Rehabilitation and physical therapy-based interventions The most widely used treatment for knee OA takes a rehabili- tation and physical therapy approach. Physical therapy interven - tions can help patients with pain and limited mobility. Within the scope of physical therapy are several interventions that can help to alleviate symptoms associated with knee OA and help to improve functional activity tolerance in these patients. Several types of interventions have been studied to treat knee OA. Spe- cific types of exercise programs include combinations of strength training, aquatic therapy, tai chi exercise, aerobic exercise, and hydrotherapy (Bhatia et al., 2012). Exercise can take on many forms and has been widely studied as an intervention to improve the symptoms associated with knee OA. Exercise interventions aim to improve muscle strength, neuromus- cular control, joint range of motion, and aerobic fitness (Fransen et al., 2015). Pain can be a barrier to participating in exercise, however, but enhancing strength of the lower limb may lessen internal knee forces, reduce pain, and improve physical function (Fransen et al.). Increasing muscle strength of the involved limb may also help to improve knee joint mechanics and decrease the joint-loading rate, which can play an important role in delaying initiation and limiting the progression of knee OA (Fransen et al.). Fransen and colleagues (2015) performed a systematic review to determine whether land-based therapeutic exercise is benefi- cial for people with knee OA in terms of reduced joint pain or improved physical function and quality of life. This study looked at 54 studies. The researchers concluded that land-based thera- peutic exercise can provide short-term benefits that are sustained for at least two to six months after cessation of formal treatment (Fransen et al.). There was a wide range of exercise modalities used, but most of the exercises evaluated were lower limb muscle strengthening and general aerobic exercise (Fransen et al.). There were no significant differences found between weight-bearing quadriceps exercise and non-weight-bearing quadriceps exercise or concentric-eccentric strengthening versus isometric strength- ening. Nevertheless, it may be more important to strengthen the quadriceps in a functional weight-bearing position based on the functional decline that occurs in patients with knee OA. Strengthening in a functional weight-bearing position may pro- vide better carryover for patients in terms of being able to perform daily functional activities. This finding is also important because patients with knee OA may not be able to tolerate weight-bearing positions toward the later stages of the disease, so it is important to know that strengthening is just as impactful in a non-weight- bearing position as it is in a weight-bearing position. The study by Fransen and colleagues (2015) also found that any type of exercise program performed regularly and monitored closely can improve pain, physical function, and quality of life related to knee OA in the short term. The researchers also con- cluded that there is high-quality evidence to support the use of land-based therapeutic exercise to reduce knee pain and improve the quality of life and moderate-quality evidence that this type of exercise improves physical function among people with knee OA (Fransen et al.). It was also shown that there was an immediate treatment effect of exercise on pain and physical function with an increasing number of face-to-face contacts with a health care professional (Fransen et al.). Strength training can improve functional abilities in patients with knee OA. Strength training includes isotonic, isometric, and iso- kinetic exercises. Isometric exercises have been shown to reduce pain but should be avoided when working with the elderly popu- lation because of increased heart rate and blood pressure, which makes this type of exercise contraindicated for patients with other comorbidities (Bhatia et al., 2013). Strengthening can help to im- prove support around the knee joint, which can decrease the im- pact on the knee joint in weight-bearing positions. By decreasing the force through the knee joint, pain may be reduced, which can improve functional activity tolerance. Tai chi is one mode of exercise that has been studied to aid with symptom relief in patients with knee OA. Tai chi is “a form of
mind-body exercise that combines deep diaphragmatic breath- ing and relaxation with slow, gentle, graceful movements that can improve both physical and psychological health among patients with chronic conditions” (Wang et al., 2004). Tai chi has been shown to improve balance, strength, cardiovascular and respira- tory functioning, flexibility, pain, depression, anxiety, and arthritic symptoms (Wang et al.). Tai chi – characterized by soft, slow, flow- ing movements that emphasize force rather than brute strength – helps to reduce tension and stress and emphasizes complete relaxation (Bhatia et al., 2013). The study by Wang and colleagues (2014) aimed to compare tai chi with a physical therapy regimen in adults with knee OA through a randomized controlled trial. Tai chi may be a more cost-effective way to help those with knee OA and can impact patients at the impairment level and from a mental health standpoint. Studies that have looked at the effects of tai chi have shown an 80% decrease in pain; decreased crepitus; and an increase in isokinetic hip flexor, adductor, and abductor angular velocity and in isotonic and iso- metric strength (Bhatia et al., 2013). Hydrotherapy is another type of exercise, performed in the wa- ter, that has been shown to have positive results for patients with knee OA (Bhatia et al., 2013). Hydrotherapy can be easier than land-based therapy for patients because of the decreased impact on the hip and knee joints when in the water. Patients may also perform their exercises in a warm water therapy pool, which helps to increase blood flow, decrease muscle tension, and reduce pain while focusing on exercises that improve strength and range of motion. Knee OA has been reported as a risk factor for falls and reduced balance in the elderly population. Physical therapy interventions can work to reduce the risk of falls for this patient population. Gait and balance disorders that are secondary to knee OA may in- crease fall risk (Mat et al., 2015). The systematic review performed by Mat and colleagues looked at studies that included balance outcomes and falls risk following physical therapy interventions for individuals with knee OA. The purpose of this systematic re- view was to determine whether physical therapy would improve balance and falls risk in individuals with knee OA. The intervention duration ranged from 2 weeks to 18 months, and the study looked at various interventions. The interventions found in the studies were tai chi, water-based exercise, walking, aerobic and resistance exercises, home-based progressive programs, weight-bearing ex- ercises, high-speed and low-speed power training, squat exer- cises with vibration, aquatic and land-based exercises, neuromus- cular electric stimulation (NMSE) with strength training, and light therapy. Assessment tools commonly used among these studies were the Timed Up and Go Test, Berg Balance Scale, Walking speed, 6-Minute Walk Test, and Sit to Stand Test. Other tests done among the studies included using a balance platform to measure standing balance, balance measured by standing on one foot with the eyes closed, and the Step Test (Mat et al.). Postural instability among individuals with knee OA may occur because of quadriceps muscle weakness, pain, or altered neuromuscular control (Mat et al.). Strengthening exercises have been found to improve muscle strength and proprioception, which may reduce the progression of OA (Mat et al., 2015). Among the 15 studies reviewed in the study by Mat and colleagues, they found that for patients with knee OA, strength training exercises, tai chi, and aerobics exercis- es improved balance and fall risk outcomes in 11 of the 15 stud- ies. This review also determined that the addition of vibration, or NMSE, in strength training also benefited balance significantly (Mat et al.). Interventions that did not improve balance outcomes included light therapy. Water-based exercises were found to be beneficial in only one out of the three studies that looked at this type of therapeutic intervention (Mat et al.). Tai chi was found to be a safe exercise that requires no special equipment and can be administered with no cost. Three studies that included tai chi
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