Physical Therapy Protocols

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 ♦ Management of Osteoarthritis:

» Osteoarthritis Research Society International (OARSI) Recommended Management of Knee & Hip Osteoarthritis:

Following are the 25 OARSI recommendation for management of Osteoarthritis:

(Zhang, W., et al., 2008 [1]) - Click on image to enlarge

» Proposed Management of Knee Osteoarthritis:

(Hochberg, M.C., et al., 1995 & Lane, N.E., et al., 1997 [2,3])

- Click on image to enlarge

» Proposed Management of Hip Osteoarthritis:

(Lane, N.E., et al., 1997; Hochberg, M.C., et al., 1995 [3,4])

- Click on image to enlarge

 ♦ Physical Therapy Management of Osteoarthritis:

• GOALS OF PHYSICAL THERAPY:
  • Prevent and minimize impairments
  • Prevent and improve functional limitations
  • Reduce levels of disability resulting from arthritis
• Physical therapy goals are accomplished through
  • Examination
  • Assessment
  • Development of individual treatment plans to address each person's functional limitations.
• Physical therapists use their understanding of pathomechanics to design and implement interventions to prevent or improve the patient's impairments 
  • Thermal and Electrical Agents
  • Exercise
  • Assistive Devices
  • Patient Education
  • Counseling
• Intervention by physical therapists is appropriate at all stages of the care continuum, from primary and secondary prevention through postsurgical rehabilitation.

 » Modalities:

• Various passive modalities have been used in patients with osteoarthritis, with varying degrees of support within the medical literature.
  • Shortwave Diathermy (SWD)
  • Paraffin Wax Bath
  • Cryotherapy
  • Electrical Stimulation (ES)
  • Ultrasound (US)
  • Transcutaneous Electrical Nerve Stimulation (TENS)

 » Philadelphia Panel Evidence Based Clinical Practice Guidelines on Selected Rehabilitation Interventions for Knee Osteoarthritis:

 (Philadelphia Panel, 2001 [5]) - Click on image to enlarge

» Thermal Modalities:

• Appropriate use of heat before stretching can help loosen tight periarticular muscles.
• RATIONAL FOR HEAT: [6]
  • Muscle relaxation is promoted with vasodilatation.
  • The extensibility of collagen tissue is increased.
  • Nonelastic fibrous tissue, joint capsules, and scar tissue as well as tendons will yield to prolonged stretching when heated as a result of the changes occurring in the viscoelastic properties of the tissues.
  • Superficial heat can also decrease joint stiffness by decreasing tension in the periarticular structure.
• Paraffin Wax Bath use with exercise produced significant improvements in range of motion and grip function.
  • Controversy exists whether deep heating agents that increase intra-articular temperature are beneficial [7] or detrimental [8] when applied to actively inflamed joints.
• Continuous Shortwave Diathermy or Pulsed Shortwave Diathermy can be used as heating modality for pain relieve but its effectiveness is not clear in literature[9, 10].
• Therapeutic Ultrasound has been shown to have no benefit for osteoarthritis [11].
• Research have shown that Cryotherapy is more beneficial effect on ROM, function, strength and sweeling than heat for osteoarthritis cases [12, 13].
• RATIONAL FOR COLD:
  • Cryotherapy numbs pain, reduces joint swelling, constricts blood vessels, and block nerve impulses to the affected joint.
• Application of ice packs after exercise can reduce the need for analgesic medications.
  • Commercial cold packs
  • Cold compression units
  • Ice massage
  • Cold bath

» Electrical Stimulation:

 

 

 

 

 

• Electrical Stimulation has been used as an treatment option since decades. Many different types of stimulation can be used for the treatment of osteoarthritis.
  • Electrical Stimulation (ES)
  • Neuromuscular Electrical Stimulation (NMES)
  • Pulsed-Electrical Stimulation (P-ES)
  • Transcutaneous Electrical Nerve Stimulation (TENS)
• Many studies have supported that electrical stimulation has beneficial effect on osteoarthritis [14, 15, 16, 17].
• RATIONAL FOR STIMULATION: [18]
  • Strengthens muscles by activating motor units that induce action potentials in the motor nerve.
  • NMES minimizes the extent of atrophy.
  • NMES provides proprioceptive, kinesthetic, and sensory input directly to the muscle.
  • Pain Relief by gate-control theory developed by Melzack and Wall [19].

 ♦ Therapeutic Exercises in Osteoarthritis:

• Therapeutic exercise is the systematic implementation of planned physical movements, postures, or activities designed to: [20]
  • Remediate or prevent impairments
  • Enhance function
  • Enhance fitness and well-being
• In Osteoarthritis, common impairments to be addressed by therapeutic exercises are as follows: [21]
  • Range of Motion
  • Decreased Strength 
  • Cardiovascular Endurance
• The therapeutic exercise program must be designed with the specific stage of the disease process in mind, the number of joints involved, and the degree of inflammation.
  • Acute - Goals of therapeutic exercise are to decrease pain and inflammation and to maintain range of motion and strength without aggravating the inflamed joints [22, 23].
  • Subacute or Chronic - Goals of therapeutic exercise are to progressively increase muscle strength, range of motion, and function [22, 23].

» Range of Motion Exercises:

• Maintaining joint ROM is important to counter OA's tendencies toward progressively worsening ROM [24].
• Pathophysiology of ROM deficits are multifactorial
  • Articular changes within the joint
  • Shortening of myotendinous structures in areas of pain or weakness
  • Joint Stiffness
• Decreased ROM is often found not only at the osteoarthritis joint but also at other joints within the same lower limb and even in the contralateral lower limb. This can have dramatic adverse effects on a person's function.
• Exercises to maintain and even improve ROM should be done on a regular basis.

          - Click on image to enlarge 

• Range-of-motion exercises have been shown to decrease discomfort and pain, which can increase function and overall independence [25].
• Patients who cannot complete full range of motion, due to either motion limitation or inadequate strength, should be assisted by the therapist to complete full ROM. (Active-Assisted ROM Exercise).
• Continuous passive motion (CPM) device can also be used to mechanically facilitate ROM. The patient does not activate any muscles as the machine passively moves the joint [26].
  • However, CPM devices are currently only clinically used with OA patients who have undergone total joint replacement and are in the acute phases of rehabilitation.

» Stretching Exercises:

• Most osteoarthritis patients have some degree of inflexibility due to
  • Shortened muscle
  • Intrinsic Joint Restriction
• When muscles are shorter than their ideal length, they are at a biomechanical disadvantage when they are required to generate force. Stretching exercises can help prevent this and have been shown to increase overall ROM.
• Before stretching, muscles should be initially warmed up, as this enables collagen fibers to be maximally stretched [27].
• Patients with osteoarthritis should be taught how to perform the stretching program properly [28].
  • Generally with slow, gentle, sustained stretching.
  • Sustained stretching generally involves holding the stretch for at least 20 to 40 seconds, and perhaps longer, before relaxing.
  • And then repeating the stretch and ideally repeated 3 times per day.
• Sudden, jerky, or ballistic stretching should be avoided since it may cause exacerbation of the osteoarthritis.
• The rehabilitation specialist should provide the osteoarthritis patient with guidance as to which muscle groups should be targeted by the stretching program.
  • For patients with osteoarthritis of the hip or knee, stretching of the quadriceps and hamstrings muscles is crucial.
  • Of course, any specific ROM deficits that have been identified as problematic within a specific patient should be addressed when formulating the stretching program.

» Strenthening Exercises:

• Muscle weakness has long been considered the best correlate of functional limitations in individuals with osteoarthritis, especially knee osteoarthritis.
• There are many potential reasons why the quadriceps muscles are important in knee osteoarthritis. 
  • Quadriceps weakness in patients with knee osteoarthritis was due to deconditioning from disuse, perhaps secondary to the pain of the osteoarthritis.
  • However, studies that are more recent have shown that quadriceps weakness actually seems to precede the development of knee osteoarthritis, that is, apparently serving as a causative factor for knee osteoarthritis rather than resultant sequelae [29].
    • Explanations for this include the role of the quadriceps muscles in knee joint protection.
    • Presumably, repeated lower-limb impulse loading may contribute to the onset or progression of knee osteoarthritis.
    • Strong knee extensors can decrease the impulse loading of the lower limb by slowing the deceleration phase before heel strike.
• Strengthening Exercises are often classified as
  • Closed Chain Exercises
  • Open Chain Exercises

 

- Click on image to enlarge

• Thus, CLOSED CHAIN EXERCISES are beneficial and more effective than Open Chain Exercises.
• Weight Bearing Exercises (closed chain exercises) are important for porper joint cartilage nutrition [33,34].
• Other classification is
  • Isometric Exercises
    • Involve contraction of muscles while they are at a fixed length, such that little or no joint motion is taking place.
    • Isometric exercises are a reasonable initial approach for strengthening in patients who cannot tolerate repetitive joint motion, such as those with painful, inflamed joints [24].
    • Although isometric contractions can be learned quickly and can result in rapid strength gains, functional benefits from isometric contraction exercises might be limited to a small range around the joint angle of training [24, 29].
  • Isotonic Exercises
    • Refers to joint movement through its ROM, against a constant weight or resistance.
    • Isotonic exercises are often used to maximize strength [24].
    • Isotonic work consists of concentric and eccentric contractions, depending on whether the muscle length is shortening or elongating during the contractions, respectively.
    • Eccentric contraction is more stressful than concentric but also results in greater strength gains.
  • Isokinetic Exercises

    • Involve constant speed of motion throughout the joint range during muscle contraction, whereas the amount of resistance may vary throughout the range.

    • Infrequently used because of equipment requirements and uncertain correlation to functional activities.

• In summary, isotonic and closed-chain exercises are probably the most beneficial exercises in patients with osteoarthritis, but individuals who find these painful may perform isometric exercises.

• The goal should be to progress to isotonic exercises that include a combination of open- and closed-chain activities. [29]

• Isotonic exercise is suggested for intial strengthening in patients with OA with exercise knee pain, and isokinetic exercise is suggested for improving joint stability or walking endurance at a later time. [32] 

» Balance Training in Osteoarthritis:

• Damage to proprioceptors has been implicated in balance deficits in osteoarthritis.
• The relationship between balance and degenerative disease of the knee has been studied and the results showed that the patient group had significantly more postural sway than the control group. [54]
• Muscle atrophy usually accompanies degenerative joint disease and may account for some balance impairment. [55]
• Any musculoskeletal problem such as impaired muscle performance or mobility or pain should be treated first, with reevaluation for continued balance impairment after resolution of the musculoskeletal problems.
• Balance training can be given with modifications in mode, posture and movement.
• Progression is made from simple to more complex patterns.
• The main principle is to improve the proprioception of the knee joint in the weight bearing position. [56]

» Aerobic Exercises:

• Patients with OA have lower aerobic capacity than general population [35]. Therefore, areobic exercises should be incorporated in exercise program for patients with OA.
• Aerobic exercise in patients with osteoarthritis commonly includes a daily walking program.
• In addition to the aerobic effects, walking adds some degree of joint loading, which helps cartilage to obtain necessary synovial nutrients through inbibition [29].
• Mechanisms how aerobic conditioning helps patients with OA:
  • Release of endogenous oioids, thereby reducing pain & symptoms of depression and anxiety [36, 37, 38].
  • Reduce morning stiffness, improved balance and increased walking speed [39].
• Factors to consider while prescribing particular aerobic exercise program:
  • Patient's cardiovascular level
  • Preference of exercises
  • Accessibility of exercise equipment
  • Cross-Training (incorporating several different aerobic exercises into patient's program)
    • Prevent the musculoskeletal overuse injuries that can occur when same exercise is performed repeatedly.
    • Prevent boredom that can occur if the same exercise is performed over time.
    • Exercise variability lessen the probability that the body will adapt to exercises being performed.
• For all aerobic exercises, patient should first strive for a target age-predicted heart rate of approximately 70% of (140 - AGE) and gradually increase it to maximum of 85% of (140 - AGE).

» Joint Manipulation:

• Joint mobilization can be used to improve mobility or decrease pain by using selected grades of accessory movements. [40, 41]
• ACCESSORY MOVEMENTS: [42, 43, 44, 45, 46]
  • Used when primary resistance is encountered from the ligament & capsule of the joint and there is minimal muscular resistance.
  • Cane be done in any part of the physiological ROM.
  • Can be done in any direction (posteriorly, caudally, anteriorly)
  • Used for tight articular structures
  • Safe method because it uses short-lever arm techniques
• Gentle distraction of the joint and stretching of the capsular tissues can be useful to increase mobility.
• However, since joint mobilization is contra indicated in severe degenerative cases, extreme care needs to be taken while mobilizing these joints.

» Mulligan's Rotational Knee Mobilization with Movement:

• Patient Position:

  • Supine with knee flexed within the limits of pain.

• Technique:

  • Grasp the lower leg and internally rotate the tibia on the femur.

  • Move the fibula ventrally at the same time.

  • Patient flexes the knee as the therapist maintains this position.

  • Overpressure is applied at the end of available range of motion.

• Patient Position (Alternative Technique):
  • Standing with partial weight bearing of affected foot resting on the step.
• Technique:
  • Grasp the lower lef and internally rotate tibia on the femur.
  • Move the fibula ventrally at the same time.
  • Ask the patient to lean forward by flexing the knee.

» Mulligan's Self Mobilization Technique: 

• Patient Position:
  • Painful leg is placed on the chair.
• Technique:
  • The patient places his hands proximally around the lower leg and rotates his tibia medially.
  • He is supposed to sustain this rotation as he moves forward in weight bearing.
  • Technique is correct if there is no pain.

» Mulligan's Taping Technique: 

• Patient Position: 
  • Standing with knee flexed about 5-10^o with inversion of the foot as much as he can.
• Technique:
  • A 5cm tape is wrapped starting from the lateral leg diagonally moving up medially in such a way that the upper edge crosses just below the joint margin.  

» Aquatic Exercises:

• Aquatic exercise is sometimes known as ’pool therapy’ or ’hydrotherapy’.
• It involves exercises in water that is heated to about 32 to 36 degrees Celsius.
• Exercises may include
  • Aerobic Activities
  • Stretching
  • Strengthening
  • Range of Motion
• EFFECTS OF AQUATIC EXERCISES:
  • Buoyancy reduces load across joints affected by pain and allows the performance of functional close-chain exercises with less effort and greater range of movement [47].
  • Water turbulence can be used as a method to increase resistance, and percentage of body weight borne across lower limbs can be  decreased or progressed in proportion to the depth of immersion [47,48].
  • Sensory inputs from water pressure and temperature may decrease feeling of pain [47,50].
  • The warmth and pressure water may further assist pain relief, swelling reduction, and ease of movement. 
  • Warm water also promotes relaxation which decreases muscle spasm and tightness.
  • Desired exercise intensity can be achieved by adjusting the velocity of movement in the water [47,51]. 
• PROTOCOLS FOR HYDROTHERAPY FOR OA:

(Fransen, M. et al., 2007 [52]) - Click on the image to enlarge

(Hinman, R.S. et al., 2007 [53]) - Click on the image to enlarge

 VIDEOS ON AQUATIC EXERCISES FOR OA:   

» Forward Walking Exercises: 

 

» Variation in Forward Walking Exercises: 

» Marching Exercises:  

 

» Variation in Marching Exercises (I):

 » Variation in Marching Exercises (II):

 » Side Walking Exercises:

 » Variation in Side Walking Exercises (I):

  » Variation in Side Walking Exercises (II):

 

  » Variation in Side Walking Exercises (III):

  » Backward Walking Exercises:

  » Variation in Backward Walking Exercises (I): 

  » Variation in Backward Walking Exercises (II):  

  » Hip & Knee Exercises: 

  » Rocking Horse Exercises:  

 VIDEOS ON EXERCISES FOR OSTEOARTHRITIC KNEE:

 » Quadriceps ROM Exercises:

» ROM Exercises for Knee:

» Leg Lift Exercise for Knee:

» Side Leg Lift for Knee: 

» Quadriceps Strengthening Exercise:

» Gastrocnemius Strengthening Exercise:

» Hamstring Strengthening Exercise:

» Gastrocnemius Stretching Exercise:

» Hamstring Stretching Exercise:

» Squat Exercise for Knee:

1. Zhang, W., Moskowitz, R.W., Nuki, G., Abramson, S., Altman, R.D., Arden, N., Bierma-Zeinstra, S., Brandt, K.D., Croft, P., Doherty, M., Dougados, M., Hochberg, M., Hunter, D.J., Kwoh, K., Lohmander, L.S., Tugwell, P. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis & Cartilage; 2008, 16(2), 137-162.

2. Hochberg, M.C., Altman, R.D., Brandt, K.D., Clark, B.M., Dieppe, P.A., Griffin, M.R., et al., Guidelines for the medical management of osteoarthritis. Part II: Osteoarthritis of the knee. American College of Rheumatology. Arthritis & Rheumatism; 1995, 38, 1541-1546.
3. Lane, N.E., & Thompson, J.M. Management of osteoarthritis in the primary-care setting: an evidence-based approach to treatment. American Journal of Medicine, 1997, 103, 25S-30S.
4. Hochberg, M.C., Altman, R.D., Brandt, K.D., Clark, B.M., Dieppe, P.A., Griffin, M.R., et al., Guidelines for the medical management of osteoarthritis. Part I: Osteoarthritis of the hip. American College of Rheumatology. Arthritis & Rheumatism; 1995, 38, 1535-1540.

5. Philadelphia Panel Members. Philadelphia Panel Evidence Based Clinical Practice Guidelines on Selected Rehabilitation Interventions for Knee Pain. Physical Therapy; 2001, 81(10), 1675-1700.

6. Licht, S.: Therapeutic heat, New Haven, CT, 1965, Elizabeth Licht.

7. Weinberger A, Fadilah R, Lev A, Pinkhas J. Treatment of articular effusions with local deep microwave hyperthermia. Clinical Rheumatology;1989;8:461-6.

8. Feibel A, Fast A. Deep heating of joints: A reconsideration. Archives of Physical Medicine Rehabilitation; 1976;57:513-4.

9. Rattanachaiyanont, M., & Kuptniratsaikul, V. No additional benefit of shortwave diathermy over exercise program for knee osteoarthritis in peri-/post-menopausal women: an equivalence trial. Osteoarthritis & Cartilage; 2008, 16(7), 823-828.

10. Laufer, Y., Zilberman, R., Porat, R., Nahir, A.M. Effect of pulsed short-wave diathermy on pain and function of subjects with osteoarthritis of the knee: a placebo-controlled double-blind clinical trial. Clinical Rehabilitation; 2005, 19(3), 255-263.

11. Welch, V., Brosseau, L., Peterson, J., Shea, B., Tugwell, P., Wells, G. Therapeutic ultrasound for osteoarthritis of the knee. Cochrane Database Systematic Reviews; 2001, 3, CD003132.

12. Brosseau, L., Yonge, K.A., Robinson, V., Marchand, S., Judd, M., Wells, G., Tugwell, P. Theramotherapy for treatment of Osteoarthritis. Cochrane Database of Systematic Reviews; 2003, 4, CD004522.  

13. Silva, A.L.P., Imoto, D.M., Croci, A.T. Comparison of cryotherapy, exercise and short waves in knee osteoarthritis treatment. Acta Ortopedica Brasileria; 2007, 15(4), 204-209.

14. Durmus, D., Alayh, G., Canturk, F. Effects of quadriceps stimulation program on clinical parameters in the patients with knee osteoarthritis. Clinical Rheumatology; 2007, 26, 674-678.

15. Gaines, J.M., Metter, E.J., Talbot, L.A. The effect of neuromuscular electrical stimulation on arthritis knee pain in older adults with osteoarthritis of the knee. Applied Nursing Research; 2004, 17(3), 201-206.

16. Fary R.E., Carroll, G.J., Briffa, T.G., Gupta, R., Briffa, N.K. The effectiveness of pulsed electrical stimulation in the management of osteoarthritis of the knee: a protocol for a randomised controlled trial. BMC Musculoskeletal Disorders; 2008, 9, 18.

17. Osiri, M., Welch, V., Brosseau, L., Shea, B., McGowan J., Tugwell, P., Wells, G. Trascutaneous electrical nerve stimulation for knee osteoarthritis: review. Cochrane Database of Systematic Reviews; 2000, 4, CD002823.

18. Stiff, M.: Appliances of electrostimulation in physical conditioning: a review, J. Appl. Sport Sci. Res. 1990, 4, 20-26.

19. Melzack, R., & Wall, P.D. Pain Mechanisms: A New Theory. Science; 150(3699), 971-978.

20. American Physical Therapy Association. Guide to Physical Therapist Practice. 2nd Edition. Physical Therapy; 2001, 81(1), 9-744.

21. Minor, M.A. Exercise in the treatment of osteoarthritis. Rheumatic Disease Clinics of North America; 1999, 25(2), 397-415.

22. Bennett, K. Therapeutic Exercise for Arthritis. In: Hall, C., Brody, L. eds. Therapeutic Exercise: Moving towards function. Philadelphia, Lippincott Williams & Wilkins; 1999.

23. Kisner, C. Colby, L. Therapeutic Exercise: Foundations & Techniques. 4th Edition. Philadelphia: F.A. Davis; 2002.

24. Wrightson, J.D., & Malanga, G.A. Strengthening and other therapeutic exercises in the treatment of osteoarthritis. Physical Medicine & Rehabilitation: State of Art Reviews; 2001, 15(1), 43-56. 

25. Bashaw, R.T., & Teingstad, E.M. Rehabilitation of the osteoarthritic patient: focus on the knee. Clinical Sports Medicine; 2005, 24, 101-131.

26. Simkin, P.A., de Lateur, B.J., Alquist, A.D., Questad, K.A., Beardsley, R.M., Esselman,  P.C. Continuous passive motion of osteoarthritis of the hip: a pilot study. Journal of Rheumatology; 1999, 26, 1987-1991.

27. Oddis, C.V. New perspectives on Osteoarthritis. American Journal of Medicine; 1996, 100, 10S-15S.

28. Minor, M. Exercises and the management of osteoarthritis of the knee and hip. Arthritis Care Research; 1994, 7, 198-204.

29. Baker, K., McAlindon, T. Exercise for knee osteoarthritis. Current Opinion in Rheumatology; 2000, 12(5), 456-463.

30. Escamilla, R.F., Flisig, G.S., Zheng, N., Barrentine, S.W., Wilk, K.E., Andrews, J.R. Biomechanics of the knee during closed kinetic chain and open kinetic chain exercises. Medicine & Science in Sports & Science; 1998, 30, 556-559.

31. Lutz, G.E., Palmitier, R.A., An, K.N., Chao, E.Y. Comparison of tibiofemoral joint forces during open kinetic chain and closed kinetic chain exercises. The Journal of Bone & Joint Surgery; 1993, 75, 732-739.

32. Mao-Hsiung Huang, Yueh-Shuang Lin, Rei-Cheng Yang, Chia-Ling Lee. A comparison of various therapeutic exercises on the functional status of patients with knee osteoarthritis. Seminars in Arthritis and Rheumatology; 2003, 32, 398-406. 

33. Leroux, M.A., Cheung H.S., Bau, J.L., Wang, J.Y., Howell, D.S., Setton, L.A. Altered mechanics and histomorphometry of canine tibial cartilage followinf joint immobilization. Osteoarthritis & Cartilage; 2001, 9, 633-640.

34. Byers, K.V. Pathogenesis and treatment of osteoarthritis. Medical Clinic of North America; 1997, 81, 85-112.

35. Fontaine, K.R., Heo, M., Bathon, J. Are US adults with arthritis meeting public health recommendations for physical activity? Arthritis & Rheumatism; 2004, 50, 624-628.

36. Stuart, M.J., Meglan, D.A., Lutz, G.E., Growney, E.S., An, K.N. Comparison of intersegmenal tibiofemoral joint forces and muscle activity during various closed kinetic exercises. American Journal of Sports Medicine; 1996, 24, 792-799.

37. Schwarz, L. & Kindermann, W. Changes in beta-endorphin levels in response to aerobic and anaerobic exercise. Sports Medicine; 1992, 13, 25-36.

38. Goldfarb, A.H. & Jamurtas, A.Z., Beta-endorphin response to exercise: an update. Sports Medicine; 1997, 24, 8-16.

39. Minor, M.A., Hewett, J.E., Webel, R.R., Anderson, S.K., Kay, D.R. Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis. Arthritis & Rheumatism; 1989, 32, 1396-1405.

40. Suraj & Sudhir Kumar. Effect of knee complex mobilization on pain and active range of motion arc in osteoarthritis knee joint. Physical Therapy in Sport; 2006, 7(4), 176.

41. Moss, P., Sluka, K., Wright, A. The initial effects of knee mobilization on osteoarthritic hyperalgesia. Manual Therapy; 2007, 12(2), 109-118.

42. Barak, T., Rosen, E.R., Sofer, R. Basic concepts of orthopedic manual therapy. In Gould J.A. 2nd Edition: Orthopedics & Sports Physical Therapy. St. Louis, C.V. Mosby, 1990, 195-211.

43. Cyriax, J. Texbook of Orthopedic Medicine. Treatment by manipulation, massage and injection, volume 2. Baltimore, Williams & Wilkins, 1974.

44. McKenzie, R.A. Mechanical Diagnosis and Therapy. Waikanae, New Zealand, Spinal Publications, 1981.

45. Mennell, J. Joint pain diagnosis and treatment using manipulative techniques. New York, Little, Brown & Co, 1964, 178.

46. Kessler, R.M. Arthrology. In Hertling D, Kessler, R.M. (eds): Management of common musculoskeletal disorders: Physical Therapy Principles and Methods, ed 2. Philadelphia, Harper & Row, 1983, 33-38.

47. Konlian, C. Aquatic therapy: making a wave in treatment of low back injuries. Orthopedic Nursing; 1999, 18(1), 11-20.

48. Harrison, R., Bulstrode, S. Percentage weight-bearing during partial immersion. Physiotherapy Practice; 1987, 3, 60-63.

49. Harrison, R., Hillman, M., Bulstrode, S. Loading of the lower limb when walking partially immersed: implications for clinical practice. Physiotherapy; 1992, 78, 164-166.

50. McNeal, R.L. Aquatic therapy for patients with rheumatic disease. Rheumatic Disease Clinics North America; 1990, 16, 915-929.

51. Ferrell, K.M. Aquatics for people with arthritis. Lippincotts Primary Care Practice, 1998 2(1), 102-104.

52. Fransen, M., Nairn, L., Winstanley, J., Lam, P., Edmonds, J. Physical Activity for osteoarthritis management: A randomized controlled clinical trial evaluating hydrotherapy and tai chi classes. Arthritis & Rheumatism; 2007, 57(3), 407-414.

53. Hinman, R.S., Heywood, S.E., Day, A.R. Aquatic Therapy for hip and knee osteoarthritis: Results of a single blinded randomized controlled trial. Physical Therapy; 2007, 87, 32-43

54. Barrett, D.S., Cobb, A.G., Bently, G. Joint proprioception in normal, osteoarthritic and replaced knees. J Bone Joint Surg Br. 1991, 73, 53-56.

55. Wegener, L., Kisner, C., Nicholas, D. Static and dynamic balance responses in persons with bilateral knee osteoarthritis. J orthop Sports Phys Ther 1997;25:13-18.

56. Shumway-Cook, A., Horak, R.B. Assessing the influence of sensory interaction on balance. Phys Ther, 1986, 1548-1550.

 NOTE: Most of the videos might be from Youtube.