REVIEW OF LITERATURE

Al-Arfaj (2003) studied the relationship between osteoarthritis

of the knee, generalized osteoarthritis and serum cholesterol. Their

ages, sex, weight, height, body mass index (BMI), fasting serum

cholesterol and serum triglycerides were recorded. The results

showed an association between high serum cholesterol levels and

both knee and generalized osteoarthritis.

Altman et al. (1986) described the criteria for classification of

osteoarthritis of the knee. For the purpose of classification, it is

described as primary (idiopathic) or secondary (if related to a

known medical condition) osteoarthritis. Clinical criteria for

classification of idiopathic osteoarthritis of the knee were developed

through a multicentre study group. It is divided into three

categories: clinical examination, clinical examination and laboratory

tests and clinical examination and radiographic features. Knee pain,

stiffness, crepitus, tenderness and bony enlargement were included

in clinical examination. Changes are also seen in the biochemical

parameters. ESR < 40 mm/hr and Rheumatoid factor < 1 : 40 are

included in laboratory examination for classification. Presence of

osteophytes, reduction of joint spaces and destruction of articular

cartilage are seen in radiological examination.

Bhattacharya et al. (2006) studied 30 subjects with unilateral

knee osteoarthritis. The subjects were randomly assigned into two

groups either proprioceptive training group or conventional therapy

group. The variables like knee joint proprioception, visual analogue

scale, joint range of motion, Western Ontario and McMaster

Universities (WOMAC) index, isometric strength of quadriceps were

measured. The treatment was given for a period of six weeks. The

study demonstrated that the subjects who received proprioceptive

training improved to a greater extent in their functional ability than

subjects who received only conventional therapy.

Chamberlain et al. (1982) practiced the patients with

osteoarthritis of knee two simple exercises with graduated weights.

Patients were randomly divided into those receiving treatment at

hospital and those doing exercises at home. Both groups showed

decreased pain and increased function, maximum weight lift and

endurance at the end of 4 weeks. The subjects which continued

daily exercises retained benefits, whereas those which cease

exercising experienced more pain. It was concluded that if the

regimens were routinely used, there would be great practical

benefits for patient and physiotherapist.

The study of Christensen et al. (2005) was to assess the

effect of rapid diet induced weight loss on the function of obese,

knee osteoarthritis patients. 80 patients with knee osteoarthritis

were recruited in the study. Patients were randomized to either a

low energy diet or a control diet. The low energy diet group had

weekly dietary sessions, whereas the control was given a booklet

describing weight loss practices. Changes in body weight and body

composition were examined in osteoarthritis knee patients.

Symptoms were monitored by the WOMAC index. The total WOMAC

index of osteoarthritis improved in the low energy diet group but

not in the control group. In patients with osteoarthritis knee, a

weight reduction of 10% improved function by 28%.

Osteoarthritis of the knee is a common cause of pain and

disability, especially in the elderly. In Britain, hospital activity data

suggest that 1.5% of people will undergo surgical treatment for the

disorder (usually total knee arthroplasty) at some stage in their

lives. Case control studies have consistently demonstrated a strong

association between knee osteoarthritis and obesity and in the

Framingham longitudinal study, high body mass index (BMI)

predicted development of the disease in later life. The study of

Coggon et al. (2001) assessed the risk of osteoarthritis knee

attributable to obesity. They performed a population based case-

control study in three districts of England (Southampton,

Portsmouth and North Staffordshire). A total of 525 men and

women aged 45 years and over, consecutively listed for surgical

treatment of primary knee osteoarthritis, were compared with 525

controls matched by age, sex and family practitioner. Relative to a

body mass index of 24.0 – 24.9 kg/m2, the risk of knee

osteoarthritis increased progressively from 0.1 (95% CI 0.0 – 0.5)

for a BMI < 20 kg/m2 to 13.6 (95% CI 5.1 – 36.2) for a BMI of 36

kg/m2 or higher. If all overweight and obese people reduced their

weight by 5 kg or until their body mass index was within the

recommended normal range, 24% of surgical cases of knee

osteoarthritis (95% CI 19 – 27) might be avoided.

As hand joints are non-weight bearing joints, the association

between overweight and hand osteoarthritis (HOA) is critical to

understanding how overweight may associate with osteoarthritis

apart from axial load. Overweight might be associated with the

occurrence of osteoarthritis through other metabolic factors.

Dahaghin et al. (2007) evaluated the role of overweight in hand

osteoarthritis. The role of diabetes, hypertension and total

cholesterol: high-density lipoprotein-cholesterol (TC:HDL-c) ratio on

hand osteoarthritis, and whether they play an intermediate role in

the association of overweight, hand osteoarthritis was investigated.

Independently of other metabolic factors, overweight showed a

significant association with hand osteoarthritis. The association

between diabetes and hand osteoarthritis was only present in

people aged 55–62 years. An increase in the prevalence of hand

osteoarthritis, however, seems to be present when overweight

occurs together with hypertension and diabetes especially at a

relatively young age.

The importance of systemic and metabolic factors in the

association of obesity with radiographic knee osteoarthritis was

examined by Davis et al. (1990) in 3,905 adults for United States

National Health and Nutrition Examination Survey. Obesity was

associated with both bilateral and unilateral osteoarthritis, but more

strongly with bilateral osteoarthritis. Obesity was also associated

with both symptomatic and non symptomatic knee osteoarthritis.

Deyle et al. (2000) evaluated the effectiveness of physical

therapy for osteoarthritis of the knee. 83 patients with osteoarthritis

of the knee were randomly assigned to receive treatment or

placebo. The treatment group received manual therapy applied to

the knee as well as to the lumbar spine, hip and ankle as required,

and performed a standardized knee exercise programme in the clinic

and at home. The placebo group had sub therapeutic ultrasound to

the knee at an intensity of 0.1 W/cm2 with a 10% pulsed mode.

Both groups were treated at the clinic twice weekly for 4 weeks.

Distance walked in 6 minutes and sum of the function, pain and

stiffness subscores of WOMAC index were measured at 4 weeks, 8

weeks and 1 year. Clinically and statistically significant

improvements in 6-minute walk distance and WOMAC score at 4

weeks and 8 weeks were seen in the treatment group but not in the

placebo group. They concluded that a combination of manual

physical therapy and supervised exercise yields functional benefits

for patients with osteoarthritis of the knee and may delay or prevent

the need for surgical intervention.

Ettinger et al. (1997) determined the effects of structured

exercise programmes on self-reported disability in older adults with

knee osteoarthritis. A total of 439 community dwelling adults, aged

60 years or older with radiographically evident knee osteoarthritis

and self reported physical disability were included in the study. A

total of 365 (85%) participants completed the trial. Overall

compliance with the exercise prescription was 68% in the aerobic

training group and 70% in the resistance training group. Older

disabled persons with osteoarthritis of the knee had modest

improvements in measures of disability, physical performance and

pain from participating in either an aerobic or a resistance exercise

programme. These data suggest that exercises should be prescribed

as part of the treatment for knee osteoarthritis.

Osteoarthritis of the knee is a very common rheumatological

disease and there are lots of treatment modalities for it. The aim of

the study of Evcik and Sonel (2002) was to investigate the effects

of home based exercise and walking programmes in the treatment

of osteoarthritis. Patients were assessed according to pain,

functional capacity and quality of life parameters. All groups

continued the programme for 3 months. It was concluded that a

simple home-based exercise therapy and a regular walking

programme are effective in treating the symptoms of osteoarthritis.

Eyigor (2004) compared the efficacy of isokinetic and

progressive resistive exercise (PRE) programmes in patients with

knee osteoarthritis. The patients in Group 1 performed isokinetic

exercises and the patients in Group 2 performed a progressive

resistive exercise programme. Disease severity, pain and walking

time were compared. Disease severity, pain, and walking time

improved with treatment in both groups. It was concluded that

isokinetic and progressive resistive exercise programmes are

efficient in the treatment of osteoarthritis knee and the progressive

resistive exercise programme, as it is cheaper, more easily

performed and efficient, may be preferable for the treatment of

osteoarthritis knee.

Factors such as reduced muscle strength and joint mal-

alignment have an important role in the initiation and progression of

osteoarthritis of the hip or knee. Currently there is no known cure

for osteoarthritis; however, disease related factors such as impaired

muscle function and reduced fitness are potentially amenable to

therapeutic exercises. Fransen et al. (2003) studied whether land

based therapeutic exercise is beneficial for people with

osteoarthritis of the hip or knee in terms of reduced joint pain and

improved physical function. They concluded that land based

therapeutic exercises was shown to reduce and improve physical

function for people with osteoarthritis of the knee. There was

insufficient data to provide useful guidelines on optimal exercise

type or dosage.

More than 45% of patients with degenerative knee arthritis

are obese. This was studied by Glimet et al. (1990). The obesity is

more marked when the medial tibial-femoral and the lateral femoro-

patellar aspects are affected. With the same degree of weight gain,

the relationship of obesity and degenerative knee arthritis is more

marked in women than in men. The significance of the overweight

increases the probability of developing degenerative knee arthritis

increasing its functional severity. The obesity precedes the arthritis

and is not its consequence. It is a mechanical effect by increase of

the articular strains. It is unknown how long the obesity must be

present in order to be pathogenic for the knee and what functional

and anatomical improvement may be expected from a weight loss.

Obesity is one of the most important risk factors for

osteoarthritis of knees. However, the relationship between obesity

and osteoarthritis in hand and hip remains controversial and needs

further investigation. The purpose of the study of Grotle et al.

(2008) was to investigate the impact of obesity on incident of

osteoarthritis in hip, knee and hand in a general population followed

in 10 years. A total of 1854 people aged 24-76 years participated in

a Norwegian study on musculoskeletal pain from 1994 and 2004.

The main outcome measure was osteoarthritis at follow up based on

self-report. Obesity was defined by a body mass index (BMI) of 30

and above. At 10 years follow-up, the incident rates were 5.8% for

hip osteoarthritis, 7.3% for knee osteoarthritis and 5.6% for hand

osteoarthritis. When adjusting for age, gender, work status and

leisure time activities, a high body mass index (> 30) was

significantly associated with knee osteoarthritis.

Gunther et al. (2002) conducted a multicenter cross-sectional

survey of patients with advanced hip and knee osteoarthritis called

the Ulm osteoarthritis study. 420 patients with hip osteoarthritis

and 398 patients with knee osteoarthritis scheduled for unilateral

total joint replacement in Germany underwent detailed clinical

investigations and a standardized interview in addition to

radiographic analyses of ipsilateral and contralateral hip or knee

joint and both hands. In 41.7% of patients with hip osteoarthritis

and 33.4% of patients with knee osteoarthritis, an underlying

pathological condition allowed a classification as secondary

osteoarthritis. A positive association could be observed between

hypercholesterolemia and generalized osteoarthritis in knee patients

as well as between serum uric acid and generalized osteoarthritis in

hip patients. Obesity and overweight were associated with bilateral

knee osteoarthritis, but not bilateral hip osteoarthritis nor

generalized osteoarthritis. The data added to the evidence

regarding the independent role of different systemic risk factors for

osteoarthritis.

Hart et al. (1995) studied the association of metabolic risk

factors and knee osteoarthritis in women. One thousand three

women aged 45-64 years were included in the study. Blood

pressure, fasting blood glucose, serum cholesterol, serum

triglycerides, serum high density lipoprotein cholesterol (HDL-c) and

uric acid levels were measured. These variables were significantly

associated with raised blood glucose and moderately with raised

serum cholesterol. Serum uric acid was non-significantly increased.

No association was found with raised serum triglyceride or serum

high density lipoprotein cholesterol levels or with current systolic

blood pressure. These data suggest that hypercholesterolemia and

blood glucose are associated with both unilateral and bilateral knee

osteoarthritis independent of obesity and support the concept that

osteoarthritis has an important systemic and metabolic component

in its etiology.

Howell (1990) studied the development of new technologies in

the fields of cellular and molecular biology which is contributing

significantly to the understanding of the disease processes involved

in the development and progression of osteoarthritis. In particular,

the relationships between enzymes degradative pathways are

becoming increasingly clear. It was found that two prominent

metalloenzymes and the specific tissue inhibitor of

metalloproteinase have been studied in humans and animal models.

Results indicate that such enzyme pathways may play a significant

role in the degenerative tissue changes that are observed in

osteoarthritis.

Huang et al. (2003) investigated the therapeutic effects of

different muscle-strengthening exercises on the functional status of

patients with knee osteoarthritis. Patients with bilateral knee

osteoarthritis were divided into 4 groups. The patients in group I

received isokinetic muscle-strengthening exercise, patients in group

II received isotonic muscle-strengthening exercise, group III

received isometric muscle-strengthening exercise and group IV

acted as controls. Isotonic exercise is suggested for initial

strengthening in patients with osteoarthritis with exercise knee pain

and isokinetic exercise is suggested for improving joint stability or

walking endurance at a later time.

Huang et al. (2000) evaluated the effect of weight reduction

on the rehabilitation of patients with knee osteoarthritis and

obesity. A total of 126 patients with bilateral knee osteoarthritis and

obesity were classified into 3 groups by their stages of

osteoarthritis. Each group was divided into subgroups a, b, and c.

The subjects in subgroup a received weight reduction treatment,

those in subgroup b received weight reduction and electrotherapy

modalities and those in subgroup c received electrotherapy

modalities to relieve pain. Pain reduction, weight reduction,

ambulation speed and changes of Lequesne's index were greater in

patients in subgroups a and b than in subgroup c after treatment.

Weight reduction was found to be a practical adjuvant treatment in

the rehabilitation of patients with knee osteoarthritis.

Muscle strength training is important for people with knee

osteoarthritis. High resistance training has been demonstrated to be

more beneficial than low resistance exercise for young subjects. The

purpose of the study of Jan et al. (2008) was to compare the effects

of high and low resistance strength training in elderly subjects with

knee osteoarthritis. 102 subjects were randomly assigned to groups

that received 8 weeks of high-resistance exercise, 8 weeks of low-

resistance exercise, or no exercise (control group). Pain, function,

walking time and muscle torque were examined before and after

intervention. The effects of high-resistance strength training appear

to be larger than those of low resistance strength training for people

with mild to moderate osteoarthritis of the knee.

Kladny (2005) studied the role of physical therapy on

osteoarthritis. Physical therapy is used as a part of guidelines and

recommendations in the treatment of osteoarthritis. Different

methods were used in the treatment of osteoarthritis. There is

evidence that manual physical therapy and exercise improve

function and reduce pain in osteoarthritic joints.

The case report of Marks (1993) describes the effect of

strengthening the quadriceps of an effused osteoarthritic knee joint

of a 53 year old man isometrically in mid-range. The instruments

included an isokinetic dynamometer, a knee scoring inventory and a

visual analogue scale. The outcome measures of isometric

quadriceps torque and work, clinical status and pain were recorded

before and after the exercise intervention. The exercises were

carried out three times per week for a 6-week period with the

subject asked to sit on an exercise chair. Following training,

quadriceps torque increased, clinical status improved and pain with

walking decreased. Subject to further investigation, isometric

training of the quadriceps in mid range could prove useful for

improving the function of persons with painful or effused knees who

might otherwise experience muscle inhibition by exercising in the

more traditional inner ranges of knee extension.

Maurer et al. (1999) evaluated the effects of isokinetic

exercise versus a programme of patient education on pain and

function in older persons with knee osteoarthritis. The study design

consisted of a randomized, comparative clinical trial with

interventions lasting 8 weeks. 113 men and women between 50 and

80 years of age with diagnosed osteoarthritis of the knee were

included in the study. Patients received either a regimen of

isokinetic exercise of the quadriceps muscle three times weekly over

8 weeks or a series of 4 discussions and lectures led by health

professionals. They concluded that isokinetic exercise is an effective

and well tolerated treatment for knee osteoarthritis, but a less

costly education programme also showed some benefits.

Minor et al. (1989) studied a group of 120 patients with

rheumatoid arthritis and osteoarthritis volunteered to be subjects

for this study of aerobic versus non-aerobic exercise. Patients were

randomized into an exercise programme of aerobic walking, aerobic

aquatics or non-aerobic range of motion exercise. The aquatics and

walking exercise groups showed significant improvement over the

control group. The findings document the feasibility and efficacy of

conditioning exercise for people who have rheumatoid arthritis or

osteoarthritis.

Miyaguchi et al. (2003) analyzed the biochemical changes in

the joint fluid and pain relief resulting from isometric quadriceps

exercise in patients with osteoarthritis of the knee. Nineteen

patients of osteoarthritis knee with joint effusion were included. The

patients performed isometric quadriceps exercise for 3 months.

Isometric muscle torque, pain (as measured using visual analogue

scale) and biochemical markers in joint fluid were evaluated before

and after the exercise. Pain score decreased, isometric muscle

torque increased and the molecular weight of hyaluron increased.

Also, the concentration of chondroitin sulfate in joint fluid

decreased. Isometric quadriceps exercise resulted in significant

changes in joint fluid biochemical parameters, and these changes

may explain the ameliorative effect of muscle exercise for

osteoarthritis of the knee.

Nagel et al. (1992) studied the acute effects of two kinds of

running i.e. intense short term running and ultra long distance

running on biochemical, haematological and endocrinological

parameters. Blood samples were taken before and after the

running. It was found that in both intense short term running and

ultra long distance running the lipid parameters serum cholesterol,

serum triglycerides and serum low density lipoprotein-cholesterol

(LDL-c) declined significantly whereas serum high density

lipoprotein cholesterol (HDL-c) was increased. Serum uric acid was

raised to 73% in long distance runners and 23% in short distance

runners. A difference was also seen in lactate and glucose levels

showing a fourfold increase and a 34% increase at 4 hour in long

distance running respectively. This study shows that the intensity of

exercise as well as its duration is an important determinant for

metabolism of lipid and blood glucose.

The prevention of disability in activities of daily living (ADL)

may prolong older person‟s autonomy. A sedentary lifestyle is an

important cause of disability. The study of Penninx et al. (2001)

examines whether an exercise programme can prevent activities of

daily living disability. The patients were assigned to an aerobic

exercise programme, a resistance exercise programme or an

attention control group. It was concluded that aerobic and

resistance exercise may reduce the incidence of activities of daily

living disability in older persons with knee osteoarthritis. Exercise

may be an effective strategy for preventing activities of daily living

disability and consequently may prolong older person‟s autonomy.

Philbin et al. (1995) evaluated the cardiovascular fitness of a

group of patients with severe osteoarthritis. Thirty-seven patients

with end-stage osteoarthritis were evaluated just before hip or knee

replacement surgery. Severity of arthritis was evaluated using

standardized techniques. Patients and age- and sex-matched

controls underwent a single, maximal, symptom-limited,

cardiopulmonary exercise test using arm or leg ergometry and a

metabolic cart to measure expired respiratory gases. Severe

musculoskeletal disability and deformity was confirmed in the

osteoarthritis patient group. During exercise testing, osteoarthritis

patients were able to perform physiologically maximal

cardiopulmonary exercise. Arthritis patients were noted to be

severely deconditioned, with reduced peak oxygen consumption. A

trend for more frequent manifestations of coronary heart disease in

osteoarthritis patients than in controls was also noted. Patients with

end-stage lower extremity osteoarthritis are severely deconditioned.

This may place them at incremental risk for the development of

coronary heart disease.

Punzi et al. (2003) studied the progress in the knowledge of

pathogenic mechanisms and a better definition of the disease,

together with the availability of new technologies which has

improved the value of laboratory investigations in osteoarthritis.

The main objectives of these findings are early diagnosis,

assessment of disease activity and severity, and evaluation of

therapeutic effects. Amongst the numerous substances increasingly

proposed for these purposes a few biochemical markers are

potentially useful like keratan sulphate, hyaluronic acid and

pyridinoline. However, serum or urinary determinations of these

molecules are difficult to interpret adequately, due to their complex

metabolism.

Reijman et al. (2007) investigated the relationship between

body mass index (BMI) and the incidence and progression of

radiological knee as well as of radiological hip osteoarthritis. 3585

people aged > or = 55 years were selected from the Rotterdam

study, on the basis of the availability of radiographs of baseline and

follow-up. Incidence of knee or hip osteoarthritis was defined as

minimally grade 2 at follow-up and grade 0 or 1 at baseline. The

progression of osteoarthritis was defined as a decrease in joint

space width. X-rays of the knee and hip at baseline and follow-up

were evaluated. Body mass index (BMI) was measured at baseline.

A high body mass index (27 kg/m2) at baseline was associated with

incident knee osteoarthritis but not with incident hip osteoarthritis.

A high body mass index was also associated with progression of

knee osteoarthritis. For the hip, a significant association between

progression of osteoarthritis and body mass index was not found.

On the basis of results, it was concluded that body mass index is

associated with the incidence and progression of knee osteoarthritis.

Furthermore, it seems that body mass index is not associated with

the incidence and progression of hip osteoarthritis.

Roddy et al. (2005) compared the efficacy of aerobic walking

and home based quadriceps strengthening exercises in patients with

knee osteoarthritis. The Medline, Pubmed, EMBASE, CINAHL and

PEDro databases and the Cochrane clinical controlled trial registers

of subjects with knee osteoarthritis comparing aerobic walking or

home based quadriceps strengthening exercise with a non-exercise

control group. Methodological quality of retrieved randomized

control trials (RCT‟s) was assessed. Outcome data were abstracted

for pain and self reported disability and the effect size calculated for

each outcome. Randomized control trials were grouped according to

exercise mode and the data pooled using both fixed and random

effect models. 35 randomized control trials were identified, 13 of

which met inclusion criteria and provided data suitable for further

analysis. Pooled effect sizes for pain were 0.52 for aerobic walking

and 0.39 for quadriceps strengthening. For self reported disability,

pooled effect sizes were 0.46 for aerobic walking and 0.32 for

quadriceps strengthening. Both aerobic walking and home based

quadriceps strengthening exercise reduce pain and disability from

knee osteoarthritis but no difference between them was found on

indirect comparison.

Rogind et al. (1998) investigated physical function in patients

with severe osteoarthritis of knees during and after a general

physical training programme. 12 patients received training in

groups of 6, twice a week for 3 months. Training focused on general

fitness, balance, coordination, stretching and lower extremity

muscle strength. From baseline to 6 months, isokinetic quadriceps

strength improved 20% in the least affected leg, isometric strength

improved 21%. General physical training appears to be beneficial in

patients with osteoarthritis of the knee. As shown by the high

compliance and low dropout frequency, such a programme is

feasible even in patients with severe osteoarthritis of the knee.

Sato et al. (2003) reviewed the evidences based on

experimental studies in which physical exercise was described as a

beneficial entity on the decreased insulin sensitivity caused by

detrimental lifestyle. The major purpose of physical exercise for

primary prevention and treatment of lifestyle-related diseases is to

improve insulin sensitivity. It is known that, during physical

exercise, glucose uptake by the working muscles rises 7 to 20 times

over the basal level, depending on the intensity of the work

performed. It was found that continued physical training with

moderate or low intensity exercise improves the reduced peripheral

tissue sensitivity to insulin in impaired glucose tolerance and

diabetes, along with regularization of abnormal lipid metabolism.

The study of Schilke et al. (1996) was designed to determine

whether an 8-week isokinetic muscle-strength-training programme

improved the functional health status of patients with osteoarthritis

of the knee joint. Twenty volunteers with osteoarthritis of the knee

joint were randomly assigned to either an experimental (n = 10) or

control (n = 10) group. The experimental group completed six sets

of five maximal contractions three times per week for 8 weeks on a

Cybex II dynamometer at 90° per second. Both groups were pre-

and post tested for extension and flexion strength of the right and

left legs, the 50-foot walk time, range of motion at the knee joint,

the Osteoarthritis Screening Index (OASI) and the Arthritis Impact

Measurement Scale (AIMS). There was a significant decrease in pain

and stiffness and a significant increase in mobility. There was also a

significant decline in arthritis activity in the experimental group as

measured by the Osteoarthritis Screening Index (OASI) and the

Arthritis Impact Measurement Scale (AIMS). The experimental

group significantly increased in all strength measures, while the

control group increased in only right leg flexion and left leg

extension across the training period.

In the case study of Shakoor and Loeser (2004), the

symptoms, evaluation and management of a woman with

osteoarthritis were described. Osteoarthritis is the most common

form of arthritis worldwide and it is a major cause of disability in the

elderly. Although there are several aging-related changes in the

musculoskeletal system that may contribute to the pathogenesis of

this disease, research suggests that osteoarthritis is not merely an

inevitable result of aging. Osteoarthritis is most likely a

multifactorial process whereby non aging related factors also

contribute to the onset, progression and symptomatology of the

disease. Specifically both biochemical factors, included physiological

properties of cartilage and bone and biomechanical factors such as

muscle strength, proprioception and joint loading have been

implicated in the pathogenesis of osteoarthritis. Newer non

pharmacological treatment options are focusing on how to improve

symptoms and prevent progression of the disease through

mechanical interventions.

Sharma et al. (2003) studied quadriceps muscle

strengthening as a common goal in the management of knee

osteoarthritis. In healthy knees, strength protects against new

osteoarthritis. In arthritic knees, greater strength may protect joints

and thereby delay osteoarthritis progression. Quadriceps strength,

knee laxity and alignment, and osteoarthritis progression was

studied. Subset-specific approaches beyond strengthening exercises

should be developed to enhance joint-protective muscle activity.

Sturmer et al. (2001) studied 809 patients with knee or hip

joint replacement due to osteoarthritis. Non insulin dependent

diabetes mellitus (NIDDM) was defined by a history of physician

diagnosed diabetes or use of antihyperglycemics. Patients with non

insulin dependent diabetes mellitus had more often bilateral

osteoarthritis. No association between non insulin dependent

diabetes mellitus and generalized osteoarthritis was observed. So, it

can be concluded that non insulin dependent diabetes mellitus

might be a potentially important systemic risk factor for knee and

hip osteoarthritis.

Sturmer et al. (1998) studied the association between serum

cholesterol and osteoarthritis. A total of 809 patients with knee or

hip osteoarthritis were studied. Radiographs of the joints as well as

blood samples for serum cholesterol were obtained. According to

the presence or absence of radiographic features in osteoarthritis,

participants were categorized as having bilateral or unilateral

osteoarthritis. 85% of participants with radiographs had bilateral

osteoarthritis and 26% had generalized osteoarthritis.

Hypercholesterolemia was independently associated with

generalized osteoarthritis. This association was almost exclusively

due to participants with knee osteoarthritis.

Sun et al. (2000) studied the association between uric acid

and patterns of osteoarthritis. Patterns of osteoarthritis were

studied in 809 patients with hip or knee osteoarthritis. Patients with

osteoarthritis were categorized as having bilateral or generalized

osteoarthritis according to the presence of radiographic features.

Odds ratios (OR) and 95% confidence intervals (CI) for serum uric

acid and osteoarthritis patterns were estimated with multivariable

logistic regression. A positive association between serum uric acid

and generalized osteoarthritis was observed. The results suggest a

possible role of elevated serum uric acid in the multifactorial

etiology of generalized osteoarthritis.

Tanamas et al. (2009) systematically reviewed the evidence

for a relationship between malalignment of the knee joint and

progression of knee osteoarthritis. Electronic searches of Medline,

EMBase, and CINAHL were performed. Fourteen studies met

inclusion criteria and eight were considered high quality. There was

a strong evidence based on 4 high-quality cohort studies that knee

malalignment is an independent risk factor for progression of

radiographic knee osteoarthritis. This finding was further supported

by 2 high-quality magnetic resonance imaging cohort studies that

found a relationship between varus and valgus alignment and

structural progression of knee osteoarthritis.

The study of Thomas et al. (2002) was to determine whether

a home based exercise programme can improve outcomes in

patients with knee pain. 786 men and women aged ≥ 45 years with

self reported knee pain were included in the study. Participants

were randomized to four groups to receive exercise therapy,

monthly telephone contact, exercise therapy plus telephone contact

or no intervention. At 24 months, highly significant reductions in

knee pain were apparent for the pooled exercise groups compared

with the non exercise groups. Regular telephone contact alone did

not reduce pain. It was concluded that a simple home based

exercise programme can significantly reduce knee pain. The lack of

improvement in patients who received only telephone contact

suggests that improvements are just due to psychosocial effects

because of contact with the therapist.

Topp et al. (2002) compared 16 weeks of isometric versus

dynamic resistance training versus a control on knee pain and

functioning among patients with knee osteoarthritis. A total of 102

volunteer subjects with osteoarthritis of the knee randomized to

isometric and dynamic resistance training groups or a control were

taken. The patients were given strength exercises for the legs, 3

times weekly for 16 weeks. Dynamic or isometric resistance training

improves functional ability and reduces knee joint pain of patients

with knee osteoarthritis.

Combined physical therapy interventions are frequently used

in clinical practice for pain relief and to improve physical function in

patients with knee osteoarthritis. The aim of the study of Tuzun et

al. (2004) was to evaluate the effectiveness of 2 different physical

therapy programmes on patients with knee osteoarthritis. A total 62

patients who fulfilled clinical and radiological criteria of the

American College of Rheumatology for primary knee osteoarthritis

were randomly allocated to two groups. After hot packs and

transcutaneous electrical nerve stimulation (TENS) application, the

first group was treated with isokinetic exercises and the second

group with isotonic exercises. Both groups showed marked

decreases of pain and increases of physical function immediately

after treatment and 3 months later. The study showed that physical

therapy intervention programmes are an effective treatment for

knee osteoarthritis.