title: Identifying potential working mechanisms behind the positive effects of exercise therapy on pain and function in osteoarthritis; a systematic review.
abstract: OBJECTIVE
  Although physical exercise is the commonly recommended for osteoarthritis (OA) patients, the working mechanism behind the positive effects of physical exercise on pain and function is a black box phenomenon. In the present study we aimed to identify possible mediators in the relation between physical exercise and improvements of pain and function in OA patients.
  
  
  METHODS
  A systematic search for all studies evaluating the effects of physical exercise in OA patients and select those that additionally reported the change in any physiological factor from pre-to post-exercise.
  
  
  RESULTS
  In total, 94 studies evaluating 112 intervention groups were included. Most included studies evaluated subjects with solely knee OA (96 out of 112 groups). Based on the measured physiological factors within the included studies, 12 categories of possible mediators were formed. Muscle strength and ROM/flexibility were the most measured categories of possible mediators with 61 and 21 intervention groups measuring one or more physiological factors within these categories, respectively. 60% (31 out of 52) of the studies showed a significant increase in knee extensor muscle strength and 71% (22 out of 31) in knee flexor muscle strength over the intervention period. All 5 studies evaluating extension impairments and 10 out of 12 studies (83%) measuring proprioception found a significant change from pre-to post-intervention.
  
  
  CONCLUSIONS
  An increase of upper leg strength, a decrease of extension impairments and improvement in proprioception were identified as possible mediators in the positive association between physical exercise and OA symptoms.
authors: Department of General Practice, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands. Electronic address: j.runhaar@erasmusmc.nl.
authors: J
authors: J
authors: Runhaar
authors: Department of General Practice, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands. Electronic address: p.luijsterburg@erasmusmc.nl.
authors: P
authors: P
authors: Luijsterburg
authors: Department of Rehabilitation Medicine and Department of Psychiatry, VU University Medical Center, Amsterdam, The Netherlands. Electronic address: j.dekker@vumc.nl.
authors: J
authors: J
authors: Dekker
authors: Department of General Practice, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Orthopedics, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands. Electronic address: s.bierma-zeinstra@erasmusmc.nl.
authors: S M A
authors: SM
authors: Bierma-Zeinstra
mesh_terms: D005081:Exercise Therapy / Q000379:methods*; D006801:Humans; D007719:Knee Joint / Q000503:physiopathology; D053580:Muscle Strength / Q000502:physiology; D010003:Osteoarthritis / Q000150:complications / Q000503:physiopathology / Q000534:rehabilitation*; D020370:Osteoarthritis, Knee / Q000150:complications / Q000503:physiopathology / Q000534:rehabilitation; D010146:Pain / Q000209:etiology; D016059:Range of Motion, Articular / Q000502:physiology
keywords: Mediation; Osteoarthritis; Physical exercise; Working mechanism