That Which Does Not Kill You Makes You Stronger: Implementing an Exercise Program for People with Hip and Knee Osteoarthritis

Article by Sonja Elsaid

Graphic design by Katrina Hass

“It is like you are an athlete, and you go to being a couch potato.” These are the words commonly heard from patients with osteoarthritis, describing the consequences of their symptoms.

Osteoarthritis (OA) is the most common form of joint disease occurring in the knee, hip, and joints. It is associated with abnormal joint load or injury and the body’s inability to repair joint tissue. As a result, joint tissue breaks down over time, causing inflammation, immobility, and pain. The older we get, the more likely we are to develop OA.1 Research shows that over 23% of people suffer from OA between ages 65-69.2 However, by the time people reach 80 years, a staggering half will be affected.2 Unfortunately, OA has no cure. The current treatment is purely to control the symptoms.1,2

Initially, with mild OA, people start experiencing joint stiffness, and some pain; however, the pain becomes more severe with time, causing functional limitations. Eventually, the walking speed gets slower, going up and down the stairs becomes problematic, and the constant feeling of pain ultimately leads to generalized fatigue and depression.1,3 Avoiding pain and activities causes most patients afflicted with OA to become ‘couch potatoes.’

“But, what if I told you that the very same cause of pain could make the pain go away?” said Dr. Aileen Davis, Professor Emeritus at the Department of Physical Therapy and Surgery, and the Graduate Departments of Rehabilitation Science, Health Policy, Management and Evaluation, and the Institute of Medical Science at the University of Toronto. Contrary to popular belief that movement and exercise could wear out or even cause damage to joints affected by OA, teaching patients how to align their joints properly during exercise could mitigate the joint pain. “It is a paradox! It tells us that when we use proper nutrition, manage our weight and engage in a supervised exercise making the affected cartilage as healthy as possible; we are reducing and not increasing the pain.”

Dr. Aileen Davis
Ph.D. Professor Emeritus at the Department of Physical Therapy and Surgery and the Graduate Departments of Rehabilitation Science, Health Policy, Management and Evaluation, and the Institute of Medical Science at the University of Toronto.

Photo credit: Dr. Davis

Dr. Davis, who is also recently retired from the Senior Scientist position at the Healthcare and Outcomes Research division of Krembil Research Institute (formerly Toronto Western Research Institute) at the University Health Network, was referring to the outcomes of one of her most notable achievements, which is bringing GoodLife with osteoArthritis in Denmark (GLA: D®) to Canada.

Access to the right type of healthcare programs is one of the most important social determinants of health. GLA:D is an education and targeted exercise program for people with OA of the knee and hip. The program originated from the University of Southern Denmark.3 The idea of implementing such a program in Canada surfaced in 2014 by Dr. Davis—then the Director of Osteoarthritis Research at Bone and Joint Canada, which had a mandate to address a huge gap in provision of social determinants of health to Canadians—a program that addresses conservative management of OA. Given that GLA:D is an evidenced-based program for managing OA, it seemed like a good idea to bring this program to Canada.3

With the help of her colleagues at the Holland Centre at Sunnybrook Hospital, Dr. Davis conducted a pilot study initially testing the program only in Toronto. Subsequently, after receiving a three-year Trillium Foundation grant with Bone and Joint Canada, the research project expanded to include several sites in Ontario and eventually British Columbia and Alberta due to its popularity. As of January 2020, the program is no longer just a research project, but a fully implemented community-based clinical program.

Essentially, GLA:DTM Canada ( consists of three main elements. The first element is a certifiable education program for healthcare workers willing to implement the GLA:D program in their practice. Initially taught by Dr. Davis herself across Canada, the course is currently being delivered by knee and hip OA experts to physiotherapists, regulated kinesiologists, and chiropractors.

The second element of the GLA:D program is patient education and exercise. During the two- to three-day education session, patients learn how to keep their OA-affected cartilage as healthy as possible by engaging in proper nutrition and improving muscle strength to minimize the load to the affected joints.3 “One of the aims of patient education is to help them learn the importance of healthy weight management and how simply losing 5-10 lbs could significantly reduce pain,” Dr. Davis explained.

“The six-to-eight-week supervised exercise program”, continued Dr. Davis, “follows the educational component of GLA:D. Under ordinary circumstances, patients with OA receive a picture with a diagram of the types of exercises they should engage in at home. However, exercising alone may be particularly challenging for those who have never been active. For this reason, GLA:D program offers in-person instruction on exercising correctly during the 12 sessions. The key feature of the exercise program is to supervise the initial stages of learning how to exercise.”  

“The third component of the GLA:D program”, emphasized Dr. Davis, “is the quality monitoring part.” At this stage, patient outcomes are evaluated and recorded in the national electronic GLA:D registry. Namely, patient-reported, validated outcome measures and functional tests are assessed at baseline, at three months—after completing the program—and at 12-month follow-up. Among other outcomes, pain, quality of life, and mobility/function are tracked throughout the three-time points.

According to the GLA:DTM Canada outcomes data, significant improvements in functional abilities have been demonstrated by 65% of hip and 73% of knee patients.3 The survey tracked 1,601 patients with hip and 2,774 with knee OA across 209 Canadian sites between 2016 and 2019.3 Moreover, clinically significant improvements in quality of life and walking speed were observed.3

The most striking results were recorded with the 30%-improvement in pain. It was noted that in nearly half of patients with knee and hip OA that pain markedly improved one year after enrolling in the program.3 Furthermore, compared to the baseline, at both three and 12-month timepoints, knee patients indicated using fewer intra-articular injections to manage pain. Significant decreases were also seen in the percentage of patients being afraid of damaging their joints by exercise.3

Overall, the program addresses one of the social determinants of health—improving access to healthcare—as it significantly improved OA patient health outcomes. Although Dr. Davis retired in June 2020, the GLA:D program remains her legacy, passed on to her colleagues at the Schroeder Arthritis Institute, and Bone and Joint Canada to cultivate, expand and evolve it further. During the COVID-19 pandemic, the program has already moved to the online platform to accommodate the mandated social isolation during the lockdown. As for Dr. Davis, many of her former colleagues are enormously grateful that they get to carry on her legacy of showing the world how science can improve lives.


  1. Cramer P and Hochberg MC. Osteoarthritis. Lancet. 1997;350:503-09.
  2. Public Health Agency of Canada (PHAC). Osteoarthritis in Canada. Ottawa (ON): PHAC; 2019 [cited 2021 Jun 01]. Available from:
  3. Zywiel MG and McGlasson R. GLA:DTM Canada Implementation and Outcomes: 2019 Annual Report. Bone and Joint Canada. [Internet] 2020 June 1 [cited 2021 June 1]. Available from: