[ brief report ]

CECILIE BARTHOLDY, PT, MSc1,2 • LOUISE KLOKKER, PT, MSc1 • ELISABETH BANDAK, PT, MSc1
HENNING BLIDDAL, MD, MDSc1 • MARIUS HENRIKSEN, PT, PhD1,2

A Standardized “Rescue” Exercise

Program for Symptomatic Flare-up
of Knee Osteoarthritis: Description
and Safety Considerations

E
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xercise is recommended as a primary treatment for patients particular weight bearing, may seem in-
with knee osteoarthritis (OA)3,7,15; however, studies have appropriate to the patient,2 and adjust-
indicated low adherence to exercise therapy programs among ing the exercise program is common in
clinical physical therapy practice to ac-
patients with knee OA, partly because of the fluctuating
Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

commodate this situation. In exercise in-

symptoms.4,10,12 On a day with symptomatic exacerbation, exercise, in
TTSTUDY DESIGN: Secondary analysis of clinical
trial data.
TTBACKGROUND: Knee osteoarthritis (OA)
management has changed significantly over recent
decades toward nonpharmacological treatments,
particularly exercise. However, the optimal exercise
Journal of Orthopaedic & Sports Physical Therapy®
TTRESULTS: Of 131 participants included, 2 never
commenced the exercise program, leaving 129
to be included in the analysis. The analysis was
observational and thus had no comparison group.
During the program, 36 participants (28%) were
referred to the rescue exercises. In 63% of the
tervention studies, a description of these
adjustments rarely exists in sufficient de-
tail for replication.1
Having standardized and prespeci-
fied principles of adjustments would
serve several important purposes. First,
it would increase the reproducibility of
exercise interventions delivered in clini-

program remains to be established.
TTOBJECTIVE: To describe the implementation
of standardized rescue exercises for patients
with pain exacerbations and to assess whether
performing these benefit or further worsen
symptoms in patients with exacerbated symptoms
of knee OA.
TTMETHODS: The data from 2 randomized
controlled studies of exercise in patients with knee
OA were used. A supervised, standard exercise
program that included standardized “rescue” exer-
cises to be performed in the event of symptomatic
exacerbation, defined as knee pain of greater than
5 on a 0-to-10 numeric pain-rating scale, was
conducted for 12 weeks at 3 sessions per week.
Pain ratings were obtained before and after each
exercise session.
rescue sessions, the participants experienced de- cal trials, thus increasing the likelihood
creased pain intensity (average ± SD, –2.6 ± 2.3),
that patients who are referred to exercise
27% reported no change in pain, and 10% reported
would actually receive evidence-based
increased pain intensity (average ± SD, 1.3 ± 0.5).
exercise interventions—even in the case
TTCONCLUSION: Having a predefined and
of symptomatic exacerbations. Further, a
standardized rescue exercise option appears ben-
“rescue” option as a standardized part of
eficial, and did not result in further worsening of
exacerbated knee OA symptoms. The intervention the intervention may empower patients
may be particularly relevant for patients with knee to attend an exercise session and might
OA who have more severe symptoms. even cause an immediate decrease in
TTLEVEL OF EVIDENCE: Therapy, level 2b.
pain.9 Finally, a standardized rescue op-
Registered at www.clinicaltrials.gov (NCT01545258 tion would encourage the participants to
and NCT01945749). J Orthop Sports Phys
attend an exercise session, despite having
Ther 2016;46(11):942-946. Epub 28 Sep 2016.
a “bad knee day,” thereby enhancing over-
doi:10.2519/jospt.2016.6908
all adherence and ultimately improving
TTKEY WORDS: pain exacerbation, safe exercise,
symptomatic OA, therapeutic exercise clinical outcomes. Currently, guidelines
are being developed to improve the stan-

1
The Parker Institute, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark. 2Department of Physical and Occupational Therapy, Copenhagen
University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark. The Danish Council for Independent Research/Medical Sciences (grant number 10-093704), Danish
Physiotherapists Association, The Lundbeck Foundation, and The Oak Foundation provided funding to cover salaries and running costs. The study was approved by the Danish
Ethics Committee (H-2-2011-159), the Danish Health and Medicines Authority, and the Regional Health Research Ethics Committee. The trial was registered with the mandatory
European Union clinical trials register EudraCT (number 2012-002607-18). The trial was also registered at www.clinicaltrials.gov (NCT01545258 and NCT01945749). The data
set will be available from the corresponding author as part of an academic collaboration. The authors certify that they have no affiliations with or financial involvement in any
organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Professor Marius Henriksen, The
Parker Institute, Copenhagen University Hospital Bispebjerg and Frederiksberg, Nordre Fasanvej 57, DK-2000 Copenhagen F, Denmark. E-mail: marius.henriksen@regionh.dk t
Copyright ©2016 Journal of Orthopaedic & Sports Physical Therapy®

942 | november 2016 | volume 46 | number 11 | journal of orthopaedic & sports physical therapy

46-11 Bartholdy.indd 942 10/19/2016 7:36:20 PM

 dard for reporting exercise interventions,
and including standardized “rescue” op-
tions would increase the transparency of
such reports.1
A standardized rescue option was
part of an exercise intervention used in
2 trials5,6 that investigated the effect of a
functional and individualized therapeu-
tic exercise program for patients with
knee OA (FITE-OA). The program was
designed to increase the patients’ general
physical function, knee-specific function
during functional tasks, and coordination
and muscle strength, as well as reduce
Downloaded from www.jospt.org at on June 11, 2021. For personal use only. No other uses without permission.
pain. The components of the exercise
program are not novel, but the standard-
ized rescue option is. The application of
the standardized rescue exercises for pa-
tients with symptom exacerbations has
Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
not been evaluated before.
The aims of this study were to de-
scribe the implementation of standard-
ized rescue exercises and assess, by
measuring immediate pain intensity
changes, whether these rescue exercises
are possible to perform on days with
symptomatic exacerbations in patients
with knee OA.
Journal of Orthopaedic & Sports Physical Therapy®
METHODS
Participants and Settings
D
ata were collected from 2 ran-
domized controlled trials (RCTs)
that applied the FITE-OA program
(www.clinicaltrials.gov; NCT01545258
and NCT01945749). The first RCT in-
cluded 60 participants, who were ran-
domized to a FITE-OA group (n = 31)
or control group (n = 29) that received
no intervention.6 The second RCT in-
cluded 100 participants who all re-
ceived FITE-OA,5 resulting in a total of
131 participants allocated to FITE-OA
across the 2 RCTs. The 2 RCTs shared
the following inclusion criteria: age of
40 years or more, clinical diagnosis of
knee OA confirmed by radiography, and
body mass index between 20 and 35 kg/
m2. The 2 studies recruited separate pa-
tient populations. Exclusion criteria were
participation in exercise therapy within
journal of orthopaedic & sports physical therapy | volume 46 | number 11 | november 2016 |
46-11 Bartholdy.indd 943
the previous 3 months; systemic inflam-
matory and autoimmune diseases; other
significant cardiovascular, neurological,
or psychiatric disease; and widespread
or regional pain syndromes such as fi-
bromyalgia. Participants were recruited
from March 2012 to October 2013 from
the OA outpatient clinic of Copenhagen
University Hospital at Bispebjerg and
Frederiksberg, Denmark.
The details of the FITE-OA program
have been described previously6; a full
description of the exercise program, in-
cluding progression guidelines and the
standardized rescue option, is provided
in the APPENDIX (available at www.jospt.
org). In brief, the program is facility
based, lasts for approximately 1 hour, and
occurs 3 times per week over a 12-week
period. Each session was performed in a
gymnasium at a hospital in Copenhagen,
with a trained physical therapist present
at all times. An average of 15 people par-
ticipated per training session, each par-
ticipant arriving at a specific time and
performing the program at his or her pre-
ferred pace. The program consisted of a
warm-up period, strengthening exercises,
and functional tasks.
Rescue Exercise Sessions
If a participant reported current knee
pain above 5 on a 0-to-10 numeric pain-
rating scale (NPRS), with 0 as no pain
and 10 as the worst imaginable pain,14 be-
fore an exercise session, standardized res-
cue exercises were applied individually to
accommodate fluctuations in knee pain.
The rescue exercises were only applied
for one session at a time. Knee pain was
reassessed at the subsequent session to
evaluate whether a rescue session should
be applied once more.
The rescue exercises were a modi-
fication of the full program, excluding
weight-bearing exercises and with the
addition of longer warm-up on the er-
gometer bicycle (15 minutes), followed by
exercises within the 3 focus areas: core
strength and coordination, hip coordina-
tion, and hip abductor strength. These 3
exercises were repeated after 5 minutes
of ergometer cycling. Core strength and
coordination was performed as a knee
plank, full plank, or lateral plank for two
1-minute sets, depending on the individ-
ual’s level of progression at that time. Hip
coordination was performed as a supine
pelvic lift, supine pelvic lift with a Swiss
ball, 1-leg pelvic lift, or 1-leg pelvic lift on
a Swiss ball for 2 to 3 sets of 6 to 8 repeti-
tions, depending on the individual’s skill
level at that time. Hip abductor strength
exercises were performed in either sidely-
ing with a rubber band around the thigh
or sidelying with a rubber band around
the ankles for 2 to 3 sets of 6 to 8 repeti-
tions, depending on the individual’s skill
level at that time (see the APPENDIX for
further details).
Participants were instructed to per-
form the rescue exercises with a mini-
mal amount of pain; if this was not
possible, the exercises were further ad-
justed with respect to range of motion,
resistance, or repetitions.
At inclusion, the participants were
informed of the possibility of exercise
modification (ie, the rescue exercises)
should they experience a bad knee day.
However, to prevent overrating of pain
by participants preferring lighter exer-
cises, the criterion (greater than 5 on
the NPRS) leading to execution of the
rescue exercises was not disclosed to
the participants.
Measurements
Assessment of Pain at the Exercise Ses-
sions Current knee pain was recorded
before and after each exercise session
using a 0-to-10 NPRS, with 0 as no pain
and 10 as the worst imaginable pain,
to assess whether the session affected
pain intensity. For the full FITE-OA
program, a pain intensity of 0 to 2 was
considered safe, 3 to 5 acceptable, and 6
to 10 a risk,14 in which case the partici-
pant was referred to the standardized
rescue program.
Baseline Assessment of the Knee in-
jury and Osteoarthritis Outcome Score
(KOOS) In both parent trials, partici-
pants answered the KOOS13 to assess
943
10/19/2016 7:36:21 PM
 [ brief report ]
TABLE Baseline Characteristics of the Study Participants by Group*

Did Not Receive Rescue Received Rescue Exercises

All Participants (n = 129) Exercises (n = 93) (n = 36) Mean Difference† P Value
Age, y 64 ± 9 64 ± 9 62 ± 9 2.4 (–1.1, 5.9) .18
Female, n (%) 87 (67) 61 (66) 26 (72) ... ...
Body weight, kg 84.0 ± 13.5 84.4 ± 13.6 82.9 ± 13.5 1.4 (–3.9, 6.7) .60
Height, cm 170.4 ± 9.5 170.9 ± 9.1 168.9 ± 10.3 2.1 (–1.6, 5.8) .27
Body mass index, kg/m2 28.9 ± 3.7 28.8 ± 3.8 29.1 ± 3.5 –0.2 (–1.7, 1.2) .77
KOOS‡
Pain 54.6 ± 14.0 58.2 ± 12.6 45.3 ± 13.5 12.9 (8.0, 17.9) <.0001
Function 62.2 ± 15.9 66.1 ± 14.7 52.2 ± 14.7 13.9 (8.2, 19.6) <.0001
Quality of life 37.5 ± 13.7 40.3 ± 13.2 30.4 ± 12.4 9.9 (4.9, 14.8) .0002
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Sport/activity 28.5 ± 18.5 32.2 ± 19.1 18.9 ± 12.9 13.3 (7.5, 19.1) <.0001
Symptoms 57.6 ± 17.0 60.3 ± 16.2 50.9 ± 17.3 9.4 (2.9, 15.8) .0047
Abbreviation: KOOS, Knee injury and Osteoarthritis Outcome Score.
*Values are mean ± SD unless otherwise indicated.
†
Values in parentheses are 95% confidence interval.
Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

‡
Subscales are scored from 0 to 100, with 0 being the worst and 100 the best score.

their opinion about their knee and as- ticipants were referred between 1 (n = the ninth session (in the first quarter of
sociated problems. 16, 44%) and 3 (n = 5, 14%) times, and the program).
the median number of rescue sessions
Statistics for a participant was 2 (with 23 [64%] DISCUSSION
Participant demographics and pain in- referred once or twice). The maximum

T
tensities are reported as mean values number of consecutive rescue sessions he aim of the present study was
with standard deviations. Numbers of was 5, observed in 1 participant. Average to describe standardized rescue
Journal of Orthopaedic & Sports Physical Therapy®

rescue sessions are presented. To evaluate
the safety of the rescue sessions, changes
in knee pain from start to end of a res-
cue session were calculated. The mean
± SD changes, together with counts and
proportions of participants experiencing
decreased pain, no change, or increased
pain, are reported as well.
RESULTS
adherence to the exercise program was
80%, and 79% in participants referred to
rescue sessions.
The demographics of participants re-
ferred to the rescue exercises were not
different from those of the rest of the
participants, but they had significantly
worse KOOS scores at baseline (TABLE).
Pain at Rescue Sessions
In 63% (53 sessions) of the rescue ses-
exercises for knee OA patients
with pain exacerbations and evaluate
whether these rescue exercises would
be possible to perform on days in which
patients experienced symptomatic exac-
erbations. In most cases, pain intensity
was reduced following a rescue session,
indicating that modified exercises may
be performed on days when there are
symptomatic flare-ups.
On an individual level, the possibil-

O
ne hundred thirty-one partici-
pants from the 2 parent trials were
allocated to the FITE-OA pro-
gram; participant characteristics are
summarized in the TABLE. Two partici-
pants withdrew from the 2 parent trials
before commencing the exercise pro-
gram, resulting in a sample in this study
of 129 participants. A total of 36 (28%)
participants were referred to the rescue
program between 1 and 7 times each,
resulting in a total of 84 rescue sessions
(2.4%). Twenty-eight (78%) of these par-
sions, the participants reported de-
creased knee pain intensity (mean ±
SD decrease, 2.6 ± 2.3). In 27% (23
sessions), no change in pain from pre-
session to postsession occurred, and in
10% (8 sessions) participants reported
increased pain intensity from pre-
exercise to postexercise (mean ± SD
increase, 1.3 ± 0.5). Seventy-seven per-
cent of the rescue sessions (65 sessions)
occurred during the first half of the
FITE-OA program (first 18 sessions),
and 57% (48 sessions) occurred before
ity of participating in an exercise session
despite excessive pain could facilitate
positive attitudes toward exercising and
promote self-efficacy. Maintaining con-
tact and performing exercise in a group,
despite “a bad knee day,” may further
enhance the positive experience11 and in-
crease adherence to exercise programs in
the future.
It is noticeable that the participants
who received the rescue exercises had sig-
nificantly worse symptoms at inclusion
into the exercise programs. This indicates

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46-11 Bartholdy.indd 944 10/19/2016 7:36:21 PM

 that patients with more severe symptoms
can complete an exercise program when
adequate rescue exercise is an option.
Though the symptomatic flare-ups re-
sulting in referral to the rescue program
could be considered an adverse effect of
the full FITE-OA program, symptomatic
flare-ups are a natural feature of knee OA
and may originate from other factors.
The majority of the rescue sessions
(57%) were executed during the first
quarter of the 12-week program. This
distribution of rescue sessions indicates
that the beneficial effects of the FITE-
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OA program occurred after the first 18
sessions (6 weeks), which is in accor-
dance with the recommended minimum
duration of such training programs,8 as
behavioral and biological adaptations
Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
to exercise need time to set in. This ob-
served decrease in frequency of rescue
sessions over time could reflect a posi-
tive change in the participants’ ability to
plan and adjust their everyday activity
level to their symptoms, as well as bio-
logical adaptations in the knee. On the
other hand, remission of symptoms can
also occur naturally, which could explain
Journal of Orthopaedic & Sports Physical Therapy®
the changes seen, and further studies are
needed to investigate this.
The participants referred to the rescue
sessions all completed the entire 12-week
program and had an adherence to the
total program similar to that of partici-
pants who were not referred to the rescue
program, suggesting that symptomatic
flare-ups may not be regarded as a com-
plication resulting in withdrawal from
the exercise program.
A standardized rescue option could be
useful in the management of participants
who experience symptomatic flare-ups
during an exercise program in clinical
practice. A rescue option may facilitate
day-to-day fine tuning of the program ac-
cording to current knee symptoms when
patients are left to manage the condition
after treatment.
The data presented in this study were
extracted from the 2 parent trials5,6 that
had matching inclusion criteria and par-
ticipant demographics. Although no dif-
journal of orthopaedic & sports physical therapy | volume 46 | number 11 | november 2016 |
46-11 Bartholdy.indd 945
ferences between the 2 cohorts have been
identified in this study, it is possible that
there were differences across the cohorts
in unmeasured variables related to feasi-
bility and participant experiences. Five of
the included participants had a Kellgren-
Lawrence grade of 1, which is considered
doubtful as a sole diagnosis of knee OA;
however, participants were not included
unless they had symptomatic knee OA.
The positive effects of the rescue pro-
gram are relevant, but the possible ben-
efits in relation to other types of exercise
on clinical outcomes or performing the
FITE-OA program without the rescue
part are unknown. Future research could
investigate the effects of exercise with
a standardized rescue option (eg, the
FITE-OA program) versus the same pro-
gram without the rescue part.
CONCLUSION
A
standardized rescue exercise
option seems to be relevant for
knee OA patients who experience
symptomatic flare-ups, and typically
resulted in a clinically significant pain
reduction. Clinicians and researchers
should consider using a standardized
rescue option in the management of pa-
tients with knee OA. Furthermore, such
standardization can help improve current
reporting standards by increasing trans-
parency, and ease replication of exercise
trial interventions. t
KEY POINTS
FINDINGS: The standardized rescue
exercises appeared beneficial and did
not result in further worsening of
exacerbated knee OA symptoms. It is
possible to prespecify and standardize a
rescue option for patients with knee OA
in exercise interventions.
IMPLICATIONS: Planning an exercise
intervention designed to be adaptable
to patients with knee OA experiencing
pain exacerbations is possible and
seems useful.
CAUTION: This study described a
standardized rescue option for those
persons with pain exacerbation and
assessed whether it was possible to
exercise despite the increase in pain.
The results indicated that it was
possible; however, the observational
study design does not allow attribution
of effects to the rescue intervention, as
no comparison was done between the
full FITE-OA program with the rescue
option and the FITE-OA program
without the rescue option.
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 APPENDIX

FUNCTIONAL AND INDIVIDUALIZED THERAPEUTIC EXERCISE

PROGRAM FOR PARTICIPANTS WITH KNEE OSTEOARTHRITIS
This exercise program runs for 12 weeks, with exercise sessions 3 times per week. Each training session is scheduled to last approximately 60 minutes.
The exercise is facility based and takes place in groups, under the supervision of 1 or more physical therapists. The program consists of a warm-up and a
circuit training program. The circuited program contains core stability training, hip stability training, hip muscle strengthening, and specific knee training
that focuses on coordination, stability, strengthening, and translational and functional tasks.

Focus of the exercises is on the quality of the performance, not quantity. Each exercise has a specific focus, as specified below. During the initial sessions,
emphasis is on the specified focus area, and each participant is instructed and informed about the importance of performing each exercise correctly and
with the proper technique. All exercises have several levels of difficulty. The physical therapist supervises each participant individually and adjusts the
exercises and their progression in difficulty, individually, during the entire course of the program.

Monitoring of Knee Pain

A 0-to-10 numeric rating scale (0, no pain; 10, worst imaginable pain) (FIGURE) is used to monitor each participant’s current knee pain intensity before,
during, and after each training session. If a participant experiences knee pain of an intensity of 5 or more before or during a training session, the par-
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ticipant will be referred to the “rescue exercise program” (see below) to reduce the physical demands on the knee. The pain ratings are recorded in the
participant’s exercise diary at each session.

If unacceptable pain ratings (greater than 5) persist for more than 3 consecutive exercise sessions, the participant is referred to a rheumatologist associ-
ated with the program.
Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

FIGURE. Numeric pain-rating scale for pain monitoring, ranging from 0 (no pain) to 10 (worst imaginable pain), with safe, acceptable, and risk pain
Journal of Orthopaedic & Sports Physical Therapy®

zones indicated.

1. Warm-up
The warm-up period consists of 10 minutes of ergometer cycling at 80 to 100 rpm or moderate intensity (corresponding to 11 to 15 on the Borg Rating
of Perceived Exertion [somewhat hard]). During each warm-up period, the rpm and Borg scale rating are noted in the exercise diary to ensure that the
participant warms up at the same intensity or higher at each training session.

2. Circuit program
The circuit program features 8 exercise stations, each with a main area in focus: core stability, hip stability, hip muscle strengthening, knee coordina-
tion/stability, knee muscle strengthening, and translation and functional exercises. The exercises are adjusted individually according to the individual’s
level and progress.

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46-11 Bartholdy.indd 1 10/20/2016 1:49:47 PM

 APPENDIX

2.1 Core stability

Purpose: to maintain core stability and adequate trunk muscle activation control during limb movement.
Focus: the main focus is on keeping the lower back straight during limb movement. If the lower back cannot be held steady, the participant should
be instructed to take a short break and start again. From levels D through F, maintaining the body in the frontal plane and making sure the
pelvis does not drop are in focus.
Time: levels A through D: the position is held for two 1-minute sessions.
Repetitions: levels E and F: 2 sets of 6 to 8 movement repetitions, left and right sides.
Progression: the exercise is progressed from level A (easiest) to F (most difficult).
A. Selective abdominal activation exercise: supine with feet placed on the ground. A finger is placed just medial to each anterior superior iliac
spine to monitor selective activation of the transversus abdominis without activation of the other abdominal muscles. Once this is possible,
1 hip is slowly externally rotated (lowering of the knee sideways toward the floor) and moved slowly back again, without easing the tension
in the transversus abdominis (felt by the fingers), pelvic rotation, excessive activation of the other abdominal muscles, or forced breathing.
The exercise is performed with each leg at a time until the correct muscle tension is sustained with good control during the hip movement.
Progression: when the participant is able to selectively activate the transversus abdominis with no pelvic rotation, without holding his/her breath
or activating additional abdominal muscles, and perform the movement freely and effortlessly, the participant is progressed to the next level.
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B. Kneeling plank: prone kneeling position resting on knees and elbows. The body is raised to form a straight line from the neck to the knees
(a plank).
Progression: when the participant is able to perform the exercise without distinct exertion and good trunk control, progress to next level.
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C. Full plank: forward lying with both elbows and feet on the floor. The entire body is now lifted so the body weight is supported only by the elbows
and toe tips. From head to toe, the body is forming a straight line (a plank).
Progression: when the participant is able to perform the exercise without distinct exertion and shows good control of the trunk, the participant
is progressed to the next level.
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D. Lateral plank: sidelying and resting on 1 elbow positioned below the shoulder. The body is raised to form a straight line, with the resting point
at the lateral aspect of the foot and elbow. The body is kept straight in the frontal plane. The exercise is repeated bilaterally.
Progression: when the participant is able to perform the exercise without distinct exertion and shows control of the trunk, the participant is
progressed to the next level.
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E. Lateral plank with arm movement, progression with dumbbell: starting position as in D. When the body is raised, the arm is raised to vertical
and lowered in front of the body (shoulder adduction) and back to vertical. Direction of arm movement is changed regularly to ensure maximum
challenge of the task. If it is too easy, a dumbbell can be used.
Progression: when the participant is able to perform the arm movement slowly and with good control of the trunk, without distinct exertion,
the participant can progress to the next level.
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F. Lateral plank with jumping-jack movement, further progression via dumbbell/Swiss ball: starting position as in D. Top leg and arm are abducted
and adducted simultaneously. The dumbbell may be used as in E.
Progression: if further progression is needed, a Swiss ball can be placed under the elbow to introduce an unstable base of support.
Journal of Orthopaedic & Sports Physical Therapy®

2.2 Pelvis/hip stability

Purpose: to maintain hip and trunk stability during dynamic movements with an external load or unstable base of support.
Focus: the pelvis must be lifted to the same height each time. It is important that the pelvis is kept from tilting in the frontal and transverse planes;
the participant should aim to control the pelvic movement and position throughout the exercises. At all levels, good knee control is emphasized;
the knee is kept approximately 1 hip-width apart, without hyperextension or excessive flexion.
Repetitions: 2 to 3 sets of 6 to 8 repetitions. In E and F, 2 to 3 sets of 6 to 8 repetitions on both sides.
Progression: the exercises are progressed from level A (easiest) to F (most difficult).
A. Supine pelvic lift: supine with hips and knees flexed and the feet flat on the floor, approximately 1 hip-width apart. Arms placed along the side
of the body. The pelvis is steadily lifted up and down again.
Progression: when the participant is able to perform the exercise without exertion and keep the pelvis stable during movement, progress to
the next level.

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B. Pelvis lift as in A: arms are crossed over the chest to decrease the base of support.
Progression: when the participant is able to perform the exercise without exertion and keep the pelvis stable during movement, progress to
the next level.
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C. Pelvis lift with both feet on a Swiss ball: supine with hips and knees flexed and heels placed on a Swiss ball. Arms placed along the side (if
relevant, a bit abducted). The pelvis is steadily lifted up and down with no or minimal ball movement.
Progression: when the participant is able to lift the pelvis with no rotation or tilt, the knee flexed, without ball movement, and no distinct exer-
Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

tion, progress to the next level.

Journal of Orthopaedic & Sports Physical Therapy®

D. Pelvis lift as in C, except for the arms, which are flexed at the elbows (only the upper arm touching the floor) to reduce base of support (can
be further progressed by crossing arms across the chest before moving to level E).
Progression: when the participant is able to lift the pelvis while maintaining it in a stable position and keeping the knee flexed, without ball
movement and with no distinct exertion, progress to the next level.

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E. One-legged pelvic lift: the exercise is performed as in A or B, except that this time only 1 leg is used for support. Each leg is held parallel to the
other. The exercise is repeated on both sides.
Progression: when the participant is able to lift the pelvis with no rotation or tilt, and no distinct exertion, progress to the next level.
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F. One-legged pelvic lift with Swiss ball: the exercise is performed as in C, except that this time only 1 leg is used for support on the ball. The other
leg is held above the Swiss ball. The exercise is repeated with both sides.
Further progression: reducing the arm support (eg, elbow flexion as in D or arms crossed across chest as in B).
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2.3 Gluteus medius strengthening

Purpose: to strengthen the hip abductors.
Focus: from A through D, the starting position is important: sidelying, the upper body leaning slightly forward and the knees bent to 90° of flexion.
When the knees are drawn apart, it is important that the upper body is kept steady; if not, the exercise will not effectively target the gluteus
medius. In A through D, the movement is done in 2 parts. First, with feet held together, the hips are maximally externally rotated (by separating
the knees). When maximal external hip rotation is reached, the heels are drawn apart in a vertical movement.
Repetitions: 2 to 3 × 6 to 8.
Progression: the exercises are progressed from level A (easiest) to F (most difficult). All exercises are repeated on both sides.
A. Sidelying, knees in 90° of flexion, rubber band (light resistance) placed around the thighs just proximal to the knees: without moving the trunk
or feet, the knees are drawn apart (external hip). When maximal external hip rotation is reached, the heels are drawn apart. After this, the heels
are drawn back together, followed by the knees.
Progression: when the participant is able to perform the maximal number of repetitions without exertion and with no rotation of the pelvis,
progress to the next level.
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B. As in A, but with heavy-resistance rubber band.

Progression: when the participant is able to perform the maximal number of repetitions without exertion and with no rotation of the pelvis,
progress to the next level.
C. As in A, but with light-resistance rubber band placed around the ankles.
Progression: when the participant is able to perform the maximal number of repetitions without exertion and with no rotation of the pelvis,
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progress to the next level.

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D. As in C, but with heavy-resistance rubber band.

Progression: when the participant is able to perform the maximal number of repetitions without exertion and with no rotation of the pelvis,
progress to the next level.
E. Standing hip abduction/extension: standing on 1 leg with light-resistance rubber band around the ankles. With the pelvis and upper body in
neutral position, the hip of the unsupported leg is moved backward and outward (abduction plus extension).
Progression: when the participant is able to perform the maximal number of repetitions without distinct exertion and can perform the abduction
without additional movement of the hip and control of the trunk, progress to the next level.
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F. Same as A, but with heavy-resistance rubber bands around the ankles.

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2.4 Knee control and stability

2.4.1 Knee end-extension control
Focus: good knee control throughout knee range of motion of each exercise is important. This is defined as alignment of the knee above the
second toe. When the end-extension exercises are performed, it is important to avoid hyperextension of the knee. The goal for this exercise
is to make the participant able to stop the knee from hyperextending during movement.
Time: 1 to 2 minutes. In C, 1 to 2 minutes on both legs.
Progression: the exercises are progressed from level A (easiest) to C (most difficult).
A. Fast knee end extensions: standing and weight-bearing position with slight knee flexion (15°-20°). Fast (1-2 movement cycles per second)
and controlled knee extensions of the knee are performed. The motion takes place within the last 15° to 20° of knee extension.
In the beginning, the exercise is done with body weight equally placed on both feet. After this, while the movement speed is kept, weight
is transferred from one leg to the other. When this is implemented with good control, 1-legged exercise can be added.
Progression: When the participant is able to maintain a regular rhythm of the continuous knee flexion and extension movement pattern
without hyperextension, progress to the next level.
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B. Knee end extension on a small and unstable base of support: same as in A, but standing on a rubber foam block, initially under both feet,
but, as in A, progression to 1-legged exercise can be used.
Progression: when the participant is able to maintain a regular rhythm of the continuous knee end-extension movement pattern without
hyperextension, progress to the next level.
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C. Standing with 1 leg on a trampoline. All support is shifted to the leg on the trampoline, and a pumping movement is performed.
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2.4.2 Lunges
Focus: good knee control throughout the exercise is emphasized. This is defined as alignment of the knee over the second toe, to practice
movement with good varus/valgus control. The purpose of this exercise is to gain functional strength and teach the participant to control
the knee during high-load movements. The trunk should be upright, with the back as straight as possible.
Time: 1 to 2 minutes.
Progression: the exercises are progressed from level A (easiest) to C (most difficult).
A. Lunges with variable step lengths: the leg is slowly and steadily moved forward to match the participant’s normal step length. When the
foot is placed on the ground, a controlled flexion of the knee is done to approximately 90°. Then, the leading knee is extended and the
participant pushes back to the starting position. When this is done with good control, the step length is increased.
Progression: when the participant is able to perform a long lunge on both legs with good control, push straight back, with the center of
mass placed over the trailing limb and with no pain or safe or acceptable pain intensity, progress to the next level.
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B. Lunges will focus on knee control during landing and take-off of the foot: performed as in A, but now the push-off is done with greater force.
Journal of Orthopaedic & Sports Physical Therapy®

Progression: when the participant is able to do the push-off with no, safe, or acceptable pain intensity and land with good balance, the
exercise is progressed to the next level.
C. Lunge walking: as in A, except that now, instead of pushing back to the starting position, a similar movement with the trailing limb is done,
resulting in a lunge walk. When this is done with good control, the step lengths and knee flexion are increased.

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2.5 Strengthening exercise for the knee

2.5.1 Leg press or ball on the wall
Focus: good knee control throughout the exercise is emphasized. This is defined as alignment of the knee over the second toe. Feet are
positioned approximately 1 hip-width apart. In B and C, it is important that the back is straight and that the knees are aligned over the
feet. Knee flexion should happen in a way that makes the trunk move vertically up and down.
Repetitions: 2 to 3 sets of 8 to 10 repetitions. If it is possible for the participant to take more than 10 repetitions per set, the exercise is
too easy and more external weight should be applied.
Progression: the exercises are progressed from level A (easiest) to C (most difficult).
A. Small Swiss ball between the popliteal fossa and the wall. The ball is squeezed against the wall by performing a knee extension. Avoid
hyperextension. The exercise is performed with one leg at a time.
Progression: when the participant is able to create a clear contraction of the vastus medialis obliquus, progress to the next level.
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B. Squat with a Swiss ball between the back and a wall. The feet are placed a bit away from the wall, and knee flexion to 90° is performed.
The trunk is kept upright with a straight back during the movement.
Progression: when the participant is able to perform the maximal number of repetitions, with knees bent to 90° each time, without exer-
tion and with no, safe, or acceptable knee pain, progress to the next level.
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C. Squat with ball and dumbbell/weight vest: as in B, except a dumbbell is held in each hand or a weight vest is put on (5-10 kg).
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2.5.2 Step-ups with rubber band

Focus: knee control, defined as the knee aligned over the second toe. It is important to minimize use of vision to practice the participant’s
ability to sense whether he or she has good knee control.
Repetitions: 3 sets of 1 to 2 minutes.
Progression: the exercises are progressed from level A (easiest) to E (most difficult).
A. Low step height, light rubber band, straight forward steps: from stride standing, one leg after the other is lifted up on the step and weight
is transferred to the step (step-up) and backward down again. This exercise is repeated until the performance is steady and with good
knee control.
Progression: when the participant is able to perform the maximal number of repetitions, with no, safe, or acceptable pain, the knee aligned
over the second toe during weight transfer and step-ups, and no pelvis drop during movement, progress to the next level.
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B. Low step height, tight rubber band, varied steps: same as in A, except that now the steps should be varied, for example, lifting the leg
higher or taking wider steps, picking up the pace or slowing it down, or stepping up and over (photo).
Progression: when the participant is able to perform the maximal number of repetitions, with no, safe, or acceptable pain, the knee aligned
over the second toe, and no pelvis drop during movement, progress to the next level.
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C. Medium step height, light rubber band, varied steps: as in B, except the step is higher and a light rubber band is used.
Progression: when the participant is able to perform the maximal number of repetitions, with no, safe, or acceptable pain, the knee aligned
over the second toe, and no pelvis drop during step-up, progress to the next level.
D. Medium step height, tight rubber band, varied steps: as in C, but with tight rubber band.
Progression: when the participant is able to perform the maximal number of repetitions, with no, safe, or acceptable pain, the knee aligned
Journal of Orthopaedic & Sports Physical Therapy®

with the second toe, and no pelvis drop during step-up, progress to the next level.
E. High step height, tight rubber band, varied steps: as in D, except the step height is higher. If this is too difficult but D is too easy, a light
rubber band can be used.

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2.6 Functional exercises (level and stair walking)

Focus: good knee alignment and a controlled and stable gait. When this is acquired, the participant should be encouraged to walk without looking
down and sense whether there is good knee alignment and control. Experiences acquired from exercises 2.1 through 2.5 are emphasized to
the participants during walking and stair walking.
A “good” walking pattern includes looking straight ahead, natural rotation of the trunk, with arms swinging freely. Trendelenburg and/or other
compensatory walking patterns should be avoided. With each stride, the goal is to have symmetry and normal clearance of the foot. The foot
should be placed on the ground, with the heel first and a nice roll over the foot to the greater toe at toe-off. If relevant, the participant should
be encouraged to wear ergonomic shoes.
Repetitions: 5 to 10 minutes of continuous level and stair walking.
Progression: the exercises are progressed from level A (easiest) to B (most difficult).
A. Walk with a “good” walking pattern and combine with staircase walking to simulate everyday movements. Focus should be on performing these
everyday movements as efficiently as possible. The physical therapist should instruct each participant individually of his or her focus areas,
recalling acquired skills and experiences from exercises 2.1 through 2.5.
Progression: when the participant is able to perform the physical therapist’s individual instruction with ease, progress to the next level.
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B. As in A, except that external resistance is added. This could be increased speed, a rubber band around the thighs, ankle weights, or a weight
vest to increase difficulty and/or resistance. The physical therapist decides what external resistance is suitable for the individual participant.
Rescue Exercise Program
If a participant scores knee pain above 5 on a 0-to-10 numeric rating scale (0 is no pain, 10 is excruciating pain) when attending an exercise session, he
or she is transferred to the rescue program.

The rescue program is a modified program consisting of an extended warm-up (15-20 minutes) and exercises 2.1, 2.2, and 2.3 (as described above),
repeated twice with 5 minutes of ergometer cycling in between.

The rescue program excludes any weight-bearing activities to avoid unwarranted symptom provocation during a period of symptomatic flare-up.

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