ervention evaluations.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Baker et al47
9
Components of Home Exercise Programs Included in
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Studies
No
No
Brismee et al46
8
The interventions used as home exercise programs in
the reviewed studies included a combination of open
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Kawasaki et al45
8
and closed kinematic chain exercises as home exercise
programs.13,16-18,38,44,47,49 Three studies used muscle stretch-
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Chaipinyo et al44
7
ing (quadriceps, hamstring, and calf),16,39,48 range-of-motion
exercise,16,45,48 and 4 studies used balance exercises38,41,43,44
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Rogers et al43
4
Yes
Yes
Yes
No
No
Talbot et al42
8
Yes
Yes
Yes
No
No
Rogers et al41
8
Outcome Measures
Yes
Yes
Yes
Yes
No
No
No
No
Konishi et al40
4
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Aoki et al39
7
Yes
Yes
Yes
Yes
Yes
No
No
McCarthy et al36
8
Yes
Yes
Yes
Yes
No
No
No
No
No
Sled et al20
5
Yes
Yes
Yes
Yes
No
No
No
No
No
Tunay et al19
5
Yes
Yes
No
No
No
No
No
5
Yes
Yes
Yes
No
No
No
No
No
No
No
Evcik et al17
3
Yes
Yes
Yes
No
Yes
Yes
Yes
No
No
No
No
O’Reilly et al13
6
size point estimates that favored the group and home exer-
cise compared with no intervention; the test for an overall
Intention-to-treat analysis?
Group comparisons?
Random allocation?
Cumulative score
Blind assessors?
Follow-up?
Table 2. Risk of Bias of Included Studies (Yes, Low Risk of Bias; No, High Risk of Bias)
Adequate Sequence Allocation Incomplete Outcome Free of Selective
Citations Generation? Concealment? Blinding? Data Addressed? Reporting? Conclusions
O’Reilly et al13 Yes Yes No Yes Yes High risk of bias
Thomas et al15 Yes Yes Yes Yes Yes Low risk of bias
Deyle et al16 Yes Yes Yes Yes Yes Low risk of bias
Evcik et al17 No No No Yes Yes High risk of bias
Bruce-Brand et al18 Yes Yes Yes No Yes High risk of bias
Tunay et al19 No No No Yes Yes High risk of bias
Sled et al20 No No No Yes Yes High risk of bias
McCarthy et al38 Yes Yes Yes Yes Yes Low risk of bias
Aoki et al39 Unclear No Yes Yes Yes High risk of bias
Konishi et al40 No No No Yes Yes High risk of bias
Rogers et al41 Yes Yes Yes Yes Yes Low risk of bias
Talbot et al42 Yes Unclear No Yes Yes High risk of bias
Rogers et al43 Unclear No No Unclear No High risk of bias
Chaipinyo et al44 Yes Yes Yes Yes Yes Low risk of bias
Kawasaki et al45 Yes Yes Unclear Yes Yes Unclear risk of bias
Brismee et al46 Yes Yes Yes Yes Yes Low risk of bias
Baker et al47 Yes Yes Unclear Yes Yes Unclear risk of bias
Bezalel et al48 Yes No Unclear Yes Yes Unclear risk of bias
Ravaud et al49 Yes Yes No Yes Yes High risk of bias
favored home exercise compared with no intervention; supervised clinic-based exercises are used commonly in
the test for an overall effect across the 9 included studies clinical physical therapy practice for individuals with knee
was significant (P < .001), with an overall small effect OA. Among the 19 studies evaluated using the PEDro
size point estimate of 0.35 (95% CI, 0.15-0.55) based scale,21 17 were considered of high methodological quality.
on a random-effects model (Figure 5). Meta-analysis of On the basis of the present review, the home exercise pro-
5 trials16,19,38,41,45 showed that 2 studies had an effect grams used in the reviewed literature can be considered as
size point estimate that favored the other intervention treatment possibilities for individuals with knee OA.
compared with home exercise; however, 3 studies indi- The methodological guidelines of the evaluated studies
cated insignificant effect size point estimate to favor any were properly prepared and described, allowing clinical
one intervention (P > .05) (Figure 6). Meta-analysis of 2 reproducibility. This systematic review and meta-analysis
trials46,48 showed effect size point estimates that favored demonstrated the effectiveness of home exercise program
group and home exercise compared with no intervention; compared with no intervention in individuals with knee
the test for an overall effect was significant (P < .001), OA.13,15,17,18,20,39,40,42,43,47,49 Our findings concur with
with an overall large effect size point estimate of 0.88 those obtained in previous systematic reviews that have
(95% CI, 0.45-1.30) based on a random-effects model demonstrated the benefits of exercise programs for reduc-
(Figure 7). ing pain and disability in individuals with knee OA.50,51
However, in the present review, 4 studies20,40,43,49 failed
DISCUSSION to achieve a statistically significant effect size of functional
score changes and 4 studies40,42,43,49 on pain score changes.
This study is the first systematic review of the literature and The cause of nonsignificant effect size could be due to the
meta-analysis investigating the effectiveness of home exer- methods we adopted to calculate effect sizes. We calculated
cise program on pain and function in patients with knee effect size on the basis of the baseline and final end point
OA. The present review evaluated 19 studies (15 RCTs and scores, which included the potential detraining effect.
4 case-controlled studies, 4270 subjects with knee OA) to Brismee et al46 reported significant reduction of pain and
examine evidence regarding the effectiveness of home exer- functional disability in the tai chi group at weeks 9 and
cise program in the management of knee OA. The analysis 12 (P = .0089 and P = .0157, respectively). However, no
indicated that home exercise programs with and without significant difference was found in pain and function scores
42 Volume 39 • Number 1 • January-March 2016
Copyright © 2016 The Academy of Geriatric Physical Therapy of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
within tai chi or in comparison with the control group, or In the present review, the home exercise compared with
between the 2 groups throughout the follow-up detraining other intervention showed that both interventions dem-
period. onstrated similar effects on pain in 2 studies19,45 and on
function in 3 studies.19,41,45 This is consistent with previous
studies that found no difference in functional improvement
Study name Statistics for each study Hedges's g and 95% CI for older persons with knee OA when comparing clinic-
Hedges's Lower Upper based exercise with home exercise.52,53 Another study
g limit limit P-Value
Study name Statistics for each study Hedges's g and 95% CI Study name Statistics for each study Hedges's g and 95% CI
Hedges's Lower Upper
Hedges's Lower Upper g limit limit P-Value
g limit limit P-Value Tunay et al (2010) –0.346 –0.849 0.157 .178
McCarthy et al (2004) –0.325 –0.594 –0.056 .018
Brismee et al (2007) 0.874 0.243 1.505 .007 Kawasaki et al (2009) –0.076 –0.493 0.341 .720
Bazalel et al (2010) 0.747 0.182 1.312 .010 Deyle et al (2005) –0.612 –0.976 –0.248 .001
Rogers et al (2011) –0.958 –2.071 0.154 .091
0.804 0.383 1.224 .000 –0.370 –0.573 –0.167 .000
–1.00 –0.50 0.00 0.50 1.00 –1.00 –0.50 0.00 0.50 1.00
Favors Control Favors Group and Home Exercise Favors Others Favors Home Exercise
demonstrated similar effect of knee exercise as compared ria. However, of the 19 included studies, only 2 reported
to intra-articular hyaluronic acid on functional improve- the degree of knee OA included in the sample.18,39
ment.54 In the present review, the group education or Most studies reported a priori sample size calculation to
therapy along with home exercise compared with no inter- determine the minimum number of subjects necessary for
vention demonstrated significant reduction of knee pain each group for adequate power.13,15,16,20,38,44,46-49 Although
and improvement of function in individuals with knee OA. wide variation was found in the methods and interventions
Regarding the assessed outcomes, the use of reliable used in these studies, most reported significant improve-
and valid instruments in the studies strengthens the qual- ments in outcome measures following home exercise with
ity of outcomes. The WOMAC index and visual analog and without supervised exercise program. There was con-
pain scale were the most widely used assessment tools. The siderable variation in the content and duration of the exer-
WOMAC consists of 3 subscales consisting of pain (0-20 cise programs included in our systematic review. Length
points), stiffness (0-8 points), and physical function (0-68 of intervention ranged from 6 weeks to 2 years, while the
points), and a summated total score of the subscales.55,56 home exercise programs included various types of exercises
The WOMAC and visual analogue scale are the most reli- such as isometric quadriceps, isometric hamstrings, isotonic
able and valid tools to assess pain and function in individu- quadriceps, isotonic hamstring, stretching, tai chi, range
als with knee OA.55-58 of motion, and resistance exercise. However, the majority
In 7 studies,13,38,43-46,49 the knee OA diagnosis was of high-quality studies included a combination of open
based on the American College of Rheumatology criteria, and closed kinematic chain exercises as a home exercise
which include clinical and radiographic evaluations, in program with consistent positive outcomes.13,16,18,38,44,47,49
accordance with the Kellgren and Lawrence Scale (grades 1 Adherence to home exercise program is a key predictor
through 4). In 5 studies,15,17,39,42,47 the diagnosis was made of response,59 and encouraging patients with knee OA to
on the basis of radiographic imaging, in 2 studies16,20 based continue exercise programs beyond a supervised period of
on Altman clinical criteria, in 1 study arthroscopically,18 instruction is a major challenge.
while 3 studies19,40,41 did not report which diagnostic cri- The validity of the present meta-analysis may be low due
teria they used. In clinical trials and observational studies, to the heterogeneity in the design and choice of outcomes
knee OA is commonly diagnosed according to these crite- of the included studies. For example, the total intervention
duration varied between 6 weeks44,48 and 2 years 15 and the
sample size varied from 25 subjects41 to 2216 subjects 49
Study name Statistics for each study Hedges's g and 95% CI
Hedges's Lower Upper
in the included studies. Another limitation is the variation
g limit limit P-Value
O'Reilly et al (1999) 0.394 0.095 0.694 .010
Thomas et al (2002) 0.240 0.097 0.384 .001 Study name Statistics for each study Hedges's g and 95% CI
Evcik et al. (2002) 0.945 0.385 1.506 .001
Bruce-Brand et al (2012) 1.624 0.514 2.734 .004
Hedges's Lower Upper
Sled et al (2010) 0.274 –0.162 0.710 .218 g limit limit P-Value
Rogers et al (2012) 0.300 –0.609 1.210 .518
Baker et al (2001) 0.840 0.190 1.491 .011
Brismee et al (2007) 0.776 0.151 1.401 .015
Ravaud et al (2004) 0.066 –0.035 0.167 .203 Bazalel et al (2010) 0.976 0.398 1.554 .001
Konishi et al (2009) 0.013 –0.581 0.608 .965 0.884 0.459 1.308 .000
0.354 0.152 0.555 .001
–1.00 –0.50 0.00 0.50 1.00 –1.00 –0.50 0.00 0.50 1.00
Favors Control Favors Home Exercise Favors Control Favors Group and Home exercise
Heterogeneity: Q-value, 25.68 (P = .001); I2, 68.85%
2
Heterogeneity: Q-value, 0.21 (P = 0.645); I , 0%
Figure 5. Effect of home exercise versus no intervention on Figure 7. Effect of group and home exercise versus no
function. intervention on function.
46 Volume 39 • Number 1 • January-March 2016
Copyright © 2016 The Academy of Geriatric Physical Therapy of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
in outcome measures selected, although pain and physical existing treatment guidelines and systematic review of current research
evidence. Osteoarthritis Cartilage. 2007;15(9):981-1000.
functions were the main outcomes reported in the majority 12. Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the
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it can be concluded that home exercise programs reduced Effects of home-based resistance training and neuromuscular electrical
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ACKNOWLEDGMENT 25. Comprehensive Meta-Analysis Version 2.0. [Computer software]. Englewood,
The authors would like to extend their sincere apprecia- NJ: Biostat; 2014.
26. Petrella RJ, Bartha C. Home based exercise therapy for older patients
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