COMPARATIVE EFFECTIVENESS HOME BASED VERSUS SUPERVISED

EXERCISES IN KNEE OA MANAGEMENT TO IMPROVE PAIN, GAIT SPEED AND

MUSCLE STRENGTH: A STRUCTURED LITERATURE REVIEW

INTRODUCTION

Osteoarthritis (OA) of the knee is one of the common musculoskeletal diseases and disabling

condition affecting a significant proportion of the global population, particularly the elderly

(Allen et al., 2022). It can be characterised by degeneration of joint cartilage and underlying

bone, and often results in pain, stiffness, reduced function, and impaired quality of life (Heidari,

2011). OA is leading to substantial healthcare costs and economic loss due to disability and

decreased productivity (Hardenberg et al., 2022). In England, OA impacts a substantial portion

of the population and poses a considerable burden on the National Health Service (NHS)

(Morgan et al., 2019). Prevalence of knee OA has seen a notable increase over recent years,

reflecting broader global trends in the incidence of this condition. From 2000/2001 to 2017/2018,

the incidence of knee OA in England increased by 2.9% per year. This rise in prevalence is

accompanied by substantial healthcare utilisation, including increased hospital admissions and

the need for surgical interventions such as joint replacements (Morgan et al., 2019, Arslan et al.,

2022). Women are more frequently diagnosed with knee OA than men, with the disease

predominantly affecting individuals aged 70 to 74 (Morgan et al., 2019). This could be due to

hormonal changes post-menopause, higher obesity rates, anatomical differences, and greater

longevity (Szilagyi et al., 2023). Additionally, women are more likely to report symptoms and

seek medical attention (Tschon et al., 2021). However, the incidence of knee OA is not limited to

older adults; there has also been a noticeable rise in diagnoses among younger populations,
particularly those aged 35 to 44, which aligns with increasing obesity rates and sedentary

lifestyles (Khan et al., 2018). This shift underscores the growing public health challenge posed

by knee OA across different age groups (Arslan et al., 2022).

Management of knee OA encompasses a range of approaches, including pharmacological

treatments, surgical interventions, and non-pharmacological therapies (Uivaraseanu et al., 2022),

aimed at alleviating pain, improving joint function, and enhancing the quality of life for patients.

Current clinical practice guidelines recommend, initially, conservative treatments, which include

pharmacological therapies such as non-steroidal anti-inflammatory drugs (NSAIDs) and

analgesics, alongside non-pharmacological interventions like weight loss and physical exercise

(Kwaśniewska et al., 2022). Physical exercise, particularly strengthening exercises, has shown

moderate effectiveness in reducing pain and improving functionality (Kwaśniewska et al., 2022).

These guidelines included National Institute for Health and Care Excellence (NICE) guideline,

American College of Rheumatology/Arthritis Foundation guidelines (Kolasinski et al., 2020).

The credibility of the information from these guidelines was very high as the Agree II scores of

these guidelines were more than 85%, with none of the individual domains being less than 75%

(Brouwers et al., 2010)(Bin et al., 2023). For patients who do not respond adequately to

conservative measures, various injectable treatments are considered (Uivaraseanu et al., 2022).

These include intra-articular injections of corticosteroids and hyaluronic acid, with newer options

like platelet-rich plasma (PRP) and mesenchymal stem cells (MSCs) showing promise in

promoting cartilage regeneration (Uivaraseanu et al., 2022). However, the clinical efficacy of

stem cell therapy remains under investigation, with concerns about dosage, delivery methods,

and long-term outcomes (Uivaraseanu et al., 2022)(Mo et al., 2023).

Many studies recommended exercise-based interventions should be considered first in the

management of knee osteoarthritis because they are non-invasive, cost-effective, and have

demonstrated significant benefits in reducing pain and improving joint function (Torstensen et

al., 2023, Thorlund et al., 2022, Nissen et al., 2022). Additionally, these interventions can

enhance muscle strength and overall mobility, potentially delaying the need for surgical

procedures and their associated risks (Lim and Al-Dadah, 2022). Systematic reviews by Bin et

al. (2023) and Mo et al. (2023) observed significant findings regarding surgical and exercise-

based interventions for knee osteoarthritis (KOA). Bin et al. (2023) assessed the efficacy of

surgical interventions, finding notable improvements in pain relief and muscle strength post-

surgery. The review study reported a mean effect size of 1.25 (large effect size) for pain

reduction (p < 0.001) and 1.10 for muscle strength (p < 0.001), indicating substantial benefits of

surgical treatments. Conversely, Ling et al. (2023) focused on exercise-based therapies, such as

aquatic exercises, resistance training, and yoga (Mo et al., 2023). The exercise interventions

demonstrated a significant reduction in pain on Visual Analogue Scale (VAS) with a weighted

mean difference (WMD) of -4.45 (95% CI: -5.69 to -3.20) for cycling and notable improvements

in muscle strength across various exercise modalities. Both interventions exhibit substantial

efficacy in managing KOA symptoms, with surgical treatments offering immediate and

pronounced relief, while exercise-based therapies provide gradual and sustained benefits. Given

the strong effect sizes and significant p-values in both studies, it is evident that surgical and

exercise interventions can be beneficial in addressing pain and enhancing muscle strength in

KOA patients. However, exercise intervention has very less or no side effects as compared to the

surgical interventions. Additionally, the cost benefit analysis by different studies favours the
exercise based interventions over surgical management (Zimmerman et al., 2023).

Within exercise-based therapies, there are two primary options: supervised and home-based

exercise programmes (Bozgeyik et al., 2024). Both approaches have their advantages and

limitations. Home-based exercises offer convenience and lower costs, making them accessible to

a broader population (Dell'Isola et al., 2020). They eliminate the need for frequent visits to

healthcare facilities, which can be particularly beneficial for individuals with mobility issues or

those living in remote areas. However, adherence to home-based exercises can be challenging,

and the lack of professional supervision may lead to improper execution of exercises, potentially

reducing their effectiveness.

Supervised exercise programmes, on the other hand, provide the benefit of professional

oversight, ensuring that exercises are performed correctly and effectively. Regular supervision

also allows for immediate adjustments to the exercise regimen based on patient feedback and

progress. Additionally, the structured nature of supervised programmes may enhance patient

motivation and adherence. Nevertheless, these programmes can be more costly and less

convenient, requiring patients to travel to exercise facilities and schedule regular appointments.

However, the current body of research has not extensively compared these two approaches.

Pain relief, improvement in gait speed, and enhancement of muscle strength are critical outcomes

in the management of knee OA (Davis et al., 2022). Pain is a primary symptom of knee OA and

a significant contributor to reduced quality of life. Effective pain management is essential for

improving patient well-being and enabling participation in physical activities (Reynaud et al.,

2020). Gait speed is a crucial indicator of functional mobility and overall physical health
(Middleton et al., 2015). Improving gait speed can significantly enhance the independence and

quality of life of individuals with knee (Gilbert et al., 2021). Muscle strength, particularly in the

quadriceps and hamstrings, is vital for knee stability and function (Keays et al., 2003, Sadeghi et

al., 2023). Strengthening these muscles can alleviate stress on the knee joint, reduce pain, and

improve functional outcomes (Roman-Blas et al., 2020).

A randomised controlled trial by Bozgeyik et al. (2024) evaluates the effectiveness of

physiotherapist-supervised exercises compared to home-based exercises for patients with knee

osteoarthritis (OA) following platelet-rich plasma (PRP) injection. For this study, 30 female

patients were divided into supervised and home-based exercise groups. Both groups performed

exercises three times a week for six weeks. The results showed significant improvements in pain,

knee function, and muscle strength in the supervised exercise group, with a median pain

reduction of 3.80 points (p = 0.002) and notable gains in quadriceps and hamstring strength. In

contrast, the home-based exercise group exhibited minimal improvements in these areas,

highlighting the superior efficacy of supervised exercise programmes in conjunction with PRP

therapy. The minimal improvements in the home-based exercise group may be due to the

absence of professional supervision and personalised adjustments, which are critical for

maximising the benefits of exercise.

In contrast, the current study aims to compare the effectiveness of home-based versus supervised

exercise programmes, specifically in managing knee OA. Outcomes considered will focus on

pain relief, gait speed, and muscle strength without the adjunctive use of PRP. While other study

provided valuable insights into the benefits of supervised exercise following PRP injections, the

current study addresses the broader context of exercise-based interventions alone. The need for

the current study is justified by the necessity to understand the independent effects of exercise
based interventions on knee OA outcomes, thereby guiding clinical decisions on non-

pharmacological management strategies tailored to patient needs without additional interventions

like PRP. Hence, this structured literature review aims to compare the effectiveness of home-

based versus supervised exercise programmes in managing knee OA, focusing on pain relief, gait

speed, and muscle strength.

METHODOLOGY

Study design

This study is carried out as a structured literature review due to its ability to minimise bias

through a systematic and transparent methodology (Boren and Moxley, 2015), ensuring

comprehensive and objective synthesis of information from existing studies. By using a

predefined inclusion and exclusion criteria, it reduces the risk of missing relevant studies and

enhances the reliability of the review (Yuan and Hunt, 2009). The rigorous quality assessment of

included studies, along with the use of a detailed search strategy and documentation of the data

extraction processes, ensures reproducibility and strengthens the credibility of the findings.

Additionally, this approach allows for the identification of research gaps, supports the

development of evidence-based conclusions for clinical practice and future research, and

provides a thorough understanding of the comparative effectiveness of home-based versus

supervised exercise programmes in managing knee osteoarthritis.

Objective of the study

The objective of this study is to systematically review and compare the effectiveness of home-

based versus supervised exercise programmes in managing knee osteoarthritis (OA), specifically

focusing on pain relief, gait speed, and muscle strength.

Databases

Databases are comprehensive collections of research articles and academic publications that

provide a structured and searchable platform for retrieving relevant literature (Bramer et al.,

2017). For this structured literature review, a selection of widely recognised and frequently used

databases was chosen to ensure a thorough and comprehensive search of the available evidence

on the comparative effectiveness of home-based versus supervised exercise programmes in

managing knee osteoarthritis (OA).

The primary databases selected for this review include MEDLINE/PubMed, CINAHL, Embase,

PsycINFO, Scopus, Web of Science, and Google Scholar. These databases were chosen for their

relevance, comprehensiveness, and frequency of use in systematic reviews of similar topics

(Solis-Navarro et al., 2022). According to literature, MEDLINE/PubMed and CINAHL are the

most commonly used, offering extensive coverage of medical, biomedical, nursing, and allied

health literature (Solis-Navarro et al., 2022, Justesen et al., 2021). A study by Justesen et al.

(2021) found that MEDLINE/PubMed was used in all systematic reviews (100%), followed by

CINAHL (81%), with their combination providing a high recall rate of 96%. Embase focuses on

medicine journals, while PsycINFO covers psychological and behavioural aspects of exercise

adherence. Scopus and Web of Science include a wide range of scientific journals and

comprehensive citation data, enhancing search breadth (Justesen et al., 2021). Google Scholar is

valuable for identifying more articles with simple phrase searching, offering resource and cost
efficiency, rapid full-text access, and substantial grey literature, though it should not be used

alone due to its limitations (Haddaway et al., 2015).

To avoid overlooking articles due to poor indexing, additional searches were performed using the

"Cited by" feature of Google Scholar (Hirt et al., 2020), screening reference lists of included

articles (Horsley et al., 2011), and hand-searching key journals and authors (Richards, 2008).

Hand searches involved manually reviewing key journals and publications, while reference lists

were meticulously examined to identify further relevant studies (Richards, 2008).

Search strategy

The digital databases were searched using a well-constructed strategy. This strategy was

developed by identifying synonyms and related search terms from the literature, conducting a

quick manual search on Google, and consulting an experienced librarian. Initially, the search

strategy was created for the Ovid Medline database and then adapted for other databases using

their specific syntaxes and thesaurus terminologies (Damarell et al., 2013). This tailored

approach ensures the strategy is optimised for the unique indexing and search capabilities of each

database, enhancing the retrieval of relevant studies and the overall comprehensiveness of the

review. The detailed search strategy is given in table 1.

Table 1: Search strategy

Population Intervention Comparison Outcome

measures

1. exp knee AND 9. Home-based AND Supervised AND 16. Pain

osteoarthritis/ [Link] [Link]

(MeSH)

2. (knee adj 10. (exercise adj 17. Muscle

osteoarthritis).ti,ab program).ti,ab strength

3. (knee adj 11. (physical adj 18.

OA).ti,ab therapy).ti,ab Quadriceps

4. [Link],ab 12. (exercise adj 19.

intervention).ti,a Hamstrings

5. (knee or 13. (exercise adj 20. Quality

tibiofemoral or training).ti,ab of life

patellofemoral).m

6. (degenerative adj 14. (physical adj

arthritis).ti,ab activity).ti,ab

7. (knee adj 15. Rehabilitation

degenerative adj (MeSH)

joint adj

disease).ti,ab
 8. exp joint diseases/

(MeSH)

Eligibility criteria

Eligibility is a set of characteristics or conditions to sort the retrieved articles from various

database. These criteria help one to make a decision on any article to be included or to be

excluded. There are several frameworks available to develop eligibility criteria, such as PEO

(Population, Exposure, Outcome), SPIDER (Sample, Phenomenon of Interest, Design,

Evaluation, Research type), and PICO (Population, Intervention, Comparison, Outcome). For

this research question, the most suitable framework is PICO, as it allows for a clear and

structured comparison of the interventions and outcomes. For this study, the population is adults

diagnosed with knee osteoarthritis, the intervention is home-based exercise programmes, the

comparison is with supervised exercise programmes, and the outcomes measured are pain relief,

gait speed, and muscle strength. The detailed eligibility criteria is given in table 1.
Table 1: Eligibility criteria

PEO Inclusion criteria Justification for the inclusion Exclusion criteria Justification for the exclusion
Study type * Randomised or non- * Including non-randomised * Studies with incomplete * These sources often lack
randomised controlled trials broadens the evidence reports such as conference detailed methodological
studies comparing base where RCTs may be proceedings, abstracts, descriptions, comprehensive
home-based and lacking. Both designs facilitate and reports. results, peer review, and
supervised exercise direct comparisons between * Case reports and grey rigorous methodological
programmes. intervention and control groups literature standards, limiting their
* Non English articles generalisability
* Non-English language studies
are excluded due to limited
resources for translation.
Population * Adults diagnosed * Adults are selected because * Studies involving * Paediatric populations have
with knee they represent the most paediatric populations. different physiological
osteoarthritis common demographic for knee * Studies involving other responses and rehabilitation
osteoarthritis, ensuring forms of arthritis. needs compared to adults,
applicability of findings * making findings less applicable.
(Heidari, 2011).
Intervention * Home-based * Ensures the review is * Interventions not related * Non-exercise interventions
exercise programmes focused to exercise (e.g., fall outside the scope of this
defined as “structured pharmacological review.
physical activity treatments).
regimens that
individuals perform
independently at
home, without the
direct supervision of a
healthcare
professional”.
Comparison * Supervised exercise * Ensures the review is * Studies without a * Studies without a control
programmes defined focused control group. group lack the necessary
as “supervised * co-interventions comparison to determine the of
 exercise programmes the intervention.
are structured physical
activity regimens
conducted under the
direct guidance and
oversight of a
healthcare
professional, such as a
physiotherapist”
Outcome Pain (any scale), gait * These outcomes are critical * Studies not reporting * Studies that do not report on
measures speed (any scale/ indicators of recovery and any of the specified the specified outcomes cannot
result from any overall effectiveness of the outcomes answer the research question
intervention such as program.
gait analysis) and
muscle strength
(quadriceps and or
hamstring)
Study selection
Data from multiple databases were imported into RefWorks reference management software
(Divecha et al., 2023). Citations from each database were placed in separate folders, collated,
and duplicates removed using the duplicate removal feature. Screening was conducted in two
stages by one reviewer: first, titles and abstracts were assessed against eligibility criteria, with
frequent reference to a physical copy of the criteria, to avoid mistakes due to habituation.
Second, full texts of included studies were reviewed. Any confusion was resolved by consulting
a supervisor.
Data extraction
Data extraction was performed using a pre-designed excel sheet that gathered essential
information pertinent to the research objectives and questions. This template included details on
study characteristics (author, year, publication source, study design), participant demographics
(sample size, age, gender), a brief description of the intervention, baseline outcome measure
values, and key findings related to the impact of exercise programmes on pain relief, gait speed,
and muscle strength.
Quality appraisal
For this review, the Risk of Bias 2 (RoB II) tool was used for randomised controlled trials
(RCTs), and the Joanna Briggs Institute (JBI) tool was employed for non-RCTs (Sterne et al.,
2019, Frampton et al., 2022, Sargeant et al., 2022, Munn et al., 2020). These tools evaluate
biases and methodological quality, focusing on study design, data collection, and statistical
analysis, allowing a comprehensive assessment of each study's strengths and weaknesses.
Data analysis
A descriptive synthesis of the extracted data was performed. This narrative synthesis began with
an initial summary of the studies, followed by an analysis of the relationships between and
within the data from different studies and an examination of any variations in the outcomes. The
findings from each study were displayed in tabular form or descriptive text, depending on which
method conveyed the data most effectively.
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