Application and effects of a self-management program for patients with knee osteoarthritis

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J Exerc Rehabil Vol. 21, No. 2, 92-101, April, 2025

Publication date (electronic) : 2025 April 30

doi : https://doi.org/10.12965/jer.2550112.056

Eun Ju Jeon, Nam Hyun Cha

Department of Nursing, College of Health Welfare, Gyeongkuk National University, Andong, Korea

^*Corresponding author: Nam Hyun Cha, Department of Nursing, College of Health Welfare, Gyeongkuk National University, 1375 Gyeongdong-ro, Andong 36729, Korea, Email: yeoreo@hanmail.net

Received 2025 February 24; Revised 2025 March 19; Accepted 2025 March 27.

Abstract

INTRODUCTION

Knee osteoarthritis (OA) is a degenerative disease caused by cartilage damage and deterioration in the knee joint. It leads to pain, joint stiffness, and movement restrictions, which, over time, can result in gait impairment, reduced physical function, increased economic burden, and decreased quality of life (Bannuru et al., 2019; Salaffi et al., 2005). Persistent pain associated with this condition can also lead to mental health issues such as depression, fatigue, and sleep disorders, further worsening the patient’s overall health status (Hunter and Bierma-Zeinstra, 2019). Given the rising incidence of knee OA due to aging and increasing obesity rates, proper management of the disease is essential (Dantas et al., 2021).

The primary goals of knee OA treatment are to alleviate pain and inflammation while improving physical function (Bannuru et al., 2019; Salaffi et al., 2005). To achieve these goals, it is necessary to apply multiple treatment strategies together. Self-management programs can effectively manage knee OA by combining various approaches such as exercise, weight management, pain management, and medication. In particular, nonpharmacological treatments, including exercise, weight loss, and education, are essential for managing chronic conditions. According to the study by Patten et al. (2022), which analyzed multiple study, an integrated approaches is necessary to alleviate symptoms and enhance patient autonomy.

Several treatment strategies should be implemented to achieve these goals. First, patient education is crucial to help individuals understand that knee OA is a manageable condition and that regular exercise, dietary modifications, and physical therapy can help alleviate symptoms (French et al., 2015; Murray et al., 2019). Second, low-intensity exercises are recommended for knee OA patients as they reduce weight-bearing stress and fall risks while strengthening muscles (Kolasinski et al., 2020; Roddy et al., 2005). Third, physical therapy interventions, such as ultrasound therapy and electrical stimulation, can help relieve pain and promote tissue healing (Bannuru et al., 2019). Fourth, dietary interventions aimed at weight reduction can alleviate joint stress and pain, while a balanced diet contributes to overall health maintenance (Kolasinski et al., 2020). Fifth, aromatherapy has been shown to promote dopamine hormone secretion, which helps relieve pain, improve mood, and alleviate sleep disorders (Pehlivan and Karadakovan, 2019; Rafii et al., 2020).

Interventions for pain relief in knee OA patients include self-management interventions, psychosocial interventions, pharmacological treatments, dietary modifications, physical therapy, and surgical procedures (Kloppenburg and Berenbaum, 2020; Skou and Roos, 2017). However, less than 40% of patients actively utilize therapeutic approaches, with most relying on pharmacological treatments, such as nonsteroidal anti-inflammatory drugs or hyaluronic acid injections (Kloppenburg and Berenbaum, 2020; Skou and Roos, 2017). While medication provides short-term relief, long-term use can lead to severe side effects (Kloppenburg and Berenbaum, 2020). Additionally, the financial burden of treatment and time and location constraints for hospital visits pose challenges for patients. Therefore, a self-management program that is cost-effective, free of side effects, and flexible in terms of time and location is necessary.

Nonpharmacological treatments, including exercise, weight loss, and education, are essential for chronic conditions such as knee OA (Bannuru et al., 2019). Since chronic diseases are more effectively managed when patients take an active role in their care, self-management strategies are highly suitable. Self-management programs promote patient independence and contribute to improved quality of life. International studies have shown that self-management programs incorporating exercise, weight management, pain management, and medication adherence are effective for knee OA patients (Ganji, 2019; Gay et al., 2020; Hatefi et al., 2019). Similarly, in South Korea, self-management programs combining physical therapy, exercise classes, and dietary interventions have had positive effects on patients (Ganji, 2019). These interventions have been shown to significantly reduce pain and physical symptoms (Gay et al., 2016) while improving quality of life and alleviating sleep disorders (Pehlivan and Karadakovan, 2019).

Therefore, implementing a self-management program that integrates exercise therapy, dietary changes, and aromatherapy is essential for the management of knee OA. This approach may help to alleviate pain and physical symptoms while improving quality of life and sleep disturbance. Although such programs are expected to have positive effects, there is a lack of sufficient research on the combined application of these interventions for the management of knee OA. Therefore, further research is needed to verify their effectiveness. Previous studies have mainly focused on the individual effects of exercise therapy, dietary changes, and aromatherapy. However, this study provides a comprehensive intervention by integrating these methods. In addition, while previous studies often relied on hospital visits or specific time constraints, this study introduces an application-based program that allows patients to practice self-management anytime and anywhere without restrictions. This approach allows for more flexible and continuous management, providing a cost-effective and side-effect-free treatment option.

This study aimed to evaluate the effects of a self-management program that integrated exercise therapy, dietary modification, and aromatherapy on pain, physical symptoms, quality of life, and sleep disturbance in patients with knee OA. The program develops and implements a structured self-management system that can be easily applied regardless of time and place. This intervention can be made more flexible and accessible by utilizing an application, allowing patients to manage self-management anytime, anywhere.

MATERIALS AND METHODS

Self-management program

This study administered a self-management program over eight weeks. Before the intervention, the participants were provided with a leaflet outlining exercise therapy, diet, aromatherapy, and management methods, followed by demonstrations. The experimental group participated in the program 5 days a week, performing knee-strengthening exercises for 10 minutes each in the morning and evening. In the evening, aromatherapy massage was applied by rolling aroma oil on the knee for 20 minutes, using four methods: stroking, rubbing, tapping, and kneading (Table 1).

Table 1

Composition of the self-management program

The effectiveness of the program was monitored by asking the participants to complete a checklist of exercise therapy and diet. A weekly phone call was made to ensure that the self-management program was being properly followed. If a participant had difficulty implementing the program, they were provided with encouragement and a practice plan to help maintain the program’s sustainability. After 8 weeks of the self-management program, feedback from participants was collected to assess their involvement. The self-management program was designed to test its effects on physical function, quality of life, and sleep disorders in patients with knee OA.

Exercise

The exercise therapy in this study consisted of muscle-strengthening exercises and stretching exercises (Fig. 1). The exercises were taught and demonstrated individually by the researcher, and the participants were encouraged to perform the exercises for 10 minutes each morning and evening, 5 days a week.

Fig. 1

Exercises to strengthen muscles and improve stretching.

RESULTS

Homogeneity test of general characteristics

The gender distribution consisted of 48.5% males and 51.5% females, with a slightly higher proportion of females. The average age was 59.6 years, with the highest percentage (39.4%) falling within the 50–64 age range. Among the participants, 41.5% reported having no religious affiliation. Regarding education level, the largest group had a high school diploma (43.9%), followed by those with a college degree or higher (33.3%) and those with a middle school education or lower (22.8%). In terms of marital status, the majority were married (75.8%). Additionally, 77.3% were employed. Monthly income was most commonly in the range of 1.51–3 million Korean won (39.4%). Regarding cohabitation, 45.5% lived with a spouse, 39.4% lived with both a spouse and children, and 15.2% lived alone. In terms of health status, 44.0% reported being in good health. Regarding body mass index (BMI), 43.9% were classified as obese, 30.3% were in the pre-obese stage, 21.2% had a normal BMI, and 4.5% were underweight (Table 2).

Table 2

Homogeneity test of general characteristics (N=66)

Homogeneity testing of gender, age, religion, education level, marital status, employment, monthly income, cohabitation status, health status, and BMI showed no statistically significant differences between the two groups. Therefore, the experimental and control groups were considered homogeneous (Table 2).

Pretest homogeneity test of dependent variables

The results of the pretest homogeneity test for the dependent variables showed no statistically significant differences between the experimental and control groups in terms of physical symptoms, quality of life, or sleep disorders. Therefore, the groups were considered homogeneous (Table 3).

Table 3

Pretest of homogeneity for the dependent variable (N=66)

Physical symptoms

The experimental group that participated in the self-management program showed significant improvements in physical symptoms (pain, daily living function, exercise function) compared to the control group, as shown in Table 4.

Table 4

Effects of the self-management programs (N=66)

The experimental group experienced a reduction in pain caused by knee OA compared to the control group. Repeated measures ANOVA results indicated a statistically significant improvement over time in the experimental group (F=62.73, P<0.001), with a significant interaction between time and group (F=34.56, P< 0.001).

Additionally, the experimental group experienced a reduction in difficulties with daily living function due to knee OA compared to the control group. Repeated measures ANOVA results showed a statistically significant improvement over time in the experimental group (F=22.68, P<0.001), with a significant interaction between time and group (F=15.42, P<0.001). Furthermore, the experimental group showed a reduction in exercise function impairment due to knee OA compared to the control group. Repeated measures ANOVA results demonstrated a statistically significant improvement over time in the experimental group (F=8.19, P<0.01), with a significant interaction between time and group (F=5.82, P<0.05).

DISCUSSION

This study aimed to apply a self-management program to patients with knee OA to examine its effects on physical symptoms (pain, daily living function, and exercise function), quality of life, and sleep disturbances. Additionally, it sought to provide foundational data for developing nursing interventions for self-care in knee OA patients. Knee OA is known to be more prevalent women and the elderly (Hame and Alexander, 2013; Patten et al., 2022). In this study, the proportion of female participants was 51.5%, higher than that of male participants at 48.5%. Additionally, the majority of participants were in their 50s and 60s, supprting the finding of Hame and Alexander (2013) and Patten et al. (2022).

The experimental group that participated in the self-management program showed significant improvements in physical function (pain, daily living function, and exercise function) compared to the control group. The interaction effect between time points and groups was also statistically significant. Although few previous studies exist for direct comparison, Khachian et al. (2020) similarly found that a self-management mobile app for OA patients reduced postintervention pain and improved daily living function. The results of this study align with previous research indicating that aerobic walking and quadriceps strengthening exercises improve pain levels and reduce physical function disabilities (Roddy et al., 2005). Other studies also support that joint-strengthening and stretching exercises enhance mobility, improve stability, and reduce pain, thereby enhancing physical function (Baker and McAlindon, 2000).

Dietary adjustments contributed to these improvements by reducing the load on the knee joint and alleviating pain (Kolasinski et al., 2020). By promoting weight loss, these adjustments decrease joint stress, helping to reduce inflammation and pain. Additionally, the use of essential oils (lavender, peppermint, and rosemary) through massage in this study demonstrated anti-inflammatory and analgesic effects through skin absorption, further improving physical function (Pehlivan and Karadakovan, 2019; Rafii et al., 2020). Exercise therapy strengthens the muscles surrounding the knee joint, enhancing joint stability and reducing weight-bearing stress, which alleviates pain (Kolasinski et al., 2020; Roddy et al., 2005). Aromatherapy helps stabilize the nervous system and reduce pain perception by providing anti-inflammatory and analgesic effects. Thus, the self-management program, which integrated exercise therapy, dietary adjustments, and aromatherapy, effectively alleviated pain and improved physical symptoms, confirming its efficacy as a nursing intervention. The synergy of these three methods enhanced their effectiveness, making the program more successful in alleviating knee OA pain than any single intervention alone.

The experimental group showed statistically significant improvements in quality of life compared to the control group, with a significant interaction effect between time and group. These findings are consistent with previous studies on knee OA patients (Bunsanong and Chaimongkol, 2021; Khachian et al., 2020). The self-management program contributed to pain reduction, improved physical function, and ultimately enhanced quality of life. Aromatherapy’s anti-inflammatory and circulation-improving effects, combined with weight management through dietary adjustments, reduced discomfort in daily activities and contributed to an overall improvement in quality of life (Martin et al., 2001; Messier et al., 2000). Furthermore, continuous emotional support and encouragement played a key role. Weekly phone monitoring helped participants adhere to the self-management program, providing psychological stability and positively influencing their quality of life.

The individualized approach of the self-management program and the ongoing emotional support provided to participants were critical factors in improving quality of life. These findings underscore the importance of personalized care for addressing pain and physical symptoms in knee OA patients. Systematic implementation of self-management programs is essential for further improving patient outcomes. Although the experimental group experienced a greater reduction in sleep disorder scores compared to the control group, the difference was not statistically significant. Sleep disorder scores decreased from 41.00 to 32.58 in the experimental group and from 41.55 to 33.06 in the control group, with only a 0.49% greater decrease in the experimental group.

These findings align with previous research demonstrating that aromatherapy (lavender oil) reduces sleep disorders in adult and elderly patients with knee OA (Her and Cho, 2021). Similarly, Mohammadi et al. (2022) found that foot massage three times per week for 6 weeks significantly improved sleep quality in elderly women. Lavender essential oil, which affects both the sympathetic and parasympathetic nervous systems, induces psychological stability and promotes better sleep (Sattayakhom et al., 2023). Additionally, reductions in knee OA pain may have contributed to improved sleep quality, consistent with previous studies (Feda et al., 2023). However, the lack of statistical significance in sleep disorder outcomes may be attributed to nerve block injections received by all participants to alleviate knee OA symptoms. As both groups received this treatment, the experimental group did not show a significant advantage over the control group. Other potential factors, such as pre-existing sleep habits, stress levels, environmental influences, and negative perceptions of pain, may have also impacted the results (Smith and Haythornthwaite, 2004). These factors likely affected both groups equally, explaining the observed improvements in sleep disorder scores in the control group as well.

The self-management program was effective for the following reasons: The exercise regimen incorporated quadriceps strengthening exercises such as leg extensions and squats designed to strengthen the muscles while minimizing the load on the knee joint. The dietary intervention recommended a low-carbohydrate, high-protein diet to promote weight loss and reduce inflammation. The aromatherapy instructed patients to perform a 20-min massage to ensure consistent and effective implementation. These structured instructions helped patients adhere to the program and improved study outcomes.

Several limitations should be considered. The relatively short duration and intensity of the intervention may have influenced the results. Future studies should implement longer and more intensive programs to better assess the effectiveness of the program. Study participants were recruited from a single medical institution, which may limit the generalizability of the results. Future studies should validate the efficacy of the program in a variety of populations, including different patient groups and settings. Additional studies should analyze individual responses to aromatherapy to optimize effectiveness. Additional studies are needed to assess the long-term effectiveness of self-management programs and to develop tailored interventions based on the specific characteristics of patients with knee OA.

This study confirms that a multidimensional self-management program combining exercise therapy, dietary modification, and aromatherapy is an effective nursing intervention to reduce pain, improve physical function, and enhance quality of life in patients with knee OA. Although the effect on sleep disturbance was not statistically significant, the program contributed to overall patient well-being. Future research should focus on extending the intervention period, diversifying the participant population, and improving the individualized approach to maximize the effectiveness of self-management programs for patients with knee OA.

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