Osteoarthritis and Exercise: Difference between revisions

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== Introduction ==
== Introduction ==
Osteoarthritis is a common form of arthritis and it leads to a major health economic burden. It commonly occurs in weight bearing joints such as hip and knee , with knee joint being more often involved.<ref name=":0">Funck‐Brentano T, Nethander M, Movérare‐Skrtic S, Richette P, Ohlsson C. Causal factors for knee, hip, and hand osteoarthritis: a Mendelian randomization study in the UK biobank. Arthritis & rheumatology. 2019 Oct;71(10):1634-41.</ref>It also involves the hand.
[[File:Exercise group.jpg|thumb|Exercise group]]
[[Exercise -Therapeutic|Exercise therapy]] has positive benefits for people with symptomatic [[Osteoarthritis]] (OA). OA is a common form of [[arthritis]] and it leads to a major health economic burden. It commonly occurs in weight bearing (WB) joints (for example [[Hip Osteoarthritis|hips]] and [[Knee Osteoarthritis|knees]]), and NWB joints (for example the [[Wrist & Hand Osteoarthritis|hands]]). In osteoarthritis patients present with pain and stiffness in affected joint.<ref>Katz JN, Arant KR, Loeser RF. Diagnosis and treatment of hip and knee osteoarthritis: a review. Jama. 2021 Feb 9;325(6):568-78.</ref> <ref name=":0">Funck‐Brentano T, Nethander M, Movérare‐Skrtic S, Richette P, Ohlsson C. Causal factors for knee, hip, and hand osteoarthritis: a Mendelian randomization study in the UK biobank. Arthritis & rheumatology. 2019 Oct;71(10):1634-41.</ref>The management of OA can be divided in to conservative and conservative<ref name=":1" />  treatments. Also, non conservative ( non operative) treatment can be divided to pharmacological and non pharmacological.<ref name=":1" />


In [[osteoarthritis]], initially there is molecular derangement (interrupted joint metabolism) followed by anatomical and physiological derangements such as cartilage degeneration, osteophyte formation, bone remodeling, joint inflammation and loss of normal function. Clinically the patients present with pain and stiffness in affected joint. Morning stiffness is also present.<ref>Katz JN, Arant KR, Loeser RF. Diagnosis and treatment of hip and knee osteoarthritis: a review. Jama. 2021 Feb 9;325(6):568-78.</ref> The overall risk of this condition is more in obese population and even those who had previous joint injury. It has been proved that knee joint pain is reduced when obese patients undergo weight reduction.<ref name=":0" />
Exercise therapy is the core for conservative Treatment,<ref name=":1" />


Therapeutic exercise is defined as bodily movement prescribed to correct impairment, improve the function of musculoskeletal system and maintain a state of well being. It is prescribed to the patients of osteoarthritis irrespective of age, comorbidity, severity of pain or disability.<ref name=":1">Burgess LC, Wainwright TW, James KA, von Heideken J, Iversen MD. The quality of intervention reporting in trials of therapeutic exercise for hip osteoarthritis: a secondary analysis of a systematic review. Trials. 2021 Dec;22(1):1-0.</ref>Therapeutic exercises(type/ dose) are decided by the physical therapist based on the need of the patient.<ref name=":1" />The exercises are decided depending on age, weight, basic fitness level, severity of the disease and comorbidities. Optimal exercise prescription will lead to exercise adherence reduce the risk of symptom flare up and maximize the outcome.<ref name=":1" />
# Muscle [[Strength Training|strengthening]] and programs containing combinations of strength, [[flexibility]], and [[aerobic exercises]], mind body exercise like [[Yoga]] and Tai Chi  are  helpful for [[Pain Assessment|pain]]  relief ,improving physical function and disability than general activity (e.g., [[Walking - Muscles Used|walking]]).
# Exercise therapy brings other benefits, beyond pain and physical function, with moderate effects on [[depression]].
# Programs including exercise therapy and education about exercise are recommended to decrease fear of activity and improve patient engagement in exercise programs.<ref>Villafañe JH. Exercise and osteoarthritis: an update. Journal of exercise rehabilitation. 2018 Aug;14(4):538. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6165969/<nowiki/>(accessed 21.9.2022)</ref>See [[Patient Education in Pain Management|Patient Education in Pain Management.]]


Exercises have beneficial effect on the patients of OA. It can improve in terms of muscle strength, mobility, coordination as well as help to relieve pain.<ref>Mazor M, Best TM, Cesaro A, Lespessailles E, Toumi H. Osteoarthritis biomarker responses and cartilage adaptation to exercise: A review of animal and human models. Scandinavian journal of medicine & science in sports. 2019 Aug;29(8):1072-82.</ref>The patient can become improve their functional status by doing exercises on regular basis. Usually weight bearing and non weight bearing exercises are given. It helps in prevention too.   
== Obesity, Exercise and OA ==
[[File:OA risk factor obesity.jpeg|thumb|Obesity: risk factor for OA]]
[[Obesity]] is one of the most significant risk factors for osteoarthritis symptoms and disease progression, especially for the knee involvement.<ref>Lim YZ, Wong J, Hussain M, Estee MM, Zolio L, Page MJ, Harrison CL, Wluka AE, Wang Y, Cicuttini FM. Recommendations for weight management in osteoarthritis: A systematic review of clinical practice guidelines. Osteoarthritis and Cartilage Open. 2022 Aug 5:100298.Available:https://www.sciencedirect.com/science/article/pii/S2665913122000668 (accessed 21.9.2022)</ref><ref name=":1">Lim WB, Al-Dadah O. Conservative treatment of knee osteoarthritis: A review of the literature. World Journal of Orthopedics. 2022 Mar 3;13(3):212.</ref>


== Physiotherapy In Osteoarthritis Of Weight Bearing Joints ==
# Exercise is beneficial for the maintenance of metabolic homeostasis. Excessive adipose tissue, as occurs in obesity, increases mechanical stresses on weight-bearing joints and additionally generates an imbalance in the secretory profile of adipokines, including leptin, adiponectin, visfatin, and resistin. These conditions create an environment of low-grade inflammation lead eventually to cartilage breakdown.
# Clinical trials have shown that exercise programs (consisting of aerobic walking, strength training, a second aerobic phase, then a cool-down period) in combination with diet, led to significant reduction in weight, total fat mass, pain relief, and improvements in mobility.<ref>Leong DJ, Sun HB. Osteoarthritis–why exercise?. Journal of exercise, sports & orthopedics. 2014;1(1).Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4350574/ (accessed 21.9.2022)</ref><ref>Bhagat P, Jagtap V, Devi P. Effect of circuit training in osteoarthritis of knee. Asian J. Pharm. Clin. Res. 2017;10:333-5.</ref><ref>Lavie CJ, Carbone S, Kachur S, O'keefe EL, Elagizi A. Effects of physical activity, exercise, and fitness on obesity-related morbidity and mortality. Current sports medicine reports. 2019 Aug 1;18(8):292-8.</ref>


* Land based stationary bike enhances the total leg muscles. Tip toe , isometric quadriceps, hamstrings and gluteal muscles, dynamic quadriceps strengthening such as SLR, heel drags, high sitting knee extension, hip abductor muscle strengthening are proved to be effective in reducing the symptoms of OA.<ref>Raposo F, Ramos M, Lúcia Cruz A. Effects of exercise on knee osteoarthritis: A systematic review. Musculoskeletal care. 2021 Dec;19(4):399-435.</ref>
NB Knee OA: Obesity also causes thinner medial tibial cartilage compared to normal BMI individuals.<ref>Chen L, Zheng JJ, Li G, Yuan J, Ebert JR, Li H, Papadimitriou J, Wang Q, Wood D, Jones CW, Zheng M. Pathogenesis and clinical management of obesity-related knee osteoarthritis: impact of mechanical loading. Journal of orthopaedic translation. 2020 Sep 1;24:66-75.</ref>
 
=== Physiotherapy ===
Therapeutic exercises(type/ dose) are decided by the physical therapist based on the need of the patient and are dependent on age, weight, basic fitness level, severity of the disease and comorbidities.<ref>Breen C, O’Connell J, Geoghegan J, O’Shea D, Birney S, Tully L, Gaynor K, O’Kelly M, O’Malley G, O’Donovan C, Lyons O. Obesity in adults: a 2022 adapted clinical practice guideline for Ireland. Obesity Facts. 2022 Oct 24;15(6):736-52.</ref><ref>O'Donoghue G, Blake C, Cunningham C, Lennon O, Perrotta C. What exercise prescription is optimal to improve body composition and cardiorespiratory fitness in adults living with obesity? A network meta‐analysis. Obesity Reviews. 2021 Feb;22(2):e13137.</ref>
* Low contact sports are effective to manage OA, it prevents maximum joint stress and improves muscle strength and joint stability. High contact sports are avoided.
* Low contact sports are effective to manage OA, it prevents maximum joint stress and improves muscle strength and joint stability. High contact sports are avoided.
* Mind and body exercises such as Tai Chi and yoga are also prescribed.<ref>Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SM, Kraus VB, Lohmander LS, Abbott JH, Bhandari M, Blanco FJ. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis and cartilage. 2019 Nov 1;27(11):1578-89.</ref>
* Mind and body exercises such as Tai Chi and yoga are also prescribed.<ref>Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SM, Kraus VB, Lohmander LS, Abbott JH, Bhandari M, Blanco FJ. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis and cartilage. 2019 Nov 1;27(11):1578-89.</ref>
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* Education on weight management has to be provided.
* Education on weight management has to be provided.
* In electrotherapy, Transcutaneous Electrical Nerve Stimulation is applied.<ref>Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SM, Kraus VB, Lohmander LS, Abbott JH, Bhandari M, Blanco FJ. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis and cartilage. 2019 Nov 1;27(11):1578-89.</ref>
* In electrotherapy, Transcutaneous Electrical Nerve Stimulation is applied.<ref>Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SM, Kraus VB, Lohmander LS, Abbott JH, Bhandari M, Blanco FJ. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis and cartilage. 2019 Nov 1;27(11):1578-89.</ref>
* [[Balance Training|Balance]] Exercise <ref name=":1" />
Optimal exercise prescription will lead to exercise adherence reduce the risk of symptom flare up and maximize the outcome. See [[Adherence to Home Exercise Programs]]


== Aquatic Exercises and Osteoarthritis ==
== Aquatic Exercises ==
The exercises which are performed in water are known as aquatic exercises or hydrotherapy. It has various advantages in comparison to land based exercises. Blood circulation is improved by constant water temperature and hydrostatic pressure, it reduces the tension of soft tissue contracture. It even helps in reducing muscle spasm and fatigue. Muscle strengthening is promoted as water resistance acts in opposite direction of the body motion, which needs greater muscle activity. The buoyancy reduces the weight bearing which helps in reducing the degradation of the joints. It also give a soothing environment for osteoarthritis patients who are reluctant towards exercise.<ref>Dong R, Wu Y, Xu S, Zhang L, Ying J, Jin H, Wang P, Xiao L, Tong P. Is aquatic exercise more effective than land-based exercise for knee osteoarthritis?. Medicine. 2018 Dec;97(52).</ref>
[[File:Hydrotherapy Pool Exercises.jpg|thumb|Hydrotherapy]]
The exercises which are performed in water are known as aquatic exercises or [[hydrotherapy]]. It has various advantages in comparison to land based exercises. Blood circulation is improved by constant water temperature and hydrostatic pressure, it reduces the tension of soft tissue contracture. It even helps in reducing muscle spasm and fatigue. Muscle strengthening is promoted as water resistance acts in opposite direction of the body motion, which needs greater muscle activity. The buoyancy reduces the weight bearing which helps in reducing the degradation of the joints. It also give a soothing environment for osteoarthritis patients who are reluctant towards exercise.<ref>Dong R, Wu Y, Xu S, Zhang L, Ying J, Jin H, Wang P, Xiao L, Tong P. Is aquatic exercise more effective than land-based exercise for knee osteoarthritis?. Medicine. 2018 Dec;97(52).</ref>


== OA Hand ==
== OA Hand ==
[[File:Hand arthritis.jpeg|thumb|Hand OA]]
Osteoarthritis of hand is a common musculoskeletal disease. Its prevalence is rising rapidly with increasing age. It is usually occurs in 1st carpometacarpal joint. <ref name=":2">Kolasinski SL, Neogi T, Hochberg MC, Oatis C, Guyatt G, Block J, Callahan L, Copenhaver C, Dodge C, Felson D, Gellar K. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis & Rheumatology. 2020 Feb;72(2):220-33.</ref>The clinical features are hand pain, stiffness, reduced grip strength and compromised functional status. The primary goal of a physiotherapist will be to manage pain and improve the functional status by working on strength of the muscles.<ref>Kloppenburg M, Kroon FP, Blanco FJ, Doherty M, Dziedzic KS, Greibrokk E, Haugen IK, Herrero-Beaumont G, Jonsson H, Kjeken I, Maheu E. 2018 update of the EULAR recommendations for the management of hand osteoarthritis. Annals of the rheumatic diseases. 2019 Jan 1;78(1):16-24.</ref>Hand orthosis are strongly prescribed.<ref name=":2" />
Osteoarthritis of hand is a common musculoskeletal disease. Its prevalence is rising rapidly with increasing age. It is usually occurs in 1st carpometacarpal joint. <ref name=":2">Kolasinski SL, Neogi T, Hochberg MC, Oatis C, Guyatt G, Block J, Callahan L, Copenhaver C, Dodge C, Felson D, Gellar K. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis & Rheumatology. 2020 Feb;72(2):220-33.</ref>The clinical features are hand pain, stiffness, reduced grip strength and compromised functional status. The primary goal of a physiotherapist will be to manage pain and improve the functional status by working on strength of the muscles.<ref>Kloppenburg M, Kroon FP, Blanco FJ, Doherty M, Dziedzic KS, Greibrokk E, Haugen IK, Herrero-Beaumont G, Jonsson H, Kjeken I, Maheu E. 2018 update of the EULAR recommendations for the management of hand osteoarthritis. Annals of the rheumatic diseases. 2019 Jan 1;78(1):16-24.</ref>Hand orthosis are strongly prescribed.<ref name=":2" />


=== EULAR recommendations for Hand OA ===
'''European League Against Rheumatism Recommendations for Hand OA'''
 
* Health professionals involved in the treatment are physiotherapist, occupational therapist, rheumatologist, general practitioner, rehabilitation specialist.
 
* The patient characteristics that are consider most important include, age, type of pain, level and type of disability, mechanical factors, expectations of patients, the severity of damage, presence of erosions, inflammation and comorbidities.
 
'''Recommendations'''  
 
* Education and training in ergonomic principles ,pacing of activity and use of assistive devices should be offered to every patient.  
* Education and training in ergonomic principles ,pacing of activity and use of assistive devices should be offered to every patient.  
* Exercises to improve the function and strength and to reduce pain should be considered by the therapist.  
* Exercises to improve the function and strength and to reduce pain should be considered by the therapist.  
* Orthoses should be prescribed in thumb base OA for symptom relief.  
* Orthoses should be prescribed in thumb base OA for symptom relief.  
* Long term follow up of patients with hand OA should be as per the patient's requirement.  
* Long term follow up of patients with hand OA should be as per the patient's requirement. <ref>Kloppenburg M, Kroon FP, Blanco FJ, Doherty M, Dziedzic KS, Greibrokk E, Haugen IK, Herrero-Beaumont G, Jonsson H, Kjeken I, Maheu E. 2018 update of the EULAR recommendations for the management of hand osteoarthritis. Annals of the rheumatic diseases. 2019 Jan 1;78(1):16-24.</ref>
 
*
== References  ==
== References  ==


Latest revision as of 07:46, 12 December 2023

Original Editor - Nupur Smit Shah

Top Contributors - Nupur Smit Shah, Shaimaa Eldib and Lucinda hampton  

Introduction[edit | edit source]

Exercise group

Exercise therapy has positive benefits for people with symptomatic Osteoarthritis (OA). OA is a common form of arthritis and it leads to a major health economic burden. It commonly occurs in weight bearing (WB) joints (for example hips and knees), and NWB joints (for example the hands). In osteoarthritis patients present with pain and stiffness in affected joint.[1] [2]The management of OA can be divided in to conservative and conservative[3] treatments. Also, non conservative ( non operative) treatment can be divided to pharmacological and non pharmacological.[3]

Exercise therapy is the core for conservative Treatment,[3]

  1. Muscle strengthening and programs containing combinations of strength, flexibility, and aerobic exercises, mind body exercise like Yoga and Tai Chi are helpful for pain relief ,improving physical function and disability than general activity (e.g., walking).
  2. Exercise therapy brings other benefits, beyond pain and physical function, with moderate effects on depression.
  3. Programs including exercise therapy and education about exercise are recommended to decrease fear of activity and improve patient engagement in exercise programs.[4]See Patient Education in Pain Management.

Obesity, Exercise and OA[edit | edit source]

Obesity: risk factor for OA

Obesity is one of the most significant risk factors for osteoarthritis symptoms and disease progression, especially for the knee involvement.[5][3]

  1. Exercise is beneficial for the maintenance of metabolic homeostasis. Excessive adipose tissue, as occurs in obesity, increases mechanical stresses on weight-bearing joints and additionally generates an imbalance in the secretory profile of adipokines, including leptin, adiponectin, visfatin, and resistin. These conditions create an environment of low-grade inflammation lead eventually to cartilage breakdown.
  2. Clinical trials have shown that exercise programs (consisting of aerobic walking, strength training, a second aerobic phase, then a cool-down period) in combination with diet, led to significant reduction in weight, total fat mass, pain relief, and improvements in mobility.[6][7][8]

NB Knee OA: Obesity also causes thinner medial tibial cartilage compared to normal BMI individuals.[9]

Physiotherapy[edit | edit source]

Therapeutic exercises(type/ dose) are decided by the physical therapist based on the need of the patient and are dependent on age, weight, basic fitness level, severity of the disease and comorbidities.[10][11]

  • Low contact sports are effective to manage OA, it prevents maximum joint stress and improves muscle strength and joint stability. High contact sports are avoided.
  • Mind and body exercises such as Tai Chi and yoga are also prescribed.[12]
  • Gait aids can be recommended.
  • Cryotherapy can be used as an adjunct along with land based exercises.[13]
  • Education on weight management has to be provided.
  • In electrotherapy, Transcutaneous Electrical Nerve Stimulation is applied.[14]
  • Balance Exercise [3]

Optimal exercise prescription will lead to exercise adherence reduce the risk of symptom flare up and maximize the outcome. See Adherence to Home Exercise Programs

Aquatic Exercises[edit | edit source]

Hydrotherapy

The exercises which are performed in water are known as aquatic exercises or hydrotherapy. It has various advantages in comparison to land based exercises. Blood circulation is improved by constant water temperature and hydrostatic pressure, it reduces the tension of soft tissue contracture. It even helps in reducing muscle spasm and fatigue. Muscle strengthening is promoted as water resistance acts in opposite direction of the body motion, which needs greater muscle activity. The buoyancy reduces the weight bearing which helps in reducing the degradation of the joints. It also give a soothing environment for osteoarthritis patients who are reluctant towards exercise.[15]

OA Hand[edit | edit source]

Hand OA

Osteoarthritis of hand is a common musculoskeletal disease. Its prevalence is rising rapidly with increasing age. It is usually occurs in 1st carpometacarpal joint. [16]The clinical features are hand pain, stiffness, reduced grip strength and compromised functional status. The primary goal of a physiotherapist will be to manage pain and improve the functional status by working on strength of the muscles.[17]Hand orthosis are strongly prescribed.[16]

European League Against Rheumatism Recommendations for Hand OA

  • Education and training in ergonomic principles ,pacing of activity and use of assistive devices should be offered to every patient.
  • Exercises to improve the function and strength and to reduce pain should be considered by the therapist.
  • Orthoses should be prescribed in thumb base OA for symptom relief.
  • Long term follow up of patients with hand OA should be as per the patient's requirement. [18]

References[edit | edit source]

  1. ↑ Katz JN, Arant KR, Loeser RF. Diagnosis and treatment of hip and knee osteoarthritis: a review. Jama. 2021 Feb 9;325(6):568-78.
  2. ↑ Funck‐Brentano T, Nethander M, Movérare‐Skrtic S, Richette P, Ohlsson C. Causal factors for knee, hip, and hand osteoarthritis: a Mendelian randomization study in the UK biobank. Arthritis & rheumatology. 2019 Oct;71(10):1634-41.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 Lim WB, Al-Dadah O. Conservative treatment of knee osteoarthritis: A review of the literature. World Journal of Orthopedics. 2022 Mar 3;13(3):212.
  4. ↑ Villafañe JH. Exercise and osteoarthritis: an update. Journal of exercise rehabilitation. 2018 Aug;14(4):538. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6165969/(accessed 21.9.2022)
  5. ↑ Lim YZ, Wong J, Hussain M, Estee MM, Zolio L, Page MJ, Harrison CL, Wluka AE, Wang Y, Cicuttini FM. Recommendations for weight management in osteoarthritis: A systematic review of clinical practice guidelines. Osteoarthritis and Cartilage Open. 2022 Aug 5:100298.Available:https://www.sciencedirect.com/science/article/pii/S2665913122000668 (accessed 21.9.2022)
  6. ↑ Leong DJ, Sun HB. Osteoarthritis–why exercise?. Journal of exercise, sports & orthopedics. 2014;1(1).Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4350574/ (accessed 21.9.2022)
  7. ↑ Bhagat P, Jagtap V, Devi P. Effect of circuit training in osteoarthritis of knee. Asian J. Pharm. Clin. Res. 2017;10:333-5.
  8. ↑ Lavie CJ, Carbone S, Kachur S, O'keefe EL, Elagizi A. Effects of physical activity, exercise, and fitness on obesity-related morbidity and mortality. Current sports medicine reports. 2019 Aug 1;18(8):292-8.
  9. ↑ Chen L, Zheng JJ, Li G, Yuan J, Ebert JR, Li H, Papadimitriou J, Wang Q, Wood D, Jones CW, Zheng M. Pathogenesis and clinical management of obesity-related knee osteoarthritis: impact of mechanical loading. Journal of orthopaedic translation. 2020 Sep 1;24:66-75.
  10. ↑ Breen C, O’Connell J, Geoghegan J, O’Shea D, Birney S, Tully L, Gaynor K, O’Kelly M, O’Malley G, O’Donovan C, Lyons O. Obesity in adults: a 2022 adapted clinical practice guideline for Ireland. Obesity Facts. 2022 Oct 24;15(6):736-52.
  11. ↑ O'Donoghue G, Blake C, Cunningham C, Lennon O, Perrotta C. What exercise prescription is optimal to improve body composition and cardiorespiratory fitness in adults living with obesity? A network meta‐analysis. Obesity Reviews. 2021 Feb;22(2):e13137.
  12. ↑ Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SM, Kraus VB, Lohmander LS, Abbott JH, Bhandari M, Blanco FJ. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis and cartilage. 2019 Nov 1;27(11):1578-89.
  13. ↑ Dantas LO, Jorge AE, da Silva Serrao PR, Aburquerque-Sendin F, de Fatima Salvini T. Cryotherapy associated with tailored land-based exercises for knee osteoarthritis: a protocol for a double-blind sham-controlled randomised trial. BMJ open. 2020 Jun 1;10(6):e035610.
  14. ↑ Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SM, Kraus VB, Lohmander LS, Abbott JH, Bhandari M, Blanco FJ. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis and cartilage. 2019 Nov 1;27(11):1578-89.
  15. ↑ Dong R, Wu Y, Xu S, Zhang L, Ying J, Jin H, Wang P, Xiao L, Tong P. Is aquatic exercise more effective than land-based exercise for knee osteoarthritis?. Medicine. 2018 Dec;97(52).
  16. ↑ 16.0 16.1 Kolasinski SL, Neogi T, Hochberg MC, Oatis C, Guyatt G, Block J, Callahan L, Copenhaver C, Dodge C, Felson D, Gellar K. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis & Rheumatology. 2020 Feb;72(2):220-33.
  17. ↑ Kloppenburg M, Kroon FP, Blanco FJ, Doherty M, Dziedzic KS, Greibrokk E, Haugen IK, Herrero-Beaumont G, Jonsson H, Kjeken I, Maheu E. 2018 update of the EULAR recommendations for the management of hand osteoarthritis. Annals of the rheumatic diseases. 2019 Jan 1;78(1):16-24.
  18. ↑ Kloppenburg M, Kroon FP, Blanco FJ, Doherty M, Dziedzic KS, Greibrokk E, Haugen IK, Herrero-Beaumont G, Jonsson H, Kjeken I, Maheu E. 2018 update of the EULAR recommendations for the management of hand osteoarthritis. Annals of the rheumatic diseases. 2019 Jan 1;78(1):16-24.
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