Makarm et al.

Egyptian Rheumatology and Rehabilitation (2021) 48:28

https://doi.org/10.1186/s43166-021-00073-2
Egyptian Rheumatology
and Rehabilitation

RESEARCH Open Access

Impact of home exercise program on self-

efficacy and quality of life among primary
knee osteoarthritis patients: a randomized
controlled clinical study
Wafaa K. Makarm1,2 , Doaa M. Sharaf1,3 and Rabab S. Zaghlol1,4*

Abstract
Background: Knee osteoarthritis (KOA) is a common joint disorder in elderly individuals, causing pain, loss of
physical functioning, disability, and reduction of life quality. Home exercise programs (HEP) serve as a crucial
complement to outpatient rehabilitation therapy, as they save the cost of supervised physical therapy sessions,
while also offering a high level of treatment. The aim of this study was to evaluate the effectiveness of the 6-month
HEP on pain, quality of life, and self-efficacy in patients with primary KOA and to identify the adherence level to
exercises and associations with patients’ characteristics and clinical outcomes.
Results: After 6 months of HEP, there were statistically significant differences between groups for self-efficacy (p ≤
0.001, from 58.29 to 71.5) (p = 0.23, from 55.98 to 57.72), quality of life (p ≤0.001, from 60.1 to 72.2) (p = 0.074, from
60.35 to 60.92), and pain severity (P ≤0.001, from 58.29 to 41.4) (P = 0.88, from 61.2 to 60.9) in favor of exercise group.
Conclusions: Home-based exercise program improves pain score, self-efficacy, and quality of life in patients with knee
osteoarthritis. Adherence level to the exercise program may have a positive impact on patient improvement.
Keywords: Osteoarthritis, Knee, Adherence, Home exercise, Self-efficacy, Quality of life

Background while also offering a high level of treatment [3]. This

Knee osteoarthritis (KOA) is a common joint disorder in recommendation of HEP is now overemphasized during
elderly individuals, causing pain, loss of physical func- the coronavirus disease 2019 (COVID-19) pandemic
tioning, disability, and reduction of life quality [1]. Non- which causes quarantine or lockdown; it may be a suit-
pharmacological approaches, e.g., patient education, able and preferred choice for patients suffering from
weight reduction, coping strategies, exercise, and phys- KOA who are often unable to make direct personal con-
ical therapies, are recommended for management of tact with their physician [4].
KOA [2]. Knee pain may induce worsening of self-efficacy with
Home exercise programs (HEP) serve as a crucial deterioration of the quality of life and physical depend-
complement to outpatient rehabilitation therapy, as they ency [5]. Self-efficacy relates to the patient confidence
save the cost of supervised physical therapy sessions, level and exercise adherence. Exercise programs may at-
tract patients with a greater belief in their abilities to
manage their diseases [6].
* Correspondence: rszaghlol@zu.edu.eg; rababzaghlol@yahoo.com
1
Rheumatology and Rehabilitation Department, Faculty of Medicine, Zagazig Most previous studies have focused on the effect of
University, Zagazig, Egypt home-based exercise programs on pain and quality of
4
Physical Medicine and Rehabilitation Department, Security Forces Hospital, life measures in knee osteoarthritis [7], however, rarely
Makkah, Saudi Arabia
Full list of author information is available at the end of the article considering self-efficacy.

© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
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Makarm et al. Egyptian Rheumatology and Rehabilitation (2021) 48:28 Page 2 of 11

Therefore, the present study aimed to investigate the frequent knee pain and radiographic findings (Kellgren–
effect of 26 weeks of HEP on pain severity, self-efficacy, Lawrence ≥ grade 2) in the same knee [12, 13].
and quality of life scores in primary knee osteoarthritis
patients and to determine adherence to exercises in the Randomization
HEP intervention group. We hypothesized that partici- Eligible participants that met the inclusion criteria were
pants receiving HEP will show improvement of pain se- randomly assigned to either the HEP group or the con-
verity, self-efficacy, and life quality compared to those trol group by a computer-generated random sequence
receiving health education without HEP. list performed by a statistician who is independent of
this study.
Methods
Study design Blinding
A single blinded parallel randomized, controlled clinical Outcome measure assessments were performed by one
study was conducted in accordance with CONSORT investigator, who was blinded to group assignment and
guidelines. not involved in intervention management.

Participants and setting Interventions

Eligibility criteria During the first visit to the exercise and control groups,
research team clarified the goals and steps of the study
Inclusion criteria Individuals aged 40–65 years who and presented detailed information on the etiology of
met the American College of Rheumatology clinical and osteoarthritis, how to cope with osteoarthritis, lifestyle
radiological criteria [8] for primary KOA were recruited recommendations, treatments according to guidelines,
from the outpatient clinic of rheumatology and rehabili- and strategies to reduce pain and enhance functional ac-
tation department of university hospitals during the tivity [14]. All participants in both groups were
period of July 2018 through July 2020. The participants instructed to follow the usual care (medical treatment
with knee pain for at least 3 months and of radiographic and lifestyle recommendations) offered by their health-
severity ≥ grade 2 according to Kellgren–Lawrence were care providers throughout the study period. However,
included in the study [9]. A written informed consent analgesics should be avoided for 24 h before follow-up
was obtained before enrollment to this study. assessment.
Patients randomized to the intervention exercise group
Exclusion criteria Participants with history of knee were subjected to 1-h educational session on the import-
trauma, surgery, inflammatory knee pain, or history of ance of HEP; the participants were taught the exercises
intra-articular injections within the last 3 months and and conducted in front of the physiatrist to address any
other medical disease that may affect their ability to per- questions. They were given printout of illustrated book-
form exercise (e.g., uncontrolled cardiovascular, respira- let and videos in Arabic for exercise prescription and re-
tory, or neurological diseases) were excluded. Patients ceived a monthly phone call for motivation and to
with psychiatric diseases and communication disorder, support exercise compliance. This was supported by an
e.g., hearing or cognitive disorders, were also excluded. individual session, which took place after 3 months.
During this session, the physiatrist received the exercise
Data collection and tools log to assess compliance over the previous period and
Demographic data of each participant about age, sex, focused on the beneficial role of exercise therapy and
marital status, employment status, education level and encouraging patient to continue HEP, while patients al-
socioeconomic status [10], height, and weight were col- located to the control group did not receive HEP-related
lected via a self-administered questionnaire. information and they were not eligible for telephone
The clinical variables included body mass index (BMI) calls. Patients were then re-invited to assess any long-
[11], disease duration, and presence of comorbidities. term progress after 6 months from the date of their ini-
Laboratory tests were performed such as complete blood tial visit.
cell picture, acute phase reactants, and serum uric acid
to rule out other cause of knee pain. Home-based exercise intervention
Routine weight-bearing plain X-ray radiography of an- Exercises were taught to the participants of the exercise
teroposterior and lateral knee view was taken for the group, as described in a previous study [15]. The HEP
most symptomatic side. Severity was assessed, and the program included active knee joint range of motion ex-
patients were graded according to the Kellgren– ercises, 10 repetitions, twice per day. Stretching for the
Lawrence grading system [9]. Symptomatic knee osteo- hamstring muscles was performed in a supine position
arthritis was defined as the concurrent existence of with a towel wrapped around the foot, and the leg was
Makarm et al. Egyptian Rheumatology and Rehabilitation (2021) 48:28 Page 3 of 11

completely extended at the knee and then raised from includes eight subscale scores including the physical
the position of rest until the stretch is felt behind the function, role-physical, bodily pain, energy, health
knee. Stretching of the quadriceps muscle was per- perception, social function, role-emotional, and
formed in sitting or prone position, with the knee flexed mental health, and contains 36 items. It is calcu-
as much as possible; flexion was assisted by hand. The lated by scoring each item on a linear scale ranging
stretching was maintained for about 30 s and was carried from 0 to 100, and then, all items in the same scale
out for 5 repetition in two sets [16]. Isometric quadri- were averaged together. The total score ranges from
ceps exercises were carried out as 10 repetitions for two 0 to 100, and higher scores reflect better health sta-
sets; the patient should lie relaxed in recumbent pos- tus and less disability, where 0 indicates the worst
ition, and knee at 20° of flexion was supported with a possible health status [21, 22].
rolled up towel beneath the knee and tried to press the
towel to floor for 10 s. Isometric hamstring exercises
were performed with knees at full extension and a towel Sample size
placed under ankles by applying maximum pushing of Participation by 174 patients per group (348 total) would
10 s and relaxation of 10 s, as 10 repetitions for two sets provide 80% power at the 5% significance level to detect
[15, 17]. They were instructed to perform the suggested difference of 7.83 with a standard deviation of 1.9 be-
exercises, three times per week for 26 weeks. tween groups in the SF-36 score [23] and an effect size
of 0.31 using a two-sided t-test with alpha = 0.05 accord-
Adherence ing to relevant study on exercise therapy among knee
Adherence to HEP has been assessed via self-completed osteoarthritis patients [24]. Anticipating a 20% drop-out
exercise log. Adherence level is calculated as the mean rate, 217 participants should be enrolled for each group.
number of days on which patient performed the pre-
scribed exercises during the entire intervention period.
At 26 weeks, participants who completed ≥ 70% of their Statistical analysis
prescribed exercise plan were graded as high adherence, All data were collected, tabulated, and statistically ana-
while participants with < 70% were rated as low adher- lyzed using SPSS 23.0 for windows (IBM SPSS Statistics
ence [18]. for Windows, Version 23.0. Armonk, NY: IBM
Corp2015). Quantitative data were expressed as the
Outcome measures mean ± SD and median (range), and qualitative data
The primary outcomes were knee pain severity and were expressed as absolute frequencies (number) and
health-related quality of life while secondary outcomes relative frequencies (percentage). Independent t-test was
included exercise adherence and questionnaires to meas- used to compare between two groups normally distrib-
ure exercise self-efficacy. uted. Mann-Whitney test was used to compare between
The baseline assessments and follow-up assessments two groups of non-normally distributed. Paired t test
included the following: was used to compare outcome variable changes of par-
ticipants in the exercise and control groups. Percent of
(1) The Exercise Self-efficacy Scale: the scale was devel- categorical variables were compared using Chi-square
oped to measure the confidence of participants in test or Fisher’s exact test. Pearson’s correlation coeffi-
their ability to exercise regularly. “A validated cient was calculated to assess relationship between vari-
Arabic version containing 18 questions, which as- ous study variables, (+) sign indicates direct correlation,
sess how the participants were able to perform rou- and (−) sign indicates inverse correlation; also, values
tine exercise regularly (three times per week), under near to 1 indicate strong correlation, and values near 0
certain barriers. Then, patients rated their answers indicate weak correlation. All tests were two sided. P-
using a 10-point scale ranging from 0% (I cannot do value ≤ 0.05 was considered statistically significant, and
this activity at all) to 100 (I am certain that I can do p-value > 0.05 was considered statistically insignificant.
this activity successfully)”. Total score was calcu-
lated by adding the numerical ratings for each item jE 1 −E 2 j
divided by the number of responses. So, higher % Difference ¼ 100
1
scores indicate better self-efficacy [19]. ðE 1 þ E 2 Þ
2
(2) Visual analog scale: the patients were asked to mark
a point on a 100-mm line that represented the se-
verity of their current pain [20]. where
(3) Health-related quality of life: the Arabic version of • E1 is the first experimental measurement.
36-Item Short-Form Health Survey was used which • E2 is the second experimental measurement.
Makarm et al. Egyptian Rheumatology and Rehabilitation (2021) 48:28 Page 4 of 11

Results −28.9%), SF36 (percent of change = 20.13%), and ESE-A

As shown in Fig. 1, a total of 457 were screened, and (percent of change = 22.6%) at baseline compared to
207 individuals were excluded. Among those who com- follow-up assessment. By contrast, those who received
pleted the screening, 250 participants fulfilled the eligi- education showed no improvement in any of the previ-
bility criteria and were randomly allocated to either ous outcome measures at the follow-up assessment as
groups. Two hundred ten individuals completed the 6- shown in Table 2.
month follow-up assessment (104 exercise, 83.2%; and Regarding the home exercise program adherence in
106 control, 84.8%). exercise group, 86 (82.7%) of the patients were highly
The characteristics of the participants are described in adherent to HEP, while 18 (17.3 %) patients were of low
Table 1. No significant differences were observed for adherence level, and there were statistically significant
demographic and clinical characteristics or any of partic- differences (p≤ 0.05) between high-adherence and low-
ipants’ scores of pain severity, quality of life scale, self- adherence groups as regards age and educational and so-
efficacy, and radiological severity (Kellgren-Lawrence cioeconomic status. However, no statistically significant
grade) between the two groups at baseline evaluation. differences (p > 0.05) between the two groups regarding
Individuals who received HEP intervention experi- BMI, gender, marital status, residence, and employment
enced improvement in VAS (percent of change = status were detected (Table 3).

Fig. 1 Flowchart of the study

Makarm et al. Egyptian Rheumatology and Rehabilitation (2021) 48:28 Page 5 of 11

Table 1 Demographic, clinical, and radiological characteristics of the studied groups

Exercise group (n = 104) Control group (n = 106) Test p-value
Age (years)
Mean±SD 54.9 ±7.22 55.6±6.37 t=0.74 0.45
Median(range) 55 (41–65) 55 (45–65)
BMI (kg/m2)
Mean± SD 27.22±4.06 27.05±3.2 t=0.34 0.73
Median(range) 25.7 (23–42.9) 26.5 (22.4–37.5)
Disease duration (years)
Mean± SD 6.5±3.1 5.9±2.7 t=1.49 0. 14
Median(range) 6 (2–15) 5 (1–14)
No. % No. %
Gender
Male 22 21.2 27 25.5 0.42 0.52
Females 82 78.8 79 74.5
Educational status
Illiterate 11 10.6 22 20.8 2.9 0.09
Educated 93 89.4 84 79.2
Employment
Employer 39 37.5 33 31.1 0.302
Unemployed 47 45.2 46 43.4 2.39
Manual worker 18 17.3 27 25.5
Marital status
Married 62 59.6 69 65.1 0.99 0.31
Single 42 40.4 37 34.9
Residence
Rural 60 57.7 59 55.7 0.17 0.67
Urban 44 42.3 47 44.3
Smoking
No 89 85.6 87 82.1 0.32 0.56
Yes 15 14.4 19 17.9
Socioeconomic status
Low 30 28.8 24 22.6
Moderate 65 62.5 75 71.7 1.84 0.39
High 9 8.7 7 6.6
Comorbidities
Yes 45 43.3 54 50.9 1.55 0.21
No 59 56.7 52 49.1
K-L grade
Grade 2 53 50.9 58 54.7
Grade 3 40 38.5 41 38.7 1.13 0.57
Grade 4 11 10.6 7 6.6
χ2 chi-square test, t t test, SD standard deviation, BMI body mass index, K-L grade Kellgren–Lawrence radiological grading
Insignificant = p > 0.05

As regarding clinical manifestations, there was no sta- comorbidities was significantly associated with high ad-
tistically significant differences (p > 0.05) between adher- herence level for HEP. Also, there was statistically sig-
ent and non-adherent groups except for patients with nificant improvement within high-adherence group in all
comorbidities (p≤ 0.05) where absence of other evaluated outcome scores after 6 months (Table 4).
Makarm et al. Egyptian Rheumatology and Rehabilitation (2021) 48:28 Page 6 of 11

Table 2 Outcome measures of the exercise group and the control group at baseline and 6 months post-intervention
Studied groups t- p Mean
test difference (%
Exercise group (n = 104) Control group (n = 106)
of difference)
VAS Baseline
Mean± SD 58.29±17.4 61.2±13.7 1.3 0.17 2.9(4.86%)
Median(range) 60 (20–90) 60 (20–90)
After 6 months
Mean± SD 41.4±14.2 60.9±14.7 9.7 ≤0.001* 19.5 (38.12%)
Median(range) 40 (20–70) 60 (20–90)
*p ≤0.001* 0.88
Mean change −16.89 −0.3
% of change −28.9 % −0.49%
SF 36 Baseline
Mean± SD 60.1±7.5 60.35±10.7 0.15 0. 87 0.25 (0.41%)
Median(range) 62 (43–77) 62 (35–81)
After 6 months
Mean± SD 72.2 ±10.2 60.92±10.54 7.8 ≤0.001* 11.28 (16.9%)
Median(range) 73(50–92) 61 (35–81)
*p ≤0.001 * 0.074
Mean change 12.1 0.57
% of change 20. 13% 0.94%
ESE_A Baseline
Mean± SD 58.29± 6.9 55.98±11.3 1.7 0.075 2.3 (4.1%)
Median (range) 59.4 (37.7–74.4) 55.3 (37.5–82.6)
After 6 months
Mean± SD 71.5 ±7.6 57.72±11.1 10.4 ≤0.001 * 13.7 (21.3%)
Median(range) 72.4 (54.8–84.6) 55.9 (38.6–84.5)
*p ≤0.001 * 0.23
Mean change 13.2 1.74
% of change 22.6% 3.1%
t t test of significance, SD standard deviation, VAS visual analog scale, ESE-A Exercise Self-efficacy Scale, SF-36 Short-Form Health Survey
*Paired t test, *p ≤0.05, significant

Additionally, there was statistically significant negative quality of life among symptomatic primary KOA pa-
correlation between adherence rate and age of patients tients. Also, the adherence to HEP may have an impact
per years and also with visual analog scale (p≤ 0.05), on patient improvement.
while there was statistically significant positive correl- The present result agreed with a previous randomized
ation between adherence rate and quality of life, also controlled study of 786 participants with knee pain that
with self-efficacy after intervention at 6 months (p≤ improvements in pain, stiffness, and physical function
0.05) suggesting an improvement in pain severity, quality were found after 6 months of exercise program [25].
of life, and exercise self-efficacy scale-Arabic scores with Previous studies indicated that quadriceps muscle sim-
high adherence levels (Table 5, Figs. 2 and 3). ple home exercise programs could significantly improve
self-reported knee pain and disability among knee osteo-
Discussion arthritis patients as well as the results for quality of life
To the best of authors’ knowledge, this is the first study [26]. Another Jordanian research found that participants
in Egypt to evaluate the effect of home-based exercise who exercised more often and for longer periods had
program intervention on self-efficacy and quality of life more exercise self-efficacy [19].
in primary KOA patients in a controlled manner. The improvement in pain could be attributed to the
The present results indicated that the addition of 26 increased discharges from mechanosensitive afferent
weeks of HEP with the usual care resulted in improve- nerve fibers A-delta and IV (C) resulting from skeletal
ment of self-efficacy, pain severity, and health-related muscles secondary to rhythmic muscle contraction that
Makarm et al. Egyptian Rheumatology and Rehabilitation (2021) 48:28 Page 7 of 11

Table 3 Relation of adherence level to HEP among exercise group with regard to demographic characteristics
Exercise group test p-
value
High adherence n = 86 Low adherence n = 18
No. % No. %
Age (years)
Mean± SD 54.9 ±7.1 59.2 ±5.8 t = 2.4 0.015*
Median (range) 54.5 (41–65) 59 (50–65)
BMI (kg/m2)
Mean± SD 27.15±4.3 27.6±2.8 t = 0.41 0.68
Median(range) 25.3 (23–43) 26.5 (23–33)
Gender
Male (22) 20 90.9 2 9.1 f 0.56
Females (82) 66 80.49 16 19.51
Education
Illiterate (11) 6 54.5 5 45.5 9.3 0.002*
Educated (93) 80 86.1 13 13.9
Employment
Employer (39) 33 84.62 6 15.38
Unemployed (47) 39 82.9 8 17.1 0.41 0.81
Manual worker (18) 14 77.78 4 22.22
Marital status
Married (62) 53 85.48 9 14.52 1.3 0.25
Single (42) 33 78.6 9 21.4
Residence
Rural (60) 52 86.7 8 13.3 1.1 0.29
Urban (44) 34 77.27 10 22.73
Smoking
No (89) 71 79.8 18 20.2 F 0.067
Yes (15) 15 100.00 0 .00
Socioeconomic status
Low (30) 19 63.33 11 36.67 10.5 0.005*
Moderate (65) 58 89.2 7 10.8
High (9) 9 100.00 0 .00
χ2 chi-square test, t t test, f Fisher exact test, SD standard deviation, BMI body mass index
*p≤0.05, significant

can stimulate central opioid systems, resulting in pain patients to their prescribed HEP is approximately 53–
relief and a reduction in disability. Exercise has also been 89% [31].
shown to improve blood beta-endorphin levels [27]. It is important to note that the adherence rate in an-
Since the efficacy of any therapeutic exercise program other study was higher with written and verbal informa-
is directly linked to patient compliance [28, 29], mea- tion (77%) than those given verbal information only
sures to increase efficiency by optimizing adherence (38%), which is consistent with our finding [32]. The
should be taken when setting up exercise programs for high rate of adherence recorded in this study was also
patients with knee osteoarthritis [30]. enhanced by monthly telephone support to the enrolled
So, the adherence level in the exercise group of pa- patients and direct physician access after 3 months. The
tients was examined, and it was noticed that 86 (82.7%) authors presume that the wide range reported in other
of the patients were highly adherent to the home exer- studies may be a consequence of varying sample sizes,
cise program while 18 (17.3 %) patients were of low ad- different patient characteristics, different intervention
herence level. In agreement with the findings of the methods, and the inclusion of different outcome
previous reports, the frequency of completely adherent measures.
Makarm et al. Egyptian Rheumatology and Rehabilitation (2021) 48:28 Page 8 of 11

Table 4 Relation of adherence level to HEP among exercise group with regard to clinical characteristics and outcome measures
Exercise group test p-
value
High adherence Low adherence
n = 86 n = 18
No. % No. %
Disease duration (years)
Mean± SD 6.57±3.5 7.5±2.7 t=1.1 0.26
Median (range) 6 (2–15) 6 (4–14)
Comorbidities
Yes (45) 31 68.89 14 31.11 9 0.003*
No (59) 55 93.2 4 6.8
K-L grade:
Two (53) 42 79.25 11 20.75 0.88 0.64
Three (40) 34 85 6 15
Four (11) 10 90.91 1 9.09
VAS (baseline)
Mean± SD 56.9±18.3 64.2±11.2 MW=1.7 0.08
Median(range) 60 (20–90) 60 (30–80)
SF-36 (baseline)
Mean± SD 61.1±7.5 57.9±5.8 t=1.7 0.08
Median (range) 63 (43–77) 58 (45–71)
ESE A (baseline)
Mean± SD 58.6±7.3 56.3±4.6 t=1.3 0.19
Median(range) 59.4 (37.7–74.4) 56.6 (48.3–65)
VAS (6month)
Mean± SD 38.7±13.4 50.6±9.8 t=2.1 0.0004*
Median (range) 40 (20–60) 50 (30–70)
SF-36 (6month)
Mean± SD 74.1±9.7 64.1±10.7 t=3.9 ≤0.001*
Median (range) 73 (52–92) 61 (50–86)
ESE A (6month)
Mean± SD 72.8 ±9.8 61.6 ±4.6 MW=5.8 ≤0.001*
Median (range) 73.2 (54.8–84.6) 60 (55.9–68.3)
χ2 chi-square test, t t test, MW Mann-Whitney test, f Fisher exact test, K-L grade Kellgren–Lawrence radiological grading, SD standard deviation, VAS visual analog
scale, ESE-A exercise self-efficacy scale, SF-36 Short-Form Health Survey
*p≤0.05, significant

In addition, several factors affecting adherence have

been identified in this study. There was a statistically sig-
Table 5 Correlation between home exercise adherence rate
and some of the related factors and outcome measures after (6 nificant difference between high-adherence and low-
months) home exercise period adherence groups in terms of age, educational level, so-
Parameters Adherence rate
cioeconomic status, and the presence of other co-
morbidities (p ≤ 0.05). However, no statistically signifi-
(r) p
cant differences (p > 0.05) between the two groups were
Age per years −0.231 0.018*
identified with regards to BMI, gender, marital status,
Disease duration per years −0.181 0.064 residence, employment status, disease duration, and
BMI −0.064 0.516 radiological grades.
VAS at 6 months after intervention −0.245 0.012* Similarly, another study determined the relationship
SF-36 at 6 months after intervention 0.41 <0.001* between adherence to HEP and age [33, 34]. Also, it has
been previously reported that educated patients were
ESE_A at 6 months after intervention 0.73 <0.001*
more adherent than uneducated ones as educated pa-
(r) correlation coefficient, BMI body mass index, VAS visual analog scale, ESE-A
Exercise Self-efficacy Scale, SF-36 Short-Form Health Survey tients usually have better health literacy and would know
*p≤0.05, significant the importance of adhering to treatment [35].
Makarm et al. Egyptian Rheumatology and Rehabilitation (2021) 48:28 Page 9 of 11

Fig. 2 Scatter diagram for correlation between adherence rate and quality of life of osteoarthritis patients after intervention

As far as comorbidity and exercise compliance is con- remote treatment may be a more effective and cost-
cerned, the present result agreed with a previous de- effective solution for preventing overburdened health in-
scriptive cross-sectional study that patients with chronic stitutions and reducing healthcare spending or face-to-
diseases continue to report exercises of less than the face visits [37].
optimum amount despite the need to exercise [36]. Furthermore, HEP can be recommended as an effect-
Most notably, the clinical condition of patients with ive strategy for knee osteoarthritis patients that may be
KOA during the COVID-19 surge can be enhanced if implicated for clinical practice. Further future research
patients are contacted regularly by phone or engaged in with a large population sample and for long term is rec-
live virtual sessions with their physician [4]. As a result, ommended to confirm these findings.

Fig. 3 Scatter diagram for correlation between adherence rate and visual analog scale of osteoarthritis patients after intervention
Makarm et al. Egyptian Rheumatology and Rehabilitation (2021) 48:28 Page 10 of 11

Study limitations Author details

1
One of the limitations of the current study is related to the Rheumatology and Rehabilitation Department, Faculty of Medicine, Zagazig
University, Zagazig, Egypt. 2Zagazig, Egypt. 3Nasr, Egypt. 4Physical Medicine
subjective assessment of adherence level as it was subject- and Rehabilitation Department, Security Forces Hospital, Makkah, Saudi
ive being based on a personal documentation. In addition, Arabia.
this study is considered a short-term intervention that did
Received: 8 April 2021 Accepted: 20 May 2021
not allow for evaluation of long-term effects of HEP.
Also, the HEP did not include static or dynamic balance
exercises for postural control, neither muscle endurance References
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