Introduction
Osteoarthritis is a chronic age-related degenerative disease that begins at the age of 50-60 years and usually affects the knee and hip joints. Knee osteoarthritis (KO) refers to the breakdown of cartilage in the knee joint leading to bone-on-bone friction. This condition is associated with pain and mental health problems such as kinesiophobia; therefore, it has become a major global concern [4]. One of the appropriate treatments for KO is exercise or physical activity. One of the effective exercises is water exercise. The present study aims to determine the effect of aquatic exercise with Theraband versus aquatic exercise based on the National Academy of Sports Medicine (NASM) approach on pain, kinesiophobia, and mood in older women with KO.

Methods & Materials
This is a quasi-experimental study. The study population consists of older women with KO referred to Mahmoudieh, Hilal-Ahmar and Sepehr rehabilitation clinics in Isfahan, Iran, in 2023. Forty-five women were selected using a purposeful non-probability sampling method and were randomly divided into three groups of 15, including the Theraband, NASM, and control. The inclusion criteria were having KO with pain for at least three months, no intra-articular injection of drugs, not taking energizing supplements, and not participating in other exercise programs. The exclusion criteria were absence from two consecutive training sessions, injury, blood pressure drop during exercise, fear of water, hip or ankle osteoarthritis, and osteoporosis or other joint diseases other than KO. Participants’ KO was identified by a physiotherapist through clinical tests and radiographic evaluations. 
To measure the body height, a caliper (SECA 210, Germany) with an accuracy of 3 mm was used. In addition, a digital scale (KEEP FIT 6657, China) was used to measure the body weight. The BMI was calculated using the formula: BMI = Weight (kg) / height (m)2. Visual analog scale (VAS), Tampa scale of kinesiophobia (TSK), and the Brunel mood scale (BRUMS) were used to measure the pain, kinesiophobia, and mood variables in two stages, pre-test and post-test. The exercise programs were performed for eight weeks, three sessions per week, each for 60 minutes in the water. During this period, the control group had their usual activities and treatment methods. To analyze the data, MANCOVA and Bonferroni’s post hoc test were conducted in SPSS software, version 26, considering a significance level of P≤0.05.

Results
According to the results in Table 1, after exercises, the amount of pain, Kinesiophobia, and mood decreased significantly in both exercise groups (P=0.001).


Also, there was a significant difference among the groups (P=0.001). The results of the post hoc test showed significant differences between the control group and the two exercise groups in all variables (P=0.001), but these differences were not significant between the two exercise groups (P>0.05).

Conclusion
These results showed the beneficial effects of aquatic exercise with Theraband or based on the NASM approach on pain, kinesiophobia, and mood in older women with KO. Exercise in water can relieve pain and improve psychological factors in these women. Therefore, these aquatic exercise methods are recommended as a suitable prevention and treatment method for women with KO.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Islamic Azad University, Khorasgan Branch, Isfahan, Iran (Code: IR.IAU.KHUISF.REC.1403.157).

Funding
This study was extracted from the master’s thesis of Zohreh Mohammadi Kamalabadi, at the Department of Sports Pathology and Corrective Movements, Faculty of Physical Education & Sports Sciences, Islamic Azad University, Khorasgan Branch, Isfahan. This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
Conceptualization, data analysis, investigation, editing & review, supervision, project administration: Allahyar Arabmomeni: methodlogy, validation, initial draft preparation, visualization: Zohreh Mohammadi Kamalabadi; 

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank all seniors participated in this study for their cooperation.

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