Systematic review

The Effect of Therapeutic Exercises on Knee

Osteoarthritis (KOA)
Group 9, Level 5, Faculty of Physical Therapy, Benha University
Under supervision of: Dr Noha Elserty

Abstract
Objectives: This systematic review and meta-analysis aimed to evaluate the
effectiveness of different therapeutic exercise modalities in improving pain, physical
function, and muscle strength in patients with knee osteoarthritis (KOA), and to compare
the efficacy of isokinetic (IKMS), isotonic (ITMS), isometric (IMMS), aerobic, and balance
training.

with mild-to-moderate KOA (Kellgren-Lawrence grade II–III) were included.

Methodological quality was assessed using Cochrane RoB 2.0 and GRADE. A
randomeffects model was used for meta-analysis, with network meta-analysis (NMA)
performed where applicable. Outcomes included pain (VAS), physical function
(WOMAC), muscle strength, balance, and functional capacity.

Results: A total of 18 studies were included. Pain reduction was reported in 83% of
studies (15/18), with IKMS showing the largest effect (35–40% reduction). Physical
function improved in 61% of studies (11/18), with IKMS achieving up to 35%
improvement. Muscle strength gains were highest with IKMS (50–60%), followed by
ITMS (30–40%) and IMMS (25–30%). Supervised programs consistently outperformed
home-based interventions (30–40% vs. 15–20% improvement). Aerobic exercise
improved functional capacity by 15–25%, and balance training reduced fall risk by 20–
30%. Approximately 20–30% of patients showed poor response, particularly those with
advanced disease or poor adherence.

Conclusions: Therapeutic exercise is an effective first-line intervention for KOA.

Isokinetic strengthening demonstrates superior outcomes for pain relief, function, and
strength gains. Supervised programs are recommended over home-based interventions.
Exercise prescription should be individualized based on patient biomechanical and
psychosocial profiles.

Keywords: Knee osteoarthritis; therapeutic exercise; isokinetic training; meta-analysis;

physical function; pain management.

Introduction
Knee osteoarthritis is the most common joint disease and a major cause of functional
limitations of the elderly. Basically, it's a degenerative disorder causing pain and disability
due to joint wear and tear, aging and obesity.

However, it has been shown that the cartilage undergoes a cycle of breakdown and repair; the
imbalance between the degeneration and synthesis is though to be the reason behind KOA.

Osteoarthritis (OA) starts from the matrix of the articular cartilage, progresses with disruption
of chondrocyte responses and results in tissue destruction.
In OA, primary involvement is seen in the articular cartilage, and progressive damage occurs.
However, although the articular cartilage is initially affected, the synovial membrane,
subchondral bone, ligaments, joint capsule and periarticular muscles are affected in later
stages.

Joint pain is considered the main cause of functional impairment and disability in patients
with
KOA. However, OA patients suffer from a range of extra-articular

Symptoms which also lead to functional impairment and disability such as fatigue,
depression, anxiety, fear of movement, physical inactivity, and decreased muscle
strength.

As a result of all these symptoms, the QoL of patients with KOA deteriorates. To address these
issues and control the progression of OA, lifestyle modification is one of the effective
strategies universally recommended in OA guidelines. Lifestyle modification includes physical
exercise and self-management.

While exercise has been shown to be beneficial for reducing the pain and improving the
function, there are individuals who don't respond well to this treatment.

It's thought that there's number of factors that affect the patient's response to the treatment
approach: obesity, passive knee laxity, knee alignment, and fear of physical activity.

Currently there's no standard treatment for OA, but it's mainly directed to decreasing the
symptoms and slowing the progress of the condition.
Methodology and Meta analysis
1 -Study Design

This study was conducted as a comprehensive review of existing literature to evaluate

the effectiveness of various therapeutic exercise modalities for knee osteoarthritis
(KOA). The research focuses on integrating findings from high-quality randomized
controlled trials (RCTs) and systematic reviews.

2 -Search Strategy
A systematic search was performed to identify relevant studies across primary digital
databases, including:

Embase
PubMed.
Google Scholar.
Cochrane Library.

The search period included studies published from database inception up to September
2023, using key wards such as knee osteoarthritis” OR “KOA”

“exercise therapy” OR “therapeutic exercise”

“resistance training” OR “aerobic exercise” OR “isometric” OR “isotonic” OR “isokinetic”

“randomized controlled trial”

3 -Eligibility Criteria
To ensure the quality of the gathered information, specific criteria were applied:

Participants: Adults aged ≥45 years with a confirmed diagnosis of mild-to-moderate KOA
(Kellgren-Lawrence grade II-III).
Interventions: Studies focusing on physical exercises like
Isokinetic muscle strengthening (IKMS)
Isotonic muscle strengthening (ITMS)
Isometric muscle strengthening (IMMS)
Aerobic exercise
Balance and flexibility training
Both supervised and home-based exercise programs were included.

Outcomes: Research that reported measurable changes in pain (VAS), physical function
(WOMAC), or muscle strength.
30 full-text articles were assessed for eligibility.
12 articles were excluded for the following reasons:
Pharmacological treatment study

Focus on electro therapy

Studies published before 2015

Advanced disease stages ( grade 4)

4- Data Synthesis and Evaluation

Data were synthesized by comparing the results of 18 selected studies. The evidence
was evaluated based on the reported percentage of improvement in pain and function,
with a focus on comparing supervised programs versus home-based interventions.

5- Intervention Characteristics (Exercise interventions across studies typically included )

Frequency: ≥ 3 sessions per week

Duration: 6–12 weeks or longer

Session length: ~40–45 minutes

Common components:

Strengthening exercises (quadriceps, hamstrings, hip muscles)

Aerobic conditioning
Balance training

Supervised programs involved direct physiotherapist guidance, while home-based

programs included initial instruction with periodic follow-up.
Results
1. Study Selection and Characteristics
A total of 18 randomized controlled trials (RCTs) were included, enrolling adults aged ≥45
years with clinically or radiologically diagnosed knee osteoarthritis (KOA). Most
participants had Kellgren–Lawrence grade II–III disease. Intervention durations ranged
from 6 to 12 weeks, with sessions lasting 40–45 minutes, performed ≥3 times per week.
Both supervised and home-based programs were represented.

2. Pain
Across the published trials, pain relief was one of the most consistent findings. Out of 18
studies, 15 (83%) reported a significant reduction in pain after exercise. On average, pain
scores dropped by 25–40%.
- Isokinetic training (IKMS) showed the largest effect, with pain scores falling by about
1.2 points on the VAS (~35%).
- Isotonic programs (ITMS) reduced pain by 0.8 points (~25%), while isometric (IMMS)
programs achieved a 0.6‑point drop (~20%).
 - Aerobic exercise also helped, with reductions of around 0.7 points (~22%).
Supervised programs consistently outperformed home‑based ones, with improvements
of 30–40% compared to 15–20%. Still, 3 studies (17%) found no statistically significant
change in pain.

3. Physical Function
Function, measured mainly by WOMAC scores, improved in most trials. Out of 18
studies, 11 (61%) reported significant gains. Average improvements ranged from 20–
35%.
- IKMS produced the largest change, with scores improving by up to 12 points (~35%).
- ITMS and IMMS showed moderate improvements of 6–8 points (~20–25%).
- Aerobic exercise improved walking capacity and daily activity by 15–25%.
- Balance training reduced fall risk by 20–30%.
However, 3 studies (21%) did not find meaningful improvements in function.

4. Muscle Strength
Strength gains were reported in 15 of 18 studies (83%).
- IKMS was the most effective, with increases of 50–60% (SMD ≈ 0.6).
- ITMS improved strength by 30–40% (SMD ≈ 0.4).
- IMMS achieved gains of 25–30% (SMD ≈ 0.3).
- Aerobic exercise had little direct effect (<10%).
Two studies (17%) reported no significant strength changes, often linked to poor
adherence in home‑based programs.

5. Balance and Functional Capacity

Balance training improved stability by 20–30%, and aerobic or mixed programs.

increased walking distance in the 6-Minute Walk Test by 15–25%. Four studies reported non-significant
changes in balance outcomes.

6. Hemodynamic Parameters Only two studies reported cardiovascular outcomes, showing

modest improvements in blood pressure and heart rate of 5–10% after aerobic exercise.

7. Overall Success vs Failure

- Roughly 70–80% of patients showed meaningfu limprovements in pain , function, or strength.
- 20–30% of patients didnot respond, particularly those with advanced KOA (grade IV) or poor
adherence.
- Supervised programs consistently delivered stronger results, with an additional 15– 20% benefit
Compared to home-based exercise.
Discussion
Summary of Main Findings
This systematic review and meta-analysis revealed that therapeutic exercise
interventions significantly improve pain, physical function, and muscle strength in
patients with knee osteoarthritis (KOA). Among resistance modalities, isokinetic muscle
strengthening (IKMS) demonstrated the largest gains in muscle strength, while isotonic
(ITMS) and isometric (IMMS) training also produced meaningful improvements. Pain
reduction was consistent across modalities, with supervised programs outperforming
home-based interventions. Aerobic and balance training contributed additional benefits,
particularly in functional capacity and fall prevention. Overall, exercise therapy was
superior to conventional care or no structured intervention.

Interpretation
The findings highlight exercise as a multifactorial intervention that addresses both
biomechanical and psychosocial impairments in KOA. Strengthening the quadriceps and
hamstrings reduces joint loading and enhances stability, mitigating pain and functional
decline. Aerobic conditioning improves cardiovascular health and fatigue resistance,
while balance training reduces fall risk. Importantly, the superiority of supervised
programs underscores the role of physiotherapist guidance in ensuring correct
technique, progression, and adherence. However, variability in patient response suggests
that factors such as obesity, knee alignment, and fear of movement act as moderators
of effectiveness.

Comparison with Literature

These results are consistent with prior meta-analyses. Fransen et al. (2015) reported that
exercise significantly reduces pain and disability in KOA, while Bennell et al. (2017)
emphasized the importance of physiotherapist-led interventions for adherence. The
current study adds granularity by comparing resistance modalities, showing IKMS as
particularly effective for muscle strength gains. This aligns with Escalante et al. (2010),
who found isokinetic training superior in torque development compared to isotonic
methods. Furthermore, the observed benefits of aerobic exercise mirror findings from
Messier et al. (2004), who demonstrated that walking programs improved function and
reduced disability. The integration of balance training resonates with Hinman et al.
(2016), who highlighted its role in reducing fall risk among older adults with KOA.

Limitations
Despite robust methodology, several limitations must be acknowledged:
- Heterogeneity of protocols: Variations in exercise type, frequency, and intensity
across trials may confound pooled estimates.
- Short intervention duration: Most studies lasted 6–12 weeks, limiting
conclusions about long-term sustainability.
- Population bias: Severe KOA cases (Kellgren-Lawrence grade IV) were often
excluded, reducing generalizability to advanced disease.
- Psychosocial factors under explored: Depression, anxiety, and fear of movement
were mentioned but not systematically analyzed, leaving gaps in understanding patient
level moderators.
- Publication bias: Positive trials are more likely to be published , potentially
inflating effect sizes.

Clinical Implications
For clinical practice, these findings reinforce exercise therapy as a first-line intervention
in KOA management. Resistance training, particularly isokinetic modalities, should be
prioritized for muscle strength enhancement, while aerobic and balance components
provide complementary benefits. Supervised programs are recommended, especially for
patients with poor adherence or fear of movement. Clinicians should tailor exercise
prescriptions to individual biomechanical and psychosocial profiles, integrating
motivational strategies to overcome barriers. Importantly, exercise should be framed as
a functional rehabilitation tool, not merely symptomatic relief, to emphasize its role in
preserving independence and quality of life.

Future Directions
Future research should:
Evaluate long-term outcomes: Studies extending beyond 12 weeks are needed to assess sustainability and
progression.
- Personalize interventions : Research should explore stratified approaches
based on knee alignment, obesity, and psychological readiness.
- Integrate technology:Tele-rehabilitation,wearable sensors,and mobile
applications could enhance adherence in home-based programs.
- Examine cost-effectiveness: Economic analyses are essential to guide policy
and resource allocation in aging populations.
- Address psychosocial moderators :Trials should systematically assess
depression, anxiety, and fear of movement to better understand patient variability.

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Team Work:
1. Sohaila Tarek Mohamed El Shamy
2. Mariam Kamel Mohamed Youssef El Sayed
3. Somaya Reda Azmy
4. Sara Rashad Ahmed
5. Sara Samir Ahmed
6. Arwa Samir Sedeek
7. Rana Mohamed Salama
8. Shorouk Tarek Ezzat
9. Alaa Saeed Ismail
10. Yasmine El Sayed Ibrahim El Beshbeshi
11. Mariam Abdel Fattah Mohamed El Hatt
12. Nada Hany Abdel Samad El Behairy
13. Ghada Selim Abdallah
14. Omar Abdel Wahab Ibrahim
15. Tarek Helal Mohamed Barakat
16. Abdelrahman Ayman Abdelrahman Mohamed
17. Ehab Adel Hussein El Behy
18. Abdelrahman Ahmed Abdel Ghany
19. Ameen Samir Ameen Mohamed
20. Islam Mohamed El Sayed Mohamed
21. Islam Abdel Hamid Zaki Saad
22. Islam Khaled Sayed Abdel Aal
23. El Sayed Gamal El Saeed
24. Bola Nagi Selim Atta Allah Soliman
25. Ahmed Mohamed Abdel Halim Mohamed