Ottawa Panel Evidence-Based Clinical Practice Guidelines for Aerobic Walking Programs in the Management of Osteoarthritis

Published:March 13, 2012DOI:https://doi.org/10.1016/j.apmr.2012.01.024

      Abstract

      Loew L, Brosseau L, Wells GA, Tugwell P, Kenny GP, Reid R, Maetzel A, Huijbregts M, McCullough C, De Angelis G, Coyle D, and the Ottawa Panel. Ottawa Panel evidence-based clinical practice guidelines for aerobic walking programs in the management of osteoarthritis.

      Objective

      To update the Evidence-Based Clinical Practice Guidelines (EBCPGs) on aerobic walking programs for the management of osteoarthritis (OA) of the knee.

      Data Sources

      A literature search was conducted using the electronic databases MEDLINE, PubMed, and the Cochrane Library for all studies related to aerobic walking programs for OA from 1966 until February 2011.

      Study Selection

      The literature search found 719 potential records, and 10 full-text articles were included according to the selection criteria. The Ottawa Methods Group established the inclusion and exclusion criteria regarding the characteristics of the population, by selecting adults of 40 years old and older who were diagnosed with OA of the knee.

      Data Extraction

      Two reviewers independently extracted important information from each selected study using standardized data extraction forms, such as the interventions, comparisons, outcomes, time period of the effect measured, and study design. The statistical analysis was reported using the Cochrane collaboration methods. An improvement of 15% or more relative to a control group contributes to the achievement of a statistically significant and clinically relevant progress. A specific grading system for recommendations, created by the Ottawa Panel, used a level system (level I for randomized controlled studies and level II for nonrandomized articles). The strength of the evidence of the recommendations was graded using a system with letters: A, B, C+, C, D, D+, or D–.

      Data Synthesis

      Evidence from 7 high-quality studies demonstrated that facility, hospital, and home-based aerobic walking programs with other therapies are effective interventions in the shorter term for the management of patients with OA to improve stiffness, strength, mobility, and endurance.

      Conclusions

      The greatest improvements were found in pain, quality of life, and functional status (grades A, B, or C+). A common limitation inherent to the EBCPGs is the heterogeneity of studies included with regards to the characteristics of the population, the interventions, the comparators, the outcomes, the period of time, and the study design. It is strongly recommended to use the Cochrane Risk of Bias Summary assessment to evaluate the methodologic quality of the studies and to consider avenues for future research on how aerobic walking programs would be beneficial in the management of OA of the hip.

      Key Words

      List of Abbreviations:

      AIMS (Arthritis Impact Measurement Scales), BI (behavioral intervention), BMI (body mass index), CCT (controlled clinical trial), EBCPG (Evidence-Based Clinical Practice Guideline), FU (follow-up), OA (osteoarthritis), PICOPS (population, intervention, comparator, outcomes, period of time, and study design), QOL (quality of life), RCT (randomized controlled trial), SMD (standardized mean difference)
      OSTEOARTHRITIS (OA) is the most common joint disorder, often affecting the knees and hips.
      • Klippel J.H.
      • Crofford L.J.
      • Stone J.H.
      • White P.H.
      Primer on the rheumatic diseases.
      Symptoms include pain, temporary stiffness, crepitus, swelling, fatigue, and movement limitation. OA is rarely present before the age of 40.
      • Klippel J.H.
      • Crofford L.J.
      • Stone J.H.
      • White P.H.
      Primer on the rheumatic diseases.
      Incidence is greater among men before the age of 45 but higher among women after the age of 55. After the age of 70, there is a dramatic increase in prevalence of OA among both sexes, and the majority of older adults will develop OA in 1 or several joints.
      • Rottensten K.
      Série de monographies sur les maladies liées au vieillissement: IX Arthrose.
      Currently, more than 50% of Americans aged over 65 (over 24 million individuals) are affected by OA.
      • Singh G.
      • Miller J.D.
      • Lee F.H.
      • Pettitt D.
      • Russell M.W.
      Prevalence of cardiovascular disease risk factors among US adults with self-reported osteoarthritis: data from the Third National Health and Nutrition Examination Survey.
      With the aging population, some researchers predict that by 2030, approximately 72 million Americans will have developed the disorder.
      • Walker J.M.
      • Helewa A.
      Physical therapy in arthritis.
      National Institute of Arthritis and Musculoskeletal and Skin Diseases
      Osteoarthritis.
      In general, people diagnosed with OA will gradually become sedentary,
      • Hootman J.M.
      • Macera C.A.
      • Helmick C.G.
      • Blair S.N.
      Influence of physical activity-related joint stress on the risk of self-reported hip/knee osteoarthritis: a new method to quantify physical activity.
      because most of them are approximately 3 times more likely to have difficulty walking, and to have 5 or more functional limitations.
      • Rottensten K.
      Série de monographies sur les maladies liées au vieillissement: IX Arthrose.
      The belief that physical activity causes an increase in pain to the affected joint has resulted in a negative chain reaction. Inactivity leads to decreased endurance and mobility, loss of independence, and thus it can reduce quality of life (QOL).
      • Messier S.P.
      • Loeser R.F.
      • Mitchell M.N.
      • et al.
      Exercise and weight loss in obese older adults with knee osteoarthritis: a preliminary study.
      In addition, OA is responsible for a reduction in productivity, and an increase in disability compensation and work absenteeism. These indirect costs represent one third of the overall costs attributed to OA, where the total cost is estimated at $16,146. Direct costs are disbursed for pain medication and general medical treatments. Together, individuals affected by OA present an annual average cost of $11,542.
      • Zhang W.
      • Moskowitz R.W.
      • Nuki G.
      • et al.
      OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines.
      The Ottawa Panel is a group of researchers producing Evidence-Based Clinical Practice Guidelines (EBCPGs) with the objective of reporting recommendations regarding specific interventions. General aerobic exercise is recommended as a core treatment for subjects with OA. An aerobic walking program is defined as “a dynamic physical activity with an intensity sufficient to improve aerobic capacity, and muscle strength, which establishes to improve functional status among older individuals with OA.”
      • Van den Ende C.H.
      • Vliet Vlieland T.P.
      • Munneke M.
      • Hazes J.M.
      Dynamic exercise therapy in rheumatoid arthritis: a systematic review.
      (p677) Many previous systematic reviews have already determined that walking is an effective and safe way to treat OA, but these reviews are now dated.
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      Ottawa Panel Members Ottawa
      Panel EBCPGs for therapeutic exercises and manual therapy in the management of osteoarthritis.
      American College of Rheumatology Subcommittee on Osteoarthritis Guidelines
      Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update.
      The scientific evidence recommends that aerobic physical activities, such as walking programs, have a therapeutic effect in the short-term (2–6mo) for pain relief, improved strength, and functional status in subjects diagnosed with OA.
      • Albright J.
      • Allman R.
      • Bonfiglio R.P.
      • et al.
      Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions: overview and methodology.
      • Roddy E.
      • Zhang W.
      • Doherty M.
      Aerobic walking or strengthening exercise for osteoarthritis of the knee? A systematic review.
      • van Baar M.E.
      • Assendelft W.J.
      • Dekker J.
      • Oostendorp R.A.
      • Bijlsma J.W.
      Effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review of randomized clinical trials.
      However, these existing guidelines do not provide detailed recommendations regarding effective walking programs for OA. Therefore, an update of clinical practice guidelines for aerobic walking programs for OA would be a valuable resource for clinicians and researchers.
      • Zhang W.
      • Moskowitz R.W.
      • Nuki G.
      • et al.
      OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines.
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      Ottawa Panel Members Ottawa
      Panel EBCPGs for therapeutic exercises and manual therapy in the management of osteoarthritis.
      American College of Rheumatology Subcommittee on Osteoarthritis Guidelines
      Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update.
      The objective of this project was to create an EBCPG for an aerobic walking program in the management of OA of the knee, in order to support health professionals and their patients diagnosed with OA in choosing the most effective aerobic walking programs for this population. Evidence shows that an inactive patient with OA will present a gradual deterioration of the affected joint, an increase of functional dependency, and a poorer QOL.
      • Messier S.P.
      • Loeser R.F.
      • Mitchell M.N.
      • et al.
      Exercise and weight loss in obese older adults with knee osteoarthritis: a preliminary study.
      It is, therefore, important to persuade inactive individuals to follow an aerobic walking program, which helps relieve pain and promote remodeling without increasing stress in the affected joint.
      • Williams S.B.
      • Brand C.A.
      • Hill K.D.
      • Hunt S.B.
      • Moran H.
      Feasibility and outcomes of a home-based exercise program on improving balance and gait stability in women with lower-limb osteoarthritis or rheumatoid arthritis: a pilot study.
      Even though aerobic walking promotes low impact on the weight-bearing articulations, positive changes are still attributed to improving joint loads and biomechanics, stability, and neuromuscular function.
      • Williams S.B.
      • Brand C.A.
      • Hill K.D.
      • Hunt S.B.
      • Moran H.
      Feasibility and outcomes of a home-based exercise program on improving balance and gait stability in women with lower-limb osteoarthritis or rheumatoid arthritis: a pilot study.
      Therefore, the stability of the affected joint assists persons with OA to be more functional in everyday living, which will progressively improve their QOL.
      • Ytterberg S.R.
      • Mahowald M.L.
      • Krug H.E.
      Exercise for arthritis.
      Promotion of aerobic walking, especially in a community-based context, is a priority for health organizations serving the general population and is highly recommended for subjects affected by OA, because it is easily accessible to walk in a shopping center or a community place, without having to spend too much money. In other words, walking is one of the safest no-cost ways of doing physical activity, because no special equipment is needed other than good walking shoes.
      • Hootman J.M.
      • Macera C.A.
      • Helmick C.G.
      • Blair S.N.
      Influence of physical activity-related joint stress on the risk of self-reported hip/knee osteoarthritis: a new method to quantify physical activity.

      Methods

       Protocols and Registration

      The development process of the EBCPGs was similar to that of the Philadelphia Panel and other EBCPGs created by the Ottawa Panel.
      • Albright J.
      • Allman R.
      • Bonfiglio R.P.
      • et al.
      Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions: overview and methodology.
      The methodology of this project followed the Preferred Reporting Items for Systematic and Meta-Analyses
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      PRISMA Group
      Reprint–preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      checklist from the Journal of the American Physical Therapy Association, the Ottawa Expert Panel methods, and used a quantitative grading system.
      In conjunction with the methodology of previous Ottawa Panel publications,
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for aerobic fitness exercises in the management of fibromyalgia: part 1.
      the construction of the EBCPGs was developed using the Appraisal of Guidelines Research and Evaluation criteria (www.agreetrust.org). The Ottawa Panel individual recommendations were graded as A, B, C, C+, D, D+, or D– based on the strength of evidence (table 1). An alphabetical grading system was presented according to the Ottawa Panel methodology
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for aerobic fitness exercises in the management of fibromyalgia: part 1.
      in table 2. Appendix 1 and an additional alphabetical system recently adopted by the Cochrane Collaboration (www.cochrane.org) have the corresponding levels in parenthesis.
      Table 1Grading for Recommendations
      Reprinted with permission Physical Therapy (2011;91:843-61). Copyright 2008 American Physical Therapy Association.
      GradeClinical Importance (%)Statistical Significance (P)Study Design
      A (strongly recommended)≥15<.05RCT (single or meta-analysis)
      B (recommended)≥15<.05CCT or observational (single or meta-analysis)
      C+ (suggested used)≥15Not significantRCT/CCT or observational (single or meta-analysis)
      C (neutral)<15Not significantAny study design
      D (neutral)<15 (favors control)Not significantAny study design
      D+ (suggested no use)<15 (favors control)Not significantRCT/CCT or observational (single or meta-analysis)
      D− (strongly not recommended)≥15 (favors control)<.05 (favors control)Well-designed RCT with >100 patients (if <100 patients, becomes grade D)
      NOTE. Combined Grading Recommendations according to the Ottawa Panel
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines for aerobic fitness exercises in the management of fibromyalgia: part 1.
      for alphabetical grading system and the Cochrane collaboration (www.cochrane.org) for international nominal grading system.
      Table 2Inclusion and Exclusion Criteria According to the PICOPS Strategy
      InclusionExclusion
      Participants/population
      • Outpatients or inpatients
      • Diagnosis of OA of the lower extremity(ies)
      • Chronic vs acute conditions
      • Healthy weight (BMI<25kg/m2)
      • Age groups of more than 40y old
      • Medically stable
      • Mentally competent
      Participants/population
      • Cancer (and other oncologic conditions)
      • Dermatologic conditions
      • Healthy normal
      • Juvenile arthritis
      • Mixed population (other than OA and/or RA)
      • Multiple conditions (presenting other chronic problems additional to OA)
      • Neurologic conditions
      • Pediatric conditions (no juvenile arthritis)
      • Psychiatric conditions
      • Pulmonary conditions
      • Scoliosis
      • Condition where rapid weight loss or exercise is contraindicated (unstable angina, frailty, advanced osteoporosis)
      • Food allergies or reactions to the meal replacements
      • Obese or overweight patient (BMI≥25kg/m2)
      Interventions
      • Eligible interventions: therapeutic program related to aerobic walking training, in community or not, and with or without:
        • 1
          Concurrent programs (eg, strengthening and stretching exercises, behavioral approach)
        • 2
          Supervision
      • Eligible control groups: conventional therapy, untreated, waiting list, active physiotherapy treatments, educative pamphlets (not surgery, not drugs, or injections)
      Interventions
      • Surgery of all lower extremities and lower back (ie, not the effect of the surgery)
      • Medication (eg, phonophoresis with medications)
      • Thermal biofeedback
      • Interventions related to weight loss (dietary advices, medication, etc) alone or in combination with walking program
      Comparisons
      • Studies were included if they compare an intervention group (eg, walking group, walking and behavioral group, walking and strengthening group) with a comparison group (eg, uncontrolled cohort trials)
      Comparisons
      • Studies were excluded if they did not compare the intervention group with a comparison group (eg, uncontrolled cohort trials)
      • Studies were excluded if they compared the intervention with a walking and diet group
      Outcomes
      • Absenteeism, sick leave, return to work (if available)
      • Balance status
      • Cardiopulmonary functions
      • Coordination status
      • Fatigue
      • Flexibility
      • Functional status, activities of daily living (self-care activities)
      • Gait status
      • Girth, volume
      • Inflammation
      • Joint imaging
      • Medication intake (if reported)
      • Mobility
      • Muscle strength, walking endurance, and power
      • Pain
      • Patient satisfaction
      • Postural assessment
      • Quality of life
      • Range of motion, flexibility, mobility
      • Side effects (if reported)
      • Swelling
      • Compliance
      • Morning stiffness
      • Walking endurance
      • Number of steps
      • Stride length
      • Stairs management
      Outcomes
      • Biochemical measures
      • Patient compliance to medication
      • Psychosocial measures (depression, home and community activities, leisure, social roles, sexual functions)
      • Serum markers (except ESR)
      • Weight loss
      Period of time
      • Studies were included if the intervention period lasts more than 1mo, with or without a follow-up period.
      Period of time
      • Studies were excluded if the intervention period lasts <1mo
      Study designs
      • RCT
      • CCT
      • Cohort study
      • Case-control study
      Study designs
      • Case-series/case report
      • Uncontrolled cohort studies
      • Data (graphic) without a mean and SD
      • Sample size of <5 patients per experimental group
      • Studies with more than 20% dropout rate
      NOTE. English and French articles only.
      Abbreviations: ESR, erythrocyte sedimentation rate; RA, rheumatoid arthritis.

       Eligibility Criteria

      To accomplish systematic literature reviews, a list of eligibility criteria was developed by the Ottawa Methods Group, who decided to follow the population, intervention, comparator, outcomes, period of time, and study design (PICOPS) strategy, in order to ensure inclusion of relevant studies. Therefore, the inclusion and exclusion criteria include the characteristics of the population, intervention, comparator, outcomes, the period of time an intervention becomes effective, and the study design (see table 2). Only articles written in English or French, from 1966 until February 2011, were selected. The Ottawa Methods Group read and analyzed the articles and organized several evidence tables. The Ottawa Panel experts later reviewed the work to attain a consensus.

       Type of Participants

      Studies were chosen if the comparison groups were composed of participants aged over 40 years who were diagnosed with OA of the knee, as defined by Klippel et al.
      • Klippel J.H.
      • Weyand C.M.
      • Wortmann R.L.
      Primer on the rheumatic diseases.
      For the inclusion of participants, the studies were required to follow the Kellgren-Lawrence grading scale, according to the radiologic and/or clinical assessment of OA.
      • Kellgren J.H.
      • Lawrence J.S.
      Radiological assessment of osteo-arthritis.
      The patients had to show no signs of psychiatric conditions, demonstrate stable physical and medical status, and have a healthy weight (body mass index [BMI]<25kg/m2).
      • Cole T.J.
      • Bellizzi M.C.
      • Flegal K.M.
      • Dietz W.H.
      Establishing a standard definition for child overweight and obesity worldwide: international survey.
      Mixed populations were permitted only if they consisted of patients with OA or rheumatoid arthritis, where the patients with OA were the majority. For the complete list of exclusion criteria and the PICOPS process please refer to table 2.

       Risk of Bias Across Studies

      Studies that were described only in an abstract, where authors could not be contacted for further details, were automatically excluded because they did not provide enough results for the data analysis. Time and translation costs were limited, therefore only English and French studies were selected (see table 2).

       Information Sources

      The library scientist (J.M.) performed a systematic search of the literature using a search strategy proposed by the Cochrane Collaboration. The main focus of the search was to identify the methodology and study design determined by primary studies, rather than identifying outcomes. In other words, the library scientist based her search on relevant topics, by including OA terms, physical therapy terms (eg, walking), and study design terms. The systematic approach, which consisted of an organized method for the selection of articles, data extraction, and synthesis analyses decreased the possibility of presenting bias. See appendix 2 for more details on how the literature search was completed.
      The search was conducted using the electronic databases EMBASE, PubMed, CINAHL, PEDro, SCOPUS, BioMed, SUMsearch, and Cochrane Library and also included case-control, cohort, and nonrandomized studies up until February 2011.

       Data Collection Process

       Study selection/data items

      After a systematic search of the literature, a pair of reviewers (L.L. and G.M.) evaluated the studies. Referring to the inclusion and exclusion criteria (see table 2), the reviewers created a list of the included and excluded articles. The reviewers referred to the principal assessor (L.B.) when uncertainty was present.

       Data Extraction

      The reviewers independently extracted important information from each included study using standardized data extraction forms. This included the characteristics of participants, treatment, study design, allocation concealment, comparative results, and period of data collection.

       Methodologic Quality Assessment/Risk of Bias in Individual Studies

      The Jadad scale was used to assess the methodologic quality of each study selected.
      • Jadad A.R.
      • Moore R.A.
      • Carroll D.
      • et al.
      Assessing the quality of reports of randomized clinical trials: is blinding necessary?.
      • Olivo S.A.
      • Macedo L.G.
      • Gadotti I.C.
      • Fuentes J.
      • Stanton T.
      • Magee D.J.
      Scales to assess the quality of randomized controlled trials: a systematic review.
      Each study was awarded a maximum of 5 points: 2 points for the randomization method, 2 points for double-blinding, and 1 point for a description of the dropouts. The reviewers referred to the principal assessor when differences were noticed in data extraction and Jadad scale scoring. A study assessed at a Jadad scale score of 3 or more points is typically considered as having high methodologic quality. The Ottawa Panel accepted the inclusion of studies with a Jadad scale score of less than 3 points. Points for double-blindness were rarely given because of the nature and difficulties of blinding therapists or participants during physical therapy treatments.
      • Olivo S.A.
      • Macedo L.G.
      • Gadotti I.C.
      • Fuentes J.
      • Stanton T.
      • Magee D.J.
      Scales to assess the quality of randomized controlled trials: a systematic review.
      • Deyo R.A.
      • Walsh N.E.
      • Schoenfeld L.S.
      • Ramamurthy C.
      Can trials of physical treatments be blinded? The example of transcutaneous electrical nerve stimulation for chronic pain.
      Consequently, more importance was given to the 2 other categories of the Jadad scale, which are randomization and withdrawals (appendix 3). Articles were excluded if they did not meet the selected inclusion criteria according to the Ottawa Panel (see table 2).

       Data Analysis/Summary Measures

      The Cochrane Collaboration methods were used to perform statistical analysis (www.cochrane.org). Weighted mean differences between the experimental and control groups were calculated for continuous data, allowing for the calculation of the mean and SD corresponding to the sample size of each group. According to the Cochrane Collaboration, for each specific outcome, weighted mean differences were indicated by a square and the SD of the weighted mean difference was illustrated by a horizontal line. As long as the horizontal line reached the central vertical axis, the weighted mean difference between the 2 comparative groups was not statistically different because the confidence interval included zero (fig 1A at 9mo). By subtracting the improvement of the experimental group with the improvement in the control group, it is possible to calculate the absolute benefit. The relative difference can be found by dividing the absolute benefit out of the baseline mean (weighted for the treatment and control groups). Selected by the Philadelphia Panel and adopted by the rheumatology and biostatistician experts of the Ottawa Panel, an improvement of 15% relative to a control group contributes to the achievement of clinical improvement. For dichotomous variables, the clinical improvement is calculated as the difference between the percent improved among the experimental and control groups. For more details about the statistical analysis, see the previous publications of the Ottawa Panel.
      • Brosseau L.
      • Wells G.A.
      • Tugwell P.
      Ottawa Panel Members Ottawa
      Panel EBCPGs for therapeutic exercises and manual therapy in the management of osteoarthritis.
      According to the Cochrane Collaboration, the standardized mean difference is used as a summary statistic, which represents the recommended effect size when studies select the same outcome but are measured with a different scale in the meta-analysis. The goal of calculating this value is to standardize and combine the results of the studies to a uniform statistic for pooling and comparison purposes (figs 1B and 1C). The individual results for each randomized controlled trial (RCT) are shown in figures 1B and 1C. The global effect of the pooled results of figures 1B and C is indicated in the Results section.
      Figure thumbnail gr1
      Fig 1(A) Results from the only RCT evaluating an aerobic walking program versus a control: aerobic capacity with a maximum oxygen consumption test.
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      (B) Pooled results of RCTs evaluating aerobic walking programs versus controls: pain relief with AIMS.
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      • Péloquin L.
      • Bravo G.
      • Gauthier P.
      • Lacombe G.
      • Billiard J.S.
      Effects of a cross-training exercise program in persons with osteoarthritis of the knee A randomized controlled trial.
      • Kovar P.A.
      • Allegrante J.P.
      • Mackenzie C.R.
      • Peterson M.G.
      • Gutin B.
      • Charlson M.E.
      Supervised fitness walking in patients with osteoarthritis of the knee A randomized, controlled trial.
      (C) Pooled results of RCTs evaluating an aerobic walking program versus a control: endurance walking with a six-minute walk test
      • Kovar P.A.
      • Allegrante J.P.
      • Mackenzie C.R.
      • Peterson M.G.
      • Gutin B.
      • Charlson M.E.
      Supervised fitness walking in patients with osteoarthritis of the knee A randomized, controlled trial.
      and five-minute walk test.
      • Péloquin L.
      • Bravo G.
      • Gauthier P.
      • Lacombe G.
      • Billiard J.S.
      Effects of a cross-training exercise program in persons with osteoarthritis of the knee A randomized controlled trial.
      Abbreviation: tx, treatment.

      Results

       Study Selection

      The literature search found 719 potential records (see appendix 2). The reviewers (L.L. and G.M.) screened 88 eligible articles on aerobic walking programs and OA. According to the selection criteria (see table 2), 10 full-text articles were included and 78 articles were excluded for the following reasons (appendix 4): no walking program intervention in 31 trials
      • Blin O.
      • Pailhous J.
      • Lafforgue P.
      • Serratrice G.
      Quantitative analysis of walking in patients with knee osteoarthritis: a method of assessing the effectiveness of non-steroidal anti-inflammatory treatment.
      • Borjesson M.
      • Robertson E.
      • Weidenhielm L.
      • Mattsson E.
      • Olsson E.
      Physiotherapy in knee osteoarthrosis: effect on pain and walking.
      • Chaipinyo K.
      • Karoonsupcharoen O.
      No difference between home-based strength training and home-based balance training on pain in patients with knee osteoarthritis: a randomised trial.
      • Christensen R.
      • Astrup A.
      • Bliddal H.
      Weight loss: the treatment of choice for knee osteoarthritis? A randomized trial.
      • Collins E.
      • O'Connell S.
      • Jelinek C.
      • Miskevics S.
      Evaluation of psychometric properties of Walking Impairment Questionnaire in overweight patients with osteoarthritis of knee.
      • Farr J.N.
      • Going S.B.
      • Lohman T.G.
      • et al.
      Physical activity levels in patients with early knee osteoarthritis measured by accelerometry.
      • Jan M.H.
      • Lin J.J.
      • Liau J.J.
      • Lin Y.F.
      • Lin D.H.
      Investigation of clinical effects of high- and low-resistance training for patients with knee osteoarthritis: a randomized controlled trial.
      • Lim B.W.
      • Kemp G.
      • Metcalf B.
      • et al.
      The association of quadriceps strength with the knee adduction moment in medial knee osteoarthritis.
      • Lin D.H.
      • Lin C.H.J.
      • Lin Y.F.
      • Jan M.H.
      Efficacy of 2 non-weight bearing interventions, proprioception training versus strength training for patients with knee osteoarthritis: a randomized clinical trial.
      • O'Reilly S.C.
      • Muir K.R.
      • Doherty M.
      Effectiveness of home exercise on pain and disability from osteoarthritis of the knee: a randomised controlled trial.
      • Sharma L.
      • Cahue S.
      • Song J.
      • Hayes K.
      • Pai Y.C.
      • Dunlop D.
      Physical functioning over three years in knee osteoarthritis.
      • Suomi R.
      • Collier D.
      Effects of arthritis exercise programs on functional fitness and perceived activities of daily living measures in older adults with arthritis.
      • Thomas K.S.
      • Muir K.R.
      • Doherty M.
      • Jones A.C.
      • O'Reilly S.C.
      • Bassey E.J.
      Home based exercise programme for knee pain and knee osteoarthritis: randomized controlled trial.
      • Thorstensson C.A.
      • Petersson I.F.
      • Jacobsson L.T.
      • Boegard T.L.
      • Roos E.M.
      Reduced functional performance in the lower extremity predicted radiographic knee osteoarthritis five years later.
      • Abbott J.H.
      • Robertson M.C.
      • McKenzie J.E.
      • Baxter G.B.
      • Theis J.C.
      • Campbell A.J.
      Exercise therapy, manual therapy, or both, for osteoarthritis of the hip or knee: a factorial randomised controlled trial protocol.
      • Barrios J.A.
      • Crossley K.M.
      • Davis I.S.
      Gait retraining to reduce the knee adduction moment through real-time visual feedback of dynamic knee alignment.
      • Dunlop D.D.
      • Semanik P.
      • Song J.
      • et al.
      Moving to maintain function in knee osteoarthritis: evidence from the osteoarthritis initiative.
      • Fallah Yakhdani H.R.
      • Abbasi Bafghi H.
      • Meijer O.G.
      • et al.
      Stability and variability of knee kinematics during gait in knee osteoarthritis before and after replacement surgery.
      • Green J.
      • McKenna F.
      • Redfern E.J.
      • Chamberlain M.A.
      Home exercises are as effective as outpatient hydrotherapy for osteoarthritis of the hip.
      • Heiden T.L.
      • Lloyd D.G.
      • Ackland T.R.
      Knee joint kinematics, kinetics and muscle co-contraction in knee osteoarthritis patient gait.
      • Huang M.H.
      • Lin Y.S.
      • Yang R.C.
      • Lee C.L.
      A comparison of various therapeutic exercises on the functional status of patients with knee osteoarthritis.
      • Lange A.K.
      • Vanwanseele B.
      • Foroughi N.
      • et al.
      Resistive Exercise for Arthritic Cartilage Health (REACH): a randomized double-blind, sham-exercise controlled trial.
      • Liikavainio T.
      • Bragge T.
      • Hakkarainen M.
      • Karjalainen P.A.
      • Arokoski J.P.
      Gait and muscle activation changes in men with knee osteoarthritis.
      • Macht Sliwinski M.
      • Sisto S.A.
      Gait, quality of life, and their association following total hip arthroplasty.
      • Messier S.P.
      • Legault C.
      • Mihalko S.
      • et al.
      The Intensive Diet and Exercise for Arthritis (IDEA) trial: design and rationale.
      • Perron M.
      • Malouin F.
      • Moffet H.
      • McFadyen B.J.
      Three-dimensional gait analysis in women with a total hip arthroplasty.
      • Puett D.W.
      • Griffin M.R.
      Published trials of nonmedicinal and noninvasive therapies for hip and knee osteoarthritis.
      • Roddy E.
      • Zhang W.
      • Doherty M.
      • et al.
      Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee − the MOVE consensus.
      • Rutherford D.J.
      • Hubley-Kozey C.L.
      • Stanish W.D.
      The neuromuscular demands of altering foot progression angle during gait in asymptomatic individuals and those with knee osteoarthritis.
      • Akyol Y.
      • Durmus D.
      • Alayli G.
      • et al.
      Does short-wave diathermy increase the effectiveness of isokinetic exercise on pain, function, knee muscle strength, quality of life, and depression in the patients with knee osteoarthritis? A randomized controlled clinical study.
      • Lim J.Y.
      • Tchai E.
      • Jang S.N.
      Effectiveness of aquatic exercise for obese patients with knee osteoarthritis: a randomized controlled trial.
      dropout rates of over 20% in 12 studies
      • Ağlamis A.
      • Toraman N.F.
      • Yaman H.
      The effect of a 12-week supervised multicomponent exercise program on knee OA in Turkish women.
      • Ettinger Jr, W.H.
      • Burns R.
      • Messer S.P.
      • et al.
      A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis: The Fitness Arthritis and Seniors Trial (FAST).
      • Fisher N.M.
      • Pendergast D.R.
      • Gresham G.E.
      • Calkins E.
      Muscle rehabilitation: its effect on muscular and functional performance of patients with knee osteoarthritis.
      • Fransen M.
      • Margiotta E.
      • Crosbie J.
      • Edmonds J.
      A revised group exercise program for osteoarthritis of the knee.
      • Frost H.
      • Lamb S.E.
      • Roberston S.
      A randomised controlled trial of exercise to improve mobility and function after elective knee arthroplasty Feasibility, results and methodological difficulties.
      • Ghroubi S.
      • Elleuch H.
      • Kaffel N.
      • Echikh T.
      • Abid M.
      • Elleuch M.H.
      Contribution of exercise and diet in the management of knee osteoarthritis in the obese.
      • Hughes S.L.
      • Seymour R.B.
      • Campbell R.
      • Pollak N.
      • Huber G.
      • Sharma L.
      Impact of the fit and strong intervention on older adults with osteoarthritis.
      • McCarthy J.C.
      • Mills P.M.
      • Pullen R.
      • Roberts C.
      • Silman A.
      • Oldham J.A.
      Supplementing a home exercise programme with a class-based exercise programme is more effective than home exercise alone in the treatment of knee osteoarthritis.
      • Rejeski W.J.
      • Branley L.R.
      • Ettinger W.
      • Morgan T.
      • Thompson C.
      Compliance with exercise therapy in treating seniors with knee osteoarthritis.
      • Sullivan T.
      • Allegrante J.P.
      • Peterson M.G.
      • Kovar P.A.
      • MacKenzie C.R.
      One-year follow up of patients with osteoarthritis of the knee who participated in a program of supervised fitness walking and supportive patient education.
      • Yip Y.B.
      • Sit J.W.
      • Wong D.Y.
      • Chong S.Y.
      • Chung L.H.
      A 1-year follow-up of an experimental study of a self-management arthritis programme with an added exercise component of clients with osteoarthritis of the knee.
      • Ng N.
      • Heesch K.C.
      • Brown W.J.
      Efficacy of a progressive walking program and glucosamine sulphate supplementation on osteoarthritic symptoms of the hip and knee: a feasibility trial.
      no control group in 5 trials,
      • Angst F.
      • Aeschlimann A.
      • Steiner W.
      • Stucki G.
      Responsiveness of the WOMAC osteoarthritis index as compared with the SF-36 in patients with osteoarthritis of the legs undergoing a comprehensive rehabilitation intervention.
      • Fisher N.M.
      • Gresham G.E.
      • Abrams M.
      • Hicks J.
      • Horrigan D.
      • Pendergast D.R.
      Quantitative effects of physical therapy on muscular and functional performance in subjects with osteoarthritis of the knees.
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Dreisinger T.E.
      • Kay D.R.
      Exercise tolerance and disease related measures in patients with rheumatoid arthritis and osteoarthritis.
      • Thorstensson C.A.
      • Roos E.M.
      • Petersson I.F.
      • Ekdahl C.
      Six-week high-intensity exercise program for middle-aged patients with knee osteoarthritis: A randomized controlled trial.
      • Thorstensson C.A.
      • Henriksson M.
      • von Porat A.
      • Sjödahl C.
      • Roos E.M.
      The effect of eight weeks of exercise on knee adduction moment in early knee osteoarthritis - a pilot study.
      outcome measures not considered in this review (eg, markers of chronic inflammation, psychosocial aspects, compliance, cost estimate) in 5 trials
      • Nicklas B.J.
      • Ambrosius W.
      • Messier S.P.
      • et al.
      Diet-induced weight loss, exercise, and chronic inflammation in older, obese adults: a randomized controlled clinical trial.
      • Penninx B.W.
      • Rejeski W.J.
      • Pandya J.
      • et al.
      Exercise and depressive symptoms: a comparison of aerobic and resistance exercise effects on emotional and physical function in older persons with high and low depressive symptomatology.
      • Rejeski W.J.
      • Brawley L.R.
      • Ettinger W.
      • Morgan T.
      • Thompson C.
      Compliance to exercise therapy in older participants with knee osteoarthritis: implications for treating disability.
      • Sevick M.A.
      • Miller G.D.
      • Loeser R.F.
      • Williamson J.D.
      • Messier S.P.
      Cost-effectiveness of exercise and diet in overweight and obese adults with knee osteoarthritis.
      • Semble E.L.
      • Loeser R.F.
      • Wise C.M.
      Therapeutic exercise for rheumatoid arthritis and osteoarthritis.
      only healthy subjects in 2 studies
      • White S.M.
      • Wójcicki T.R.
      • McAuley E.
      Physical activity and quality of life in community dwelling older adults.
      • Zeni Jr, J.A.
      • Higginson J.S.
      Dynamic knee joint stiffness in subjects with a progressive increase in severity of knee osteoarthritis.
      no intervention in 3 studies,
      • Thorstensson C.A.
      • Roos E.M.
      • Petersson I.F.
      • Ekdahl C.
      Six-week high-intensity exercise program for middle-aged patients with knee osteoarthritis: A randomized controlled trial.
      • Focht B.C.
      • Gauvin L.
      • Rejeski W.J.
      The contribution of daily experiences and acute exercise to fluctuations in daily feeling states among older, obese adults with knee osteoarthritis.
      • Guo M.
      • Axe M.J.
      • Manal K.
      The influence of foot progression angle on the knee adduction moment during walking and stair climbing in pain free individuals with knee osteoarthritis.
      methodology was a systematic review or meta-analysis in 5 studies,
      • Roddy E.
      • Zhang W.
      • Doherty M.
      Aerobic walking or strengthening exercise for osteoarthritis of the knee? A systematic review.
      • van Baar M.E.
      • Assendelft W.J.
      • Dekker J.
      • Oostendorp R.A.
      • Bijlsma J.W.
      Effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review of randomized clinical trials.
      • Williams S.B.
      • Brand C.A.
      • Hill K.D.
      • Hunt S.B.
      • Moran H.
      Feasibility and outcomes of a home-based exercise program on improving balance and gait stability in women with lower-limb osteoarthritis or rheumatoid arthritis: a pilot study.
      • Richmond J.
      • Hunter D.
      • Irrgang J.
      • et al.
      Treatment of osteoarthritis of the knee (nonarthroplasty).
      • Semble E.L.
      • Loeser R.F.
      • Wise C.M.
      Therapeutic exercise for rheumatoid arthritis and osteoarthritis.
      diet intervention with physical activity including walking, with individuals who are obese or overweight in 8 studies,
      • Toda Y.
      • Toda T.
      • Takemura S.
      • Wada T.
      • Morimoto T.
      • Ogawa R.
      Change in body fat, but not body weight or metabolic correlates of obesity, is related to symptomatic relief of obese patients with knee osteoarthritis after a weight control program.
      • Toda Y.
      The effect of energy restriction, walking, and exercise on lower extremity lean body mass in obese women with osteoarthritis of the knee.
      • Miller G.D.
      • Nicklas B.J.
      • Davis C.
      • Loeser R.F.
      • Lenchik L.
      • Messier S.P.
      Intensive weight loss program improves physical function in older obese adults with knee osteoarthritis.
      • Wang X.
      • Miller G.D.
      • Messier S.P.
      • Nicklas B.J.
      Knee strength maintained despite loss of lean body mass during weight loss in older obese adults with knee osteoarthritis.
      • Focht B.C.
      • Rejeski J.
      • Ambrosius W.T.
      • Katula J.A.
      • Messier S.P.
      Exercise, self-efficacy, and mobility performance in overweight and obese older adults with knee osteoarthritis.
      • Rejeski W.J.
      • Focht B.C.
      • Messier S.P.
      Obese, older adults with knee osteoarthritis: weight loss, exercise, and quality of life.
      • Tak E.
      • Staats P.
      • van Hespen A.
      • Hopman-Rock M.
      The effects of an exercise program for older adults with osteoarthritis of the hip.
      • van Gool C.H.
      • Penninx B.W.
      • Kempen G.I.
      • et al.
      Determinants of high and low attendance to diet and exercise interventions among overweight and obese older adults Results from the arthritis, diet, and activity promotion trial.
      not enough statistical data in 1 trial,
      • Minor M.A.
      • Brown J.D.
      Exercise maintenance of persons with arthritis after participation in a class experience.
      main intervention focused on nutrition in 1 trial,
      • Messier S.P.
      • Loeser R.F.
      • Mitchell M.N.
      • et al.
      Exercise and weight loss in obese older adults with knee osteoarthritis: a preliminary study.
      only qualitative data in 1 trial,
      • van Baar M.E.
      • Assendelft W.J.
      • Dekker J.
      • Oostendorp R.A.
      • Bijlsma J.W.
      Effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review of randomized clinical trials.
      design but no measurement in 1 study,
      • Ng N.
      • Heesch K.C.
      • Brown W.J.
      Efficacy of a progressive walking program and glucosamine sulphate supplementation on osteoarthritic symptoms of the hip and knee: a feasibility trial.
      a pilot study in 2 trials,
      • Ytterberg S.R.
      • Mahowald M.L.
      • Krug H.E.
      Exercise for arthritis.
      • Hoogeboom T.J.
      • Dronkers J.J.
      • van den Ende C.H.
      • Oosting E.
      • van Meeteren N.L.
      Preoperative therapeutic exercise in frail elderly scheduled for total hip replacement: a randomized pilot trial.
      and no control group results in 1 trial (data not shown).
      • Minor M.A.
      • Brown J.D.
      Exercise maintenance of persons with arthritis after participation in a class experience.
      Please refer to the Ottawa Panel article.
      • Brosseau L.
      • Wells G.A.
      • Tugwell M.D.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines in the management of osteoarthritis in adults who are obese or overweight.

       Study Characteristics

      Most of the studies chosen for this project presented an aerobic walking program where the participants from experimental groups were supervised by at least 1 therapist. Of the 10 included trials, 9 were RCTs. Only 1 study
      • Evcik D.
      • Sonel B.
      Effectiveness of a home-based exercise therapy and walking program on osteoarthritis of the knee.
      was a controlled clinical trial (CCT). All studies included patients who presented radiographic and/or clinical criteria for primary OA of the knee.
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      • Péloquin L.
      • Bravo G.
      • Gauthier P.
      • Lacombe G.
      • Billiard J.S.
      Effects of a cross-training exercise program in persons with osteoarthritis of the knee A randomized controlled trial.
      • Kovar P.A.
      • Allegrante J.P.
      • Mackenzie C.R.
      • Peterson M.G.
      • Gutin B.
      • Charlson M.E.
      Supervised fitness walking in patients with osteoarthritis of the knee A randomized, controlled trial.
      • Evcik D.
      • Sonel B.
      Effectiveness of a home-based exercise therapy and walking program on osteoarthritis of the knee.
      • Peterson M.G.
      • Kovar-Toledano P.A.
      • Otis J.C.
      • et al.
      Effect of a walking program on gait characteristics in patients with osteoarthritis.
      • Bautch J.C.
      • Malone D.G.
      • Vailas A.C.
      Effects of exercise on knee joints with osteoarthritis: a pilot study of biological markers.
      • Dias R.C.
      • Dias J.M.
      • Ramos L.R.
      Impact of an exercise and walking protocol on quality of life for elderly people with OA of the knee.
      • Messier S.P.
      • Thompson C.D.
      • Ettinger M.H.
      Effects of long-term aerobic or weight training regimens on gait in an older, osteoarthritic population.
      • Penninx B.W.
      • Messier S.P.
      • Rejeski W.J.
      • et al.
      Physical exercise and the prevention of disability in activities of daily living in older persons with osteoarthritis.
      • Talbot L.A.
      • Gaines J.M.
      • Ling S.M.
      • Metter E.J.
      A home-based protocol of electrical muscle stimulation for quadriceps muscle strength in older adults with osteoarthritis of the knee.
      All the participants were aged 40 years old or older. One CCT
      • Evcik D.
      • Sonel B.
      Effectiveness of a home-based exercise therapy and walking program on osteoarthritis of the knee.
      compared a control group where participants were asked to continue their normal daily activities with a walking program group. Two RCTs
      • Bautch J.C.
      • Malone D.G.
      • Vailas A.C.
      Effects of exercise on knee joints with osteoarthritis: a pilot study of biological markers.
      • Penninx B.W.
      • Messier S.P.
      • Rejeski W.J.
      • et al.
      Physical exercise and the prevention of disability in activities of daily living in older persons with osteoarthritis.
      presented educational sessions for the control group, where phone contacts were added with the patient education,
      • Penninx B.W.
      • Messier S.P.
      • Rejeski W.J.
      • et al.
      Physical exercise and the prevention of disability in activities of daily living in older persons with osteoarthritis.
      and compared this group to a walking program combined with strength training group. Three RCTs
      • Kovar P.A.
      • Allegrante J.P.
      • Mackenzie C.R.
      • Peterson M.G.
      • Gutin B.
      • Charlson M.E.
      Supervised fitness walking in patients with osteoarthritis of the knee A randomized, controlled trial.
      • Peterson M.G.
      • Kovar-Toledano P.A.
      • Otis J.C.
      • et al.
      Effect of a walking program on gait characteristics in patients with osteoarthritis.
      • Talbot L.A.
      • Gaines J.M.
      • Ling S.M.
      • Metter E.J.
      A home-based protocol of electrical muscle stimulation for quadriceps muscle strength in older adults with osteoarthritis of the knee.
      presented educational sessions for the control group, where phone contacts were added with patient education,
      • Kovar P.A.
      • Allegrante J.P.
      • Mackenzie C.R.
      • Peterson M.G.
      • Gutin B.
      • Charlson M.E.
      Supervised fitness walking in patients with osteoarthritis of the knee A randomized, controlled trial.
      • Peterson M.G.
      • Kovar-Toledano P.A.
      • Otis J.C.
      • et al.
      Effect of a walking program on gait characteristics in patients with osteoarthritis.
      and compared this group to a walking program with health education and behavioral components group. Two other RCTs
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      • Messier S.P.
      • Thompson C.D.
      • Ettinger M.H.
      Effects of long-term aerobic or weight training regimens on gait in an older, osteoarthritic population.
      compared a walking program including a multicomponent exercise group with a control group, where the participants followed educational sessions with phone contacts
      • Messier S.P.
      • Thompson C.D.
      • Ettinger M.H.
      Effects of long-term aerobic or weight training regimens on gait in an older, osteoarthritic population.
      and gentle active range of motion, isometric strengthening, and relaxation exercises.
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      Finally, 2 RCTs
      • Bautch J.C.
      • Malone D.G.
      • Vailas A.C.
      Effects of exercise on knee joints with osteoarthritis: a pilot study of biological markers.
      • Dias R.C.
      • Dias J.M.
      • Ramos L.R.
      Impact of an exercise and walking protocol on quality of life for elderly people with OA of the knee.
      presented educational sessions for the control group, and compared this group to a walking program with multicomponent exercises and health education group. See appendices 1 and 3 for more details on the characteristics of the interventions of all included studies.

       Results of the Studies

       Methodologic quality/risk of bias within studies

      The Jadad scale scores revealed that 3 out of 10 studies
      • Evcik D.
      • Sonel B.
      Effectiveness of a home-based exercise therapy and walking program on osteoarthritis of the knee.
      • Bautch J.C.
      • Malone D.G.
      • Vailas A.C.
      Effects of exercise on knee joints with osteoarthritis: a pilot study of biological markers.
      • Messier S.P.
      • Thompson C.D.
      • Ettinger M.H.
      Effects of long-term aerobic or weight training regimens on gait in an older, osteoarthritic population.
      had poor methodologic quality (<3 points). Although they achieved a low score, the 3 studies presented respectable methods and were therefore included in our database (see appendices 1 and 3). The other trials showed high methodologic quality by receiving a result of 3 out of 5 points and 2 of the articles were from the same study. All articles had a score of 0 for the second question of the Jadad scale score, because none of the investigators used the double-blinding method during the intervention.
      • Deyo R.A.
      • Walsh N.E.
      • Schoenfeld L.S.
      • Ramamurthy C.
      Can trials of physical treatments be blinded? The example of transcutaneous electrical nerve stimulation for chronic pain.

       Effectiveness of aerobic walking programs for the management of OA of the knee

      Seven RCTs with high methodologic quality (3 points according to the Jadad scale) will be described in the following section, and 3 figures from these studies were selected (see appendix 1 and fig 1B and 1C). The first pool of 3 RCTs
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      • Péloquin L.
      • Bravo G.
      • Gauthier P.
      • Lacombe G.
      • Billiard J.S.
      Effects of a cross-training exercise program in persons with osteoarthritis of the knee A randomized controlled trial.
      • Kovar P.A.
      • Allegrante J.P.
      • Mackenzie C.R.
      • Peterson M.G.
      • Gutin B.
      • Charlson M.E.
      Supervised fitness walking in patients with osteoarthritis of the knee A randomized, controlled trial.
      was done by evaluating aerobic walking programs versus the control: pain relief with AIMS.
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      • Péloquin L.
      • Bravo G.
      • Gauthier P.
      • Lacombe G.
      • Billiard J.S.
      Effects of a cross-training exercise program in persons with osteoarthritis of the knee A randomized controlled trial.
      • Kovar P.A.
      • Allegrante J.P.
      • Mackenzie C.R.
      • Peterson M.G.
      • Gutin B.
      • Charlson M.E.
      Supervised fitness walking in patients with osteoarthritis of the knee A randomized, controlled trial.
      The results showed homogeneity between the studies of high quality, because the P value was higher than .10 (P=.96) and the I2 value was less than 50% (0%). According to the global effect, the standardized mean difference (SMD) was −0.47 (95% confidence interval −0.71 to −0.23) and demonstrated statistical significance (see fig 1A and table 3). See appendix 1 for more information on the results. The second pool consisted of 2 RCTs of high quality that evaluated aerobic walking programs versus control: endurance walking with a 6-minute walk test
      • Kovar P.A.
      • Allegrante J.P.
      • Mackenzie C.R.
      • Peterson M.G.
      • Gutin B.
      • Charlson M.E.
      Supervised fitness walking in patients with osteoarthritis of the knee A randomized, controlled trial.
      or five-minute walk test.
      • Péloquin L.
      • Bravo G.
      • Gauthier P.
      • Lacombe G.
      • Billiard J.S.
      Effects of a cross-training exercise program in persons with osteoarthritis of the knee A randomized controlled trial.
      The results demonstrated homogeneity between the RCTs of high quality, because the P value was higher than 0.10 (P=.17) and the I2 value was under 50% (46%). According to the global effect, the SMD was −0.68 (−0.96 to −0.41) and demonstrated statistical significance (see fig 1B and table 4). See appendix 1 for more details. We developed a recommendation for each of the 4 aerobic walking interventions: (1) walking program alone versus control (grade B for function, pain relief, QOL); (2) walking program with strengthening training versus control (grade A for QOL, function); (3) walking program with health education and behavioral components versus control (grade A for pain relief and QOL); (4) walking program with multicomponent exercises versus control (grade A for pain relief, QOL); and (5) walking program with multicomponent exercises and health education versus control (grade A for function, QOL). The Ottawa Panel also found strong evidence that demonstrated clinically important benefits with statistical significance of an aerobic walking program versus control
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      (1 RCT, N=83, high quality with a Jadad scale score of 3/5) for improved aerobic capacity (Naughton protocol) (relative difference in change from baseline =19.83%) at the end of treatment (12wk). No improvements in aerobic capacity (Naughton protocol) were measured at 9-month follow-up (FU) (see fig 1C and table 5). See also appendix 1 for more information on the results.
      Table 3Results for the Relative Difference and SMD for an Aerobic Walking Program Versus Control: Pain Relief
      StudyTreatment GroupOutcomeNo. of PatientsBaseline MeanEnd of Study MeanAbsolute BenefitRelative Difference in Change From Baseline (%)SMD (95% CI)
      Kovar et al
      • Kovar P.A.
      • Allegrante J.P.
      • Mackenzie C.R.
      • Peterson M.G.
      • Gutin B.
      • Charlson M.E.
      Supervised fitness walking in patients with osteoarthritis of the knee A randomized, controlled trial.
      Aerobic walking program with strengthening and stretching exercises, and educational/support sessionAIMS pain

      Lower better

      End of Tx: 2mo
      475.153.77−1.28−26−0.51 (−0.94 to −0.10)
      Control454.874.77
      Minor et al
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      Aerobic walking program with strengthening and stretching exercises, education, and behavioral interventionAIMS pain

      Lower better

      End of Tx: 3mo
      285.103.90−0.50−9−0.47 (−1.00 to 0.06)
      Control285.504.80
      Péloquin et al
      • Péloquin L.
      • Bravo G.
      • Gauthier P.
      • Lacombe G.
      • Billiard J.S.
      Effects of a cross-training exercise program in persons with osteoarthritis of the knee A randomized controlled trial.
      Aerobic walking program with strengthening and stretching exercisesAIMS pain

      Lower better

      End of Tx: 3mo
      594.533.09−0.85−19−0.44 (−0.80 to −0.08)
      Control654.533.94
      Abbreviations: CI, confidence interval; Tx, treatment.
      Table 4Results for the Relative Difference and SMD for an Aerobic Walking Program Versus Control: Walking Endurance
      StudyTreatment GroupOutcomeNo. of PatientsBaseline MeanEnd of Study MeanAbsolute BenefitRelative Difference in Change From Baseline (%)SMD (95% CI)
      Kovar et al
      • Kovar P.A.
      • Allegrante J.P.
      • Mackenzie C.R.
      • Peterson M.G.
      • Gutin B.
      • Charlson M.E.
      Supervised fitness walking in patients with osteoarthritis of the knee A randomized, controlled trial.
      Aerobic walking program with strengthening and stretching exercises, and educational/support sessionSix-minute walk test (min)

      Higher better

      End of Tx: 2mo
      47381.00451.0087.0024−0.91 (−1.34 to −.048)
      Control45356.00339.00
      Péloquin et al
      • Péloquin L.
      • Bravo G.
      • Gauthier P.
      • Lacombe G.
      • Billiard J.S.
      Effects of a cross-training exercise program in persons with osteoarthritis of the knee A randomized controlled trial.
      Aerobic walking program with strengthening and stretching exercisesFive-minute walk test (min)

      Higher better

      End of Tx: 3mo
      59419.19467.7729.937−0.52 (−0.88 to −0.17)
      Control65406.93425.58
      Abbreviations: CI, confidence interval; SMD, standardized mean difference; Tx, treatment.
      Table 5Results for the Relative Difference and Weighted Mean Difference for an Aerobic Walking Program Versus Control
      StudyTreatment GroupOutcomeNo. of PatientsBaseline MeanEnd of Study MeanAbsolute BenefitRelative Difference in Change From Baseline (%)WMD (95% CI)
      Minor et al
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      Aerobic walking program with strengthening and stretching exercises, education, and BIAerobic capacity (mL/kg/min)

      Lower better

      End of Tx: 12wk
      2818.922.403.619.83−5.10 (−7.32 to −2.88)
      Control2817.417.30
      Minor et al
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      Aerobic walking program with strengthening and stretching exercises, education, and BIAerobic capacity (mL/kg/min)

      Lower better

      FU: 9mo
      2618.923.621.136.19−2.63 (−5.49 to −0.23)
      Control2017.420.99
      Abbreviations: CI, confidence interval; Tx, treatment; WMD, weighted mean difference.

      Discussion

      The Ottawa Panel created an EBCPG with this systematic review of aerobic walking programs in the management of OA of the knee. In this systematic review, the Ottawa Panel developed recommendations based on 7 out of 10 comparative controlled studies with higher quality (with a Jadad scale score of 3/5).
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      • Péloquin L.
      • Bravo G.
      • Gauthier P.
      • Lacombe G.
      • Billiard J.S.
      Effects of a cross-training exercise program in persons with osteoarthritis of the knee A randomized controlled trial.
      • Kovar P.A.
      • Allegrante J.P.
      • Mackenzie C.R.
      • Peterson M.G.
      • Gutin B.
      • Charlson M.E.
      Supervised fitness walking in patients with osteoarthritis of the knee A randomized, controlled trial.
      • Peterson M.G.
      • Kovar-Toledano P.A.
      • Otis J.C.
      • et al.
      Effect of a walking program on gait characteristics in patients with osteoarthritis.
      • Dias R.C.
      • Dias J.M.
      • Ramos L.R.
      Impact of an exercise and walking protocol on quality of life for elderly people with OA of the knee.
      • Penninx B.W.
      • Messier S.P.
      • Rejeski W.J.
      • et al.
      Physical exercise and the prevention of disability in activities of daily living in older persons with osteoarthritis.
      • Talbot L.A.
      • Gaines J.M.
      • Ling S.M.
      • Metter E.J.
      A home-based protocol of electrical muscle stimulation for quadriceps muscle strength in older adults with osteoarthritis of the knee.
      The Ottawa Panel concluded that aerobic walking combined with stretching and strengthening exercises, education, and/or behavior programs are recommended to improve pain relief, functional status, and QOL of adult individuals with OA. These recommendations had both clinical importance and statistical significance; therefore, they were given grades of A. Furthermore, positive recommendations for improvement in stiffness relief, strength in extensors of both lower extremities, and mobility (stairs climbing, number of steps) received a grade of C+. Therefore, among higher quality studies (Jadad score of 3/5 or higher), there were a total of 16 positive recommendations: 9 with a grade A (strongly recommended) and 7 with a grade C+ (suggested used). This article shows that an aerobic walking program is beneficial, especially for pain relief (2 grade A and 1 C+), improved QOL (4 grade A and 3 grade C+), and for functional status (2 grade A) in adults aged over 40 years and diagnosed with OA of the knee. Among the remaining recommendations, 16 were graded C, 6 were graded D, and 4 were graded D+.
      Several aerobic walking programs showed significant and beneficial effects on QOL compared with a control.
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      • Peterson M.G.
      • Kovar-Toledano P.A.
      • Otis J.C.
      • et al.
      Effect of a walking program on gait characteristics in patients with osteoarthritis.
      • Dias R.C.
      • Dias J.M.
      • Ramos L.R.
      Impact of an exercise and walking protocol on quality of life for elderly people with OA of the knee.
      This effect, however, was not maintained after an unsupervised period of walking program at 9 months.
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      Patients who suffered from OA felt less pain in their lower extremities.
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      • Péloquin L.
      • Bravo G.
      • Gauthier P.
      • Lacombe G.
      • Billiard J.S.
      Effects of a cross-training exercise program in persons with osteoarthritis of the knee A randomized controlled trial.
      • Peterson M.G.
      • Kovar-Toledano P.A.
      • Otis J.C.
      • et al.
      Effect of a walking program on gait characteristics in patients with osteoarthritis.
      Among these studies, the duration of the programs varied between 2 and 6 months. The literature has consistently shown that aerobic walking programs ranging from 2 to 9 months in duration are highly effective for people with OA of the lower extremities. Significant changes have been observed in the performance of daily living activities,
      • Peterson M.G.
      • Kovar-Toledano P.A.
      • Otis J.C.
      • et al.
      Effect of a walking program on gait characteristics in patients with osteoarthritis.
      • Dias R.C.
      • Dias J.M.
      • Ramos L.R.
      Impact of an exercise and walking protocol on quality of life for elderly people with OA of the knee.
      • Penninx B.W.
      • Messier S.P.
      • Rejeski W.J.
      • et al.
      Physical exercise and the prevention of disability in activities of daily living in older persons with osteoarthritis.
      walking distance,
      • Kovar P.A.
      • Allegrante J.P.
      • Mackenzie C.R.
      • Peterson M.G.
      • Gutin B.
      • Charlson M.E.
      Supervised fitness walking in patients with osteoarthritis of the knee A randomized, controlled trial.
      • Peterson M.G.
      • Kovar-Toledano P.A.
      • Otis J.C.
      • et al.
      Effect of a walking program on gait characteristics in patients with osteoarthritis.
      • Talbot L.A.
      • Gaines J.M.
      • Ling S.M.
      • Metter E.J.
      A home-based protocol of electrical muscle stimulation for quadriceps muscle strength in older adults with osteoarthritis of the knee.
      and gait velocity.
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      • Peterson M.G.
      • Kovar-Toledano P.A.
      • Otis J.C.
      • et al.
      Effect of a walking program on gait characteristics in patients with osteoarthritis.
      Long-term, facility-based walking studies (18-mo FU) using behavioral intervention (BI) components demonstrated major improvements for walking distance and QOL
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      when compared with a control.
      • Kovar P.A.
      • Allegrante J.P.
      • Mackenzie C.R.
      • Peterson M.G.
      • Gutin B.
      • Charlson M.E.
      Supervised fitness walking in patients with osteoarthritis of the knee A randomized, controlled trial.
      • Peterson M.G.
      • Kovar-Toledano P.A.
      • Otis J.C.
      • et al.
      Effect of a walking program on gait characteristics in patients with osteoarthritis.
      Regarding the considerable resources used for the majority of the included studies, 1 trial proved that a home-based, pedometer-driven walking program represented an inexpensive alternative to supervised and structured aerobic walking programs, by simply incorporating into everyday life of subjects a pedometer for monitoring their daily steps. Furthermore, this home-based walking study combined with an education program showed clinically important benefits for functional status, walking efficiency, and muscle strength.
      • Talbot L.A.
      • Gaines J.M.
      • Ling S.M.
      • Metter E.J.
      A home-based protocol of electrical muscle stimulation for quadriceps muscle strength in older adults with osteoarthritis of the knee.
      Aerobic walking programs are effective with individuals diagnosed with OA of the knee, because they help relieve pain and promote nutrition and remodeling without increasing stress in the affected joint.
      • Helewa A.
      • Walker J.M.
      Epidemiology and economics of arthritis.
      Aerobic exercise can increase endorphin production, generating an analgesic effect, which gradually induces a decrease in pain.
      • Messier S.P.
      • Legault C.
      • Mihalko S.
      • et al.
      The Intensive Diet and Exercise for Arthritis (IDEA) trial: design and rationale.
      • Helewa A.
      • Walker J.M.
      Epidemiology and economics of arthritis.
      These positive changes are attributed to improving knee joint loads, stability, joint biomechanics, neuromuscular function, and possible improved training of cardiovascular efficiency, aerobic capacity, and activity tolerance.
      • Messier S.P.
      • Legault C.
      • Mihalko S.
      • et al.
      The Intensive Diet and Exercise for Arthritis (IDEA) trial: design and rationale.
      • Helewa A.
      • Walker J.M.
      Epidemiology and economics of arthritis.
      Therefore, the stability of the affected joint assists persons with OA to be more functional in everyday living, which will progressively improve their QOL.
      • Lobstein D.D.
      • Ismail A.H.
      • Rasmussen C.L.
      Beta-endorphin and components of emotionality discriminate between physically active and sedentary men.
      The significant improvements in QOL may be in relation with physical activity, by helping patients reduce fatigue, anxiety, and recover their self-esteem, motivation, and mental health. Also, participation in physical activity with other patients may help individuals to improve social networks and increase community cohesion.
      • Brosseau L.
      • Wells G.A.
      • Tugwell M.D.
      • et al.
      Ottawa Panel evidence-based clinical practice guidelines in the management of osteoarthritis in adults who are obese or overweight.
      Behavioral strategies, such as patient education, health counseling, and phone contacts, in combination with aerobic walking programs can facilitate OA management and allow individuals to increase their exercise levels.
      • Helewa A.
      • Walker J.M.
      Epidemiology and economics of arthritis.
      Literature research also suggests that encouraging self-management,
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      improving self-efficacy, providing reinforcement,
      • Evcik D.
      • Sonel B.
      Effectiveness of a home-based exercise therapy and walking program on osteoarthritis of the knee.
      and offering education about the benefits of physical activity, are other effective behavioral strategies. It is important to know that when performing 10 minutes or more of aerobic walking, a warm-up period and a cool-down session of at least 3 minutes each are both necessary for flexibility, strength, and pain management.
      • Helewa A.
      • Walker J.M.
      Epidemiology and economics of arthritis.
      Strengthening exercises of the lower extremity are known to improve neuromuscular activity, joint protection and function, and decrease pain in the affected knee.
      • Lobstein D.D.
      • Ismail A.H.
      • Rasmussen C.L.
      Beta-endorphin and components of emotionality discriminate between physically active and sedentary men.
      High-intensity activities are considered risk factors for injury and relapse; therefore, an individual with OA should always maintain intensity at a safe level.
      • Helewa A.
      • Walker J.M.
      Epidemiology and economics of arthritis.
      An aerobic walking period should be performed for at least 30 minutes, at a level of exercise intensity above normal daily activities and at a minimal frequency of 3 to 4 times a week, in order to obtain cardiovascular fitness.
      • Helewa A.
      • Walker J.M.
      Epidemiology and economics of arthritis.
      This systematic review supports the conclusions found by the American College of Rheumatology
      American College of Rheumatology Subcommittee on Osteoarthritis Guidelines
      Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update.
      regarding the management of OA of the knee. This guideline concluded that older participants with symptomatic knee OA, who participated in an aerobic or resistance exercise program, demonstrated better performance measures of function with constant improvements in self-reported pain relief and disability.
      • Ağlamis A.
      • Toraman N.F.
      • Yaman H.
      The effect of a 12-week supervised multicomponent exercise program on knee OA in Turkish women.
      The European League Against Rheumatism
      • Pendleton A.
      • Arden N.
      • Dougados M.
      • et al.
      EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT).
      also demonstrated that strengthening exercise programs and aerobic walking training were both successful over 18-months FU. The Osteoarthritis Research Society International instead recommended that subjects should participate in a regular aerobic walking program and also perform quadriceps muscle strengthening exercises at home, in order to improve mainly their functional status. Moreover, they confirmed what has been found in this current review, by proving that monthly telephone contacts combined with a walking program had enhanced the clinical status of individuals diagnosed with OA of the knee. However, this systematic review refutes that combining pharmacologic therapies with nonpharmacologic interventions, such as walking programs, showed more beneficial effects.
      • Zhang W.
      • Moskowitz R.W.
      • Nuki G.
      • et al.
      OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines.
      The attrition of the participants with OA enrolled in short-term RCTs in which they had to follow an aerobic physical intervention including an aerobic walking program is high with dropout rates ranging from 20% to 39%.
      • Bautch J.C.
      • Malone D.G.
      • Vailas A.C.
      Effects of exercise on knee joints with osteoarthritis: a pilot study of biological markers.
      • Dias R.C.
      • Dias J.M.
      • Ramos L.R.
      Impact of an exercise and walking protocol on quality of life for elderly people with OA of the knee.
      Long-term studies will usually combine an aerobic walking program with BI components, such as log books, sessions of education, social/peer support, telephone support, goal setting, use of a pedometer to monitor daily steps, and positive feedback.
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      • Péloquin L.
      • Bravo G.
      • Gauthier P.
      • Lacombe G.
      • Billiard J.S.
      Effects of a cross-training exercise program in persons with osteoarthritis of the knee A randomized controlled trial.
      • Kovar P.A.
      • Allegrante J.P.
      • Mackenzie C.R.
      • Peterson M.G.
      • Gutin B.
      • Charlson M.E.
      Supervised fitness walking in patients with osteoarthritis of the knee A randomized, controlled trial.
      • Peterson M.G.
      • Kovar-Toledano P.A.
      • Otis J.C.
      • et al.
      Effect of a walking program on gait characteristics in patients with osteoarthritis.
      • Dias R.C.
      • Dias J.M.
      • Ramos L.R.
      Impact of an exercise and walking protocol on quality of life for elderly people with OA of the knee.
      • Messier S.P.
      • Thompson C.D.
      • Ettinger M.H.
      Effects of long-term aerobic or weight training regimens on gait in an older, osteoarthritic population.
      • Penninx B.W.
      • Messier S.P.
      • Rejeski W.J.
      • et al.
      Physical exercise and the prevention of disability in activities of daily living in older persons with osteoarthritis.
      • Talbot L.A.
      • Gaines J.M.
      • Ling S.M.
      • Metter E.J.
      A home-based protocol of electrical muscle stimulation for quadriceps muscle strength in older adults with osteoarthritis of the knee.
      Moreover, the most effective method in terms of long-term compliance rates consisted of a multifaceted approach that incorporated social support with aerobic walking programs.
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      Therefore, the long-term trials that used BI generally demonstrated lower dropout rates at FU compared with short-term studies: (1) 10% to 15% at 2 to 4 months FU; (2) 9% to 25% at 6 to 9 months FU; and (3) 10% to 49% at 10 to 18 months FU. However, walking programs at home that are combined with only telephone contacts had less improved short-term and long-term adherence rates.
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.

       Study Limitations

      A common limitation inherent to the EBCPGs is the heterogeneity of studies included with regards to the characteristics of the PICOPS strategy. Some studies presented an intervention based only on an aerobic walking program, but the majority included a variety of therapies combined with the aerobic walking program, such as complementary strengthening, stretching, and/or stabilization exercises. Some investigators proposed a home-based walking program,
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      • Talbot L.A.
      • Gaines J.M.
      • Ling S.M.
      • Metter E.J.
      A home-based protocol of electrical muscle stimulation for quadriceps muscle strength in older adults with osteoarthritis of the knee.
      others proposed a facility-based program,
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      • Dias R.C.
      • Dias J.M.
      • Ramos L.R.
      Impact of an exercise and walking protocol on quality of life for elderly people with OA of the knee.
      and/or a hospital-based program.
      • Kovar P.A.
      • Allegrante J.P.
      • Mackenzie C.R.
      • Peterson M.G.
      • Gutin B.
      • Charlson M.E.
      Supervised fitness walking in patients with osteoarthritis of the knee A randomized, controlled trial.
      • Peterson M.G.
      • Kovar-Toledano P.A.
      • Otis J.C.
      • et al.
      Effect of a walking program on gait characteristics in patients with osteoarthritis.
      • Dias R.C.
      • Dias J.M.
      • Ramos L.R.
      Impact of an exercise and walking protocol on quality of life for elderly people with OA of the knee.
      Some studies
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      • Kovar P.A.
      • Allegrante J.P.
      • Mackenzie C.R.
      • Peterson M.G.
      • Gutin B.
      • Charlson M.E.
      Supervised fitness walking in patients with osteoarthritis of the knee A randomized, controlled trial.
      • Peterson M.G.
      • Kovar-Toledano P.A.
      • Otis J.C.
      • et al.
      Effect of a walking program on gait characteristics in patients with osteoarthritis.
      • Talbot L.A.
      • Gaines J.M.
      • Ling S.M.
      • Metter E.J.
      A home-based protocol of electrical muscle stimulation for quadriceps muscle strength in older adults with osteoarthritis of the knee.
      added a BI to ensure that the participants remained active during the walking program for a longer study duration.
      Most of the time, when there is appearance of conflicting findings about the same outcome across different studies, it can be related to the use of a different PICOPS strategy among the eligible studies of this systematic review (see table 1). However, studies of high quality were combined by evaluating studies with the same outcome measures. See the Results of Studies section and figures 1B and C for more details. Some of the studies demonstrated an inadequate or unclear concealment of allocation. Eight of the studies selected
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      • Péloquin L.
      • Bravo G.
      • Gauthier P.
      • Lacombe G.
      • Billiard J.S.
      Effects of a cross-training exercise program in persons with osteoarthritis of the knee A randomized controlled trial.
      • Kovar P.A.
      • Allegrante J.P.
      • Mackenzie C.R.
      • Peterson M.G.
      • Gutin B.
      • Charlson M.E.
      Supervised fitness walking in patients with osteoarthritis of the knee A randomized, controlled trial.
      • Peterson M.G.
      • Kovar-Toledano P.A.
      • Otis J.C.
      • et al.
      Effect of a walking program on gait characteristics in patients with osteoarthritis.
      • Dias R.C.
      • Dias J.M.
      • Ramos L.R.
      Impact of an exercise and walking protocol on quality of life for elderly people with OA of the knee.
      • Messier S.P.
      • Thompson C.D.
      • Ettinger M.H.
      Effects of long-term aerobic or weight training regimens on gait in an older, osteoarthritic population.
      • Penninx B.W.
      • Messier S.P.
      • Rejeski W.J.
      • et al.
      Physical exercise and the prevention of disability in activities of daily living in older persons with osteoarthritis.
      • Talbot L.A.
      • Gaines J.M.
      • Ling S.M.
      • Metter E.J.
      A home-based protocol of electrical muscle stimulation for quadriceps muscle strength in older adults with osteoarthritis of the knee.
      presented adequate randomization procedures and no selection bias.
      • Nüesch E.
      • Reichenbach S.
      • Trelle S.
      • et al.
      The importance of allocation concealment and patient blinding in osteoarthritis trials: a meta-epidemiologic study.
      One of the 10 included studies
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      demonstrated possible withdrawal bias, as the dropout rate was 20%. Studies were not included if they demonstrated more than 20% of withdrawals of subjects. Also, it is important to note that the average withdrawal rate of the selected trials was 12.2% (excluding 3 studies that did not mention the number of participants that withdrew from the study). Some studies lacked information concerning the intervention (eg, duration, intensity, progression). Six studies had included patients with conditions of OA according to the radiologic and the clinical assessment of OA. Three trials had confirmed the diagnosis of primary OA of their participants considering only the clinical criteria, and 1 study included patients who presented only radiographic criteria for primary OA of the knee.
      Given the above limitations in many of the included studies, the Ottawa Panel based their final recommendation on only 7 comparative controlled studies with higher quality (with a Jadad scale score of 3/5).
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      • Péloquin L.
      • Bravo G.
      • Gauthier P.
      • Lacombe G.
      • Billiard J.S.
      Effects of a cross-training exercise program in persons with osteoarthritis of the knee A randomized controlled trial.
      • Kovar P.A.
      • Allegrante J.P.
      • Mackenzie C.R.
      • Peterson M.G.
      • Gutin B.
      • Charlson M.E.
      Supervised fitness walking in patients with osteoarthritis of the knee A randomized, controlled trial.
      • Peterson M.G.
      • Kovar-Toledano P.A.
      • Otis J.C.
      • et al.
      Effect of a walking program on gait characteristics in patients with osteoarthritis.
      • Dias R.C.
      • Dias J.M.
      • Ramos L.R.
      Impact of an exercise and walking protocol on quality of life for elderly people with OA of the knee.
      • Penninx B.W.
      • Messier S.P.
      • Rejeski W.J.
      • et al.
      Physical exercise and the prevention of disability in activities of daily living in older persons with osteoarthritis.
      • Talbot L.A.
      • Gaines J.M.
      • Ling S.M.
      • Metter E.J.
      A home-based protocol of electrical muscle stimulation for quadriceps muscle strength in older adults with osteoarthritis of the knee.
      In other words, the selected studies couldn't follow the procedure of double-blinding, because they had no choice of informing their participants regarding which group of interventions they will be allocated to, in order to adequately execute the exercises. Therefore, all of the included articles had a score of 0 for the second question of the Jadad scale score, because none of the investigators used the double-blinding method during the intervention. However, according to the study of Olivo et al,
      • Olivo S.A.
      • Macedo L.G.
      • Gadotti I.C.
      • Fuentes J.
      • Stanton T.
      • Magee D.J.
      Scales to assess the quality of randomized controlled trials: a systematic review.
      the Jadad score scale was not originally developed for studies evaluating physical interventions, but is often used in different systematic reviews. Moreover, the Jadad score scale was assessed by the criteria list of Terwee et al
      • Terwee C.B.
      • Bot S.D.
      • de Boer M.R.
      • et al.
      Quality criteria were proposed for measurement properties of health status questionnaires.
      and obtained the same quality score as the PEDro, known as the criterion standard—a valid measure of methodologic quality of clinical trials in the domain of physiotherapy.
      Finally, it is important to mention that the reason why it has been decided to only include studies that selected participants with healthy weight (BMI<25kg/m2) was to eliminate all the trials that were combining walking programs with diet interventions, in order to evaluate adequately the effect of walking on the symptoms of OA. Also, this article is already quite lengthy; therefore, this other reason led us to exclude studies that added a diet intervention to walking programs (already considered in the Ottawa Panel article on obesity and OA in 2011).
      • Aigner T.
      • Dudhia J.
      Genomics of osteoarthritis.
      Given that many people with OA are overweight, by presenting a BMI greater than 25kg/m2, this significantly reduces the clinical applicability of the study and subsequent findings.

      Conclusions/Clinical Implications

      The Ottawa Panel found important evidence to support the use of aerobic walking programs in the management of OA, for subjects aged over 40 years who are diagnosed with mild to moderate OA of 1 or both knees. Evidence from 7 high-quality studies demonstrates that facility, hospital, and home-based aerobic walking programs with other therapies are effective interventions in the shorter term for the management of patients with OA to improve stiffness, strength, mobility, and endurance. Moreover, the greatest improvements were found in pain, QOL, and functional status. In summary, it would be strongly recommended to use the Cochrane Risk of Bias Summary assessment to evaluate the methodologic quality of the studies. Moreover, it would be interesting to consider other avenues for future research on how aerobic walking programs would be beneficial in the management of OA of the hip, because OA most often affects the weight-bearing articulations, thus the knees and the hips. Moreover, 30% to 40% of individuals diagnosed with knee OA have concomitant hip OA.
      • Aigner T.
      • Dudhia J.
      Genomics of osteoarthritis.
      Also, in view of the fact that a number of individuals diagnosed with OA are overweight, another area for further work would be to perform a literature review by including studies that selected participants with a BMI greater than 25kg/m2 in walking programs. Finally, given the lack of long-term trials selected in this review, it would be interesting to examine further the long-term effects of the aerobic walking programs in the overall management of OA.

      Acknowledgments

      The Ottawa EBCPGs Development Group thanks the following people for their technical support and support with data extraction and data analysis: France Légaré, MD, PhD, Catherine Caron, MD, Martha Hall, MSc, Alison Marshall, MA, Gabrielle Ménard, BSc, Lilliane Francoeur, BSc, Courtney Cohoon, MA, Karen Hidalgo, MScS, Adam Teav, BSc, George Gray, BSc, Catherine Lamothe, BSc, Judith Robitaille, BSc, Lucie Lavigne, BSc, Michel Boudreau, BSc, Guillaume Michaud, BSc, Michelle Vaillant, MSc, Chantal Lavoie, BSc, Guillaume Lemieux, BSc, and Mohamed Abdi, BSc.

      Appendix 1. EBCPGs Related To Aerobic Walking Program Interventions For The Management of OA of The Knee

      Tabled 1
      • 1
        EBCPGs related to a walking program alone vs control (normal daily activities), level II (1 CCT, N=81, low quality [1,0,0]) (Evcik and Sonel
        • Evcik D.
        • Sonel B.
        Effectiveness of a home-based exercise therapy and walking program on osteoarthritis of the knee.
        ): grade B for physical function (WOMAC physical function at 3-mo FU), pain relief (NHP pain and WOMAC pain at 3-mo FU), and quality of life (NHP energy, physical mobility, and sleep at 3-mo FU) (clinically important benefit). Patients with a diagnosis of OA of the knee met the only inclusion criteria.
      • 2
        EBCPGs related to a walking program with strengthening training vs control (patient education), level I (2 RCTs, n=374, high quality [2,0,1]) (Péloquin et al,
        • Péloquin L.
        • Bravo G.
        • Gauthier P.
        • Lacombe G.
        • Billiard J.S.
        Effects of a cross-training exercise program in persons with osteoarthritis of the knee A randomized controlled trial.
        Penninx et al
        • Penninx B.W.
        • Messier S.P.
        • Rejeski W.J.
        • et al.
        Physical exercise and the prevention of disability in activities of daily living in older persons with osteoarthritis.
        ): grade A for quality of life (AIMS mobility, walking and bending, and arthritis pain at end of treatment at 12wk) (Péloquin) and functional status (incidence of disability on ADLs) (Penninx) (clinically important benefit); grade C+ for quality of life (AIMS2 work, hand, and finger function, arm function, self-care tasks, and AIMS2 household tasks at end of treatment at 12wk) (Péloquin) (clinically important benefit demonstrated without statistical significance); grade C for flexibility (hamstrings and low back flexion at end of treatment at 12wk) (Péloquin), torque (QIT at 60° for the most and least affected leg, HIT at 60° for the most and least affected leg, HIKT at 30°/s for the most and least affected leg at end of treatment at 12wk) (Péloquin), quality of life (AIMS2 social activity, support from friends, level of tension, and mood at the end of 12wk of treatment) (no benefit) (Péloquin), and functional status (disability in transferring from bed to chair, bathing, and eating) (Penninx); grade D for endurance (five-minute walk test at end of treatment at 12wk) (Péloquin) and quality of life (disability in toileting and in dressing at 18-mo FU) (no benefit demonstrated but favoring control) (Penninx); and grade D+ for functional status (incidence of disability on ADLs, transferring from bed to chair, and bathing at 18-mo FU) (clinically important benefit demonstrated favoring control) (Penninx). Patients who met the following criteria: (1) were aged ≥60; (2) had pain in the knee(s) on most days of the month; (3) had difficulty with at least 1 of the following because of knee pain: walking 0.4km; climbing stairs; getting in and out of a car, bath, or bed; rising from a chair; or performing shopping, cleaning, or self-care activities; and (4) showed radiographic evidence of knee OA.
      • 3
        EBCPGs related to a walking program with health education and behavioral components vs control (normal daily activities), level I (3 RCTs, n=126, high quality [2,0,1]) (Kovar et al,
        • Kovar P.A.
        • Allegrante J.P.
        • Mackenzie C.R.
        • Peterson M.G.
        • Gutin B.
        • Charlson M.E.
        Supervised fitness walking in patients with osteoarthritis of the knee A randomized, controlled trial.
        Peterson et al,
        • Peterson M.G.
        • Kovar-Toledano P.A.
        • Otis J.C.
        • et al.
        Effect of a walking program on gait characteristics in patients with osteoarthritis.
        Talbot et al
        • Talbot L.A.
        • Gaines J.M.
        • Ling S.M.
        • Metter E.J.
        A home-based protocol of electrical muscle stimulation for quadriceps muscle strength in older adults with osteoarthritis of the knee.
        ): grade A for pain relief (AIMS pain at end of treatment at 8wk) (Kovar), endurance (six-minute walk test at end of treatment at 8wk) (Kovar), quality of life (AIMS physical activity at end of treatment at 8 wk) (Kovar), and AIMS pain and AIMS medication use at end of treatment at 8wk (Peterson) (clinically important benefit); grade C+ for pain relief (McGill Pain Questionnaire present pain intensity at 12-wk FU) (Talbot), AIMS arthritis impact at end of treatment at 8wk (Kovar), mobility (steps per day, timed stair climb at end of treatment at 12wk) (Talbot), and torque (right knee extensor isometric peak torque at 120° at end of treatment at 12wk, left knee extensor isometric peak torque at 140°, right knee extensor isometric peak torque at 140° at end of treatment at 12wk) (Talbot) (clinically important benefit demonstrated without statistical significance); and grade C for pain relief (McGill Pain Questionnaire pain rating index total [0–45] at end of treatment at 12wk) (Talbot), mobility (timed chair rise, 100-foot timed turn walk usual speed, and 100-foot timed walk-turn-walk fast pace at end of treatment at 12wk) (Talbot), mobility (free walking speed and fast walking speed at end of treatment at 8wk) (Peterson), quality of life (AIMS arthritis impact at end of treatment at 8wk, AIMS pain at end of treatment at 12wk and 9-mo FU) (Peterson), and torque (left knee extensor isometric peak torque at 120° at end of treatment at 12wk and 3-mo FU, left knee extensor isometric peak torque at 140° at 3-mo FU) (Talbot) (no benefit). Patients who were ≥40y; had a documented diagnosis of chronic, stable, primary OA of 1 or both knee joints in association with at least 4-mo history of symptomatic knee pain occurring during weight-bearing activities (patients with multiple joint involvement, those who had undergone major joint surgery, or had a lower joint prosthesis were also eligible); who had radiographic evidence of primary OA of 1 or both knee joints, as demonstrated by joint space narrowing, marginal spur formation, or subchondral cyst formation; who used any of the various common, over-the-counter NSAIDs ≥2d/wk; and who were not participating in a regular program of physical activity at the time of enrollment.
      • 4
        EBCPGs related to a walking program with multicomponent exercises vs control (patient education), level I (2 RCTs, n=186, 1 low quality [2,0,0] and 1 high quality [2,0,1]) (Messier et al,
        • Messier S.P.
        • Thompson C.D.
        • Ettinger M.H.
        Effects of long-term aerobic or weight training regimens on gait in an older, osteoarthritic population.
        Minor et al
        • Minor M.A.
        • Hewett J.E.
        • Webel R.R.
        • Anderson S.K.
        • Kay D.R.
        Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
        ): grade A for pain relief (pain intensity in transfer at 3mo, 9mo, end of treatment 18mo, and pain frequency in transfer at 3mo) (Messier) and quality of life (AIMS physical activity at end of treatment at 12wk) (Minor) (clinically important benefit); grade C+ for pain relief (pain intensity ambulation and pain frequency in ambulation at 3mo, pain frequency in transfer at 9mo) (Messier), quality of life (AIMS physical activity at 9-mo FU) (Minor), and stiffness (morning stiffness at end of treatment at 12wk) (Minor) (clinically important benefit demonstrated without statistical significance); grade C for pain relief (pain intensity ambulation and pain frequency in ambulation at 9mo and end of treatment at 18mo, pain frequency in transfer at end of treatment at 18mo) (Messier), pain relief (AIMS pain at end of treatment at 12wk) (Minor), mobility (walking speed at 3mo, 9mo, and end of treatment at 18mo) (Messier), mobility (50-foot walking time at end of treatment at 12wk and at 9-mo FU) (Minor), endurance (exercise endurance at end of treatment at 12wk) (Minor), stiffness (morning stiffness at end of treatment at 12wk) (Minor), and force (grip force at end of treatment at 12wk and 9-mo FU) (Minor) (no benefit); grade D for flexibility (trunk flexibility at end of treatment at 12wk) (Minor), endurance (exercise endurance at 9-mo FU) (Minor), and cardiopulmonary function (maximum oxygen consumption at 9-mo FU) (Minor) (no benefit demonstrated but favoring control); and grade D+ for flexibility (trunk flexibility at 9-mo FU), pain relief (AIMS pain at 9-mo FU) (Minor), and cardiopulmonary function (maximum oxygen consumption at 12wk) (Minor) (clinically important benefit demonstrated favoring control). Patients who met the following criteria: (1) were ≥60y old, (2) had pain on most days of the month in 1 or both knees, (3) showed radiographic evidence of knee OA in the tibial-femoral compartments of the painful knee, and (4) had difficulty with at least 1 of the following activities because of knee pain—walking 0.4km, climbing stairs, getting in and out of a car, rising from a chair, lifting and carrying groceries, getting out of bed, getting out of a bathtub, shopping, cleaning, or self-care.
      • 5
        EBCPGs related to a walking program with multicomponent exercises and health education vs control (health education), level I (1 RCT, N=77, 1 low quality [1,0,0] and 1 high quality [2,0,1]) (Bautch et al
        • Bautch J.C.
        • Malone D.G.
        • Vailas A.C.
        Effects of exercise on knee joints with osteoarthritis: a pilot study of biological markers.
        Dias et al
        • Dias R.C.
        • Dias J.M.
        • Ramos L.R.
        Impact of an exercise and walking protocol on quality of life for elderly people with OA of the knee.
        ): grade A for functional status (Health Assessment Questionnaire at end of treatment at 3mo and at 3-mo FU) (Dias), functional status (LI at end of treatment at 3mo and at 3-mo FU) (Dias), and quality of life (SF-36 functional capacity, SF-36 physical role limitation, SF-36 bodily pain at end of treatment at 3mo and at 3-mo FU, and SF-36 general health at 3-mo FU) (Dias) (clinically important benefit); grade C+ for pain relief of past week (0–10 visual analog scale at end of treatment at 12wk) (Bautch) (clinically important benefit demonstrated without statistical significance); grade C for quality of life (SF-36 vitality at 3-mo FU) (Dias), quality of life (SF-36 general health at end of treatment at 3mo) (Dias) (no benefit); and grade D for quality of life (SF-36 vitality at end of treatment at 3mo) (Dias) and quality of life (AIMS total at end of treatment at 12wk (Bautch) (no benefit demonstrated but favoring control). Patients who met the following criteria: ACR clinical and radiographic criteria for primary OA of the knee; were ≥58y old and living independently, without physical or medical problems for which exercise program would be contraindicated; were not currently enrolled in a regular exercise program; had not received intraarticular or systematic steroids within the past 2y; and did not routinely use NSAIDs.
      Abbreviations: ACR, American College of Rheumatology; ADLs, activities of daily living; AIMS2, Arthritis Impact Measurement Scales 2 (2nd version); HIKT, hamstrings isokinetic torque; HIT, hamstrings isometric torque; LI, Lequesne index; NHP, Nottingham Health Profile; NSAID, nonsteroidal anti-inflammatory drug; QIT, quadriceps isometric torque; SF-36, Medical Outcomes Study 36-Item Short-Form Health Survey; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.

      Appendix 2. Literature Search Strategy

      Tabled 1
      The systematic literature search strategy used was as follows:
      • 1
        Osteoarthritis/(24341)
      • 2
        osteoarthritis, knee/(6688)
      • 3
        osteoarthritis, hip/(4209)
      • 4
        arthrit* knee.ti,ab. (185)
      • 5
        arthrit* hip.ti,ab. (72)
      • 6
        osteoarthritis.ti,ab. (25565)
      • 7
        1 or 2 or 3 or 4 or 5 or 6 (42257)
      • 8
        walking/(13257)
      • 9
        exercise therapy/(20413)
      • 10
        walking program*.ti,ab. (318)
      • 11
        aerobic.ti,ab. (43065)
      • 12
        8 or 9 or 10 or 11 (74491)
      • 13
        cost benefit analysis/(49718)
      • 14
        exp health care costs/(36692)
      • 15
        cost effectiveness*.ti,ab. (25875)
      • 16
        cost benefit analys*.ti,ab. (2579)
      • 17
        health care cost*.ti,ab. (6934)
      • 18
        Quality-Adjusted Life Years/(4769)
      • 19
        quality of life/(87463)
      • 20
        economics.fs. (278576)
      • 21
        health care utilization.ti,ab. (2678)
      • 22
        quality of life.ti,ab. (102532)
      • 23
        13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 (431448)
      • 24
        randomized controlled trial.pt. (299739)
      • 25
        controlled clinical trial.pt. (81734)
      • 26
        randomized.ab. (216087)
      • 27
        clinical trials as topic.sh. (152139)
      • 28
        randomly.ab. (159587)
      • 29
        trial.ti. (92501)
      • 30
        24 or 25 or 26 or 27 or 28 or 29 (692948)
      • 31
        7 and 12 and 23 (116)
      • 32
        7 and 12 and 23 and 30 (65)
      • 33
        limit 31 to systematic reviews (15)
      • 34
        32 or 33 (75)
      • 35
        limit 34 to updaterange=”prmz[20100901-]” (3)

      Appendix 3. Summary Of The Included Studies

      Tabled 1
      AuthorPopulation DetailsSymptom DurationAgeTreatmentComparison GroupConcurrent TherapySession/WeekFollow-Up
      Bautch et al
      • Bautch J.C.
      • Malone D.G.
      • Vailas A.C.
      Effects of exercise on knee joints with osteoarthritis: a pilot study of biological markers.
      Inclusion: ACR clinical and radiographic criteria for primary OA of the knee; were ≥58y old and living independently, physically and medically stable; were not enrolled in a regular exercise program; had not received intra-articular or systematic steroids within the past 2y; and did not use NSAIDs.

      Exclusion: having intra-articular injections in the past 6mo, being involved in regular physical activity and physiotherapy, unable to exercise, having chronic condition, and using any assistive equipment.
      NA69yGroup 1: 1h of walking on treadmill, with range of motion and strengthening exercises (trunk, upper and lower extremities muscles). Intensity: individualized low intensity walking on treadmill, beginning at 3.22km/h and grade 0, increasing by 1% each minute.Group 2: educational session.Educational program consisting of content related to health, exercise, and arthritis.Frequency: 3 times a wk for 12wk.NA
      Dias et al
      • Dias R.C.
      • Dias J.M.
      • Ramos L.R.
      Impact of an exercise and walking protocol on quality of life for elderly people with OA of the knee.
      Inclusion: aged ≥65y of age, clinical diagnosis of knee OA with knee pain during the past month, and no cognitive deficits.

      Exclusion: previous knee surgery, hip or knee arthroplasty, and unable to participate.
      NAMedians (interquartile range):

      Group 1: 74y (70–78y)

      Group 2: 76y (70–78y)
      Group 1: 40min of walking, with concentric/eccentric/isotonic progressive resistance exercises, closed kinetic chain weight-bearing exercises, stretching exercises, and cooling off exercises. Supervised facility based by a physiotherapist. Intensity: at a self- selected pace.Group 2: educational session.1-h educational session about disease characteristics, joint protection, pain management, and strategies to overcome difficulties in ADLs.Frequency:

      Group 1: 3 times per week for walking, 2 times per wk for other exercises for 24wk.

      Group 2: 6-mo period.
      3mo
      Evcik and Sonel
      • Evcik D.
      • Sonel B.
      Effectiveness of a home-based exercise therapy and walking program on osteoarthritis of the knee.
      Inclusion: knee OA, ages between 48–71y, x-rays of the knees confirming the diagnosis.

      Exclusion: grade 4 OA according to Kellgren-Lawrence criteria, quads exercises during the past 6mo, effusion on knees, previous knee replacement, severe cardiovascular diseases.
      Disease duration

      Group 1: 8±3.5

      Group 2: 7.9±3.7

      Group 3: 8.2±2.7
      Group 1: 56.3±6.1

      Group 2: 56.9±6.5

      Group 3: 55.8±6.9
      Group 1: home exercise program (isometric straight leg lifts, isometric quads contraction, and isotonic quads exercises progressed with weight from 0.5–5kg). 10 reps

      2 times a d for 3mo.

      Group 2: regular walking program (10min, 3 times a wk for 3mo, gradually increased walking time up to 30min).

      Intensity: not indicated.
      Group 3: continue their normal daily activities.NAFrequency:

      Group 1: 2 times a d for 3mo.

      Group 2: 3 times a wk for 3mo
      3mo
      Kovar et al
      • Kovar P.A.
      • Allegrante J.P.
      • Mackenzie C.R.
      • Peterson M.G.
      • Gutin B.
      • Charlson M.E.
      Supervised fitness walking in patients with osteoarthritis of the knee A randomized, controlled trial.
      and Peterson et al
      • Peterson M.G.
      • Kovar-Toledano P.A.
      • Otis J.C.
      • et al.
      Effect of a walking program on gait characteristics in patients with osteoarthritis.
      Inclusion: aged ≥40y; diagnosis of primary OA of 1 or both knees; at least 4mo symptomatic knee pain during weight-bearing activities (clinical diagnosis); had radiographic evidence of OA by joint space narrowing, spur formation, subchondral cyst formation; use of NSAID ≥2 times per week; not participating in a regular program of physical activity.

      Exclusion: exercise is contraindicated, symptomatic primary OA of 1 or both knees, inability to give informed consent, nonambulation, and involvement in another treatment program or study protocol.
      Group 1: 12y±11.8y

      Group 2: 11.4y±10.9 (mean ± SD)
      Group 1: 70.38±9.11y

      Group 2: 68.48±11.32y
      Group 1: 24 sessions: 30-min of walking with strengthening and stretching exercises, with 1h of educational and encouragement and support session (medical aspect of OA and exercise, group discussion about barriers and benefits of walking, instruction in the proper walking techniques and the maintenance of a walking program, supportive encouragement).

      Intensity: at a self-selected pace for intensity.
      Group 2: each week, telephone contacts to discuss the nature of their ADLs.NAFrequency: 3 times a wk for 8wkNA
      Messier et al
      • Messier S.P.
      • Thompson C.D.
      • Ettinger M.H.
      Effects of long-term aerobic or weight training regimens on gait in an older, osteoarthritic population.
      Inclusion: aged ≥60y, pain on most days of the month in 1 or both knees (clinical diagnosis), radiographic evidence of knee OA in the tibial-femoral compartments of the painful knee, and had difficulty with activities, eg, walking 0.4km, climbing stairs, getting in and out of a car, rising from a chair, lifting and carrying groceries, getting out of bed, getting out of a bathtub, shopping, cleaning, or self-care.

      Exclusion: dementia, active cancer, anemia, several renal insufficiencies, hepatic disease, and inability to walk, unassisted, at least 128m in 6min.
      NAGroup 1: 70.3±1.3 y

      Group 2: 67.2±0.9y

      Group 3: 69.2±1.0y
      Group 1: 40-min walking phase with 5-min warm-up (slow walk, arm circles, trunk rotations, shoulder and chest stretch, side stretch) and 5-min cool-down (slow walk, hamstring stretch, lower back stretch, chest stretch).

      Intensity: equal to 50%–85% of the subjects' heart rate reserve.

      Group 2: warm-up (arm circles, trunk rotations, shoulder and chest stretch, chest stretch), 9 upper and lower body exercises using dumbbells and cuff weights (leg extension, leg curl, step-up, heel raise, chest fly, upright row, military press, bicep curls, and pelvic tilt) and a cool-down phase (hamstring stretch, lower back stretch, chest stretch). Two sets of 10–12 reps were performed for each exercise.
      Group 3: regularly scheduled contacts similar to those of the 2 interventions groups. Subjects were divided into groups of 12–15 to participate in monthly onsite health education sessions during months 1–3. Each session was 1h and presentation of material concerning arthritis followed by a socialization period. During the transition phase (4–6mo), biweekly telephone contact was made. The maintenance phase (7–18mo) consisted of monthly phone calls. The maintenance phase (7–18mo) consisted of monthly phone calls similar to those of the transition phase 3 times per wk for 18mo.For Groups 1 and 2: 18-mo period. 3-mo facility-based program followed by a 15-mo home-based program: (1) 3-mo transitory phase of biweekly contacts (4 home visits and 6 telephone calls and (2) 12-mo maintenance phase of triweekly telephone contacts during the first 3mo and monthly contact during months 9–18.Frequency: 3 times a wk for 3mo.NA
      Minor et al
      • Minor M.A.
      • Hewett J.E.
      • Webel R.R.
      • Anderson S.K.
      • Kay D.R.
      Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis.
      Inclusion: symptoms of chronic pain and stiffness in involved weight-bearing joints with OA, evidence of joint pain and crepitation with passive ROM, and roentgenographic signs of hypertrophic changes, subchondral sclerosis, or nonuniform joint space narrowing in involved joints (clinical diagnosis).

      Exclusion criteria: only upper extremity or spine symptoms or only roentgenographic signs of OA.
      Duration of arthritis (y):

      OA patients: 14.6±10.7y (1–40)
      Age:

      OA patients: 63.8y±8.6y (36-83y) (mean ± SD [range])
      Group 1:

      10–30min of walking, with warm-up, general flexibility and isometric strengthening of postural muscles, aerobic stimulus period progressing to 30-min of continuous activity and a cool-down of 10-min of active. ROM and stretching exercises proposed with education and BI.

      Group 2: jogging in shallow and deep water and modified calisthenics performed in chest- high water.
      Group 3:

      Gentle, active ROM and isometric strengthening and relaxation exercises with no aerobic stimulus period.
      Groups 1 and 2: Exercise heart rate ranges of 60%–80% of maximum heart rate. Classes included a warm-up, general flexibility and isometric strengthening of postural muscles, an aerobic stimulus period progressing to 30min of continuous activity, and a cool down of 10min of active ROM and stretching.Frequency: 3d per week for 12wk9mo
      Péloquin et al
      • Péloquin L.
      • Bravo G.
      • Gauthier P.
      • Lacombe G.
      • Billiard J.S.
      Effects of a cross-training exercise program in persons with osteoarthritis of the knee A randomized controlled trial.
      Inclusion: aged ≥50y; diagnosis of minimal to moderate idiopathic OA of 1 or both knees; had no contraindications to exercise; not absent from city for more than 2wk; independent, noninstitutional lifestyle; no intra-articular steroid or viscoelastic device injections within the previous 2mo; stable regimen using analgesics or NSAIDs for at least 2wk before the beginning of the study; <15° fixed-flexion deformity; <10° of genu varum or valgum; and no joint blocking (clinical diagnosis).

      Exclusion: inability to walk, unassisted, at least 128m in 6min.
      Group 1: 7.92±7.9y

      Group 2: 6.38±6.05y
      Group 1: 65.64±7.41y

      Group 2: 66.43±6.39y
      Group 1: <50 min of aerobic brisk walking, with 5-min warm-up, muscle strengthening, resistance program (isometric contractions) and 5- min cool-down.

      Intensity: not indicated.
      Group 2: 1-h education sessions twice a wk.NA
      Penninx et al
      • Penninx B.W.
      • Messier S.P.
      • Rejeski W.J.
      • et al.
      Physical exercise and the prevention of disability in activities of daily living in older persons with osteoarthritis.
      Inclusion: aged ≥60y; radiographic evidence of knee OA; pain in the knee(s) on most days of the month; difficulty with at least 1 of the following activities: walking 0.4km; climbing stairs; getting in and out of a car, bath, or bed; rising from a chair; or performing shopping, cleaning, or self-care activities.

      Exclusion: medical condition that precluded safe participation in an exercise program, inflammatory arthritis, regular exercise participation (>1 time per wk for at least 20min), and inability to walk on a treadmill or walk, unassisted 128m in 6min.
      NAGroup 1: 68.8±5.2y

      Group 2: 69.9±5.8y

      Group 3: 68.5±5.4y
      Group 1: 10-min warm-up and cool-down phase and 40-min phase consisting of 2 sets of 12 reps of 9 exercises: leg extension, leg curl, step up, heel raise, chest fly, upright row, military press, bicep curls, and pelvic tilt. Upper body exercises were performed with dumbbells and lower body exercises with cuff weights. During the home-based phase (3–18mo), patients continue their exercises at home (1-h session, 3 times per wk). Intensity: beginning with a low resistance, weight was increased in a stepwise fashion as long as participants could complete 2 sets of 12 reps.

      Group 2:

      0–3mo: facility-based walking program 3 times a wk for 1h, 10-min warm-up and cool-down phase, including slow walking and flexibility stretches, and a 40-min period of walking. During 3–18mo: home-based walking program. During 4–6mo, the exercise leader visited participants 4 times and called 6 times to offer assistance and support in the development of a walking exercise program in their home environment. For the remainder of the exercise program, telephone contacts were made every 3wk (7–9mo) or monthly (10–18mo).

      Intensity: equivalent to 50%–70% of the participants' heart rate reserve.
      Group 3: the first 3mo: monthly group sessions on education related to arthritis management, including time for discussions and social gatherings. Later, participants were called bimonthly (mo 4–6) or monthly (mo 7–18) to maintain health updates and provide support.NAFrequency: 3 times a wk 3-mo supervised facility-based program, and 15-mo home-based programNA
      Talbot et al
      • Talbot L.A.
      • Gaines J.M.
      • Ling S.M.
      • Metter E.J.
      A home-based protocol of electrical muscle stimulation for quadriceps muscle strength in older adults with osteoarthritis of the knee.
      Inclusion: aged ≥60y, symptomatic knee OA (pain in 1 or both knees on most days) (clinical diagnosis), difficulty performing at least 1 functional task and radiographic evidence of OA, community-dwelling adults.

      Exclusion: participation in an exercise study, exercise is contraindicated, and a score of <24 on the Mini-Mental State Examination.
      NAGroup 1: 69.59±6.74y

      Group 2: 70.76±4.71y
      Group 1: walking at home, with instruction in the use of a pedometer and written activity logs. Intensity: goal of increasing the step count by 30% of the baseline count.Group 2: educational sessions.12h of arthritis self-management education (the use of a pedometer to monitor daily steps; how to write activity logs to mark and monitor progress; booklet explaining principles of exercise and arthritis).Frequency: group

      1: daily for 12wk
      3mo (home-based)
      Abbreviations: ACR, American College of Rheumatology; ADLs, activities of daily living; NA, not applicable; NSAID, nonsteroidal anti-inflammatory drug; reps, repetitions; ROM, range of motion.

      Appendix 4. Flow Diagram

      Tabled 1
      Reprinted with permission from Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Reprint–preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Phys Ther 2009;89:873-80.
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      PRISMA Group
      Reprint–preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.

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