An Ongoing Series

Osteoarthritis
Pathophysiology, Prevalence, Risk Factors, and
Exercise for Reducing Pain and Disability

Joseph J. Knapik, ScD1; Rodney Pope, PhD2; Robin Orr, PhD3; Ben Schram, PhD4

ABSTRACT
Osteoarthritis (OA) is a disorder involving deterioration of individuals with higher socioeconomic status; and those with
articular cartilage and underlying bone and is associated with high school diplomas or higher levels of education.3 Globally,
symptoms of pain and disability. The incidence of OA in the hip and knee OA was ranked as 11th highest contributor to
military increased over the period 2000 to 2012 and was the disability among 291 medical conditions.4 Certain therapeutic
first or second leading cause of medical separations in this pe- modalities can relieve pain and improve physical functioning,
riod. Risk factors for OA include older age, black race, genet- but these cannot alter the course of this degenerative disease.5
ics, higher body mass index, prior knee injury, and excessive
joint loading. Animal studies indicate that moderate exercise The incidence of OA appears to be higher in the military than
can assist in maintaining normal cartilage, and individuals in comparable age-adjusted civilians, with differences between
performing moderate levels of exercise show little evidence these two groups becoming larger with increasing age.6 OA
of OA. There is considerable evidence that among individuals was ranked the most common reason for medically related
who develop OA, moderate and regular exercise can reduce separation from service in early 2001 and the second most
pain and disability. There is no firm evidence that any partic- common reason (after back pain) in early 2009 (after the
ular mode of exercise (e.g., aerobic training, resistance exer- Iraq-Afghanistan conflicts were well underway).7 As in the ci-
cise) is more effective than another for reducing OA-related vilian sector, there is evidence that OA incidence is increasing
pain and disability, but limited research suggests that exercise in the military over time.6,8,9
should be lifelong and conducted at least three times per week
for optimal effects. In this article, we review the pathophysiology of OA, describe
the prevalence, incidence, and trends in the military, and ex-
Keywords: osteoarthritis; exercise; pain; disability amine the evidence that exercise can reduce the pain and dis-
ability associated with OA. This is the first of a series that will
address various interventions to reduce the pain and disability
associated with OA.
Introduction
Osteoarthritis (OA) is an orthopedic disorder characterized
Pathophysiology
by progressive deterioration of articular cartilage and under-
lying bone and associated with symptoms of joint pain and OA is a degenerative joint disease involving progressive loss
disability.1 It most often affects the knees, hips, spine, and of articular cartilage, hardening and compacting of underly-
joints of the hands.2 The overall age-adjusted prevalence of ing bone (sclerosis), and often formation of bony outgrowths
OA in the United States in the years 1999 to 2014 was 9.7%; (osteophytes). Articular cartilage is a specialized type of con-
however, it more than doubled in this period from 6.6% to nective tissue that lines the bones where they connect within
14.3%. The increase was seen in many demographic groups: a joint. This cartilage normally provides a smooth, lubricated
men and women; white, black, and Hispanic populations; surface that allows for low-friction movement between bone
*Correspondence to joseph.knapik@JSOMonline.org
1
Dr Knapik served in the US military as a wheel vehicle mechanic, medic, Medical Service Corps officer, and Department of Defense civilian. He
is currently a senior epidemiologist/research physiologist with the Henry M. Jackson Foundation and an adjunct professor at Uniformed Services
University, Bethesda, Maryland, and Bond University, Robina, Australia. 2Dr Pope is professor of Physiotherapy at Charles Sturt University and
coleads the Tactical Research Unit headquartered at Bond University. He has spent much of his 30-year career researching, practicing, and advis-
ing on injury risk management in military and other tactical populations. 3Dr Orr served in the Australian Regular Army for over 20 years as an
infantry Soldier, physical training instructor, physiotherapist, and human performance officer. He currently serves in the Army Reserves and is an
associate professor and leader of the Tactical Research Unit at Bond University. 4Dr Schram serves as an officer in the Australian Army Reserve.
He is involved in injury minimization, strength and conditioning, and validating fitness standards. He is an assistant professor at Bond University
and is the research and data coordinator for the Tactical Research Unit.

94
surfaces when the joint moves and assists in joint load bearing. FIGURE 2 Osteoarthritis incidence in the US Military by year.
It is surrounded by synovial fluid, which is contained within
the joint in the joint capsule. Articular cartilage is composed
of a dense, fibrous material (extracellular matrix) that includes
water, collagen fibers, proteoglycans (which fill the spaces be-
tween other components and bind them together to maintain
the cartilage structure), and specialized cells called chondro-
cytes. The water within the articular cartilage, together with
that in the proteoglycans, is critical for its load-bearing and
lubrication properties. Articular cartilage has no blood vessels,
lymphatics, or nerves and, if damaged, has limited capacity for
repair. Under normal physiological loading of the joint and its
articular cartilage, the chondrocytes function to maintain the
cartilage matrix by establishing a balance between anabolic
(building up or synthesis) and catabolic (breaking down or
2000 to 2015. These rates were compiled from two investiga-
degradation) processes in the matrix. However, if an injury oc-
tions that used identical methods.8,9 In these studies, spondy-
curs or loading of the joint and articular cartilage is excessive,
losis was defined as OA of the spine and the term “OA” was
degradation can exceed synthesis, leading to a gradual break-
used for all other anatomic locations. From 2003 to 2011, the
down of the articular cartilage and the eventual development
incidence of OA in the military population doubled, increas-
of OA. Degradation of the cartilage matrix involves the colla-
ing at a rate of about 35 cases per 100,000 person-years. In
gen fibers and proteoglycans, as well as a number of enzymes,
the same period, the incidence of spondylosis increased more
which cause the degradation.10–14
than six-fold at a rate of 69 cases per 100,000 person-years.
In 2012 and afterward, the incidence of both disorders has
Clinical symptoms of OA include joint pain, stiffness, move-
leveled off or declined.
ment limitations, crepitus (grating, crackling, or creaking in
the joint), effusion (excessive fluid in the joint), and bone and
From 2010 to 2016, more than two-thirds of incident cases
joint deformity. A more definitive diagnosis is usually achieved
of OA involved the knee joint (311 cases per 100,000 per-
from radiographs, by observing joint-space narrowing, osteo-
son-years) and shoulders (176 cases per 100,000 person-years).
phytes, sclerosis of the bone covered by the cartilage (subchon-
In this same period, the lumbar region of the spine was the site
dral bone). Advanced cases involve subchondral bony cysts
of more than twice the number of incident cases of spondylosis
from leakage of synovial fluid into the subchondral bone. All
(466 cases per 100,000 person years) compared with other
the tissues of the affected joint are involved (joint capsule,
spinal regions.
synovial lining of the joint capsule, bone, cartilage), but the
articular cartilage is the most affected. Progression of the dis-
ease can be characterized by decreasing cartilage thickness, Risk Factors for Osteoarthritis
formation of rough and irregular cartilage surfaces, escape of
According to population data in the US military,8,9 the inci-
cartilage fragments into the joint space, and/or fissures that
dence of OA and spondylosis increased dramatically with
can reach into the subchondral bone.1,11,12,15 Figure 1 shows the
age, as shown in Figure 3. In the period 2010 to 2015, the
various stages in the development of OA of the knee.16
incidence of OA was 83 times higher among Servicemembers
aged 40 years or older (3,073 cases per 100,000 person-years)
Incidence of OA in the Military when compared with those younger than 20 years (37 cases
per 100,000 person years). For spondylosis, the incidence was
Figure 2 shows the incidence of OA and spondylosis in the en-
44 times higher among Servicemembers aged 40 years or older
tire population of active-duty Military Servicemembers (Army,
(2,304 cases per 100,000 person-years) when compared with
Navy, Air Force, and Marine Corps) over the 16 years from
those younger than 20 years (52 cases per 100,000 person
years).8
FIGURE 1 Stages of osteoarthritis of the knee.

Besides age, military service, race and ethnicity, and rank were
additional risk factors in the military. Incidence was highest in

FIGURE 3 Osteoarthritis incidence in the US Military by age.

From https://www.medicalmasters.org/knee-pain-treatment/
treating-osteoarthritis/

Osteoarthritis and Exercise  |  95

the Army (Figure 4A), blacks (Figure 4B), and among senior
officers (Figure 4C). Incidence was similar in men and women
(Figure 4D). In civilian samples, older age and race and ethnic-
ity are associated with higher OA risk,17–19 but contrary to the
military data, civilian women are at higher risk than civilian
men.17,20,21
FIGURE 4 Incidence of osteoarthritis by (A) Military Service,
(B) race/ethnicity, (C) rank, and (D) gender. (C) Ranks listed as
O1-O4 include warrent ranks 1-3; ranks listed as O5-O10 include
warrant ranks 3-4. (B) Asian includes Pacific Islander and
Alaska Native. AF, Air Force; Am Ind, American Indian; MC,
Marine Corps.
Besides the demographic factors identified in the military and
listed above, other risk factors for OA include genetics, higher
body mass index (BMI), prior knee injury, and excessive joint
loading. Studies involving twins indicated that at least 50% of
the variability in susceptibility to OA is explained by genetic
factors, but this heritability differed somewhat by anatomic
location, with estimates of about 70% for the spine, 65% for
the hand, 60% for the hip, and 45% for the knee.22 Variations
in genes influencing the cartilage matrix structure, bone min-
eral density, chondrocyte activity, and inflammatory factors
(e.g., interleukin-1, interleukin-6, tumor necrotic factor) have
been implicated in the pathogenesis of OA.23
With regard to BMI, two meta-analyses17,21 concluded that the
risk of onset of knee OA was 2.63 (95% confidence interval
[CI], 2.28, 3.05)17 or 2.66 (95% CI, 2.15, 3.28)21 times higher
among those with BMI greater than 30kg/m2 when compared
with those with BMI less than 25kg/m2. Another meta-analy-
sis of 18 studies found that a 5-unit (kg/m2) increase in BMI
increased the risk of knee OA by 35%.24
With regard to prior injury, two meta-analyses17,21 found that
those with prior knee injury were 3.86 (95% CI, 2.61, 5.70)17
or 2.83 (95% CI, 1.91, 4.19)21 times more likely to develop
knee OA. All meta-analyses of studies on BMI and prior in-
jury indicated there was considerable heterogeneity among the
studies (i.e., differences in the exact risk ratios or odds ratios
between studies), but virtually all studies included in these
meta-analyses showed that higher BMI or previous injury in-
creased OA risk.
Joint Loading and Osteoarthritis Development
Excessive loading of joints appears to increase the likelihood
of OA. Experimental studies using animal models indicate that
96  |  JSOM Volume 18, Edition 3 / Fall 2018
single impacts, repetitive impacts, and/or torsional loading can
damage articular cartilage.25–30 In humans, participation in
sports (overall) seems to increase the risk of OA,31 but when in-
dividual sports are examined, OA is more likely to be observed
in high-impact sports like soccer, elite-level long-distance run-
ning, competitive weight lifting, and wrestling.32–34 Studies of
heavy or arduous occupational activities that involve kneeling,
squatting, stair climbing, crawling, lifting and carrying, elite
sports, and work while standing have been shown to increase
the risk of OA.23,35
Although excessive joint loading increases OA risk, if loading
is moderate, it appears that the cartilage can adapt. Repetitive,
cyclic loading of normal, isolated cartilage tissue produces
biochemical signals that increase the anabolic activity of the
chrondrocytes.36,37 Loading in the physiological range gener-
ates proteoglycan synthesis, proliferation of chondrocytes,
and type II collagen growth.36–39 One study that compared
male beagles that had either normal cage activity or exercise
5 days/week, 75 minutes/day, for over 10 years found no evi-
dence in either group of knee joint ligament or meniscal injury,
cartilage erosion, or osteophytes; articular cartilage thickness
and mechanical properties of the cartilage did not differ be-
tween groups.40 Athletes engaged in lower-impact sports like
swimming show much lower indications of cartilage damage
than those in higher-impact sports like running.41 Elite and
competitive runners who have presumably run more high-in-
tensity miles have a higher risk of OA than nonrunners or rec-
reational runners.34
Regular exercise may be important to maintain healthy car-
tilage. For OA that is induced or has developed over time,
moderate exercise has been shown to have protective effects
in animal models.42–44 A systematic review of 29 randomized
controlled trials investigating the impact of daily exercise in
healthy animals (i.e., dogs, rodents, rabbits, and sheep) sug-
gested that, in regard to cartilage composition and thickness,
there were (1) inconclusive effects from a low daily exercise
dose, (2) positive effects from a moderate daily exercise, and
(3) negative effects from a high daily exercise dose.45 Rec-
reational runners tend to have a lower risk of OA than do
nonrunners.34
Exercise- and Osteoarthritis-Related Pain and
Disability: Literature Reviews
Once an individual has developed symptomatic OA, regu-
lar exercise is considered an important nonpharmacological
treatment for reducing the pain and disability associated with
OA and is recommended by several national and international
organizations for this purpose.46–48 Systematic reviews have
provided meta-analyses examining the effectiveness of exer-
cise as a treatment for OA. Given the large number of these re-
views49–64 and the overall consensus that exercise reduces pain
and disability, a review of these reports is provided here. Only
reviews examining randomized controlled trials and perform-
ing meta-analysis were included.
Methods Used in Reviews
For a review to be included in this review of reviews, studies
within the review had to compare exercising groups with ei-
ther a nonexercising control group or with another mode of
exercise (e.g., compared aquatic exercise to land-based exer-
cise). OA could be determined clinically from symptoms or
diagnosed radiographically, although some reviews used only
radiographic evidence. Exercise was generally considered to be
any regular, systematic physical activity (e.g., walking, aquatic
activity, resistance training, flexibility, calisthenics).
The outcome measures examined in the reviews were self-re-
ported pain and/or physical function or disability as quantified
on self-reporting instruments. Examples of instruments used
were the Western Ontario and McMaster University Osteoar-
thritis Index (WOMAC), the Knee Injury and Osteoarthritis
Outcome Score (KOOS), and the Visual Analogue Scale (VAS).
The WOMAC has 24 questions that are summarized in 3 sub-
scales including pain (5 questions), stiffness (2 questions),
physical functioning (17 questions), and a total score (24 ques-
tions by adding the three subscales). Different versions of the
questionnaire contain either a 5-point Likert-like scale or a
100mm VAS (range, “none” to “extreme”). Patients answer
the questions based on their pain, stiffness, and physical func-
tioning over the last 48 hours.65,66 The KOOS is specific to
the knee. It includes many questions from the WOMAC but
has additional subscales and was developed for younger pa-
tients. The KOOS has 42 questions summarized in 5 subscales
including pain (9 questions), other symptoms (7 questions),
functions of daily life (17 questions), function in sport and
recreation (5 questions), and knee-related quality of life (4
questions). A 5-point Likert-like scale is used to answer each
question. The questionnaire can be used over short and longer
time intervals, for example, to assesses changes from week to
week due to a treatment.67,68 Although there are variations, the
VAS is generally a 10-point scale on which participants rate
the intensity of their pain (e.g., “no pain” to “worst possible
pain”).69
Differences between groups (e.g., exercise versus nonexercise)
in the reviews were determined by the standardized mean dif-
ference (SMD). A SMD is the difference in the average change
in pain or disability (before minus after treatment) between
the two groups divided by the pooled standard deviation, as
follows:
(pre-post treatmentgroup 1 − pre-post treatmentgroup 2) /
standard deviation.
This measure reflects the difference in the change in the ratings
of pain or disability between the two groups while considering
the amount of variability in the measurement. A SMD of 0.2
to 0.4 is considered small, 0.5 to 0.7 as moderate, and 0.8
or greater as large.70,71 If any included review did not provide
pooled SMD, SMDs were calculated from data provided in the
article using Comprehensive Meta-Analysis Software, version
3.3 (Biostat, https://www.meta-analysis.com/).
Overall Results
Table 1 provides the pooled SMD from the included reviews
of randomized controlled trials examining the effectiveness of
exercise for reducing pain and disability associated with OA.
All reviews in Table 1 considered studies that compared exer-
cising groups with nonexercising groups, but several50,55,57,59,61
looked at more than one mode of exercise, allowing compari-
sons between modes.
As shown in Table 1, virtually all reviews reported lower lev-
els of pain and higher levels of physical functioning among
groups involved in exercise compared with those that did not
exercise. Reviews that pooled results from six or more studies
and examined outcomes at the end of training programs re-
ported SMDs ranging from 0.1659 to 0.8157 for pain and 0.2151
to 0.8656 for physical functioning. Two more recent reviews59,60
containing 35 to 47 studies found SMDs of 0.50 and 0.49
for pain and 0.49 and 0.52 for physical functioning. These
findings indicate exercise had a moderate effect on reducing
pain and improving physical functioning among individuals
with OA.
Two reviews that looked at longer term follow-ups (after the
end of formal physical training) reported lower SMDs of 0.0860
and 0.1651 for pain, and 0.2060 and 0.2151 for physical func-
tioning. This was likely because many patients did not con-
tinue to exercise after the formal training concluded.51 There
were two or three investigations where the authors provided
“booster sessions,”51 but the definition of booster sessions was
not clear. An examination of the individual studies suggested
that booster sessions involved unsupervised exercise sessions
at home,72 some with periodic communication to assess ex-
ercise compliance and efficacy.73 Much higher SMDs were
shown in the few studies that included these booster sessions
after the end of the “formal” training (see Table 1, row 3).51
Not surprisingly, this suggests that exercise must be continued
to maintain the favorable effects.
Characteristics of Exercise Programs
Characteristics of exercise programs that can be manipulated
include the mode of training (e.g., aerobic, resistance, flexi-
bility), frequency (sessions/week), duration (minutes/session),
intensity (e.g., speed in aerobic training or load in resistance
training), and length (weeks).74
The most studied characteristic is the mode of training. A low
level of strength or power in the knee extensor muscles has
been related to knee pain and functional disability75–77 and
this has been hypothesized to contribute to the pain and dis-
ability of OA.78 Thus, it is possible that strength training of
muscle groups around symptomatic areas might be more ef-
fective than other modes of exercise in reducing pain and im-
proving physical functioning. Several reviews50,57,59 separately
compared aerobic and resistance exercise with nonexercising
control subjects. An early review50 involving 14 studies found
larger SMDs for walking versus resistance exercise for both
pain and disability (Table 1, row 2), but the latest review59
(Table 1, row 11), involving 35 to 47 studies, found SMDs
differed little between the two modes of exercise (aerobic ver-
sus resistance training) for either pain or physical functioning.
One review57 (Table 1, row 9) used a network meta-analysis in
which various exercise interventions were compared equally
by comparing treatments within the same trial (direct evi-
dence) and across different trials (indirect evidence) so that
the most effective type(s) of exercise could be determined.
They concluded that a training program incorporating aero-
bic training, resistance training, and flexibility exercises would
likely be most effective in the management of OA.
Aquatic exercise may be advantageous for individuals with
OA because (1) water buoyancy supports the body, making
movement less painful; (2) warm water promotes relaxation,
which may reduce muscle spasm and tightness; and (3) ex-
ercise intensity can be increased by increasing the speed of
movement in the water.79 However, the one review55 (Table 1,
row 7) that examined seven studies comparing aquatic and
Osteoarthritis and Exercise  |  97
 TABLE 1 Standardized Mean Differences Reported in Reviews of Randomized Controlled Trials on the Effect of Exercise on Osteoarthritis-Related Pain and Disability Outcomes
Outcomes
Pain Functional Capacity
Row Inclusion Criteria, Type of Exercise Trialsa SMD Trialsa SMD
No. First Author (Range of Years Considered in Review) Comparisons (no.) (95% CI) (no.) (95% CI)
1 VanBarr49, b Patients with clinically or radiologically diagnosed knee or hip Any exercise versus no exercise 7 0.39 (0.28, 0.50) 6 0.58 (0.41, 0.74)
OA. Exercise defined as activity designed to improve strength
ROM, endurance, or mobility. (Study years 1966–1997)
2 Roddy50 Patients with knee OA. Exercises performed at home and mode Walking versus no exercise 4 0.52 (0.34, 0.70) 2 0.46 (0.25, 0.67)
was either primarily walking or quadriceps strengthening. (Study
years 1966–2003) Quadriceps strengthening versus no exercise 10c 0.32 (0.23, 0.42) 11 0.32 (0.23, 0.41)
51, b
3 Pisters Patients with clinically or radiologically diagnosed knee or hip Exercise versus control (after initial training) 6 0.40 (0.24, 0.56) 6 0.31 (0.08, 0.54)
OA. Exercising group compared with nonexercise control group. Exercise versus control (long-term follow-up) 6 0.16 (0.03, 0.28) 6 0.21 (0.08, 0.33)
Long-term follow-up assessment >6 months. (Study years 1966–
2005) Exercise and booster sessions versus control 3 0.98 (0.29, 1.66) 2 1.63 (0.50, 2.76

98  |  JSOM Volume 18, Edition 3 / Fall 2018

(short term)
Exercise and booster sessions versus control 3 1.70 (0.31, 3.09) 2 2.18 (0.86, 3.49)
(long term)
4 Fransen52 Patients with clinically or radiologically diagnosed knee OA. Any Land-based exercise versus no exercise 32 0.40 (0.30, 0.50) 32 0.37 (0.25, 0.49)
land-based exercise program compared with any nonexercise
control. (Study years up to 2007)
5 Lathan53 Knee or hip OA patients >65 years old. Only strength training Strength training versus control 8 0.35 (0.18, 0.52) 8 0.33 (0.18, 0.49)
programs involving progressive resistance, 3–5 times/week versus
nonexercise control. (Study years not provided).
6 Fransen54 Hip OA based on accepted criteria. Comparing land-based Exercise versus no exercise 5 0.38 (0.09, 0.67) 5 0.02 (−0.28, 0.31)
exercise programs with nonexercise control group (Study years up
to 2009)
7 Batterham55 Patients with rheumatoid arthritis or OA. Compared aquatic with Aquatic versus land-based exercise ND ND 7 0.07 (−0.26, 0.12)
land-based exercise of any types. (Study years up to 2010)
8 Kang56 OA at any joint location. Compared tai chi exercise with Tai chi versus control 6 0.79 (0.39, 1.19) 6 0.86 (0.52, 1.20)
nonexercise control. (Study years up to 2010)
9 Uthman57 Patients with clinically or radiologically diagnosed knee or hip Flexibility versus control 2 0.66 (0.00, 1.33) 1 0.17 (−0.93, 1.26)
OA. Any aquatic- or land-based exercise compared with no Strength versus control 16 0.81 (0.50, 1.13) 16 0.37 (−0.09, 0.84)
exercise control or another mode of exercise. (Study years up to
2012) Aerobic versus control 3 0.41 (-0.30, 1.13) 2 0.30 (−0.92, 1.53)
Strength and flexibility versus control 11 0.50 (0.16, 0.85) 10 0.40 (−0.12, 0.92)
Aerobic and flexibility versus control 3 0.26 (−0.47, 1.00) 3 0.18 (−0.89, 1.24)
Strength and aerobic versus control 3 0.13 (−0.61, 0.88) 3 0.17 (−0.91, 1.25)
Combined versus control 12 0.69 (0.35, 1.04) 10 0.63 (0.10, 1.16)
Aquatic strength versus control 3 0.75 (0.07, 1.42) 3 0.43 (−0.56, 1.41)
Aquatic strength and flexibility versus control 2 0.96 (0.28, 1.64) 1 0.61 (−0.52, 1.75)
Aquatic aerobic and flexibility versus control 2 0.07 (−0.83, 0.98) 2 0.07 (−1.36, 1.23)
Aquatic aerobic and strength versus control 1 0.92 (−0.25, 2.08) 1 0.86 (−0.79, 2.52)
Aquatic combined versus control 3 0.45 (−0.11, 1.02) 3 0.49 (−0.35, 1.32)
10 Lauche58 Patient with clinical or radiographic evidence of OA. Compared Tai chi exercise versus control 5 0.72 (0.44, 1.00) 5 0.72 (0.44, 1.01)
tai chi with any nonexercise control. (Study years up to 2013)
(continues)
 TABLE 1 Cont.
Outcomes
Pain Functional Capacity
Row Inclusion Criteria, Type of Exercise Trialsa SMD Trialsa SMD
No. First Author (Range of Years Considered in Review) Comparisons (no.) (95% CI) (no.) (95% CI)

11 Juhl59 Patients with clinically or radiologically diagnosed knee OA. Any exercise versus no exercise 47 0.50 (0.39, 0.62) 35 0.49 (0.35, 0.63)
Exercise group compared with nonexercise control group. (Study Aerobic versus control 9 0.67 (0.39, 0.94) 8 0.56 (0.24, 0.87)
years up to 2012)
Strength versus control 32 0.62 (0.45, 0.79) 23 0.60 (0.37, 0.83)
Mixed exercise versus control 13 0.16 (−0.04, 0.37) 10 0.22 (0.07, 0.37)
12 Fransen60 Participants with knee OA according to accepted criteria. Any Exercise versus control immediately after 44 0.49 (0.39, 0.59) 44 0.52 (0.39, 0.64)
land-based exercise program compared with nonexercise control. treatment
(Study years up to 2013) Exercise versus control at 2–6 months 12 0.24 (0.14, 0.35) 10 0.15 (0.04, 0.26)
Exercise versus control >6 months 6 0.08 (−0.15, 0.30) 7 0.20 (0.08, 0.32)
13 Beumer61 Adults with clinically or radiologically diagnosed hip OA. Any Aquatic exercise versus control on WOMAC 4 0.53 (0.29, 0.70) ND ND
aquatic or land-based exercise program. Compared effects at (<3.3 months)
different times, including <3 months, 4–12 months, and >12 Land-based exercise versus control on 4 0.40 (−0.25, 1.06) ND ND
months. (Study years up to 2014) WOMAC (<3.3 months)
Land-based exercise versus control on VAS 6 0.49 (0.29, 0.70) ND ND
(<3.3 months)
Land-based exercise versus control on 3 0.23 (−0.03, 0.48) ND ND
WOMAC (4–12 months)
Land-based exercise versus control on 2 0.22 (−0.06, 0.51) ND ND
WOMAC (>12 months)
14 Bartholdy62 Individuals diagnosed with knee OA. Compared lower-limb Any strength training versus control 56 0.57 (0.42, 0.73) 50 0.56 (0.39, 0.73)
strength training with nonexercise control. Studies following Strength training using ACSM guidelines versus 22 0.62 (0.32, 0.93) 19 0.64 (0.28, 1.00)
ACSM recommendations for strength training analyzed.74 (Study control
years up to 2015)
Strength training not using ACSM guidelines 34 0.52 (0.35, 0.68) 31 0.49 (0.33, 0.65)
versus control
15 Zhang63 Participants diagnosed with knee OA. Studies included if involved Chinese exercise versus nonexercise control 8 0.77 (0.41, 1.13) 8 0.75 (0.52, 0.98)
traditional Chinese exercises (e.g., tai chi, Baduanjin) compared
with nonexercising controls. (Study years 1900–2016)
16 Magni64 Participants with hand OA. Included studies compared resistance Resistance training versus control 5 0.23 (0.04, 0.42) 4 0.10 (−0.13, 0.33)
training of hands (e.g., elastic bands, squeezing rubber balls,
isometrics) with nonexercise control. (Study years 1975–2016)
ACSM, American College of Sports Medicine; CI, confidence interval; ND, no data provided in review; OA, osteoarthritis; ROM, range of motion; SMD, standardized mean difference; VAS Visual Analog
Scale; WOMAC, Western Ontario and McMaster Universities Arthritis Index.
a
Trials are the number of interventions. Some studies included more than one intervention (e.g., aerobic exercise and resistance training) and were included in the meta-analysis as two separate interventions
within the single study.
b
A secondary analysis of pooled-effect sizes was performed because the article did not provide this.
c
One study excluded by authors because of large effect size.

Osteoarthritis and Exercise  |  99

land-based exercise found no difference in physical function-
ing scores. Pain was not evaluated in this review.55
Tai chi is a form of aerobic exercise involving slow, deliberate,
dance-like movements. It was developed in China as a form
of martial arts and has been shown to improve strength and
balance.80,81 Because this is a form of aerobic exercise, it is
not surprising that two reviews56,58 have found that tai chi is
effective in reducing the pain and disability associated with
OA. A third review examined “Chinese exercises,” but most
of these (seven of eight) were studies of tai chi.63 If all three
reviews56,58,63 are included, the SMDs for the reduction in pain
(tai chi versus nonexercising control) ranged from 0.72 to
0.79; for improved physical functioning, SMDs ranged from
0.72 to 0.86. These SMDs are generally greater than those
reported for other forms of exercise.
Besides exercise modes, length and frequency of exercise pro-
grams were examined in two reviews.52,59 and results are pre-
sented in Table 2. Having fewer than 12 supervised sessions
was less effective in reducing pain and improving function
than having at least 12 supervised sessions.59 Programs involv-
ing three or more sessions per week more effectively reduced
pain and improved physical functioning than programs in-
volving fewer than two sessions per week.
TABLE 2 Standardized Mean Differences (95% CI) From Reviews
That Examined the Effects of Length (Number of Sessions) and
Frequency (Sessions/Week) of Physical Training Programs on Pain
and Physical Functioning in Osteoarthritis
Physical
Level Pain Functioning
First Author of Variable SMD (95% CI) SMD (95% CI)
Fransen52 <12 sessions 0.28 (0.16, 0.40) 0.23 (0.09, 0.37)
≥12 sessions 0.46 (0.32, 0.60) 0.45 (0.29, 0.62)
Juhl59 <2 sessions 0.41 (0.25, 0.55) 0.33 (0.18, 0.49)
≥3 sessions 0.68 (0.51, 0.85) 0.67 (0.44, 0.89)
Abbreviations: CI, confidence interval; SMD, standardized mean
difference.
One review62 examined exclusively resistance training studies
and compared programs that followed the American College
of Sports Medicine (ACSM) guidelines for strength training
with those that did not. The ACSM guidelines were considered
to be followed if the training load was greater than 40%, of a
one-repetition maximum, that 2 to 4 sets of 8 to 12 repetitions
were performed to contraction failure or muscular exhaus-
tion, and the training frequency was at least 2 to 3 sessions per
week.74 It can be seen in Table 1, row 14, that although there
were larger SMDs for studies following the ACSM guidelines,
the authors found no statistically significant difference in the
changes in pain or disability between the two types of studies.
However, knee-extensor strength gains were greater in studies
that followed the ACSM guidelines compared with those that
did not (SMD, 0.83 [95% CI, 0.49, 1.17] versus 0.38 [95%
CI, 0.27 0.50], p = .01). The authors estimated that a 30% and
40% increase in strength could have beneficial effects on pain
and disability, respectively.
Summary
OA involves deterioration of the articular cartilage and under-
lying bone with associated pain and disability. The incidence
of OA has been on the rise in the military since at least the year
2000, although recently (since 2012) it appears to have leveled
100  |  JSOM Volume 18, Edition 3 / Fall 2018
off or actually decreased. Factors that increase OA risk include
older age, black race, genetics, higher BMI, prior knee injury,
and excessive joint loading. Regular, moderate exercise assists
in maintaining normal cartilage and individuals performing
moderate levels of exercise show little evidence of OA. Once
OA develops, there is considerable evidence that many types of
regular exercise (e.g., aerobic, resistance training) can reduce
pain and disability. In future articles, the effectiveness of other
interventions for reducing the pain and disability of OA will
be addressed.
Disclaimer
The views expressed in this presentation are those of the au-
thors and do not necessarily reflect the official policy of the
Department of Defense, Department of the Army, US Army
Medical Department or the US government. The use of trade-
mark names do not imply endorsement by the US Army but is
intended only to assist in the identification of a specific product.
Author Contributions
JJK conceived the article, performed much of the research, and
produced the first draft. RP, RO, and BS provided additional
research and edited the article to produce the final draft. RP
also focused on accessibility by key readership groups. All au-
thors approved the final version of the manuscript.
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