Open access peer-reviewed chapter

Pain Management in Knee Osteoarthritis

Written By

Shahnawaz Anwer and Ahmad Alghadir

Submitted: 26 October 2015 Reviewed: 04 March 2016 Published: 25 May 2016

DOI: 10.5772/62862

From the Edited Volume

Pain Management

Edited by Milica Prostran

Chapter metrics overview

2,225 Chapter Downloads

View Full Metrics


Osteoarthritis (OA) of the knee is the commonest degenerative joint disease affecting older adults. Risk factors for the knee OA includes female gender, advanced age, overweight, obesity, previous knee injuries, previous knee surgery, and certain jobs that require continuous knee bending. Pain is the major symptom of knee OA and increased pain causes reduced physical function and poor quality of life. In addition to pain, patients may have joint stiffness, knee extensor muscle weakness, and altered proprioception. A multitude of structural, physical, and psychosocial factors influences symptom and severity of pain in knee OA. Rehabilitation of knee OA aims to train the patients in coping strategies, improves physical health, quality of life, and maintains their independence in daily livings. Management of knee OA often requires a combination of pharmacologic and nonpharmacologic treatment approaches.


  • Knee
  • osteoarthritis
  • pain
  • rehabilitation
  • physiotherapy

1. Introduction

Osteoarthritis (OA) of the knee is a prevalent musculoskeletal disorder causing pain and disability in older population [1]. Worldwide statistics indicates more than 100 million individuals globally affected by OA [2, 3]. The prevalence of OA is expected to double at the end of the year 2020 [4]. The prevalence of symptomatic knee OA in male and female is approximately 40 and 47%, respectively [5]. Evidence of radiographic knee OA in the United States is approximately 19% in adults aged 45 years and older [5]. While male and female are equally affected by OA, it is reported to be more common in young adult male (<45 years) and in the older adult female (>45 years) [69].

Risk factors for the knee OA includes female gender, advanced age, overweight, obesity, previous knee injuries, previous knee surgery, and certain jobs that require continuous knee bending (kneeling and lifting) [10, 11]. Biomechanical factors including, abnormal joint congruity, muscle weakness, mal-alignment, or internal derangement of knee, facilitate the progression of knee OA in those persons, who are susceptible to the development of the knee OA [12, 13]. Lower extremity muscle weakness has vital role in the progression of the knee OA [14, 15]. Previous studies indicate that weaker quadriceps muscle is associated with symptomatic knee OA and weakness of muscles increases the risk of physical disability [14, 15].

Knee OA can be classified either symptomatically or radiographically. The Kellgren–Lawrence (KL) [16] grading scale has been used to diagnose radiographic knee OA. The symptomatic knee OA has been diagnosed clinically followed by radiographic confirmation.

The symptoms of knee OA includes pain, stiffness, limited range of motion, swelling, crepitus, and muscle weakness [17, 18]. Knee pain significantly influences physical function depending on the site of pain and unilateral or bilateral involvement [19]. Knee pain affects variety of activities including the limited ability to use stairs, standing up from the chair, walking on uneven terrain, floor sitting, and squatting [2022].

Rehabilitation of knee OA aims to train the patients in coping strategies, improves physical health, quality of life, and maintains their independence in daily livings. These goals can be achieved by variety of interventions including, pharmacological approach, physical therapy, education, weight reduction, orthotic, and surgery.


2. Risk factors

There are variety of risk factors including age, gender, occupation, osteoporosis, genetics, nutritional factors, previous injury, knee extensor muscle weakness, and obesity [23, 24]. A recent meta-analysis provides further evidence that increased body mass index (BMI), past knee injury, age, female gender, and hand OA are the major risk factors causing knee OA [11]. The frequency of OA is increased in older population. In the United Kingdom, up to 40% people above the age of 65 years has been suffering from the symptoms associated with knee or hip OA [25]. While male and female are equally affected by OA, it is reported to be more common in the young adult male (<45 years) and in the older adult female (>45 years) [69].

A previous study reported some occupational activities, for example, kneeling, high levels of physical activity, farming, and construction work are potential risk factors for developing knee OA [11]. Another study reported double the risk of developing knee OA in individuals whose jobs required carrying and kneeling, or squatting activities compared to individuals whose jobs did not require such physical activities [26]. In addition, jobs which require repetitive task or sports, particularly endurance sports in which joint injuries are common, may predispose OA [27].

Obesity is recognized as major risk factors for mechanical joint damage, particularly in weight-bearing joints, and is often present with sedentary people with knee OA [28, 29]. The risk of incidence and progression of lower extremity OA increases with obesity [30], and the risk of knee OA increases four times more compared with individuals with a BMI of <30 kg/m2 [31]. Another study reported 83% of the female participants had knee OA who were obese compared to 42% of non-obese control group [32]. In addition, obesity can alter the mechanics of joint and develop inflammation and cause increased pain [33, 34]. Furthermore, increased fat around the quadriceps muscle causes reduced activity of the muscle, resulting in decreased function [35].

Previous studies had reported knee extensor muscle weakness, a major risk factor for knee OA, especially in women [36, 37]. Other studies found knee extensor muscle weakness in people with knee OA compared to control subjects [7, 15, 38]. In addition, Segal et al. [39] reported low risk of symptomatic knee OA in individuals with greater quadriceps muscle strength. The weakness of quadriceps muscle causes reduced functional disability in knee OA [22]. Furthermore, the presence of pain causes disused atrophy which results quadriceps weakness in knee OA [14].


3. Diagnosis of osteoarthritis

The diagnosis of the OA often made clinically, and radiological features confirm the diagnosis. The presence of pain in the knee, morning stiffness lasting over the 30 min, limited movement, crepitus, swelling, and advanced age usually the main characteristics that indicate the diagnosis of knee OA. The narrowing of joint space, sclerosis of subchondral bone, and formation of subchondral cyst and osteophytes are radiological features seen in knee OA [40].

Kellgren and Lawrence [16] have developed a radiological scale to classify knee OA into four grades on antero-posterior view of radiograph taken in standing position. “Grade 0 is defined as no radiographic findings of osteoarthritis, Grade 1 as minute osteophytes of doubtful clinical significance, Grade 2 as definite osteophytes with unimpaired joint space, Grade 3 as definite osteophytes with moderate joint space narrowing, and Grade 4 as definite osteophytes with severe joint space narrowing and subchondral sclerosis” [41]. In addition, the American Rheumatism Association (ARA) has developed a more specific classification system in 1986, known as the American College of Rheumatology (ACR) criteria. These criteria included several validated clinical and radiological features [42].


4. Clinical manifestations

Pain is the major symptom of knee OA, and increased pain causes reduced physical function and poor quality of life [43]. In addition, knee pain causes difficulty in performing activities of daily livings including shopping, household chores, stair climbing as well as participation in social and outdoor activities [44]. Furthermore, pain related to knee OA influences work productivity and employment status [45]. In addition to pain, patients may have joint stiffness, knee extensor muscle weakness, and altered proprioception [4648]. These symptoms often cause restriction in the ability to get up from the chair, difficulty in walking, and stair climbing [46]. Limping gait, poor limb alignment, and instability are some other features seen in people with knee OA [49]. A crepitus sound can be heard during movements due to the presence of irregular joint surfaces in knee OA [50].

A multitude of structural, physical, and psychosocial factors influences symptom and severity of pain in knee OA [43, 51, 52]. Although the role of nociceptors in the capsule, subchondral bone, ligaments, and other joint tissues precipitation symptom of pain was established, however, structural deformation in knee OA is not associated with the severity of pain [53]. Previous studies reported that the impairments in the physical and psychological functions are the major predictors of the severity of knee pain. Reduced muscle strength, especially of the quadriceps, is associated with severity of pain and low level of physical function [52, 54]. Psychological impairments such as pain catastrophizing [55], reduced pain coping skills [56], depression [57, 58], anxiety [57], and reduced social participation [58] are also associated with the severity of pain in individuals with knee OA. Furthermore, pain and physical and psychological impairments have shown bi-directional relationships, that is, physical and psychological impairments can influence, and in turn be influenced by severity of pain, results a further reduced physical and mental functioning [59].


5. Rehabilitation

Management of knee OA often requires a combination of pharmacologic and nonpharmacologic treatment approaches [60, 61]. Several clinical guidelines have been published by the scientific society for nonpharmacological treatment approach in knee OA [6268]. Several randomized, controlled clinical trials have been published showing therapeutic effectiveness of exercise-based approaches, including range-of-motion exercises, aerobic exercise programs, and muscle-strengthening exercises [60, 61, 69, 70]. A previous study reported significant reduction in pain and functional disability scores of the Western Ontario and McMaster Universities (WOMAC) outcome measure following a home exercise program [69]. Another study reported significant reduction in pain following isometric quadriceps exercises for 3 months in knee OA [70]. Stitik et al. [71] had reported a significant reduction in pain intensity following combined use of hyaluronate injections and home exercise program in moderately severe pain in individuals with knee OA. Furthermore, previous randomized controlled studies reported that a simple quadriceps exercise performed at home was effective in reducing pain as well as functional disability [72, 73]. Another study reported a significant reduction in pain intensity and improved function following a simple group education program in patients with knee OA [74].

Passive treatment in the form of physiotherapeutic modalities such as short-wave diathermy, transcutaneous electrical nerve stimulation (TENS), ultrasound and hot packs often used to reduce both acute and chronic pain in knee OA [75]. However, Moffett et al. [76] reported that the short-wave diathermy had no additional benefits than placebo effects when used for 3 weeks in knee OA. In a recent published review, Zeng et al. [77] reported that the interferential current seems to be effective pain relief intervention in knee OA. Furthermore, they recommended that the other electrical stimulation therapy such as TENS, neuromuscular electrical stimulation, pulsed electrical stimulation, and noninvasive interactive neurostimulation is either uncertain or not appropriate for pain relief in knee OA [77].

Fransen and McConnell published a Cochrane review, in which, land-based therapeutic exercise (aerobic, resistance, stretching, strengthening, and range-of-motion exercises exercises) was compared with the non-exercise control group (home visits, education, waiting list, telephone call, relaxation, no intervention) in patients with hip or knee OA. The results of review indicate a significant reduction of self-reported pain and physical function for therapeutic exercise compared with control group [78]. Quadriceps strengthening is vital for alleviating pain and improving function in individuals with medial compartment knee OA [79]. Previous studies reported a reduced pain and improved function following knee flexors and extensors or hip abductors strengthening in knee OA [8083]. Recently, a systematic review of 18 randomized controlled trials published, most of the included studies involved home-based exercise of quadriceps or lower extremity strengthening in knee OA. The results of this study indicate a significant reduction of pain and improvements in self-reported physical function following strengthening exercise in knee OA [79]. In another review, aerobic walking or home-based quadriceps-strengthening exercise was compared with a non-exercise control group in patients with knee OA. The results of review indicate both the types of exercise (aerobic walking or home-based quadriceps-strengthening exercise) significantly reduced knee pain compared with control group [84].

Cognitive behavioral therapy (CBT) is a psychological approach to train and enhance pain coping skills and found to be effective in reducing pain and improvement in self-efficacy in patients with knee OA [8588]. CBT protocol includes three components: (i) patients education about the pain and the effect of pain coping skills on pain reduction, (ii) use of several cognitive and behavioral pain coping skills in a systematic manner, and (iii) the most challenging is to teach the patients how to use learned coping skills in a real-life situations [89]. A meta-analysis published recently had found that CBT is the most common studied psychosocial therapy approach for pain management in patients with arthritis [85]. Other studies recommended the use of pain coping skills training based on CBT, to reduce pain and improve psychological well-being in chronic pain conditions in patients with knee OA [90, 91].

Various other treatment techniques had shown significant effects on pain reduction in knee OA. Hinman et al. [92] reported significant reduction of pain following 3 weeks of therapeutic taping. Mulligan’s mobilization with movement (MWM) technique seems to provide immediate pain relief and improved function in patients with knee OA [93]. Previous study recommended the use of laterally elevated wedge insoles inserting inside the shoes in patients with medial compartment knee OA [94]. Another study reported significant relief of pain using laterally elevated wedged insoles compared to neutrally wedged insoles in patients with knee OA [95]. However, other study reported no additional benefits of using braces and orthoses for the management of knee OA [96].



The Project was full financially supported by King Saud University, through Vice Deanship of Research Chairs, Rehabilitation Research Chair.


  1. 1. Kim KW, Han JW, Cho HJ, Chang CB, Park JH, Lee JJ, Lee SB, Seong SC, Kim TK: Association between comorbid depression and osteoarthritis symptom severity in patients with knee osteoarthritis. J Bone Joint Surg Am. 2011;93(6):556–63. doi:10.2106/JBJS.I.01344
  2. 2. Hinman RS, Hunt MA, Creaby MW, Wrigley TV, McManus FJ, Bennell KL: Hip muscle weakness in individuals with medial knee osteoarthritis. Arthritis Care Res (Hoboken). 2010;62(8):1190–3. doi:10.1002/acr.20199
  3. 3. Heiden TL, Lloyd DG, Ackland TR: Knee extension and flexion weakness in people with knee osteoarthritis: is antagonist cocontraction a factor? J Orthop Sports Phys Ther. 2009;39(11):807–15. doi:10.2519/jospt.2009.3079
  4. 4. Gupta S, Hawker GA, Laporte A, Croxford R, Coyte PC: The economic burden of disabling hip and knee osteoarthritis (OA) from the perspective of individuals living with this condition. Rheumatology (Oxford). 2005;44(12):1531–7. doi:10.1093/rheumatology/kei049
  5. 5. Neogi T, Zhang Y: Epidemiology of osteoarthritis. Rheum Dis Clin N Am. 2013;39(1):1–19. doi:10.1016/j.rdc.2012.10.004
  6. 6. Childs JD, Sparto PJ, Fitzgerald GK, Bizzini M, Irrgang JJ: Alterations in lower extremity movement and muscle activation patterns in individuals with knee osteoarthritis. Clin Biomech (Bristol, Avon). 2004;19(1):44–9. doi:10.1016/j.clinbiomech.2003.08.007
  7. 7. Liikavainio T, Lyytinen T, Tyrvainen E, Sipila S, Arokoski JP: Physical function and properties of quadriceps femoris muscle in men with knee osteoarthritis. Arch Phys Med Rehabil. 2008;89(11):2185–94. doi:10.1016/j.apmr.2008.04.012
  8. 8. Liikavainio T, Bragge T, Hakkarainen M, Karjalainen PA, Arokoski JP: Gait and muscle activation changes in men with knee osteoarthritis. Knee. 2010;17(1):69–76. doi:10.1016/j.knee.2009.05.003
  9. 9. Hinman RS, Bennell KL, Metcalf BR, Crossley KM: Delayed onset of quadriceps activity and altered knee joint kinematics during stair stepping in individuals with knee osteoarthritis. Arch Phys Med Rehabil. 2002;83(8):1080–6. doi:10.1053/apmr.2002.33068
  10. 10. Loeser RF: Aging and osteoarthritis. Curr Opin Rheumatol. 2011;23(5):492–6. doi:10.1097/BOR.0b013e3283494005
  11. 11. Silverwood V, Blagojevic-Bucknall M, Jinks C, Jordan JL, Protheroe J, Jordan KP. Current evidence on risk factors for knee osteoarthritis in older adults: a systematic review and meta-analysis. Osteoarthritis Cartilage. 2015;23(4):507–15. doi:10.1016/j.joca.2014.11.019
  12. 12. Felson DT: Risk factors for osteoarthritis: understanding joint vulnerability. Clin Orthop Relat Res. 2004;427(Suppl):S16–21.
  13. 13. Felson DT, Goggins J, Niu J, Zhang Y, Hunter DJ: The effect of body weight on progression of knee osteoarthritis is dependent on alignment. Arthritis Rheum. 2004;50(12):3904–9. doi:10.1002/art.20726
  14. 14. O’Reilly SC, Jones A, Muir KR, Doherty M: Quadriceps weakness in knee osteoarthritis: the effect on pain and disability. Ann Rheum Dis. 1998;57(10):588–94. doi:10.1136/ard.57.10.588
  15. 15. Slemenda C, Brandt KD, Heilman DK, Mazzuca S, Braunstein EM, Katz BP, Wolinsky FD: Quadriceps weakness and osteoarthritis of the knee. Ann Intern Med. 1997;127(2):97–104. Epub 1997/07/15. doi:10.7326/0003-4819-127-2-199707150-00001
  16. 16. Kellgren JH, Lawrence JS: Radiological assessment of osteo-arthrosis. Ann Rheum Dis. 1957;16(4):494–502. doi:10.1136/ard.16.4.494
  17. 17. Stevens-Lapsley JE, Kohrt WM: Osteoarthritis in women: effects of estrogen, obesity and physical activity. Womens Health (Lond Engl). 2010;6(4):601–15. doi:10.2217/whe.10.38
  18. 18. Reid CR, Bush PM, Cummings NH, McMullin DL, Durrani SK: A review of occupational knee disorders. J Occup Rehabil. 2010;20(4):489–501. doi:10.1007/s10926-010-9242-8
  19. 19. White DK, Zhang YQ, Felson DT, Niu JB, Keysor JJ, Nevitt MC, Lewis CE, Torner JC, Neogi T: The independent effect of pain in one versus two knees on the presence of low physical function in a multicenter knee osteoarthritis study. Arthritis Care Res. 2010;62(7):938–43. doi:10.1002/acr.20166
  20. 20. Fisher NM, Pendergast DR, Gresham GE, Calkins E: Muscle rehabilitation—its effect on muscular and functional performance of patients with knee osteoarthritis. Arch Phys Med Rehabil. 1991;72(6):365–74.
  21. 21. Ettinger WH, Davis MA, Neuhaus JM, Mallon KP: Long-term physical functioning in persons with knee osteoarthritis from nhanes-I—effects of comorbid medical conditions. J Clin Epidemiol. 1994;47(7):809–15. doi:10.1016/0895-4356(94)90178-3
  22. 22. Mcalindon TE, Cooper C, Kirwan JR, Dieppe PA: Determinants of disability in osteoarthritis of the knee. Ann Rheum Dis. 1993;52(4):258–62. doi:10.1136/ard.52.4.258
  23. 23. Khaltaev N, Pfleger B, Woolf AD, Mathers C, Akesson K, Hazes JM, Symmons D: Assessing the burden of musculoskeletal conditions: a joint World Health Organization-Bone and Joint Decade project. Arthritis Res Ther. 2003;5(Suppl 3):174. doi:10.1186/ar805
  24. 24. Blagojevic M, Jinks C, Jeffery A, Jordan KP: Risk factors for onset of osteoarthritis of the knee in older adults: a systematic review and meta-analysis. Osteoarthr Cartil. 2010;18(1):24–33. doi:10.1016/j.joca.2009.08.010
  25. 25. Dawson J, Linsell L, Zondervan K, Rose P, Randall T, Carr A, Fitzpatrick R: Epidemiology of hip and knee pain and its impact on overall health status in older adults. Rheumatology (Oxford). 2004;43(4):497–504. doi:10.1093/rheumatology/keh086
  26. 26. Felson DT, Hannan MT, Naimark A, Berkeley J, Gordon G, Wilson PW, Anderson J: Occupational physical demands, knee bending, and knee osteoarthritis—results from the Framingham-study. J Rheumatol. 1991;18(10):1587–92.
  27. 27. Kujala UM, Kettunen J, Paananen H, Aalto T, Battie MC, Impivaara O, Videman T, Sarna S: Knee osteoarthritis in former runners, soccer players, weight lifters, and shooters. Arthritis Rheum. 1995;38(4):539–46. doi:10.1002/art.1780380413
  28. 28. Wearing SC, Hennig EM, Byrne NM, Steele JR, Hills AP: Musculoskeletal disorders associated with obesity: a biomechanical perspective. Obes Rev. 2006;7(3):239–50. doi:10.1111/j.1467-789X.2006.00251.x
  29. 29. Brady TJ, Sniezek JE: Implementing the National Arthritis Action Plan: new population-based approaches to increasing physical activity among people with arthritis. Arthritis Rheum. 2003;49(3):471–6. doi:10.1002/art.11052
  30. 30. Janke EA, Collins A, Kozak AT: Overview of the relationship between pain and obesity: what do we know? Where do we go next? J Rehabil Res Dev. 2007;44(2):245–62. doi:10.1682/JRRD.2006.06.0060
  31. 31. Anderson JJ, Felson DT: Factors associated with osteoarthritis of the knee in the first national Health and Nutrition Examination Survey (HANES I). Evidence for an association with overweight, race, and physical demands of work. Am J Epidemiol. 1988;128(1):179–89.
  32. 32. Leach RE, Baumgard S, Broom J: Obesity: its relationship to osteoarthritis of the knee. Clin Orthop Relat Res. 1973;93:271–3.
  33. 33. Hartz AJ, Fischer ME, Bril G, Kelber S, Rupley D, Jr., Oken B, Rimm AA: The association of obesity with joint pain and osteoarthritis in the HANES data. J Chronic Dis. 1986;39(4):311–9. doi:10.1016/0021-9681(86)90053-6
  34. 34. Griffin TM, Guilak F: The role of mechanical loading in the onset and progression of osteoarthritis. Exerc Sport Sci Rev. 2005;33(4):195–200. doi:0091-6331/3304/195–200
  35. 35. Zhai G, Blizzard L, Srikanth V, Ding C, Cooley H, Cicuttini F, Jones G: Correlates of knee pain in older adults: Tasmanian Older Adult Cohort Study. Arthritis Rheum. 2006;55(2):264–71. doi:10.1002/art.21835
  36. 36. Slemenda C, Heilman DK, Brandt KD, Katz BP, Mazzuca SA, Braunstein EM, Byrd D: Reduced quadriceps strength relative to body weight: a risk factor for knee osteoarthritis in women? Arthritis Rheum. 1998;41(11):1951–9. doi:10.1002/1529-0131(199811)41:11<1951
  37. 37. Segal NA, Torner JC, Felson D, Niu J, Sharma L, Lewis CE, Nevitt M: Effect of thigh strength on incident radiographic and symptomatic knee osteoarthritis in a longitudinal cohort. Arthritis Rheum. 2009;61(9):1210–7. doi:10.1002/art.24541
  38. 38. Palmieri-Smith RM, Thomas AC, Karvonen-Gutierrez C, Sowers MF: Isometric quadriceps strength in women with mild, moderate, and severe knee osteoarthritis. Am J Phys Med Rehabil. 2010;89(7):541–8. doi:10.1097/PHM.0b013e3181ddd5c3
  39. 39. Segal NA, Glass NA: Is quadriceps muscle weakness a risk factor for incident or progressive knee osteoarthritis? Phys Sportsmed. 2011;39(4):44–50. doi:10.3810/psm.2011.11.1938
  40. 40. Hunter DJ, Felson DT: Osteoarthritis. BMJ. 2006;332(7542):639–42. doi:10.1136/bmj.332.7542.639
  41. 41. Kijowski R, Blankenbaker D, Stanton P, Fine J, De Smet A: Arthroscopic validation of radiographic grading scales of osteoarthritis of the tibiofemoral joint. AJR Am J Roentgenol. 2006;187(3):794–9. doi:10.2214/AJR.05.1123
  42. 42. Altman R, Asch E, Bloch D, Bole G, Borenstein D, Brandt K, Christy W, Cooke TD, Greenwald R, Hochberg M, et al.: Development of criteria for the classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee. Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association. Arthritis Rheum. 1986;29(8):1039–49. doi:10.1002/art.1780290816
  43. 43. Dieppe PA, Lohmander LS: Pathogenesis and management of pain in osteoarthritis. Lancet. 2005;365(9463):965–73. doi:10.1016/S0140-6736(05)71086-2
  44. 44. Davis MA, Ettinger WH, Neuhaus JM, Mallon KP: Knee osteoarthritis and physical functioning: evidence from the NHANES I Epidemiologic Followup Study. J Rheumatol. 1991;18(4):591–8.
  45. 45. Sayre EC, Li LC, Kopec JA, Esdaile JM, Bar S, Cibere J: The effect of disease site (knee, hip, hand, foot, lower back or neck) on employment reduction due to osteoarthritis. Plos one. 2010;5(5):e10470. doi:10.1371/journal.pone.0010470
  46. 46. Kaufman KR, Hughes C, Morrey BF, Morrey M, An KN: Gait characteristics of patients with knee osteoarthritis. J Biomech. 2001;34(7):907–15. doi:10.1016/S0021-9290(01)00036-7
  47. 47. Hurley MV, Scott DL, Rees J, Newham DJ: Sensorimotor changes and functional performance in patients with knee osteoarthritis. Ann Rheum Dis. 1997;56(11):641–8. doi:10.1136/ard.56.11.641
  48. 48. McCloskey DI: Kinesthetic sensibility. Physiol Rev. 1978;58(4):763–820.
  49. 49. Carvalho NA, Bittar ST, Pinto FR, Ferreira M, Sitta RR: Manual for guided home exercises for osteoarthritis of the knee. Clinics (Sao Paulo). 2010;65(8):775–80.doi:10.1590/S1807-59322010000800006
  50. 50. Easton BT: Evaluation and treatment of the patient with osteoarthritis. J Fam Pract. 2001;50(9):791–7.
  51. 51. Creamer P, Hochberg MC: The relationship between psychosocial variables and pain reporting in osteoarthritis of the knee. Arthritis Care Res. 1998;11(1):60–5.
  52. 52. Sharma L, Cahue S, Song J, Hayes K, Pai YC, Dunlop D: Physical functioning over three years in knee osteoarthritis: role of psychosocial, local mechanical, and neuromuscular factors. Arthritis Rheum. 2003;48(12):3359–70. doi:10.1002/art.11420
  53. 53. Dieppe PA: Relationship between symptoms and structural change in osteoarthritis: what are the important targets for therapy? J Rheumatol. 2005;32(6):1147–9.
  54. 54. Eitzen I, Holm I, Risberg MA: Preoperative quadriceps strength is a significant predictor of knee function two years after anterior cruciate ligament reconstruction. Br J Sports Med. 2009;43(5):371–6. doi:10.1136/bjsm.2008.057059
  55. 55. Somers TJ, Keefe FJ, Pells JJ, Dixon KE, Waters SJ, Riordan PA, Blumenthal JA, McKee DC, LaCaille L, Tucker JM, Schmitt D, Caldwell DS, Kraus VB, Sims EL, Shelby RA, Rice JR: Pain catastrophizing and pain-related fear in osteoarthritis patients: relationships to pain and disability. J Pain Symptom Manag. 2009;37(5):863–72. doi:10.1016/j.jpainsymman.2008.05.009
  56. 56. van Baar ME, Dekker J, Lemmens JA, Oostendorp RA, Bijlsma JW: Pain and disability in patients with osteoarthritis of hip or knee: the relationship with articular, kinesiological, and psychological characteristics. J Rheumatol. 1998;25(1):125–33.
  57. 57. Smith BW, Zautra AJ: The effects of anxiety and depression on weekly pain in women with arthritis. Pain. 2008;138(2):354–61. doi:10.1016/j.pain.2008.01.008
  58. 58. Rosemann T, Laux G, Szecsenyi J, Wensing M, Grol R: Pain and osteoarthritis in primary care: factors associated with pain perception in a sample of 1,021 patients. Pain Med. 2008;9(7):903–10. doi:10.1111/j.1526-4637.2008.00498.x
  59. 59. Sale JE, Gignac M, Hawker G: The relationship between disease symptoms, life events, coping and treatment, and depression among older adults with osteoarthritis. J Rheumatol. 2008;35(2):335–42.
  60. 60. Recommendations for the medical management of osteoarthritis of the hip and knee—2000 update. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum. 2000;43(9):1905–15.
  61. 61. Pendleton A, Arden N, Dougados M, Doherty M, Bannwarth B, Bijlsma JWJ, Cluzeau F, Cooper C, Dieppe PA, Günther KP, et al.: EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis. 2000;59(12):936–44. doi:10.1136/ard.59.12.936
  62. 62. Hochberg MC, Altman RD, Brandt KD, Clark BM, Dieppe PA, Griffin MR, Moskowitz RW, Schnitzer TJ: Guidelines for the medical management of osteoarthritis. Part I. Osteoarthritis of the hip. American College of Rheumatology. Arthritis Rheum. 1995;38(11):1535–40. doi:10.1002/art.1780381103
  63. 63. Hochberg MC, Altman RD, Brandt KD, Clark BM, Dieppe PA, Griffin MR, Moskowitz RW, Schnitzer TJ: Guidelines for the medical management of osteoarthritis. Part II. Osteoarthritis of the knee. American College of Rheumatology. Arthritis Rheum. 1995;38(11):1541–6. doi:10.1002/art.1780381104
  64. 64. Roddy E, Zhang W, Doherty M, Arden NK, Barlow J, Birrell F, Carr A, Chakravarty K, Dickson J, Hay E, et al.: Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee—the MOVE consensus. Rheumatology (Oxford). 2005;44(1):67–73. doi:10.1093/rheumatology/keh399
  65. 65. Mazieres B, Bannwarth B, Dougados M, Lequesne M: EULAR recommendations for the management of knee osteoarthritis. Report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials. Joint Bone Spine. 2001;68(3):231–40. doi:10.1016/S1297-319X(01)00271-8
  66. 66. Ottawa panel evidence-based clinical practice guidelines for therapeutic exercises and manual therapy in the management of osteoarthritis. Phys Ther. 2005;85(9):907–71.
  67. 67. Hunter DJ: Quality of osteoarthritis care for community-dwelling older adults. Clin Geriatr Med. 2010;26(3):401–17. doi:10.1016/j.cger.2010.03.003
  68. 68. Brand CA, Ackerman IN, Bohensky MA, Bennell KL: Chronic disease management: a review of current performance across quality of care domains and opportunities for improving osteoarthritis care. Rheum Dis Clin N Am. 2013;39(1):123–43. doi:10.1016/j.rdc.2012.10.005
  69. 69. Thomas KS, Muir KR, Doherty M, Jones AC, O’Reilly SC, Bassey EJ: Home based exercise programme for knee pain and knee osteoarthritis: randomised controlled trial. BMJ. 2002;325(7367):752–5. doi:10.1136/bmj.325.7367.752
  70. 70. Miyaguchi M, Kobayashi A, Kadoya Y, Ohashi H, Yamano Y, Takaoka K: Biochemical change in joint fluid after isometric quadriceps exercise for patients with osteoarthritis of the knee. Osteoarthr Cartil. 2003;11(4):252–9. doi:10.1016/S1063-4584(02)00372-2
  71. 71. Stitik TP, Blacksin MF, Stiskal DM, Kim JH, Foye PM, Schoenherr L, Choi ES, Chen B, Saunders HJ, Nadler SF: Efficacy and safety of hyaluronan treatment in combination therapy with home exercise for knee osteoarthritis pain. Arch Phys Med Rehabil. 2007;88(2):135–41. doi:10.1016/j.apmr.2006.11.006
  72. 72. Petrella RJ, Bartha C: Home based exercise therapy for older patients with knee osteoarthritis: a randomized clinical trial. J Rheumatol. 2000;27(9):2215–21.
  73. 73. O’Reilly SC, Muir KR, Doherty M: Effectiveness of home exercise on pain and disability from osteoarthritis of the knee: a randomised controlled trial. Ann Rheum Dis. 1999;58(1):15–9. doi:10.1136/ard.58.1.15
  74. 74. Bezalel T, Carmeli E, Katz-Leurer M: The effect of a group education programme on pain and function through knowledge acquisition and home-based exercise among patients with knee osteoarthritis: a parallel randomised single-blind clinical trial. Physiotherapy. 2010;96(2):137–43. doi:10.1016/
  75. 75. Cetin N, Aytar A, Atalay A, Akman MN: Comparing hot pack, short-wave diathermy, ultrasound, and TENS on isokinetic strength, pain, and functional status of women with osteoarthritic knees: a single-blind, randomized, controlled trial. Am J Phys Med Rehabil. 2008;87(6):443–51. doi:10.1097/PHM.0b013e318174e467
  76. 76. Moffett JA, Richardson PH, Frost H, Osborn A: A placebo controlled double blind trial to evaluate the effectiveness of pulsed short wave therapy for osteoarthritic hip and knee pain. Pain. 1996;67(1):121–7. doi:10.1016/0304-3959(96)03100-4
  77. 77. Zeng C, Li H, Yang T, Deng ZH, Yang Y, Zhang Y, Lei GH. Electrical stimulation for pain relief in knee osteoarthritis: systematic review and network meta-analysis. Osteoarthr Cartil. 2015;23(2):189–202. doi:10.1016/j.joca.2014.11.014
  78. 78. Fransen M, McConnell S: Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2008;4:CD004376. doi:10.1002/14651858.CD004376.pub2
  79. 79. Lange AK, Vanwanseele B, Singh MA: Strength training for treatment of osteoarthritis of the knee: a systematic review. Arthritis Rheum. 2008;59(10):1488–94. doi:10.1002/art.24118
  80. 80. Bennell KL, Hunt MA, Wrigley TV, Hunter DJ, McManus FJ, Hodges PW, Li L, Hinman RS: Hip strengthening reduces symptoms but not knee load in people with medial knee osteoarthritis and varus malalignment: a randomised controlled trial. Osteoarthr Cartil. 2010;18(5):621–8. doi:10.1016/j.joca.2010.01.010
  81. 81. Lim BW, Kemp G, Metcalf B, Wrigley TV, Bennell KL, Crossley KM, Hinman RS: The association of quadriceps strength with the knee adduction moment in medial knee osteoarthritis. Arthritis Rheum. 2009;61(4):451–8. doi:10.1002/art.24278
  82. 82. King LK, Birmingham TB, Kean CO, Jones IC, Bryant DM, Giffin JR: Resistance training for medial compartment knee osteoarthritis and malalignment. Med Sci Sports Exerc. 2008;40(8):1376–84. doi:10.1249/MSS.0b013e31816f1c4a
  83. 83. Sled EA, Khoja L, Deluzio KJ, Olney SJ, Culham EG: Effect of a Home program of hip abductor exercises on knee joint loading, strength, function, and pain in people with knee osteoarthritis: a clinical trial. Phys Ther. 2010;90(6):895–904. doi:10.2522/ptj.20090294
  84. 84. Roddy E, Zhang W, Doherty M: Aerobic walking or strengthening exercise for osteoarthritis of the knee? A systematic review. Ann Rheum Dis. 2005;64(4):544–8. doi:10.1136/ard.2004.028746
  85. 85. Dixon KE, Keefe FJ, Scipio CD, Perri LM, Abernethy AP: Psychological interventions for arthritis pain management in adults: a meta-analysis. Health Psychol. 2007;26(3):241–50. doi:10.1037/0278-6133.26.3.241
  86. 86. Keefe FJ, Blumenthal J, Baucom D, Affleck G, Waugh R, Caldwell DS, Beaupre P, Kashikar-Zuck S, Wright K, Egert J, Lefebvre J: Effects of spouse-assisted coping skills training and exercise training in patients with osteoarthritic knee pain: a randomized controlled study. Pain. 2004;110(3):539–49. doi:10.1016/j.pain.2004.03.022
  87. 87. Keefe FJ, Caldwell DS, Baucom D, Salley A, Robinson E, Timmons K, Beaupre P, Weisberg J, Helms M: Spouse-assisted coping skills training in the management of knee pain in osteoarthritis: long-term followup results. Arthritis Care Res. 1999;12(2):101–11.
  88. 88. Keefe FJ, Caldwell DS, Williams DA, Gil KM, Mitchell D, Robertson C, et al. Pain coping skills training in the management of osteoarthritic knee pain —a comparative-study. Behav Ther. 1990;21(1):49–62.
  89. 89. Hunt MA, Keefe FJ, Bryant C, Metcalf BR, Ahamed Y, Nicholas MK, Bennell KL: A physiotherapist-delivered, combined exercise and pain coping skills training intervention for individuals with knee osteoarthritis: a pilot study. Knee. 2013;20(2):106–12. doi:10.1016/j.knee.2012.07.008
  90. 90. Devos-Comby L, Cronan T, Roesch SC: Do exercise and self-management interventions benefit patients with osteoarthritis of the knee? A metaanalytic review. J Rheumatol. 2006;33(4):744–56.
  91. 91. Hurley MV, Walsh NE: Effectiveness and clinical applicability of integrated rehabilitation programs for knee osteoarthritis. Curr Opin Rheumatol. 2009;21(2):171–6. doi:10.1097/BOR.0b013e3283244422
  92. 92. Hinman RS, Crossley KM, McConnell J, Bennell KL: Efficacy of knee tape in the management of osteoarthritis of the knee: blinded randomised controlled trial. BMJ. 2003;327(7407):135. doi:10.1136/bmj.327.7407.135
  93. 93. Takasaki H, Hall T, Jull G: Immediate and short-term effects of Mulligan’s mobilization with movement on knee pain and disability associated with knee osteoarthritis—a prospective case series. Physiother Theory Pract. 2013;29(2):87–95. doi:10.3109/09593985.2012.702854
  94. 94. Reilly KA, Barker KL, Shamley D: A systematic review of lateral wedge orthotics—how useful are they in the management of medial compartment osteoarthritis? Knee. 2006;13(3):177–83. doi:10.1016/j.knee.2006.02.003
  95. 95. Hatef MR, Mirfeizi Z, Sahebari M, Jokar MH, Mirheydari M: Superiority of laterally elevated wedged insoles to neutrally wedged insoles in medial knee osteoarthritis symptom relief. Int J Rheum Dis. 2014;17(1):84–8. doi:10.1111/1756-185X.12036
  96. 96. Brouwer RW, Jakma TS, Verhagen AP, Verhaar JA, Bierma-Zeinstra SM: Braces and orthoses for treating osteoarthritis of the knee. Cochrane Database Syst Rev. 2005;1:CD004020. doi:10.1002/14651858.CD004020.pub2

Written By

Shahnawaz Anwer and Ahmad Alghadir

Submitted: 26 October 2015 Reviewed: 04 March 2016 Published: 25 May 2016