The PRICE regimen may help provide initial relief for patients in pain: protection with limited weight

bearing by
using a cane or modification of exercise to reduce stress; relative rest (or taking adequate rests throughout the day,
avoiding prolonged standing, climbing of stairs, kneeling, deep knee bending); ice (applied while the skin is protected
with a towel for up to 15 minutes at a time several times a day; note, however, that some patients with chronic pain
may find better relief with moist heat); compression (if swelling exists, wrapping with an elastic bandage or a sleeve
may help); and elevation (may help diminish swelling, if it is present).

Rehabilitation
Exercise
Exercise is the mainstay of non-pharmacologic and nonsurgical treatment of knee OA. A recent meta-analysis showed
exercise to be equally effective to oral analgesics in knee OA.14 Randomized studies definitively support the benefits
of exercise (even if it is home based) on pain, function, and quality of life in patients with knee OA.15 Because there is
currently no cure for OA, most research continues to evaluate the use of exercise as a treatment to alleviate symptoms
of the disease and to enhance functional capacity.

Exercise programs for knee OA typically consist of (1) lower extremity stretching, (2) lower extremity strengthening
focusing on the quadriceps but also with attention to the hamstrings and hip muscles, (3) aerobic conditioning with a
stationary bike, treadmill, water aerobics, or elliptical trainer, and (4) balance and proprioceptive exercises or
perturbation exercises.

The resistance should slowly be increased with time if possible

and use of ice should be employed to manage pain during
treatment. Exercise bicycles and walking should be recommended
to enhance aerobic capacity. Deep knee bends in
the presence of effusion should be avoided. Particular attention
must be paid to strengthening of the medial quadriceps
in patients with genu valgum who have lateral subluxation
of the patella. Maintaining activity is critical to maintaining
function. Even those patients scheduled for total knee
arthroplasty should pursue static and dynamic strengthening
as well as cardiovascular conditioning preoperatively to
ease postoperative rehabilitation

Newer approaches are being employed in the treatment

of OA, including Tai Chi, which was shown to be equally
effective to standardized PT in a recent randomized trial,19
Therapeutic Modalities
Transcutaneous electrical nerve stimulation, the application
of an electrical current through the skin with the aim of
pain modulation, is a frequently used modality in knee OA.
Although this is a popular treatment option, research supporting
its efficacy is lacking.21
Additional therapeutic modalities, such as electrical
stimulation or massage, may also be used. Therapists may
also review postural alignment and joint positioning techniques,
especially for when the patient is sleeping. In particular,
the use of a pillow under bent knees, much favored
by many patients when they are supine, should be avoided
because resulting knee flexion contractures, even if small,
can significantly increase stresses on the knee during gait.
Stretching of the hamstrings and quadriceps may also prove beneficial

Adaptive Equipment
Adaptive equipment, such as a cane or walker, can reduce
hip or knee loading, thereby reducing pain. It may also
reduce fall risk in patients with impaired balance. Proper
training in the use of a cane is important because it reduces
joint loading in the contralateral hip but amplifies forces in
the ipsilateral hip.

Bracing and Footwear

The basic rationale for a knee brace for unicompartmental
knee OA is to improve function by reducing the patient’s
symptoms. This can be accomplished, in theory, by reducing
the biomechanical load on the affected compartment of
the knee.
A review of the published literature on knee bracing
for OA points out limitations of clinical trials to date, but
acknowledges limited evidence for improvement in pain and
function in patients using OA braces.23
Heel lifts or built-up shoes may be required in the presence
of leg length discrepancy to prevent compensatory
knee flexion gait on the longer side. In the presence of
knee deformity, therapists can also evaluate for altered biomechanics
(e.g., genu varum may lead to femoral internal
torsion, resulting in compensatory external rotation of the
tibia, which predisposes the patient to increased arthritic
changes). Therapists can also visit the homes and workplaces
of patients to suggest adjustments, such as raised toilet
seats, grab bars, reachers, and the like.

The ACR strongly recommends land-based cardiovascular

(aerobic) and resistance exercises, aquatic exercises, Tai
Chi, and weight loss (in overweight individuals) for patients
with OA of the hip and knee.13
Clinical experience suggests that cold, heat, and manual
therapy can be helpful in decreasing pain and increasing
mobility. Thermal agents and manual therapy in combination
with supervised exercise are also recommended by the
ACR.13
Braces and splints may be helpful for symptomatic relief
in certain joints. There are conflicting data on the effectiveness
of knee bracing.34 One recent meta-analysis showed
that knee bracing had little to no clinical effect on pain,
knee function, or quality of life.32 However, other studies
have shown some benefit from unloading valgus braces on
patients with medial compartment arthritis. Many patients
experience side effects such as discomfort due to poor fit,
skin irritation, or sweating and thus stop using these braces.33
Splints may be useful for OA of the thumb.35 The ACR recommends
splinting for patients with hand OA, specifically
of the trapeziometacarpal joint (first CMC joint), but offers
no recommendations on knee bracing.13 The wearing of a
thumb-base OA splint at night has been shown to decrease
pain and possibly decrease disability.36
Orthotic wedged insoles and medially directed patellar
taping may be helpful for knee OA to off-load the joint or
to improve biomechanics. Patellar taping affords effective
short-term relief of pain with patellofemoral arthritis.37
Adaptive equipment, such as a cane or walker, can be
used if necessary by patients with impaired balance to prevent
falls or for pain reduction by decreasing joint loading. In
the setting of significant functional impairments, therapists

can provide assistive devices that help with feeding, grooming,

dressing, and other activities of daily living.
The use of transcutaneous electrical nerve stimulation
is supported by a few small short-term trials. Systematic
review of the data has been inconclusive.38 For most
patients in these studies, pain relief was experienced only
during active use of the device. Nevertheless, transcutaneous
electrical nerve stimulation is conditionally recommended
by the ACR for knee OA.13 Ultrasound appears to
have no proven benefit in the treatment of OA.
Acupuncture is also recommended for the treatment of
chronic moderate to severe pain in knee OA. Overall there
is evidence that acupuncture can be effective as adjunctive
therapy for reducing pain and improving function in patients
with knee OA.39 A recent meta-analysis of two to three sessions
per week of acupuncture in the treatment of chronic
knee OA showed significant benefits in long- and shortterm
function but only short-term improvement in pain.40