What are the guidelines for physical therapy in patients with osteoarthritis (OA)?

Physical Therapy Guidelines for Osteoarthritis Management

Exercise therapy is strongly recommended as the cornerstone of physical therapy treatment for all patients with osteoarthritis of the knee, hip, and hand, with supervised programs by physical therapists being more effective than unsupervised home programs for improving pain and function. 1, 2

Core Components of Physical Therapy for OA

Exercise Prescription

1. Types of Exercise (strongly recommended for all OA patients):

   • Aerobic exercise: Walking (treadmill or supervised community-based), stationary cycling 1
   • Strengthening exercises: Using weight machines, resistance bands, or isometric exercises 1
   • Neuromuscular training: Dynamic maneuvers of increasing complexity for knee OA 1
   • Aquatic exercise: Low-impact environment combining aerobic and range of motion exercises 1, 3
   • Balance exercises: Conditionally recommended for knee and hip OA 1, 2

2. Delivery Method:

   • Supervised programs are more effective than unsupervised home programs 2, 4
   • At least 12 supervised sessions, 2 sessions per week initially 4
   • Exercise frequency typically 3 times weekly for optimal outcomes 2

3. Exercise Intensity:

   • While specific prescriptions cannot be recommended based on current evidence, exercise should meet general exercise guidelines for healthy adults when possible 5
   • Interim goals may be necessary due to barriers in this patient population 5

Weight Management

• Weight loss is strongly recommended for overweight/obese patients with knee/hip OA 1, 2
• Target initial weight loss of ≥5% of body weight 1, 2
• Greater clinical benefits with 5-10%, 10-20%, and >20% weight loss 1, 2
• Combining weight loss with exercise enhances efficacy 1, 2

Self-Management Education

• Self-efficacy and self-management programs are strongly recommended 1, 2
• Should include:
  • Skill-building (goal-setting, problem-solving, positive thinking)
  • Education about OA and medications
  • Joint protection techniques
  • Fitness and exercise guidance 1, 2

Complementary Approaches

• Tai chi: Strongly recommended for knee and hip OA 2
• Yoga: Conditionally recommended for knee OA 2
• Thermal therapies: May provide pain relief 6

Implementation Algorithm

1. Initial Assessment:

   • Determine OA severity, affected joints, pain level, and functional limitations
   • Assess BMI and need for weight management
   • Identify patient preferences and barriers to exercise

2. Exercise Selection:

   • For knee/hip OA: Prioritize aerobic, strengthening, and balance exercises
   • For hand OA: Focus on specific strengthening and range of motion exercises
   • For overweight patients: Combine with structured weight loss program

3. Program Structure:

   • Begin with supervised sessions (minimum 12 sessions, 2-3 times weekly)
   • Incorporate self-management education
   • Add complementary approaches based on patient preference (tai chi, yoga)

4. Progression and Monitoring:

   • Gradually increase exercise intensity and duration
   • Implement adherence strategies (goal-setting, monitoring, feedback)
   • Transition to maintenance program with periodic supervision

Prognostic Indicators for PT Response

Patients more likely to benefit from physical therapy include those with:

• Milder disease (unilateral OA, symptoms <1 year)
• Higher baseline pain (≥6 on numerical pain rating scale)
• Better baseline function (40-m self-paced walking test <25.9 seconds) 3

Common Pitfalls to Avoid

• Overreliance on passive modalities: TENS is strongly recommended against for knee OA 2
• Insufficient supervision: Home programs alone are less effective than supervised programs 2, 4
• Inadequate dosage: Exercise benefits are dose-dependent; insufficient frequency or intensity limits outcomes 5
• Neglecting weight management in overweight patients with knee OA 2
• Using manual therapy alone without exercise provides limited benefit 2
• Delayed referral: Earlier PT intervention may yield better outcomes 3

Physical therapy for OA should be viewed as an ongoing process rather than a fixed intervention, with periodic reassessment and adjustment of the treatment plan as the patient's condition and needs change 6.