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This study aimed to compare the efficacy of four treatments in the management of knee osteoarthritis. We carried out a randomized clinical trial with four study arms in an outpatient Department of Physical Medicine and Rehabilitation at a University Hospital. In total, 120 patients with knee osteoarthritis ≥50 years of age were randomly allocated to four groups. The primary outcome was knee pain in visual analog scale and the secondary outcome was the Knee Injury and Osteoarthritis Outcome Score. The exercise was prescribed daily for all participants throughout the study. For physical therapy (group 1), participants received superficial heat, transcutaneous electrical nerve stimulation and pulsed ultrasound. We administered a single intra-articular injection of botulinum neurotoxin type A (group 2) and three injections of hyaluronic acid (group 3) or 20% dextrose (group 4) to patients in the corresponding groups. Mixed analysis of variance showed that there was statistically significant difference between the groups in pain (P < 0.001), and Knee Injury and Osteoarthritis Outcome Score (P < 0.001). Pairwise between- and within-group comparisons showed that botulinum neurotoxin and dextrose prolotherapy were the most, and hyaluronic acid was the least efficient treatments for controlling pain and recovering function in patients. An intra-articular injection of botulinum toxin type A or dextrose prolotherapy is effective first-line treatments. In the next place stands physical therapy particularly if the patient is not willing to continue regular exercise programs. Our study was not very supportive of intra-articular injection of hyaluronic acid as an effective treatment of knee osteoarthritis.

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Objective: To assess the effects of aqua-cycling on pain, physical function, and muscle strength among elderly people with knee osteoarthritis. Methods: We performed a randomized controlled trial from November 2016 through July 2017 in an outpatient clinic of the Department of Physical Medicine and Rehabilitation at the University Hospital. Patients were 60 years and older and had knee osteoarthritis. Among 32 patients who were randomly allocated to the groups aqua-cycling and control, 30 completed the study. We used the Knee injury and Osteoarthritis Outcome Score to assess the patients' opinion about their knees and associated problems. The measurements were performed at the baseline, and after 4, 8, and 12 sessions of aqua-cycling. Participants in the intervention group performed aqua-cycling, 3 sessions per week for 4 weeks. Each session lasted 50 minutes including 10 minutes of warm-up, 30 minutes of cycling, and 10 minutes of cool-down exercises. Both groups used acetaminophen, if needed, and followed lifestyle recommendations for 4 weeks. Results: There were significant improvements in pain reduction, physical function, and muscle strength in favor of aqua-cycling (all P < .001). Within-group analyses showed that participants in the aqua-cycling group experienced significant pain reduction (P < .001), and improved in physical function (P < .001), quadriceps (P < .001), and hamstring muscle strength (P < .001). Within-group comparisons for the group control were not significant (all P > .05). Conclusion: Aqua-cycling is effective, and can be used alone or combined with other treatments in the management of osteoarthritis.