Systematic Review
Effect of Home Exercise Program in Patients
With Knee Osteoarthritis: A Systematic Review
and Meta-analysis
Shahnawaz Anwer, PT, MPT1,2; Ahmad Alghadir, PT, PhD1;
Jean-Michel Brismée, PT, ScD3
ABSTRACT
Background: The Osteoarthritis Research Society Internation-
al recommended that nonpharmacological methods include
patient education programs, weight reduction, coping strate-
gies, and exercise programs for the management of knee
osteoarthritis (OA). However, neither a systematic review nor a
meta-analysis has been published regarding the effectiveness
of home exercise programs for the management of knee OA.
Purpose: The purpose of this systematic review was to
examine the evidence regarding the effect of home exercise
programs with and without supervised clinic-based exercises
in the management of knee OA.
Methods: We searched PubMed, CINAHL, Embase, Scopus,
and PEDro for research articles published prior to September
2014 using key words such as pain, exercise, home exercise
program, rehabilitation, supervised exercise program, and
physiotherapy in combination with Medical Subject Headings
“Osteoarthritis knee.” We selected randomized and case-con-
trolled trials published in English language. To verify the qual-
ity of the selected studies, we applied the PEDro Scale. Two
evaluators individually selected the studies based on titles,
excluding those articles that were not related to the objectives
of this review. One evaluator extracted data from the included
studies. A second evaluator independently verified extracted
data for accuracy.
Results: A total of 31 studies were found in the search. Of
these, 19 studies met the inclusion criteria and were further
analyzed. Seventeen of these 19 studies reached high meth-
1Department of Rehabilitation Sciences, College of Applied
Medical Sciences, King Saud University, Riyadh, Kingdom
of Saudi Arabia.
2Padmashree Dr. D. Y. Patil College of Physiotherapy,
Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra,
India.
3Center for Rehabilitation Research, Texas Tech University
Health Sciences Center, Lubbock.
This work was funded by the Deanship of Scientific
Research at King Saud University through the research
group project NO. RGP-VPP-209.
The authors declare no conflicts of interest.
Address correspondence to: Shahnawaz Anwer, MPT,
Department of Rehabilitation Sciences, College of Applied
Medical Sciences, King Saud University, Riyadh, Kingdom
of Saudi Arabia (anwer_shahnawazphysio@rediffmail.com).
Kevin Chiu was the Decision Editor.
DOI: 10.1519/JPT.0000000000000045
38
Copyright © 2016 The Academy of Geriatric Physical Therapy of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
JGPT-D-14-00016_LR 38
odological quality on the PEDro scale. Although the methods
and home exercise program interventions varied widely in
these studies, most found significant improvements in pain
and function in individuals with knee OA.
Discussions: The analysis indicated that both home exercise
programs with and without supervised clinic-based exercises
were beneficial in the management of knee OA.
Conclusions: The large evidence of high-quality trials sup-
ports the effectiveness of home exercise programs with and
without supervised clinic-based exercises in the rehabilitation
of knee OA. In addition, small but growing evidence supports
the effectiveness of other types of exercise such as tai chi, bal-
ance, and proprioceptive training for individuals with knee OA.
Key Words: home exercise program, osteoarthritis, pain,
rehabilitation, supervised exercise program
(J Geriatr Phys Ther 2016;39:38-48.)
INTRODUCTION
Knee osteoarthritis (OA) is a major cause of musculoskel-
etal disability in older population affecting both men and
women1-3 and reported by the World Health Organization
on the global burden of disease.4 Knee OA causes pain,
joint stiffness, and decreased quadriceps strength resulting
in physical disability and disease progression,5-8 with mod-
els showing a decrease in Western Ontario and McMaster
osteoarthritis (WOMAC) scores by 1.77 units per year in
most of knee OA population,9 leading to rapid progression
to knee arthroplasty.10
Reduction of pain and improvement of function are
the main aims of any treatment approach in the manage-
ment of knee OA. Combinations of treatment approaches,
including both pharmacological and nonpharmacological
methods, are often preferred over a single approach.11 The
Osteoarthritis Research Society International recommended
nonpharmacological methods, including patient education
programs, weight reduction, coping strategies, and exercise
programs, in the treatment of knee OA.12 Both rehabilita-
tion programs with and without supervised clinic-based
exercises have been shown to reduce pain and improve
of function in individuals with knee OA.13-15 Although
home exercise programs have advantages over supervised
clinic-based exercise programs because they are inexpensive
and require little to no equipment, concerns arise about
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03/12/15 8:54 PM

long-term compliance of home exercise programs. In a
prospective long-term study conducted by Deyle et al,16 the
effects of a home exercise program on lower extremity func-
tion were almost equal to those of supervised clinic-based
exercise programs even at 1-year follow-up. Past studies
have consistently shown that a home exercise program
is beneficial for improving strength, reducing pain, and
improving function in individuals with knee OA.13-20
However, neither a systematic review of the literature
nor a meta-analysis has been published on the effective-
ness of home exercise programs for the management of
individuals with knee OA. Hence, the objectives of this
systematic review were to investigate evidence regarding
the effectiveness of home exercise programs in the manage-
ment of individuals with knee OA.
METHODS
Search Strategy
The search was conducted in PubMed, CINAHL, Embase,
Scopus, and PEDro using a combination of key words
such as pain, exercise, home exercise program, rehabilita-
tion, supervised exercise program, and physiotherapy with
“osteoarthritis knee” and the medical subject headings
“osteoarthritis, knee” combined with “exercise” or “reha-
bilitation.” The bibliographical survey was restricted to
randomized and case-controlled trials published in English
language prior to September 1, 2014. Hand searching of the
identified papers was used to find other appropriate papers.
The authors were asked to provide full text of potential
articles that were not available online. Two evaluators indi-
vidually selected the studies based on titles, excluding those
articles not related to the objectives of this review. After
selection, the abstracts of the selected studies were analyzed
by evaluators to identify those that met the inclusion criteria.
Inclusion and Exclusion Criteria
Limits were by design as we included only randomized clini-
cal trials (RCTs) and case-controlled trials, published in the
English language prior to September 1, 2014. The interven-
tion of interest was home exercise programs for individuals
with knee OA. Trials were required to compare home exer-
cise programs with inpatient/outpatient physical therapy,
and no intervention. Studies that did not include home exer-
cise programs in their interventions were excluded. The out-
come measures of interest were pain and function in patients
with knee OA. Randomized clinical trials were excluded if
the publication was in the abstract form only.
Assessment of Methodological Quality
The PEDro Scale21 was used to assess the methodological
quality of the included studies. It consists of 11 questions
that assess the methodological quality of RCTs and focuses
on 2 aspects of the study: whether it has internal validity
(criteria 2-9) and whether it contains sufficient statistical
Journal of GERIATRIC Physical Therapy
Copyright © 2016 The Academy of Geriatric Physical Therapy of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
JGPT-D-14-00016_LR 39
Systematic Review
information to make it interpretable (criteria 10-11). Each
question is scored according to its presence or absence in
the assessed study. The final score is calculated by the sum
of all positive responses.
In accordance with Moseley et al,22 studies with a score
of 5 (50%) or greater were considered high-quality. So, in
the present review, all randomized studies with scores of
5 (5/10) or greater were considered to be of high method-
ological quality. The analysis of studies classified with the
PEDro Scale was done independently by 2 evaluators.
The Cochrane collaboration’s tool for assessing risk of
bias was used to assess risk of bias in the domain-based
evaluation. The sequence generation, allocation conceal-
ment, blinding of participants, therapist and assessors,
completeness of outcome data, and selective outcome
reporting were the domains assessed. Risk of bias was clas-
sified as low, unclear, and high in each domain.23
Data Analysis
The selected studies were screened by 2 independent
evaluators. The analysis of included studies was per-
formed according to a structured script using the follow-
ing parameters: author/year, subjects, design, outcomes
measurement, intervention, instruments, and effects
found. Disagreements between the evaluators were
resolved by discussion to reach consensus. Agreement
between the 2 evaluators was determined by using
unweighted kappa (κ).
The outcome measures of interest were pain and func-
tion. The mean and standard deviation of the baseline and
final end point scores for pain and function were extracted
from included studies. The mean change score (final end
point minus baseline score) for each outcome measure
was calculated for each intervention. Studies that did not
provide estimates of random variability or presented data
as medians were excluded from the meta-analysis. The
standardized mean difference for the outcomes (pain and
function) was computed using Hedges’ (adjusted) g (g =
M1 − M2/ Spooled, where M1 and M2 are the mean change
score of groups 1 and 2. Spooled is the estimate of the popu-
lation standard deviation).24 Cohen’s categories were used
to evaluate the magnitude of the effect size, calculated by
the standardized mean difference, with g < 0.5 as a small
effect size; g ≥ 0.5 and ≤0.8, medium effect size; and g >
0.8, large effect size. The random effects meta-analysis was
conducted to determine the overall effect size of home exer-
cise program. Ninety-five percent confidence intervals were
calculated for effect sizes on the basis of a generic inverse
variance outcome model. The z statistic was used to test for
significance of the overall effect. The Cochran’s Q statistic
and the Higgins’ I2 statistic24 were used to determine statis-
tical heterogeneity between studies. A low P value (≤.10)
for the Q statistic was considered evidence of heterogene-
ity of treatment effects. All statistics were computed using
Comprehensive Meta-Analysis software.25
39
03/12/15 8:54 PM
 Systematic Review

RESULTS meet intention-to-treat criterion,18,38-42 and 1 trial failed to

Identified Studies
The initial search resulted in 65 research studies. A total
of 34 studies that appeared in more than 1 database
or did not meet predetermined inclusion criteria were
excluded. A total of 31 studies were assessed for eligibil-
ity. Twelve studies were eliminated because they did not
match the inclusion criteria or were not available in full
text (Figure 1). The final selection, made by consensus,
resulted in the inclusion of 19 studies in the quality
assessment phase.
Quality Assessment of Study
The 19 included studies had an average PEDro score of
6.78/10, as illustrated in Table 1. These scores represent
multiple sources of bias that may skew the results. The most
common shortcomings were lack of blinding (patient, thera-
pist, or assessor) and concealed allocation. Three trials failed
to meet the randomization criterion,17,20,40 6 trials failed to
meet the baseline comparability41 criterion of PEDro.
Five trials failed to meet the follow-up13,15,18,38,45 and
point and variability measures17-19,39,46 criterion of PEDro.
However, when these studies were examined together,
there was strong scientific evidence from high-quality stud-
ies with consistent results that the home exercise programs
brought significant improvement in individuals with knee
OA.13,15-20,38,39,41,42,44-49
Agreement between evaluators was excellent (unweight-
ed κ = 0.85) in assessing risk of bias across studies.
Table 2 details the risk of bias assessment of the included
studies. The overall risk of bias assessment indicated that
the risk of bias was low in 6 studies,15,16,38,41,44,46 high in
10 studies,13,17-20,39,40,42,43,49 and unclear in the other 3
studies.45,47,48
General Data About the Selected Studies
Table 3 summarizes the studies included in this systematic
review using the following information: author, subjects,

Studies idenfied through electronic Studies idenfied through hand

database searching searching
Idenficaon

(n = 65) (n = 35)

Studies aer duplicates removed

(n = 31)
Screening

Studies screened Studies excluded26-31

(n = 31) (n = 06)
Eligibility

Full-text studies excluded (n = 06)

Full-text studies assessed Case study (n=01)32
for eligibility No control group (n=02)33,34
(n = 25) Objective not related to the
review (03)35-37

Studies included in
Included

qualitave synthesis
(n = 19)

Studies included in meta-

analysis
(n = 16)

Figure 1. Flow diagram of the study procedure.

40 Volume 39 • Number 1 • January-March 2016

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 Systematic Review

(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

as home exercise programs. One study used propriocep-

tion,19 cold compression,19 neuromuscular electrical stimu-
Yes
Yes
Yes
Yes
Yes

Yes

Yes
Yes
No

No

Talbot et al42
8

lation,18 pedometer-driven walking,40 and tai chi exercise46

as home exercise programs.
Yes
Yes
Yes
Yes
Yes

Yes

Yes
Yes
No

No

Rogers et al41
8

Outcome Measures
Yes

Yes

Yes
Yes

The outcome measures of interest were pain and func-

No
No

No
No
No

No

Konishi et al40
4

tion in patients with knee OA. Eight studies used Western

Ontario and McMaster Universities Osteoarthritis
Yes

Yes

Yes
Yes
Yes
Yes
Yes
No

No

No

Aoki et al39
7

Index (WOMAC) pain score,13,15,16,18,20,40,43,47 7 studies

used visual analogue scale,17,19,38,39,45,46,49 and 1 study
Yes
Yes
Yes

Yes
Yes

Yes
Yes
Yes
No

No

McCarthy et al36
8

used present pain intensity index of the McGill Pain

Questionnaire,42 for measuring pain. One study used
Yes

Yes
Yes
Yes
Yes
No
No

No
No
No

Sled et al20
5

Japanese Knee Osteoarthritis Measure,45 while others used

WOMAC for measuring function.
Yes

Yes

Yes
Yes
Yes
No

No
No
No

No

Tunay et al19
5

et al18 Effect of Home Exercise Program on Pain

Yes
Yes
Yes

Yes

Yes
No
No

No
No

No
5

Meta-analysis of 11 trials13,15,17,18,20,39,40,42,43,47,49 showed

Bruce-Brand

that most study outcomes displayed effect size point

Table 1. Methodological Classification Assessed by PEDro Scale

Yes

Yes
Yes
No
No

No
No
No

No
No

Evcik et al17
3

estimates that favored home exercise compared with no

intervention; the test for an overall effect across the 11
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

included studies was significant (P < .001), with an overall

Deyle et al16
10

small effect size point estimate of 0.46 (95% CI, 0.24-0.68)

Yes
Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes
No

based on a random-effects model (Figure 2). Meta-analysis

Thomas et al15
9

of 3 trials19,38,45 showed that 1 study had an effect size point

estimate that favored the other intervention compared with
Yes
Yes
Yes

Yes
Yes
Yes
No
No
No
No

O’Reilly et al13
6

home exercise; however, 2 studies displayed insignificant

effect size point estimate to favor any one intervention (P >
.05) (Figure 3). Meta-analysis of 2 trials46,48 showed effect
Point and variability measures?

size point estimates that favored the group and home exer-
cise compared with no intervention; the test for an overall
Intention-to-treat analysis?

effect was significant (P < .001), with an overall large effect

Baseline comparability?
Concealed allocation?

Group comparisons?
Random allocation?

size point estimate of 0.80 (95% CI, 0.38-1.22) based on a

Blind participants?

Cumulative score
Blind assessors?

random-effects model (Figure 4).

Blind therapists

Follow-up?

Effect of Home Exercise Program on Function

Criteria

Meta-analysis of 9 trials13,15,17,18,20,40,43,47,49 showed that

most studies displayed effect size point estimates that
Journal of GERIATRIC Physical Therapy 41
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 Systematic Review

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;
the test for an overall effect across the 9 included studies
was significant (P < .001), with an overall small effect
size point estimate of 0.35 (95% CI, 0.15-0.55) based
on a random-effects model (Figure 5). Meta-analysis of
5 trials16,19,38,41,45 showed that 2 studies had an effect
size point estimate that favored the other intervention
compared with home exercise; however, 3 studies indi-
cated insignificant effect size point estimate to favor any
one intervention (P > .05) (Figure 6). Meta-analysis of 2
trials46,48 showed effect size point estimates that favored
group and home exercise compared with no intervention;
the test for an overall effect was significant (P < .001),
with an overall large effect size point estimate of 0.88
(95% CI, 0.45-1.30) based on a random-effects model
(Figure 7).
DISCUSSION
This study is the first systematic review of the literature and
meta-analysis investigating the effectiveness of home exer-
cise program on pain and function in patients with knee
OA. The present review evaluated 19 studies (15 RCTs and
4 case-controlled studies, 4270 subjects with knee OA) to
examine evidence regarding the effectiveness of home exer-
cise program in the management of knee OA. The analysis
indicated that home exercise programs with and without
42
Copyright © 2016 The Academy of Geriatric Physical Therapy of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
supervised clinic-based exercises are used commonly in
clinical physical therapy practice for individuals with knee
OA. Among the 19 studies evaluated using the PEDro
scale,21 17 were considered of high methodological quality.
On the basis of the present review, the home exercise pro-
grams used in the reviewed literature can be considered as
treatment possibilities for individuals with knee OA.
The methodological guidelines of the evaluated studies
were properly prepared and described, allowing clinical
reproducibility. This systematic review and meta-analysis
demonstrated the effectiveness of home exercise program
compared with no intervention in individuals with knee
OA.13,15,17,18,20,39,40,42,43,47,49 Our findings concur with
those obtained in previous systematic reviews that have
demonstrated the benefits of exercise programs for reduc-
ing pain and disability in individuals with knee OA.50,51
However, in the present review, 4 studies20,40,43,49 failed
to achieve a statistically significant effect size of functional
score changes and 4 studies40,42,43,49 on pain score changes.
The cause of nonsignificant effect size could be due to the
methods we adopted to calculate effect sizes. We calculated
effect size on the basis of the baseline and final end point
scores, which included the potential detraining effect.
Brismee et al46 reported significant reduction of pain and
functional disability in the tai chi group at weeks 9 and
12 (P = .0089 and P = .0157, respectively). However, no
significant difference was found in pain and function scores
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 Systematic Review

Table 3. General Data About the Selected Studies

Study Subjects Design Interventions Outcomes Effects Found
O’Reilly et al13 Diagnostic: ACR Randomized Group 1: Home VAS Pain scores were
Inclusion: Knee pain controlled trial exercise program WOMAC index reduced by 22.5%
Age: 40-80 y (both Evaluations: at (n = 78) in the home exercise
male and female) baseline and Group 2: Control group and by 6.2%
at 6 mo (end of (n = 113) in the control group.
intervention) WOMAC score was
reduced by 17.4%
in the home exercise
group and was
unchanged in the
control group.
Thomas et al15 Diagnostic: x-ray Randomized con- Group 1: Home WOMAC index At 24 mo, the exercise
Inclusion: knee pain trolled trial exercise program groups improved
Age: >45 y Evaluations: pre, (n = 235) significantly better
6 mo, 12 mo, Group 2: control than nonexercise
18 mo, and 24 (n = 78) groups.
mo of intervention Stiffness and function
on WOMAC index
showed significant
improvements in
exercise group
compared with
nonexercise group.
Deyle et al16 Diagnostic: Altman clinical Randomized con- Group 1: Clinic- WOMAC index Both treatment groups
criteria trolled trial based exercise obtained success-
Inclusion: Knee pain and Evaluations: pre-, (n = 66) ful outcomes, as
crepitus with active mo- 4 wks and 8 wks Group 2: Home- measured by sig-
tion and morning of intervention based exercise nificant reductions in
Stiffness ≤30 min and age and follow up at (68) WOMAC scores over
≥38 y 52 wks. a 8-wk period.
Evcik et al17 Diagnostic: x-ray Pretest/posttest ex- Group 1: Home WOMAC index Simple home-based
Inclusion: knee OA perimental group Exercise program VAS (0-100 mm) exercise program
Age: 48-71 y (both male design (n = 30) leads to improve-
and female) Evaluations: pre and Group 2: Control ments in pain and
at 6 mo (end of (n = 30) function
intervention)
Bruce-Brand et al18 Diagnostic: arthroscopically Randomized con- Group 1: Home WOMAC index Home-based NMES
with grade 3 or 4 OA trolled trial based NMES (14) group significantly
Inclusion: Kellgren- Evaluations: at Group 2: Control improve functional
Lawrence severity grades baseline (familiar- (13) performance in pa-
of 3 or 4 with symptomat- ization), week 1 tients with moderate
ic moderate to severe OA (preintervention), to severe knee OA.
Aged 55-75 y week 8 (postint-
ervention) and
week 14 (6 wks
post-intervention).
Tunay et al19 Diagnostic: not reported Pretest/posttest ex- Group 1: Hospital- VAS Reduction of pain
Inclusion: age at least perimental group based treatment WOMAC index intensity is noted in
50 years, diagnosis of design (n = 30) both groups.
bilateral knee OA, not Evaluations: pre and Group 2: Home WOMAC score im-
having received treatment at 6 wks (end of exercise (n = 30) proved significantly
for knee OA in the last intervention) in both the groups.
6 mo
Sled et al20 Diagnostic: Altman clinical Pretest/posttest, Group 1: Home WOMAC Index Neither group showed
criteria control group exercise program any improvement on
Inclusion: radiographic evi- design (n = 40) WOMAC functional
dence of medial knee OA Evaluation: pre and Group 2: Control scores
Age: >40 y at 8 wks (end of (n = 40)
intervention)
(continues)

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 Systematic Review

Table 3. General Data About the Selected Studies (Continued)

Study Subjects Design Interventions Outcomes Effects Found
McCarthy et al38 Diagnostic: ACR, radiological Randomized con- Group 1: Home- VAS The supplemented
Inclusion: knee pain, trolled trial based exercise WOMAC index group showed
evidence of arthritis on Evaluations: pre and (n = 103) improvement in
x-ray at 8 wks (end of Group 2: Class- locomotor functions
Any 3 from the followings: intervention) and based exercise of the ALF outcome,
Age: >50 y follow up at 3, 6, supplemented pain experienced
Stiffness >30 min upon 9, and 12 mo. with home exer- while walking,
waking, crepitus, bony cise (n = 111) WOMAC score, bal-
tenderness ance, strength and
Bony enlargement, No range of motion.
palpable warmth
Aoki et al39 Diagnostic: x-ray 2 Randomized con- Group 1: Home- VAS Reduced pain in home
Inclusion: unilateral or bilat- trolled trial based Stretching based stretching
eral OA (grades 3-4) Evaluations: (n = 17 female) group
Age: Mean 73.3 y pre- and Group 2: Control
BMI (kg/m2): Mean 26 post-intervention (n = 19 female)
Konishi et al40 Diagnostic: Not reported A nonrandomized Group 1: Home-visit WOMAC index Home-visit physiother-
Inclusion: Aged 60 years controlled trial physiotherapy apy improves knee
or more (female), knee Evaluations: at (n = 20) pain and functions.
pain, WOMAC total score baseline and at Group 2: Control
of <20 5 months (end of (n = 22)
intervention),
Rogers et al41 Diagnostic: not reported Randomized trial Group 1: Clinic WOMAC index Both home-based and
Inclusion: physician- Evaluations: at base- based KBA exer- clinic-based KBA is
diagnosed symptomatic line and 8 wks. cise (n = 6) effective for improv-
knee OA, knee pain on Group 2: Home- ing the symptoms.
most days of previous based KBA
month, met a minimum (n = 19)
score for physical function
difficulties and free of
other rheumatic disease.
Talbot et al42 Diagnostic: x-ray Randomized con- Group 1: Home- McGill pain Ques- Home-based
Inclusion: Pain in 1 or both trolled trial based pedometer- tionnaire (MPQ) pedometer-driven
knees on most days, dif- Evaluations: at base- driven walking (n intervention with an
ficult performing at least 1 line, every 4 wks = 17) educational program
functional task because of for 24 wks. Group 2: arthritis effectively increased
pain. Aged 60 y and older self-management activity while improv-
group (n = 17) ing walking efficiency
and strength.
Rogers et al43 Diagnostic: ACR Randomized con- Group 1: KBA+RT WOMAC index KBA and RT as home
Inclusion: self-reported trolled trial training (n = 9) exercise programs
knee pain, minimum Evaluations: at base- Group 2: Control appear effective in
disability score of 17 line, at 4-wk, and (n = 8) reducing symptoms
points on physical func- at 8- wk follow-up and improving the
tion subscale of WOMAC. quality of life.
Aged 50 y and older
Chaipinyo et al44 Diagnostic: ACR A randomized trial Group 1: Home- KOOS Balance training or
Inclusion: Aged 50 y or older Evaluations: at based balance strength training
(both male and female) baseline and at training (n = 24) as home exercise
4 wks (end of Group 2: Home- program appears
intervention) based strength effective in reducing
training (n = 24) pain and improving
function.
Kawasaki et al45 Diagnostic: ACR Randomized open Group 1: Home JKOM Both HA injections and
Inclusion: postmenopausal labeled trial. exercise (n = 52) VAS home exercise equal-
female with primary OA Evaluations: at Group 2: Intra- ly resulted in relief of
of medial femorotibial baseline, and at articular injection pain and functional
compartment of the knee. 24 wk group (n = 52) improvement.
Aged 50 y and older
(continues)

44 Volume 39 • Number 1 • January-March 2016

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 Systematic Review

Table 3. General Data About the Selected Studies (Continued)

Study Subjects Design Interventions Outcomes Effects Found
Brismee et al46 Diagnostic: ACR Randomized con- Group 1: Tai chi VAS 12-wk tai chi program
Inclusion: knee pain, aged trolled trial exercise (n = 22) WOMAC index consisting of 6 wks
50 y and older, able to Evaluations: at Group 2: Group of group exercise
read or write English, able baseline, 3, 6, Education followed by 6 wks
to ambulate at least 25 ft. 9, 12 wks and (n = 19) of home exercise
follow-up at 15 reduces knee pain
and 18 wks. and improves physi-
cal function.
Baker et al47 Diagnostic: x-ray. A randomized Group 1: Home- WOMAC index Home-based progres-
Inclusion: Aged 55 y or controlled trial based strength sive strength training
older, Body mass index Evaluations: at training (n = 23) program significantly
≤40 kg/m2, pain on baseline and at Group 2: Placebo reduces pain and
more than half the days 4 months (end of intervention of improves physical
of previous month during intervention) nutrition educa- function by approxi-
activities tion (n = 22) mately 30% greater
than control group.
Bezalel et al48 Diagnostic: prediagnosed A parallel random- Group 1: Group WOMAC Group education along
case of knee OA ac- ized clinical trial education pro- with home exercise
cording to the Interna- Evaluations: at gram with Home program is associ-
tional classification of baseline, at 4 wks Exercise program ated with improved
disease-10. (end of interven- (n = 25) functional abilities
Inclusion: Aged 65 y or more tion), and at Group 2: Short wave and pain reduction.
(both male and female) 8 wks (follow-up) diathermy (n =
Knowledge of Hebrew 25)
language
Ravaud et al49 Diagnostic: ACR clinical and Randomized con- Group 1: Home VAS (0-100 mm) Home exercise group
radiological trolled trial exercise (n = WOMAC index showed a significant
Inclusion: knee pain ≥ 6 Evaluations: 550) improvement in
months, Pain score on pre- and Group 2: Control pain and WOMAC
100 mm VAS ≥ 30 mm postintervention group (n = 568) function subscale at
Pain for at least 14 d dur- 24 wks.
ing preceding month
ACR, American College of Rheumatology; BMI, body mass index; HA, Hyaluronic Acid; JKOM, Japanese Knee Osteoarthritis Measure; KBA, Kinesthesia balance and agility; KOOS, knee injury
and osteoarthritis outcome score; NMES, Neuromuscular electrical stimulation; OA, osteoarthritis; RT, Resistance training; VAS, visual analogue scale; WOMAC, Western Ontario and McMaster
Universities Osteoarthritis Index.

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

O'Reilly et al (1999) 0.356 0.056 0.655 .020

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) 0.490 0.049 0.930 .029 g limit limit P-Value
Rogers et al (2012) 0.548 -0.375 1.470 .244
Baker et al (2001) 0.864 0.212 1.516 .009 Tunay et al (2010) –0.240 –0.741 0.261 .348
Ravaud et al (2004) 0.021 -0.080 0.122 .687 McCarthy et al (2004) –0.345 –0.615 –0.076 .012
Konishi et al (2009) 0.013 -0.581 0.608 .965
Aoki et al (2009) 1.093 0.405 1.781 .002 Kawasaki et al (2009) 0.063 –0.354 0.480 .766
Talbot et al (2003) 0.599 -0.073 1.271 .080 –0.228 –0.434 –0.022 .030
0.464 0.244 0.685 .000
-1.00 -0.50 0.00 0.50 1.00
–1.00 –0.50 0.00 0.50 1.00
Favors Others Favors Home Exercise
Favors Control Favors Home Exercise
Heterogeneity: Q- value, 40.42 (P = .001); I 2, 75.26% Heterogeneity: Q- value, 2.59 (P = .273); I 2, 22.87%
Figure 2. Effect of home exercise versus no intervention on Figure 3. Effect of home exercise versus other interventions
pain. on pain.

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 Systematic Review

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

Heterogeneity: Q-value, 4.79 (P = 0.309); I2, 16.63%

Heterogeneity: Q-value, 0.09 (P = .762); I 2, 0%
Figure 6. Effect of home exercise versus other intervention
Figure 4. Effect of group and home exercise versus no on function.
intervention on pain.

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
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JGPT-D-14-00016_LR 46 03/12/15 8:54 PM


in outcome measures selected, although pain and physical
functions were the main outcomes reported in the majority
of studies.13,15,17,19,38-40,44-49 However, no studies focused
on the dosimetry of exercise (frequency, intensity, duration,
and resistance), which cannot be analyzed in this review.
Future high-quality studies are needed to assess which
duration, dose, and type of exercise are optimal for patients
with knee OA or if lifelong exercises are needed to maintain
the benefits of exercises.
CONCLUSION
Based on the high methodological quality of studies includ-
ed in this systematic literature review and meta-analysis,
it can be concluded that home exercise programs reduced
knee pain and improved function in individuals with knee
OA. The large evidence base supports the effectiveness of
a variety of home programs including open and closed
kinematic chain exercises. In addition, small but growing
evidence supports the effectiveness of other types of exer-
cise such as tai chi, balance, and proprioceptive training
for individuals with knee OA. Even though less is known
about the effects of these types of exercise, they provide
new alternatives for individuals with OA to modify or
vary their exercise program. Further direct comparison
is required to investigate the relative efficacies of these
exercise programs.
ACKNOWLEDGMENT
The authors would like to extend their sincere apprecia-
tion to the Deanship of Scientific Research at King Saud
University for funding this research through the research
group NO. RGP-VPP-209.
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