What physiotherapy management should be recommended for an overweight adult with knee or hip osteoarthritis to reduce pain, improve joint function, and support weight loss?

Physiotherapy Management of Osteoarthritis

For overweight adults with knee or hip osteoarthritis, implement a structured self-management program combining supervised exercise therapy (≥12 sessions initially), progressive resistance training, and a weight-loss program targeting 5-7.5% body weight reduction through explicit dietary goals and weekly monitoring. 1, 2

Core Exercise Components

Resistance and Strengthening Training

• Perform quadriceps and hip girdle strengthening exercises bilaterally using isometric contractions held for 6-7 seconds, repeated 5-7 times, 3-5 times daily, starting at 30% maximal voluntary contraction and progressing to 75% as tolerated 3
• Execute dynamic strengthening exercises at 60-80% of one-repetition maximum, 2-4 sets of 8-12 repetitions, at least 2 days per week 3, 4
• Lower limb strengthening reduces pain (effect size 0.29-0.53) and improves physical function (effect size 0.24-0.58) in knee OA 1, 4
• Include gluteal strengthening exercises (gluteal squeezes) with the same duration and frequency parameters 3

Aerobic Exercise

• Prescribe low-impact aerobic activities (walking, cycling, aquatic exercise) at moderate intensity (70% maximal heart rate) for 30-60 minutes per day, at least 3 days per week 3
• Aerobic exercise demonstrates clinically important improvements in pain reduction and disability for knee OA 5
• Aquatic exercise improves disability with low-strength evidence supporting its use 5

Flexibility and Range of Motion

• Perform static stretches daily when pain and stiffness are minimal (e.g., before bedtime), holding each stretch for 30-60 seconds, repeating 2-4 times per muscle group 3

Supervision and Progression Strategy

• Provide twelve or more directly supervised physiotherapy sessions initially, as this produces superior outcomes compared to fewer sessions: pain improvement (effect size 0.46 vs 0.28, p=0.03) and physical function (effect size 0.45 vs 0.23, p=0.02) 1, 3
• After initial supervised instruction, transition patients to self-managed exercises integrated into daily routines 1, 3
• Structure every exercise session with three phases: 5-10 minute warm-up, training period, and 5-minute cool-down 3

Weight Management Protocol

Target Weight Loss

• Achieve minimum 5-7.5% body weight reduction through structured dietary programs combined with exercise, as this produces clinically meaningful reductions in pain and improvements in function 2
• Weight loss ≥5% of body weight produces statistically significant functional improvement (effect size 0.69; 95% CI 0.24-1.14) in knee OA 2
• Obesity is associated with hip OA (odds ratio 1.11; 95% CI 1.07-1.16), providing biological rationale for applying the same weight-loss goal to hip disease 2

Structured Weight-Loss Program Components

• Set explicit weight-loss goals, as programs with specific targets achieve greater weight reduction (-4.0 kg; 95% CI -7.3 to -0.7) compared to programs without targets (-1.3 kg; 95% CI -2.9 to 0.3) 1, 2
• Conduct weekly supervised sessions for duration ranging from 8 weeks to 2 years to provide accountability and enhance adherence 1, 2
• Implement monthly self-monitoring of weight recorded by the patient 2
• Provide structured meal plans beginning with a defined breakfast routine to establish consistent eating patterns 2
• Utilize meal-replacement bars or powders to supply low-calorie diet while maintaining adequate vitamin and mineral intake 1, 2
• Target macronutrients: reduce saturated fat and added sugars, limit sodium, increase fruit and vegetable intake to ≥5 servings per day 2
• Apply behavioral modification addressing eating triggers (e.g., stress) and providing alternative coping strategies 2

Adjunctive Interventions

Bracing for Knee OA

• Consider soft braces or valgus/varus knee braces to improve pain and self-reported physical function in knee OA 1
• Ensure appropriate exercise is undertaken concurrently with bracing to prevent atrophy and functional loss 1

Footwear Recommendations

• Prescribe appropriate comfortable footwear with shock-absorbing properties for both knee and hip OA 1, 3
• For knee OA specifically, shoes with shock-absorbing insoles for 1 month reduced pain and improved physical function 1

Assistive Technology

• Systematically and recurrently consider walking aids, assistive technology, and adaptations at home and/or at work for all patients with hip or knee OA 1

Safety Monitoring and Exercise Modification

• Joint pain lasting more than 1 hour after exercise or joint swelling indicates excessive activity and requires immediate modification 3
• When joints are inflamed, modify exercises by decreasing range of motion or duration of static holds 3
• Avoid exercising muscles to fatigue; use submaximal resistance 3
• Do not delay exercise initiation due to pain presence, as clinical trials demonstrate patients with OA pain can still achieve improvements 3

Common Pitfalls to Avoid

• Do not focus solely on the affected joint: bilateral strengthening is recommended regardless of which hip or knee is symptomatic 3
• Do not use manual therapy as a stand-alone treatment, though it may be beneficial as an adjunct 6
• Do not rely on lateral wedge shoe insoles for symptomatic benefits, as clinical trials do not support their use despite biomechanical studies showing reduced knee load 6
• Avoid programs without explicit weight-loss goals, as they achieve significantly less weight reduction 1, 2

Long-Term Outcomes and Adherence

• Patients participating in structured physiotherapy programs report decreased pain, increased quality of life, and higher activity levels maintained up to two years after inclusion 7
• More than 80% of participants report using learned strategies at least once a week after two years 7
• The proportion of patients reporting inactive or low physical activity levels reduces from 43% to 22% following structured programs 7