Hindawi

Journal of Osteoporosis
Volume 2017, Article ID 3905492, 7 pages
https://doi.org/10.1155/2017/3905492

Research Article
Exercise Training in Treatment and Rehabilitation of Hip
Osteoarthritis: A 12-Week Pilot Trial

Kirsti Uusi-Rasi,1 Radhika Patil,1 Saija Karinkanta,1 Kari Tokola,1

Pekka Kannus,1,2 and Harri Sievänen1
1
The UKK Institute for Health Promotion Research, Tampere, Finland
2
Department of Orthopaedics and Trauma Surgery, Tampere University Hospital and Medical School,
University of Tampere, Tampere, Finland

Correspondence should be addressed to Kirsti Uusi-Rasi; [email protected]

Received 7 July 2016; Accepted 30 November 2016; Published 1 January 2017

Academic Editor: Merry Jo Oursler

Copyright © 2017 Kirsti Uusi-Rasi et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction. Osteoarthritis (OA) of the hip is one of the major causes of pain and disability in the older population. Although
exercise is an effective treatment for knee OA, there is lack of evidence regarding hip OA. The aim of this trial was to test the safety
and feasibility of a specifically designed exercise program in relieving hip pain and improving function in hip OA participants and to
evaluate various methods to measure changes in their physical functioning. Materials and Methods. 13 women aged ≥ 65 years with
hip OA were recruited in this 12-week pilot study. Results. Pain declined significantly over 30% from baseline, and joint function
and health-related quality of life improved slightly. Objective assessment of physical functioning showed statistically significant
improvement in the maximal isometric leg extensor strength by 20% and in the hip extension range of motion by 30%. Conclusions.
The exercise program was found to be safe and feasible. The present evidence indicates that the exercise program is effective in the
short term. However, adequate powered RCTs are needed to determine effects of long-term exercise therapy on pain and progression
of hip OA.

1. Introduction with hip OA. A Cochrane review by Fransen et al. included 10

exercise trials [6], and only 5 recruited solely patients with hip
Osteoarthritis (OA) is a common disease presenting with OA [7–10]; one of these was presented as an abstract only [11].
joint pain, stiffness, swelling, and instability resulting in Five other included studies had mixed sample of hip and knee
functional impairment in daily activities. Due to its high OA patients with the proportion of hip OA in these combined
prevalence in the older population, OA has a major impact programs being always smaller than the proportion with knee
on healthcare costs globally. Pharmacological treatment is not OA [12–16]. However, the results are inconsistent.
recommended as the primary treatment for OA [1–3], and Programs developed for OA of the lower limbs seem to
effects of various physical therapy techniques on relieving benefit patients with knee OA more than those with hip
pain or improving joint function have remained rather small OA. Juhl et al. found that exercise programs for knee OA
[4]. Consequently, symptomatic hip OA often leads to hip should focus on improving aerobic capacity, quadriceps mus-
replacement surgery. cle strength, or lower extremity performance. For optimal
The main treatment goal in OA is to reduce joint pain results, the program should be supervised and carried out 3
and minimize physical disability [5]. Effectiveness of aerobic times weekly and comprise at least 12 sessions [17].
and strength training is recommended as the first-line conser- Exercise therapy aims at reducing pain and disability by
vative treatment approach in adults with mild-to-moderate improving muscle strength, joint stability, range of motion
knee OA [3]. Despite current national and international (ROM), and aerobic fitness [10]. Whereas training focusing
guidelines for the use of exercise in patients with hip OA, very on improved muscle strength and aerobic capacity is known
few clinical exercise trials have been conducted in patients to alleviate OA symptoms, effects of exercise need further
2 Journal of Osteoporosis

elucidation [18]. Patients with hip OA are assumed to respond Scale, with a possible range of scores of 0–100 mm. Items
to exercise in the same way as patients with other chronic are summed for each subscale, pain (range = 0–500 mm, 5
lower limb pain conditions do. Hip OA patients need specif- items), stiffness (range = 0–200 mm, 2 items), and physical
ically developed and executed exercise training to ensure function (range = 0–1700 mm, 17 items), and for the total
adequate compliance [19]. WOMAC Index (range: 0–2400 mm). Self-reported disease-
Thus, more effective, feasible, and sustainable exercise specific disability was assessed using the pain and functioning
protocols for hip OA are needed for further developing thera- subscales at baseline and at 12 weeks [23]. Quality of life was
peutic exercise recommendations for the disease. The present assessed by the LEIPAD questionnaire [24].
12-week pilot trial aimed to test the safety and feasibility of a
specifically designed exercise program in relieving hip pain 2.4. Hip Joint Assessment and Physical Functioning. Physical
and improving function in hip OA subjects and to evaluate functioning (strength, balance, and mobility) was measured
methods to measure changes in physical functioning. objectively. The maximal isometric leg extensor muscle
strength was measured by a leg press dynamometer. Timed-
2. Participants and Methods Up and Go (TUG) [25], the Short Physical Performance
Battery (SPPB) (static balance, 4-meter walking speed and
2.1. Participants. Participants were recruited from the wait- five-time chair stand) [26], 9-step stair climb 20 cm [27], and
ing list of the orthopedic outpatient clinic of Hatanpää hip ROM [28] were assessed. Postural balance was assessed
and COXA Hospital (specialized in joint replacements) in using the force platform (Good Balance, Metitur, Jyväskylä,
Tampere, Finland. Thirteen women aged between 65 and Finland) [29]. The system uses vertical force signals from each
83 years, with moderate or severe restrictions in mobility, corner of the platform to calculate x (mediolateral, ML) and
debilitating pain, and difficulties in walking, stair climbing, or y (anteroposterior, AP) coordinates of the platform center of
putting on shoes, volunteered to participate in this pilot trial pressure (COP) when the test person stood on it. Mean ML
and gave informed consent. A health history questionnaire and AP velocity (mm/s) and moment of velocity (mm2 /s)
screened for self-reported health, comorbidities, medication, were calculated. Balance was tested in the normal standing
and lifestyle (physical activity, use of alcohol, and smoking). position in four test conditions: eyes open, eyes closed, eyes
Participants were then invited to a baseline examination, open with cognitive task (mental arithmetic), and eyes open
which included a physician’s examination, questionnaires, while standing on a foam sheet. Pedometers (Omron WS
and measurements of physical functioning (strength, balance, III; Omron Healthcare, Inc., Lake Forest, IL) were used
and mobility). throughout the 12-week period for objective assessment of
Inclusion criteria were age ≥ 65 years, living at home daily steps taken.
independently, and unilateral or bilateral hip OA with pain
in the hip region (groin and lateral hip) during the pre- 2.5. Training Program. Training was led or implemented
ceding month. Exclusion criteria were bilateral total hip as circuit training sessions by experienced exercise leaders
replacement, moderate-to-severe knee OA, fracture during (physiotherapists) 3 times a week for 12 weeks. Five sessions
the preceding 12 months, and chronic conditions such as were offered weekly, from which participants could select
rheumatoid arthritis or major surgical procedures in the any three. Training was started with a 2-week familiarizing
preceding 6 months (lower limb or lower back). Medication period to accustom the participants to the exercise, followed
used was not an inclusion or exclusion criterion. by 5 weeks in the exercise hall and 5 weeks in the gym. All
This study was conducted according to the guidelines of sessions lasted 60 minutes and included a 10-minute warm-
good clinical practice, and the study protocol was approved up as well as stretching for major muscle groups. Exercise
by the Pirkanmaa Hospital District Ethics Committee, Tam- leaders kept a record of participants’ attendance and possible
pere, Finland (R15004). adverse events.
Training was progressive and was implemented as group-
2.2. Anthropometry. Height and weight were measured with based sessions but was planned with individual goals and
standard methods. Body composition (fat and lean soft limitations in mind. Sessions in the exercise hall focused
tissue mass) and femoral neck bone mineral density were on range of motion, lower limb muscle strength, balance,
assessed with dual-energy X-ray absorptiometry (DXA, agility, mobility, and change of direction. Progression was
Lunar Prodigy Advance, GE Lunar, Madison, WI, USA) [20]. achieved with the use of different surfaces, multidirectional
DXA measurement was performed only at baseline. All other movement patterns, and changing the base of support. In
measurements described below were done at baseline and at addition to own body weight, ankle or vest weights and step-
12 weeks. boards of increasing height were used to increase the intensity
of training. Advanced programs were also aerobic in nature.
2.3. Pain and Self-Reported Physical Function. The primary During the gym sessions, resistive equipment was used.
outcome of the study was hip joint pain assessed by the All sessions included 8-9 different exercises focusing on
Western Ontario and McMaster University Osteoarthritis strengthening lower limb muscles (leg extensors, hip exten-
Index [21] (WOMAC, Finnish version [22]). WOMAC pro- sors, hip abductors, hip rotators, knee extensors, and calf
duces three subscale scores (pain, stiffness, and physical muscles) as well as other large muscle groups (abdominal,
function) and a total score (WOMAC Index) that reflects back, shoulder, and arm muscles). The first gym period began
overall disability. Each item is assessed on a Visual Analog with 30–60% of one repetition maximum (1RM) progressing
Journal of Osteoporosis 3

Table 1: Characteristics of the participants (mean (SD)).

Baseline End point

Daily walking, mean steps in 12 wks 5195 (2133) NA
Mini-Mental State Examination Score (0–30)1 27.8 (2.3) NA
Body fat, %1 42.5 (6.4) NA
Femoral neck 𝑡-score1,2 0.01 (0.93) NA
WOMAC
Total index (range: 0–2400) 796 (576) 583 (652)
Pain score (range: 0–500) 202.4 (123.4) 131.9 (143.6)
Stiffness score (range: 0–200) 99.1 (63.5) 76.8 (54.2)
Function score (range: 0–1700) 494.5 (413.9) 375.0 (474.1)
Physical functioning
Normal walking speed, m/s 0.9 (0.2) 0.9 (0.2)
Fast walking speed, m/s 1.2 (0.2) 1.75 (1.8)
TUG, s 9.1 (1.5) 10.5 (2.2)
Chair stand time, s 14.8 (3.3) 14.2 (2.6)
Stair climb, s 11.5 (1.9) 12.2 (2.4)
Isometric leg extensor strength, N/kg 19.3 (8.0) 23.2 (10.2)
SPPB score (0–12) 9.9 (1.2) 9.9 (1.9)
Balance
ML velocity, eyes open, mm/s 3.7 (2.3) 4.7 (2.5)
AP velocity, eyes open, mm/s 6.7 (2.8) 8.7 (6.3)
Moment of velocity, eyes open, mm2 /s 8.8 (5.6) 15.1 (13.0)
ROM
Hip abduction, arthritic side 33.2 (11.5) 33.8 (11.2)
Hip abduction, healthy side 42.0 (7.2) 42.6 (6.8)
Hip flexion, arthritic side 96.2 (10.2) 98.8 (14.2)
Hip flexion, healthy side 104.0 (10.7) 103.5 (11.4)
Hip extension, arthritic side 12.1 (4.5) 15.8 (5.9)
Hip extension, healthy side 16.8 (5.5) 19.5 (7.0)
1
Only baseline measurements.
2
Femoral neck bone density compared to reference population from Finland (age: 20–40 years).

to 60–75% of 1RM over 5 weeks. Two sets of each exercise 3. Results

were done, with each set consisting of 8–12 repetitions.
Intensity of training was assessed using the rate of perceived Baseline characteristics are given in Table 1. All participants
exertion scale (RPE). The target RPE ranged from 13 to 18 and were nonsmoking women with mean age (SD) of 71.6 (6.0)
advanced progressively. Balance training was included in a years. Mean height was 163.5 (7.0) cm, weight was 76.5
short warm-up period. Detailed description of the training (12.3) kg, and body mass index (BMI) was 28.5 (3.3) kg/m2 .
program is presented in Table 2. Weight remained constant [mean change: 0.1 (1.9) kg, 𝑝 =
NS] during the 12-week intervention. Three women had no
2.6. Statistical Analysis . Descriptive information is presented diagnosed illness other than hip OA, and the most common
as means and standard deviations (SD). Paired t-tests were medication was for high blood pressure (𝑛 = 8). No changes
used to compare changes over time (12 weeks) in pain and were made in OA medication during the intervention. The
physical functioning. Results related to WOMAC scores, most often used medication was the NSAIDs (nonsteroid
physical functioning, and quality of life are presented as per- anti-inflammatory drugs).
cent changes with 95% confidence intervals (CI). 𝑝 values less
than 0.05 were considered statistically significant. Because the 3.1. Safety and Feasibility of the Program. Exercise compli-
purpose of this pilot study was to test the feasibility and safety ance measured as attendance at all offered sessions was 90%
of the exercise program, power calculations for treatment (range: 42% to 100%), and all participants attended the end
effects were not done. point measurements. In general, the training program was
 4

Table 2: Detailed description of the training program.

Period Description Movements and Execution
Group training, weeks 1 and 2
Introduction (i) 10 min warm-up Warm-up and balance training in standing position
to exercise (ii) 20 min balance and agility exercises Strength and mobility while training partly while sitting on a chair
hall, 2 weeks (iii) 20 min muscle strength, flexibility, and mobility exercises Stretching while sitting on a chair
(iv) 10 min stretching
Balance and mobility:
(i) Reducing base of support using different foot positions in standing
Group training, weeks 3, 5, and 7 (ii) Swaying, reaching out in different directions
(i) 10 min warm-up (iii) Changing directions and speed during walking, multidirectional stepping patterns
(ii) 20 min balance and agility exercises (iv) Stepping over obstacles and using different surfaces for walking and stepping
(iii) 20 min muscle strength, flexibility, and mobility exercises Muscle strength:
I period:
(iv) 10 min stretching (i) Knee extension in sitting position and flexion in standing position
exercise hall,
Circuit training, weeks 4 and 6: (ii) Hip abduction, flexion, and extension in standing position
5 weeks
8 movements, 1 min work, 1 min rest, 2 rounds (iii) Sit to stand, squats, and heel raises (with or without support of a chair)
(i) 10 min warm-up (iv) Step board exercises with varying height
(ii) 40 min balance, agility, mobility, and muscle strengthening (v) Trunk flexion and extension in sitting position
(iii) 10 min stretching (vi) Body weight, resistance bands, or ankle weights for resistance
Flexibility and joint mobility:
(i) Hip area, spine, upper limbs, and shoulder-neck region
Flexibility and joint mobility:
Introduction, week 8 (i) Leg press
Circuit training in pairs, weeks 9–12 (ii) Hip abduction
(i) 10–15 min warm-up emphasizing balance and mobility exercises (iii) Standing up from the chair (using a weight vest)
Introduction (ii) 40 min training especially for the lower limbs (iv) Hip extension
to gym II (iii) 5–10 min stretching (v) Hip flexion
period: in the (iv) 6–8 exercises, 10–12 repetitions, 2 sets with 2 min rest (vi) Hip rotation
gym, 4 weeks (v) First 4 weeks, progression from the level 30% 1RM to 60% 1RM: (vii) Heel rise with a weight vest
target 60–65% 1RM (viii) Back extension
(vi) Weekly 5–10% increase in resistance, accompanied by (ix) One limb chest press with body rotation
reduction in the number of repetitions (x) Rowing, sawing
(xi) Squatting with pulley weights
Journal of Osteoporosis
Journal of Osteoporosis 5

Changes (%)
WOMAC
Pain
Function
Stiffness
ROM
Extension
Flexion
Abduction
Physical functioning
Leg extensor strength
Stair climb
Chair stand
TUG
Fast walking
Normal walking

Quality of life
−40 −20 0 20 40 60 80
Favors training (%)

Figure 1: Mean changes (95% CI) in the main outcome variables in 12 weeks.

500 Pain 3.3. Effects on Physical Functioning. Mean SPPB score was
9.9 (1.2) at baseline, with no change at 12 weeks. Also,
450 there were no significant changes in walking speed, chair
stand, or step climbing times. Mean (95% CI) isometric leg
400
extensor strength increased by 3.8 (1.1 to 6.6) N/body weight.
350 Unexpectedly, mean TUG time was 1.4 s (0.6 to 2.2 s) slower
at 12 weeks compared to baseline (Figure 1). Postural sway
300 with eyes open showed a trend for small 6.3 (−0.3 to 12.9,
𝑝 = 0.06) mm2 /s increase in moment of velocity. Closing
(mm)

250
eyes, adding a cognitive task, and standing on foam increased
200 sway and velocity compared with the eyes open test, with
no statistically significant changes (results not shown). Hip
150 extension ROM increased significantly, with the mean change
100
being 30% (7% to 54%), but no significant changes were
found in hip abduction or flexion. There was a trend for
50 improvement in quality of life, with mean change of 13.8%
(−2.4 to 29.9%, 𝑝 = 0.09).
0
Baseline 12 weeks

Figure 2: Individual changes in the WOMAC pain score in 12 weeks. 4. Discussion

The mean (SD) pain score at the baseline and 12-week time point is
marked with a dot being 202 (123) mm and at 12-week time point 131 The significant 30% reduction found in pain is large enough
(143) mm, respectively (reduction 35%, 𝑝 = 0.002). to be considered clinically relevant [9, 12]. Thus, the results
of this pilot trial support and further develop the specific
exercise program for rehabilitation of hip OA.
well tolerated and no one consulted the attending physician Besides pain, the purpose of the training was to improve
(PK), although one participant withdrew from the training joint function which was also largely achieved. Importantly,
due to back pain (additional diagnosis of prolapsus disci isometric leg extensor muscle strength improved statistically
intervertebralis was done during the intervention). significantly by 20% and hip extension ROM by 30%. How-
ever, no improvements in ROM of the hip flexion or abduc-
3.2. Effects on Pain, Stiffness, and Function. Mean changes tion were seen, possibly because both strengthening and
(95% CI) in the outcomes of interest are shown in Table 1 ROM exercises were mainly targeted towards improving hip
and Figure 1. Mean reduction in the WOMAC pain score was extension. Other outcomes of physical functioning remained
35% (8% to 62%), with large individual variations; decline unchanged or only showed a trend for improvement. Surpris-
was seen in 9 of 13 participants (Figure 2). Reduction in the ingly, the TUG test even showed 15% worsening in spite of
stiffness or function scores was also seen but did not reach reduced pain and improved leg strength and hip ROM.
statistical significance. The total WOMAC Index reduced by Hip OA may reduce postural stability, increasing the
27% (−4% to 57%, 𝑝 = 0.079). risk of falling. In our study, postural sway with eyes open
6 Journal of Osteoporosis

increased slightly, as did hip extension ROM. This may indi- and performance techniques to avoid aggravation of joint
cate that the participants have better confidence in maintain- symptoms. This resulted in excellent training compliance
ing stability as a result of training, not necessarily declined over 12 weeks. Compliance may be more difficult to maintain
balance [30]. Similarly, Nagy et al. showed greater sway in over a longer duration.
older adults after 8-week balance, strength, flexibility, and
aerobic training in spite of improved functional performance.
This might have been due to improved balance confidence
5. Conclusions
related to trainees’ better ability to control the motion of their Exercise programs focusing on improving aerobic capacity,
hip and lower limbs [31]. It has also been shown that time of quadriceps muscle strength, or lower extremity performance
day effect in postural sway measurements is high especially carried out 3 times weekly comprising at least 12 sessions
in older adults [32]. In this study, the baseline and end point have been considered optimal treatment for knee OA. These
measurements were done at the same time of the day. principles were followed in planning the exercise program for
Wide individual variation in training responses and the hip OA. The training program was found to be feasible and
small study sample possibly confounded some of the findings. safe, though it was of a short duration. This study supports
OA is a disease with intermittent symptoms aggravated by the use of exercise training in reducing hip OA pain. Further
various factors such as activity levels, lifestyle, and even time controlled studies with larger group sizes are needed to
of day [33]. These may affect performance in mobility tests, determine the long-term benefits of exercise and its effects
such as the TUG and stair climbing. Therefore, in addition to on the progression of the disease.
a larger study group, a longer follow-up period with a control
group with more than two measurement points is needed to
evaluate the effects of exercise. Competing Interests
The recent Cochrane review by Fransen et al. demon-
The authors declare that they have no competing interests.
strated a significant improvement with exercise in self-
reported pain and physical function among the small subset
of participants with hip OA only, but the pain reduction was References
rather small [6]. Physical functioning was assessed objectively
in only two studies [8, 9], and no between-group differences [1] M. C. Hochberg, R. D. Altman, K. T. April et al., “American
were observed. Results from more recent meta-analysis of College of Rheumatology 2012 recommendations for the use of
nonpharmacologic and pharmacologic therapies in osteoarthri-
land-based exercise for hip OA remain consistent with the
tis of the hand, hip, and knee,” Arthritis Care & Research, vol. 64,
Cochrane review. Similarly, water-based exercise therapy no. 4, pp. 465–474, 2012.
showed slight pain relief in patients with hip OA in the
short term [34]. However, water-based exercise therapy is not [2] W. Zhang, G. Nuki, R. W. Moskowitz et al., “OARSI recommen-
dations for the management of hip and knee osteoarthritis. Part
always feasible. Also, no benefits of physical therapy either
III: changes in evidence following systematic cumulative update
combined with exercise or alone have been found, both in of research published through January 2009,” Osteoarthritis and
terms of self-reported pain or function and in objectively Cartilage, vol. 18, no. 4, pp. 476–499, 2010.
measured changes in physical functioning [4, 34].
[3] J. P. Arokoski, A. Eskelinen, E.-K. Helminen et al. et al.,
Whereas pain relief is the most important outcome, Käypä hoito—suositus, Polvi-ja lonkkaniverikko, Suomalainen
physical functioning ought to be evaluated objectively as well, Lääkäriseura Duodecim, 2012, http://www.kaypahoito.fi/.
because it is difficult to attain long-term benefits without clin-
[4] K. L. Bennell, T. Egerton, J. Martin et al., “Effect of physical
ically meaningful improvements in function. Twelve weeks is
therapy on pain and function in patients with hip osteoarthritis:
a short time for effective progression in training. Progressing a randomized clinical trial,” JAMA, vol. 311, no. 19, pp. 1987–1997,
too rapidly could worsen pain, likely discouraging patients 2014.
to continue training. On the other hand, too light exercise
[5] M. H. Arokoski, J. P. A. Arokoski, M. Haara et al., “Hip muscle
may remain ineffective. In spite of the short duration, our strength and muscle cross sectional area in men with and
results were encouraging. Most other exercise trials in hip without hip osteoarthritis,” The Journal of Rheumatology, vol. 29,
OA patients have also been of short duration, mainly between no. 10, pp. 2185–2195, 2002.
6 and 12 weeks, with some benefits reported immediately [6] M. Fransen, S. McConnell, G. Hernandez-Molina, and S.
at the end of the intervention. Only two studies evaluated Reichenbach, “Exercise for osteoarthritis of the hip,” The
sustained benefits for physical function [7, 9], with neither Cochrane database of systematic reviews, vol. 4, 2014.
demonstrating a significant reduction in pain. One reason
[7] L. Fernandes, K. Storheim, L. Sandvik, L. Nordsletten, and M. A.
for this may be the fact that the participants had relatively Risberg, “Efficacy of patient education and supervised exercise
low WOMAC pain scores, with less room for improvement. vs patient education alone in patients with hip osteoarthritis:
This suggests that the frequency or intensity of exercise a single blind randomized clinical trial,” Osteoarthritis and
was too low or duration was too short to improve physical Cartilage, vol. 18, no. 10, pp. 1237–1243, 2010.
functioning. [8] H. P. French, T. Cusack, A. Brennan et al., “Exercise and
Effective exercise in hip OA also requires motivated manual physiotherapy arthritis research trial (EMPART) for
participants. Our training was started at low intensity and osteoarthritis of the hip: a multicenter randomized controlled
level of difficulty. Since group sizes were small, the leaders trial,” Archives of Physical Medicine and Rehabilitation, vol. 94,
were able to pay individual attention to optimal joint loading no. 2, pp. 302–314, 2013.
Journal of Osteoporosis 7

[9] R. Juhakoski, S. Tenhonen, A. Malmivaara, V. Kiviniemi, T. [23] N. F. Woolacott, M. S. Corbett, and S. J. C. Rice, “The use and
Anttonen, and J. P. A. Arokoski, “A pragmatic randomized reporting of WOMAC in the assessment of the benefit of phys-
controlled study of the effectiveness and cost consequences of ical therapies for the pain of osteoarthritis of the knee: findings
exercise therapy in hip osteoarthritis,” Clinical Rehabilitation, from a systematic review of clinical trials,” Rheumatology, vol.
vol. 25, no. 4, pp. 370–383, 2011. 51, no. 8, Article ID kes043, pp. 1440–1446, 2012.
[10] E. Tak, P. Staats, A. Van Hespen, and M. Hopman-Rock, [24] D. De Leo, R. F. W. Diekstra, J. Lonnqvist et al., “LEIPAD, an
“The effects of an exercise program for older adults with internationally applicable instrument to assess quality of life in
osteoarthritis of the hip,” The Journal of Rheumatology, vol. 32, the elderly,” Behavioral Medicine, vol. 24, no. 1, pp. 17–27, 1998.
no. 6, pp. 1106–1113, 2005. [25] D. Podsiadlo and S. Richardson, “The timed “Up and Go”: a test
[11] N. L. Carlson, Z. Christopherson, E. Arnall et al., “A pilot study of basic functional mobility for frail elderly persons,” Journal of
of the effects of strength and aerobic conditioning in patients the American Geriatrics Society, vol. 39, no. 2, pp. 142–148, 1991.
with hip osteoarthrotis,” Osteoarthritis and Cartilage, vol. 19, [26] J. M. Guralnik, E. M. Simonsick, L. Ferrucci et al., “A short
supplement 1, p. S212, 2011. physical performance battery assessing lower extremity func-
[12] J. H. Abbott, M. C. Robertson, C. Chapple et al., “Manual tion: association with self-reported disability and prediction of
therapy, exercise therapy, or both, in addition to usual care, for mortality and nursing home admission,” Journals of Gerontol-
osteoarthritis of the hip or knee: a randomized controlled trial. ogy, vol. 49, no. 2, pp. M85–M94, 1994.
1: clinical effectiveness,” Osteoarthritis and Cartilage, vol. 21, no. [27] W. J. Rejeski, W. H. Ettinger Jr., S. Schumaker, P. James, R. Burns,
4, pp. 525–534, 2013. and J. T. Elam, “Assessing performance-related disability in
[13] A. Foley, J. Halbert, T. Hewitt, and M. Crotty, “Does hydrother- patients with knee osteoarthritis,” Osteoarthritis and Cartilage,
apy improve strength and physical function in patients with vol. 3, no. 3, pp. 157–167, 1995.
osteoarthritis—a randomised controlled trial comparing a gym [28] Y.-H. Pua, T. W. Wrigley, S. M. Cowan, and K. L. Bennell,
based and a hydrotherapy based strengthening programme,” “Intrarater test-retest reliability of hip range of motion and hip
Annals of the Rheumatic Diseases, vol. 62, no. 12, pp. 1162–1167, muscle strength measurements in persons with hip osteoarthri-
2003. tis,” Archives of Physical Medicine and Rehabilitation, vol. 89, no.
[14] M. Hopman-Rock and M. H. Westhoff, “The effects of a 6, pp. 1146–1154, 2008.
health educational and exercise program for older adults with [29] P. Era, P. Sainio, S. Koskinen, P. Haavisto, M. Vaara, and A.
osteoarthritis of the hip or knee,” Journal of Rheumatology, vol. Aromaa, “Postural balance in a random sample of 7,979 subjects
27, no. 8, pp. 1947–1954, 2000. aged 30 years and over,” Gerontology, vol. 52, no. 4, pp. 204–213,
[15] M. E. van Baar, J. Dekker, R. A. B. Oostendorp et al., “The 2006.
effectiveness of exercise therapy in patients with osteoarthritis [30] Y.-C. Pai, “Movement termination and stability in standing,”
of the hip or knee: a randomized clinical trial,” The Journal of Exercise and Sport Sciences Reviews, vol. 31, no. 1, pp. 19–25,
Rheumatology, vol. 25, no. 12, pp. 2432–2439, 1998. 2003.
[16] M. Fransen, L. Nairn, J. Winstanley, P. Lam, and J. Edmonds, [31] E. Nagy, A. Feher-Kiss, M. Barnai, A. Domján-Preszner, L.
“Physical activity for osteoarthritis management: a randomized Angyan, and G. Horvath, “Postural control in elderly subjects
controlled clinical trial evaluating hydrotherapy or Tai Chi participating in balance training,” European Journal of Applied
classes,” Arthritis Care & Research, vol. 57, no. 3, pp. 407–414, Physiology, vol. 100, no. 1, pp. 97–104, 2007.
2007.
[32] M. G. Jorgensen, M. S. Rathleff, U. Laessoe, P. Caserotti, O. B.
[17] C. Juhl, R. Christensen, E. M. Roos, W. Zhang, and H. Lund,
F. Nielsen, and P. Aagaard, “Time-of-day influences postural
“Impact of exercise type and dose on pain and disability in knee
balance in older adults,” Gait & Posture, vol. 35, no. 4, pp. 653–
osteoarthritis: a systematic review and meta-regression analysis
657, 2012.
of randomized controlled trials,” Arthritis and Rheumatology,
vol. 66, no. 3, pp. 622–636, 2014. [33] R. Altman, G. Alarcón, D. Appelrouth et al., “The American col-
lege of rheumatology criteria for the classification and reporting
[18] S. Glyn-Jones, A. J. R. Palmer, R. Agricola et al., “Osteoarthritis,”
of osteoarthritis of the hip,” Arthritis and Rheumatism, vol. 34,
The Lancet, vol. 386, no. 9991, pp. 376–387, 2015.
no. 5, pp. 505–514, 1991.
[19] L. M. Bearne, N. E. Walsh, S. Jessep, and M. V. Hurley,
[34] L. Beumer, J. Wong, S. J. Warden, J. L. Kemp, P. Foster, and
“Feasibility of an exercise-based rehabilitation programme for
K. M. Crossley, “Effects of exercise and manual therapy on
chronic hip pain,” Musculoskeletal Care, vol. 9, no. 3, pp. 160–
pain associated with hip osteoarthritis: a systematic review and
168, 2011.
meta-analysis,” British Journal of Sports Medicine, vol. 50, no. 8,
[20] K. Uusi-Rasi, A. Rauhio, P. Kannus et al., “Three-month pp. 458–463, 2016.
weight reduction does not compromise bone strength in obese
premenopausal women,” Bone, vol. 46, no. 5, pp. 1286–1293,
2010.
[21] N. Bellamy, W. W. Buchanan, C. H. Goldsmith, J. Campbell,
and L. W. Stitt, “Validation study of WOMAC: a health status
instrument for measuring clinically important patient relevant
outcomes to antirheumatic drug therapy in patients with
osteoarthritis of the hip or knee,” Journal of Rheumatology, vol.
15, no. 12, pp. 1833–1840, 1988.
[22] J. V. Soininen, P. O. Paavolainen, M. A. Gronblad, and E. H.
Kaapa, “Validation study of a Finnish version of the Western
Ontario and McMasters University osteoarthritis index,” HIP
International, vol. 18, no. 2, pp. 108–111, 2008.
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