Osteoarthritis (OA) of the knee is a chronic, progressive degenerative joint disease characterized by the breakdown of articular cartilage, subchondral bone remodelling, osteophyte formation, and varying degrees of synovial inflammation. It is the most common form of arthritis and a leading cause of chronic pain and disability among the elderly population worldwide [1]. The disease burden continues to rise with increasing life expectancy and obesity, making it a significant public health concern with socioeconomic implications [2].

Globally, the World Health Organization (WHO) estimates that approximately 250 million people suffer from knee osteoarthritis, with a prevalence of 22–28% among individuals over 60 years of age [3]. In India, studies report a prevalence ranging from 22% to 39% among adults above 50 years, and knee OA accounts for nearly one-fourth of all musculoskeletal consultations in tertiary care hospitals [4]. The condition not only affects mobility and independence but also leads to psychological distress and reduced quality of life in the elderly [5].

The etiopathogenesis of knee osteoarthritis is multifactorial, involving age-related cartilage degeneration, mechanical overloading, obesity, trauma, metabolic disorders, and genetic predisposition [6]. While surgical options such as total knee replacement are effective for end-stage disease, non-surgical management remains the cornerstone of therapy for early to moderate stages, particularly in elderly individuals with comorbidities or limited surgical access [7].

Among non-surgical measures, exercise therapy, bracing, and lifestyle modification play a pivotal role in reducing pain, improving function, and delaying disease progression. Structured quadriceps strengthening and aerobic exercises have been shown to enhance joint stability, reduce stiffness, and improve gait performance [8]. Knee braces and orthotic supports redistribute load across the joint, alleviate stress on the affected compartment, and improve alignment during ambulation [9]. Simultaneously, lifestyle interventions—including weight reduction, balanced nutrition, and ergonomic modifications—help in mitigating modifiable risk factors and reducing symptom severity [10].

Despite growing evidence supporting conservative therapy, patient adherence and comparative efficacy of various non-surgical modalities remain underexplored in the Indian geriatric context. Many patients rely solely on analgesics and neglect long-term rehabilitative approaches, resulting in progressive functional decline.

The present prospective randomized study, conducted in the Department of Orthopedics, Government Medical College, Sindhudurg, Maharashtra, from August 2024 to July 2025, aims to evaluate the efficacy of exercise, bracing, and lifestyle modification—individually and in combination—in improving pain, function, and quality of life among elderly patients with knee osteoarthritis. By emphasizing sustainable, non-invasive management strategies, this study seeks to provide evidence-based guidance for optimizing conservative care and delaying surgical intervention in this growing population group.

The present prospective randomized clinical study was conducted in the Outpatient Department, Department of Orthopedics, Government Medical College, Sindhudurg, Maharashtra, over a period of one year from August 2024 to July 2025. The study included a total of 120 elderly patients diagnosed with primary knee osteoarthritis (OA) attending the orthopedic outpatient department. The diagnosis of OA knee was made according to the American College of Rheumatology (ACR) clinical and radiographic criteria, which included pain, stiffness, crepitus, and radiographic evidence of osteophyte formation and joint space narrowing.

Patients aged above 50 years of either sex presenting with radiographic Grade II or III OA according to Kellgren–Lawrence classification and willing to participate in non-surgical treatment were included. Exclusion criteria comprised patients with secondary osteoarthritis due to trauma or inflammatory diseases, previous knee surgery, severe deformity or contracture, neuromuscular disorders, or those currently undergoing intra-articular injection therapy.

All eligible patients were explained the purpose of the study, and informed written consent was obtained prior to enrolment. After baseline evaluation, participants were randomly divided into three groups of 40 each using a computer-generated randomization method:

• Group A (Exercise group): Received a structured exercise program including quadriceps strengthening, hamstring stretching, and low-impact aerobic activities such as stationary cycling and brisk walking.
• Group B (Bracing group): Provided with a knee unloader brace or neoprene sleeve, customized according to the side of involvement and degree of deformity, along with routine analgesics as required.
• Group C (Lifestyle modification group): Counselled regarding weight reduction, dietary modifications, posture correction, and avoidance of prolonged squatting or stair climbing, supplemented with mild range-of-motion exercises.

Each intervention was continued for a minimum duration of 12 weeks, with periodic reassessment at baseline, 6 weeks, 3 months, and 6 months. Participants were encouraged to maintain compliance through telephonic reminders and exercise diaries. Analgesics (paracetamol or NSAIDs) were allowed on an as-needed basis, and consumption frequency was documented.

The primary outcome measures included changes in pain intensity, joint stiffness, and functional ability, assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Visual Analogue Scale (VAS). The secondary outcome was the improvement in quality of life, measured using the Knee Injury and Osteoarthritis Outcome Score (KOOS). Objective parameters such as walking distance, time to climb stairs, and knee range of motion were also recorded.

All data were collected in a predesigned proforma and entered into Microsoft Excel for statistical analysis. The results were analysed using SPSS version 26.0. Quantitative variables were expressed as mean ± standard deviation (SD) and compared using the paired t-test or ANOVA where applicable. Qualitative variables were compared using the Chi-square test, and p < 0.05 was considered statistically significant.

Ethical approval for the study was obtained from the Institutional Ethics Committee of Government Medical College, Sindhudurg prior to commencement. All procedures adhered to the ethical principles of the Declaration of Helsinki (2013 revision), and patient confidentiality was maintained throughout the study.

A total of 120 elderly patients diagnosed with primary knee osteoarthritis were enrolled and randomly divided into three groups of 40 participants each—Group A (Exercise group), Group B (Bracing group), and Group C (Lifestyle modification group). Out of these, 114 participants (95%) completed the 6-month follow-up, while six were lost to follow-up due to noncompliance or relocation. The mean age of participants was 62.8 ± 6.4 years, with a female predominance (68.3%). The majority (71%) belonged to the 60–70 years age group, consistent with the age-related degenerative nature of osteoarthritis. The mean BMI was 28.6 ± 3.1 kg/m², and nearly 65% of participants were overweight or obese.

At baseline, the mean WOMAC total score was 62.4 ± 9.8, and the mean VAS pain score was 7.1 ± 1.1, with no statistically significant differences among the three groups (p > 0.05). After the 12-week intervention period, all groups demonstrated improvement in pain and function, but the magnitude of improvement varied.

In Group A (Exercise group), there was a marked improvement in both pain and function, with the mean WOMAC score reducing from 63.1 ± 9.5 to 37.2 ± 8.3 (a 41% reduction, p < 0.001) and the VAS score decreasing from 7.0 ± 1.0 to 3.9 ± 0.8. Participants also showed an increase in walking distance and better stair-climbing ability.

In Group B (Bracing group), the mean WOMAC score improved from 61.7 ± 10.1 to 41.5 ± 9.2 (a 33% reduction, p < 0.001), while the mean VAS score decreased from 7.2 ± 1.2 to 4.5 ± 1.1. Bracing was particularly effective in reducing pain during ambulation and providing joint stability in participants with varus deformity.

In Group C (Lifestyle modification group), improvement was comparatively modest, with the mean WOMAC score reducing from 62.5 ± 9.9 to 48.6 ± 8.8 (a 22% reduction, p < 0.05), and the mean VAS score decreasing from 7.1 ± 1.1 to 5.6 ± 1.0. Participants who adhered strictly to dietary and activity guidelines showed better outcomes than those who were inconsistent.

When compared across the three groups, exercise therapy produced the most significant functional improvement and pain relief, followed by bracing and lifestyle modification. The inter-group difference in WOMAC and VAS score reduction was statistically significant (p < 0.001) at the end of 12 weeks.

At the 6-month follow-up, the beneficial effects of exercise and bracing were sustained, with minimal deterioration in WOMAC and VAS scores. In contrast, a mild relapse of symptoms was noted in some participants from the lifestyle modification group, primarily among those who gained weight or discontinued activity routines.

No major adverse events were reported. Mild transient muscle soreness was observed in a few patients during the initial exercise sessions, which subsided with adaptation. Compliance was highest in the exercise group (93%) compared to the bracing (87%) and lifestyle modification (80%) groups.

Overall, the study established that structured exercise therapy combined with lifestyle modification provides the maximum non-surgical benefit in elderly knee osteoarthritis patients, both in terms of pain relief and functional improvement, whereas bracing serves as a useful adjunct for mechanical support and pain reduction.

Table 1: Demographic and Baseline Characteristics of Study Participants (n = 120)

Interpretation:
Participants across all three groups were comparable at baseline in terms of age, sex distribution, BMI, and osteoarthritis grade (p > 0.05), ensuring a uniform randomization.

Table 2: Comparison of WOMAC and VAS Scores Before and After Intervention

Interpretation:
All three groups demonstrated significant improvement in pain and functional scores after intervention, with exercise therapy producing the greatest reduction in both WOMAC and VAS scores (p < 0.001).

Table 3: Functional Outcome and Compliance at 6-Month Follow-Up

Interpretation:
Long-term follow-up confirmed sustained functional benefit, with the exercise group maintaining superior outcomes and higher compliance compared to other modalities.

Figure 1: Comparison of % Reduction in WOMAC and VAS Scores Across Groups

Figure 2: Functional Improvement at 6- Month Follow-up

The present prospective randomized study evaluated the role of exercise, bracing, and lifestyle modification in the non-surgical management of knee osteoarthritis among elderly patients. The findings demonstrated that all three conservative interventions significantly improved pain and functional outcomes, with the greatest improvement observed in the exercise therapy group, followed by bracing and lifestyle modification.

The mean WOMAC score reduction of 41% in the exercise group and 33% in the bracing group indicates the strong efficacy of targeted physiotherapy and joint unloading techniques in symptom relief and functional restoration. The improvement in VAS pain scores was also notable—44.3% in the exercise group, 37.5% in the bracing group, and 21.1% in the lifestyle modification group. These results are consistent with previous research highlighting that structured exercise programs are the cornerstone of conservative OA management [11].

In a randomized trial by Messier et al. (2013), the combination of aerobic and resistance exercises led to significant improvement in knee pain and function among overweight elderly patients, paralleling the outcomes of the current study [12]. Similarly, Fransen and McConnell (2015) reported that supervised strengthening and flexibility training produced greater functional gains than general physical activity, emphasizing the role of muscle conditioning in stabilizing the osteoarthritic knee [13].

The bracing group in this study also showed substantial symptomatic improvement, confirming its benefit as a mechanical support modality. These results correspond with those of Ramsey and Russell (2009), who found that valgus unloading braces reduce medial compartment load, pain, and functional limitation in moderate OA [14]. Additionally, Brouwer et al. (2006) demonstrated that long-term use of knee orthoses improves alignment and decreases pain scores without compromising mobility [15].

The lifestyle modification group, though showing lesser improvement, still achieved meaningful pain reduction and enhanced quality of life, particularly among patients who adhered to weight reduction and activity modification. Messier et al. (2018) reported that every 5% reduction in body weight is associated with a significant decline in knee joint load and pain severity [16]. This supports the present findings that patient compliance and long-term behavioural change are key determinants of successful conservative management.

At 6-month follow-up, over 90% of patients in the exercise group maintained improvement, compared to 84% in the bracing group and 75% in the lifestyle group, suggesting that exercise therapy yields the most durable benefits. Similar sustained results were noted by Roddy et al. (2005), who observed prolonged symptom control with continued home exercise practice [17].

From a pathophysiological perspective, exercise strengthens periarticular muscles, improves proprioception, and enhances joint lubrication, thereby reducing abnormal mechanical loading [18]. Bracing, on the other hand, corrects malalignment and redistributes stress across the joint surface, while lifestyle modification acts at the level of modifiable metabolic risk factors such as obesity and sedentary behaviour [19]. Together, these interventions address both biomechanical and systemic contributors to osteoarthritis progression.

The present study aligns with the OARSI 2019 guidelines, which recommend exercise, weight management, and bracing as first-line approaches for elderly patients with knee OA before considering surgical options [20]. Furthermore, the higher compliance rate in the exercise group (93%) compared to lifestyle-only intervention underscores the importance of supervised programs and patient engagement for achieving optimal outcomes.

Overall, this study reinforces that non-surgical interventions, particularly exercise therapy supplemented with bracing and lifestyle changes, are effective and safe strategies to relieve pain, enhance mobility, and improve quality of life in elderly patients with knee osteoarthritis.

The present study demonstrated that non-surgical interventions—exercise therapy, bracing, and lifestyle modification—significantly improve pain, mobility, and functional status in elderly patients with knee osteoarthritis. Among the three modalities, structured exercise therapy provided the most substantial and sustained benefits, offering superior reduction in WOMAC and VAS scores as well as better long-term functional improvement. Bracing proved to be an effective adjunct for patients requiring additional mechanical support, while lifestyle modification contributed meaningfully when adhered to consistently.

Overall, the findings highlight that a multimodal conservative approach can effectively delay functional decline, reduce symptom burden, and enhance quality of life in elderly individuals with knee OA. These results reinforce the value of exercise-centred, patient-focused, non-invasive strategies as first-line management before considering surgical options in this population.

Structured physiotherapy programs emphasizing quadriceps and hamstring strengthening, flexibility, and aerobic exercises should be routinely incorporated into osteoarthritis management to improve function and delay progression. Patients must be educated on weight reduction, posture correction, and avoidance of prolonged squatting or stair climbing to minimize joint stress. The use of knee braces or neoprene sleeves is recommended for individuals with medial compartment involvement or instability to enhance mechanical support and walking confidence. Establishing community-based OA rehabilitation clinics within primary healthcare systems can improve accessibility and adherence among elderly patients. Regular follow-up and therapy modification according to disease progression are essential for sustained outcomes. Further multicentric, long-term studies are warranted to assess the durability, cost-effectiveness, and patient satisfaction associated with combined non-surgical modalities in the Indian geriatric population.

The present study was conducted at a single tertiary-care institution with a moderate sample size of 120 participants, which may limit the generalizability of findings to the broader elderly population. The follow-up period of six months was relatively short and did not allow for assessment of long-term sustainability or progression of osteoarthritis. Although randomization minimized bias, blinding of participants and investigators was not feasible due to the nature of the interventions. Patient compliance, particularly in lifestyle modification, was self-reported, which could introduce recall and reporting bias. Additionally, radiological changes were not evaluated during follow-up, restricting correlation between structural and functional improvement.

Future multicentric studies with larger sample sizes, longer follow-up, objective adherence monitoring, and imaging-based evaluation are recommended to validate and expand upon these findings.

1. elson DT. Osteoarthritis: New insights—Part 1: The disease and its risk factors. Ann Intern Med. 2000;133(8):635–46.
2. Hunter DJ, Bierma-Zeinstra S. Osteoarthritis. 2019;393(10182):1745–59.
3. World Health Organization. Chronic rheumatic conditions. Geneva: WHO; 2021.
4. Pal CP, Singh P, Chaturvedi S, Pruthi KK, Vij A. Epidemiology of knee osteoarthritis in India and related factors. Indian J Orthop. 2016;50(5):518–22.
5. Cross M, Smith E, Hoy D, Nolte S, Ackerman I, Fransen M, et al. The global burden of hip and knee osteoarthritis: Estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014;73(7):1323–30.
6. Goldring MB, Goldring SR. Osteoarthritis. J Cell Physiol. 2007;213(3):626–34.
7. Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SMA, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019;27(11):1578–89.
8. Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee: A Cochrane systematic review. Br J Sports Med. 2015;49(24):1554–7.
9. Ramsey DK, Russell ME. Unloader braces for medial compartment knee osteoarthritis: Implications on mediating progression. Sports Health. 2009;1(5):416–26.
10. Messier SP, Mihalko SL, Legault C, Miller GD, Nicklas BJ, DeVita P, et al. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: The IDEA randomized clinical trial. JAMA. 2013;310(12):1263–73.
11. Bennell KL, Hunt MA, Wrigley TV, Lim BW, Hinman RS. The effects of muscle strengthening on knee osteoarthritis: A systematic review. Arthritis Rheum. 2008;59(10):1488–94.
12. Messier SP, Mihalko SL, Legault C, Miller GD, Nicklas BJ, DeVita P, et al. Effects of intensive diet and exercise on knee joint loads, inflammation, and outcomes among overweight and obese adults with knee osteoarthritis: The IDEA randomized clinical trial. JAMA. 2013;310(12):1263–73.
13. Fransen M, McConnell S. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2015;CD004376.
14. Ramsey DK, Russell ME. Unloader braces for medial compartment knee osteoarthritis: Implications on mediating progression. Sports Health. 2009;1(5):416–26.
15. Brouwer RW, van Raaij TM, Verhagen AP, Coene LN, Bierma-Zeinstra SM, Verhaar JA. Braces and orthoses for treating osteoarthritis of the knee. Cochrane Database Syst Rev. 2006;CD004020.
16. Messier SP, Resnik AE, Beavers DP, Mihalko SL, Miller GD, Nicklas BJ, et al. Intentional weight loss in overweight and obese patients with knee osteoarthritis: Is more better? Arthritis Care Res. 2018;70(11):1569–75.
17. Roddy E, Zhang W, Doherty M. Aerobic walking or strengthening exercise for osteoarthritis of the knee? A systematic review. Ann Rheum Dis. 2005;64(4):544–8.
18. Segal NA, Glass NA, Torner JC, Felson DT, Sharma L, Nevitt M, et al. Quadriceps weakness and osteoarthritis progression in the MOST cohort. Arthritis Rheum. 2010;62(7):1913–21.
19. Blagojevic M, Jinks C, Jeffery A, Jordan KP. Risk factors for onset of osteoarthritis of the knee in older adults: A systematic review and meta-analysis. Osteoarthritis Cartilage. 2010;18(1):24–33.
20. Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SMA, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019;27(11):1578–89.