title: Development of comorbidity-adapted exercise protocols for patients with knee osteoarthritis.
abstract: BACKGROUND
  Exercise therapy is generally recommended for patients with osteoarthritis (OA) of the knee. Comorbidity, which is highly prevalent in OA, may interfere with exercise therapy. To date, there is no evidence-based protocol for the treatment of patients with knee OA and comorbidity. Special protocols adapted to the comorbidity may facilitate the application of exercise therapy in patients with knee OA and one or more comorbidities.
  
  
  OBJECTIVE
  The purpose of this study was to develop comorbidity-adapted exercise protocols for patients with knee OA and comorbidity.
  
  
  METHODS
  Several steps were undertaken to develop comorbidity-adapted protocols: selection of highly prevalent comorbidities in OA, a literature search to identify restrictions and contraindications for exercise therapy for the various comorbid diseases, consultation of experts on each comorbid disease, and field testing of the protocol in eleven patients with knee OA and comorbidity.
  
  
  RESULTS
  Based on literature and expert opinion, comorbidity-adapted protocols were developed for highly prevalent comorbidities in OA. Field testing showed that the protocols provided guidance in clinical decision making in both the diagnostic and the treatment phase. Because of overlap, the number of exercise protocols could be reduced to three: one for physiological adaptations (coronary disease, heart failure, hypertension, diabetes type 2, chronic obstructive pulmonary diseases, obesity), one for behavioral adaptations (chronic a-specific pain, nonspecific low back pain, depression), and one for environmental adaptations (visual or hearing impairments). Evaluation of patient outcome after treatment showed significant (P<0.05) and clinically relevant improvements in activity limitations and pain.
  
  
  CONCLUSIONS
  Comorbidity-adapted exercise protocols for patients with knee OA were developed, providing guidance in clinical reasoning with regard to diagnostics and treatment. To evaluate the effectiveness of treatment in line with our protocols, a randomized clinical trial should be performed.
authors.affiliation: Amsterdam Rehabilitation Research Center, Reade, Amsterdam, the Netherlands.
authors.forename: Mariëtte
authors.initials: M
authors.lastname: de Rooij
authors.affiliation: Amsterdam Rehabilitation Research Center, Reade, Amsterdam, the Netherlands ; VU University Medical Center Department of Rehabilitation Medicine, Amsterdam, the Netherlands.
authors.forename: Marike
authors.initials: M
authors.lastname: van der Leeden
authors.affiliation: Sint Lucas Andreas Hospital, Department of Physical Therapy, Amsterdam, the Netherlands.
authors.forename: Ellis
authors.initials: E
authors.lastname: Avezaat
authors.affiliation: Department of Health Sciences, University of Jyväskylä and Jyväskylä Central Hospital, Jyväskylä, Finland.
authors.forename: Arja
authors.initials: A
authors.lastname: Häkkinen
authors.affiliation: Amsterdam Rehabilitation Research Center, Reade, Amsterdam, the Netherlands.
authors.forename: Rob
authors.initials: R
authors.lastname: Klaver
authors.affiliation: HAN University, Institute of Health, GGM, Institute for Sports and Exercise Studies, Nijmegen, the Netherlands.
authors.forename: Tjieu
authors.initials: T
authors.lastname: Maas
authors.affiliation: Amsterdam Rehabilitation Research Center, Reade, Amsterdam, the Netherlands.
authors.forename: Wilfred F
authors.initials: WF
authors.lastname: Peter
authors.affiliation: Amsterdam Rehabilitation Research Center, Reade, Amsterdam, the Netherlands.
authors.forename: Leo D
authors.initials: LD
authors.lastname: Roorda
authors.affiliation: Amsterdam Rehabilitation Research Center, Reade, Amsterdam, the Netherlands ; VU University Medical Center, Department of Rheumatology, Amsterdam, the Netherlands.
authors.forename: Willem F
authors.initials: WF
authors.lastname: Lems
authors.affiliation: Amsterdam Rehabilitation Research Center, Reade, Amsterdam, the Netherlands ; VU University Medical Center, Department of Psychiatry and Department of Rehabilitation Medicine, EMGO Institute, Amsterdam, the Netherlands.
authors.forename: Joost
authors.initials: J
authors.lastname: Dekker
mesh_terms: D000203:Activities of Daily Living; D000368:Aged; D059350:Chronic Pain / Q000150:complications; D003863:Depression / Q000150:complications; D003924:Diabetes Mellitus, Type 2 / Q000150:complications; D005081:Exercise Therapy / Q000379:methods*; D005260:Female; D006311:Hearing Disorders / Q000150:complications; D006331:Heart Diseases / Q000150:complications; D006801:Humans; D006973:Hypertension / Q000150:complications; D017116:Low Back Pain / Q000150:complications; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000150:complications; D020370:Osteoarthritis, Knee / Q000150:complications / Q000628:therapy*; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications; D011788:Quality of Life; D016896:Treatment Outcome; D014786:Vision Disorders / Q000150:complications
keywords: arthritis; coexisting disease; comorbidity; exercise therapy; knee osteoarthritis; rehabilitation