Each recommendation is followed by recommendation grades (Level I or II and A, B, C+, C and D). Definitions of the recommendation grades are presented at the end of the "Major Recommendations" field.
Note: The recommendations state the disease stage for which the intervention is most appropriate. If, however, the trial on which the recommendation was based did not mention disease stage, neither does the recommendation (see Appendix 2 in the original guideline document for more information).
Strengthening Exercises
Lower-extremity (LE) strengthening versus control, level 1 (randomized controlled trial [RCT], n=345): grade A for pain getting up from floor and functional status (clinically important benefit); grade C+ for pain during walking, pain while climbing stairs, functional tasks, and quadriceps femoris muscle peak torque (clinical benefit); grade C for stiffness, mobility, quadriceps femoris muscle force, muscle activation, and quality of life (no benefit). Patients with a diagnosis of osteoarthritis (OA) of the knee.
Lower-extremity isometric strengthening versus control, level 1 (RCT, n=102): grade A for pain getting down to and up from floor (clinically important benefit); grade C+ for pain getting down and up stairs and timed functional tasks (clinical benefit); grade C for stiffness and functional status (no benefit). Patients with a diagnosis of OA of the knee.
Isotonic resistance training versus isotonic combined with isokinetic (Kinetron) resistance training for knee, level 1 (RCT, n=32): grade C for quadriceps femoris muscle peak torque (no benefit). Patients with a primary diagnosis of OA of the knee.
Isotonic combined with isokinetic (Kinetron) resistance training for knee versus control, level 1 (RCT, n=32): grade C for muscle force (no benefit). Patients with primary diagnosis of OA of the knee.
Eccentric resistance training (Cybex) for knee versus control, level 1 (RCT, n=32): grade C for muscle force (no benefit). Patients with primary diagnosis of OA of the knee.
Concentric resistance training for knee versus control, level 1 (RCT, n=23): grade A for pain at rest and during activities (clinically important benefit); grade C for global functional status (no benefit). Patients with knee OA bilaterally and grade II or III OA.
Concentric-eccentric resistance training for knee versus control, level 1 (RCT, n=23): grade A for pain at rest and during specific functional activities: 15-m walk and stair climbing/descending time (clinically important benefit). Patients with knee OA bilaterally and grade II or III OA.
Home program strengthening for knee versus control, level 1 (controlled clinical trial [CCT], n=81): grade A for pain, functional status, energy level, and range of motion (ROM) in flexion (clinically important benefit); grade C for physical mobility, muscle force, swelling, and exercise (no benefit). Patients with OA of the knee.
General LE exercise program (including muscle force, flexibility, and mobility/coordination) versus control, level 1 (RCT, n=490): grade A for pain at night and ability on stairs (clinically important benefit); grade C for knee flexion ROM, muscle force, knee joint position, gait, functional status, quality of life, muscle activation, stiffness, and physical activity (no benefit). Patients with a diagnosis of OA.
Progression versus no-progression LE strengthening exercises, level 1 (RCT, n=179): grade A for pain at rest and ROM (clinically important benefit); grade C for stiffness and functional status (no benefit). Patients with radiographic evidence of OA in the tibiofemoral compartment.
Hand strengthening versus control, level 1 (RCT, n=40): grade A for pain and grip force (clinically important benefit). Patients who met the American College of Rheumatology criteria for hand OA. (Altman et al., 1990)
General Physical Activity, Including Fitness and Aerobic Exercises
Whole-body functional exercise versus control, level 1 (RCT, n=864): grade A for pain and functional status (mobility, walking, work, disability in activities of daily living [ADL]) (clinically important benefit); grade C for knee flexor ROM, quadriceps femoris muscle force, hamstring muscle force, gait, and quality of life (no benefit). Patients with OA of the knee.
Walking program versus control, level 1 (RCT, n=1,089): grade A for pain, functional status, stride length, disability transferring from bed, disability bathing, aerobic capacity, energy level, and medication use (clinically important benefit); grade C+ for disability in ADL (clinical benefit); grade C for walking speed, disability toileting, disability dressing, blood pressure, morning stiffness, and quality of life (no benefit). Patients with OA.
Jogging in water versus control, level 1 (RCT, n=115): grade A for physical activity and aerobic capacity (clinically important benefit); grade C for morning stiffness, pain, grip force, trunk ROM, functional status, and exercise endurance (no benefit). Patients with current symptoms of chronic pain and stiffness in involved weight-bearing joints.
Water exercises versus control, level 1 (RCT, n=30): grade C for torque and ROM (no benefit). Patients with OA or rheumatoid arthritis (RA) diagnosed by a rheumatologist or an orthopedic physician.
Yoga versus control, level 1 (RCT, n=30): grade A for pain during activity and ROM (clinically important benefit); grade C for tenderness, muscle force, swelling, and hand function (no benefit). Patients with OA of the distal interphalangeal or proximal interphalangeal joints of the fingers.
Combination of Exercises
Manual therapy combined with exercise versus control, level 1 (RCT, n=83): grade A for pain (clinically important benefit); grade C for functional status (no benefit). Patients with a diagnosis of OA.
Definitions:
The recommendations were graded by their level (I for RCTs, II for nonrandomized studies) and strength (A, B, C+, C, or D) of evidence.
Grade A: Evidence from one or more RCTs of a statistically significant, clinically important benefit (>15%)
Grade B: Statistically significant, clinically important benefit (>15%) if the evidence was from observational studies or CCTs
Grade C+: Evidence of clinical importance (>15%) but not statistical significance
Grade C: An appropriate outcome was measured in a study that met the inclusion criteria but no clinically important difference and no statistical significance were shown
Grade D: Evidence from one or more RCTs of a statistically significant benefit favoring the control group (<0%: favors controls.)
