الفهرس 
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Abstract
Knee osteoarthritis (KOA) is among the ten leading causes of global disabil¬ity, representing a major health problem worldwide. Therapeutically, exercises underlined as a first line treatment in all contemporary clinical guidelines for management of KOA. However, the effect size of such modality is less impressive, highlighting the urgent need for a novel exercise strategies. Toward this end, an innovative integrated exercise program was developed by the researcher. The integrated exercise program was built on the neuromuscular model and the stages of motivational readiness for change model, and consisted of two main components (a) exercises, and (b) behavior change interventions. Hence, the present study aimed to evaluate the effect of implementing an integrated exercise program on physical functions for women with moderate knee osteoarthritis.
The aim of this study was to:
Evaluate the effect of implementing an integrated exercise program on physical functions for women with moderate knee osteoarthritis.
Research design:
A quasi experimental research design was utilized.
Setting:
The present study was conducted at the Physical Medicine, Rheumatology and Rehabilitation Clinic, El-Hadara Orthopedic and Traumatology University Hospital, Alexandria.
Subjects:
The study populations were adult literate women with moderate knee osteoarthritis, and attending the above mentioned setting. A convenience sample of 50 adult women constituted the study subjects, and they were divided alternatively into two equal groups, 25 women in each group.
Materials and method:
Tools of the study:
Four tools were used to collect the data of the present study:
Tool I: Women with unilateral knee osteoarthritis biosociodemographic and physical assessment
This tool was developed by the researcher to elicit data about biosociodemographic characteristics and physical assessment. It comprised of two parts:
Part I: Biosociodemographic data.
Part II: Physical assessment.
Tool II: The Knee injury and Osteoarthritis Outcome Score (KOOS)
The Knee injury and Osteoarthritis Outcome Score (KOOS) was developed by Roos et al. (Roos et al., 1998), and adopted by the researcher, to assess the symptoms and function of people enduring from knee injuries and osteoarthritis.
Tool III: Visual Numeric Pain Scale
The visual numeric pain scale (VNS) was developed by Ritter et al. (Ritter et al., 2006), and adapted by the researcher to measure pain intensity.
Tool IV: Mobility Index of the Knee
This tool was developed to measure physical functions, and it was divided into five parts.
Part I: Range of Motion of the Affected Knee
This part was developed by the researcher, to measure the flexibility of the knee joint in performing the range of motion of the affected knee as flexion and extension.
Part II: Quadriceps Muscle Strength of the Affected Knee
This part was developed by the researcher, to assess the strength of quadriceps muscle.
Part III: Get Up and Go Test (GUG)
The “Get Up and Go test” was developed by Hurley et al. (Hurley et al., 1997), and adopted by the researcher to measure functional performance among patients with KOA.
Part IV: 30-second Chair Stand Test (30s-CST)
The 30-second chair stand test was developed by Jones et al. (Jones et al., 1999), and adopted by the researcher to measure lower body strength and dynamic balance.
Part V: 40 Meter Fast Paced Walk (40m FPWT) Test
The 40 meter fast paced walk test was developed by Kennedy et al. (Kennedy et al., 2005), and adopted by the researcher to measure short distance walking activity.
Method
After securing the official approval from the hospital directors at the selected setting, the developed tools were submitted to three experts in medical surgical nursing and two experts in orthopedic and rehabilitation field for content validity, completeness, clarity of the items and necessary modifications were done. The reliability of the tools was measured by the test-retest, and was equal (r = 0.99) for tool III, and (r = 0.95) for tool IV. For tool V test-retest reliability was (r = 0.97; 0.82; 0.85; 0.96; 0.90) for part I, II, III, IV, and V, respectively. A pilot study was conducted. Next, a convenience sample of 50 adult literate women with moderate knee osteoarthritis were included after obtaining a written informed consent. The sample assigned alternatively into two equal groups (25 patients in each group).
• The study group (I): was exposed to the integrated exercise program and routine care specifically, medication prescription and a brief counseling about the KOA treatment.
• The control group (II): was exposed to the routine care without any interference from the researcher.
Then, the study was carried out on four phases:
• Assessment phase:
Initial assessment was carried out for both groups (study and control) immediately once the participant was eligible for study before application of the integrated exercise program to collect baseline data using all tools.
• Planning phase:
Based on the data obtained from the assessment phase and review of the related literature, the integrated exercise program was developed. It consisted of two main components (1) exercises, and (2) behavior change interventions. The former was developed based on a neuromuscular model, and the latter was developed based on stages of motivational readiness for change model. The goals, and expected outcomes of the program were established, as well as the illustrative colored booklet and audiovisual aids were prepared by the researcher for the study group in the implementation phase.
• Implementation phase:
The integrated exercise program was implemented individually for each participant of the study group in the above mentioned setting using discussion, problem solving, demonstration, redemonstration and colored booklet. In total, the integrated exercise program comprised of 18 sessions; held three sessions a week on alternate days for 6 weeks in succession. Each session lasted for 90 minutes; namely 30 minutes behavior change interventions, and 60 minutes exercises.
• Evaluation phase:
All participants were evaluated two times immediately before the integrated exercise program implementation, and immediately post finishing the program using all tools.
Results:
The main results of the study were:
• At baseline, both studied groups were well balanced, with no statistically significant difference in all outcomes measures.
• After implementing the integrated exercise program, patients in study group reported a statistically and clinically significant increments in:
The self reported physical function and disease specific health status, and the largest increments was in the ADL domain (Δ = 20.4 [95% CI -25.0--15.8], P = <0.001).
The pain level (Δ = -2.72[95% CI -3.3 - -2.1], P = <0.001).
The knee extension, and flexion (Δ = 0.48 [95% CI -0.8 - -0.2], P = 0.005), and (Δ = +5.80[95% CI 4.6 - 7.0], P = <0.001), respectively.
The quadriceps muscle strength (Δ = -0.77[95% CI -0.93 - -0.60], P = 0.003).
The physical functions performance tests namely; GUG (Δ = -1.53[95% CI -1.9 - -1.2], P = <0.001), 40m FPWT (Δ = -2.91[95% CI -3.5 - -2.29], P = <0.001), and 30s-CST (Δ = +3.24[95% CI -3.8 - -2.6], P = <0.001).
• All measures of self reported physical function and disease specific health status, pain intensity, physiological parameters, and physical functions performance showed a large effect size (ES). Except for sports and recreation activates which was intermediate (ES= 0.79), and knee extension which had a small effect size (ES= 0.24).
• On individual level, 48% to 84% had a meaningful change in the self reported physical function and disease specific health status following the integrated exercise program.
• Finally, 48% to 76% of the control group would be spared from a decline in the self reported physical function and disease specific health, if they had exposed to the integrated exercise program.
Conclusion:
The integrated exercise program offers a viable treatment option to decrease the intensity of pain and symptoms associated with KOA, as well as to improve the performance of daily living activities. Also, it allowed patients to enhance their quadriceps muscle strength, knee range of motion, and physical function.
Recommendations
The integrated exercise program appears promising to improve physical functions for women with moderate KOA, and is recommended as part of an overall treatment regimen.