Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis

Abstract

Objective To determine whether there is sufficient evidence to conclude that exercise interventions are more effective than no exercise control and to compare the effectiveness of different exercise interventions in relieving pain and improving function in patients with lower limb osteoarthritis. Data sources Nine electronic databases searched from inception to March 2012.Study selection Randomised controlled trials comparing exercise interventions with each other or with no exercise control for adults with knee or hip osteoarthritis.Data extraction Two reviewers evaluated eligibility and methodological quality. Main outcomes extracted were pain intensity and limitation of function. Trial sequential analysis was used to investigate reliability and conclusiveness of available evidence for exercise interventions. Bayesian network meta-analysis was used to combine both direct (within trial) and indirect (between trial) evidence on treatment effectiveness.Results 60 trials (44 knee, two hip, 14 mixed) covering 12 exercise interventions and with 8218 patients met inclusion criteria. Sequential analysis showed that as of 2002 sufficient evidence had been accrued to show significant benefit of exercise interventions over no exercise control. For pain relief, strengthening, flexibility plus strengthening, flexibility plus strengthening plus aerobic, aquatic strengthening, and aquatic strengthening plus flexibility, exercises were significantly more effective than no exercise control. A combined intervention of strengthening, flexibility, and aerobic exercise was also significantly more effective than no exercise control for improving limitation in function (standardised mean difference −0.63, 95% credible interval −1.16 to −0.10). ConclusionsAs of 2002 sufficient evidence had accumulated to show significant benefit of exercise over no exercise in patients with osteoarthritis, and further trials are unlikely to overturn this result. An approach combining exercises to increase strength, flexibility, and aerobic capacity is likely to be most effective in the management of lower limb osteoarthritis. The evidence is largely from trials in patients with knee osteoarthritis. PROSPERO (www.crd.york.ac.uk/prospero/) No CRD42012002267. Protocol registration IntroductionOsteoarthritis is the most common form of arthritis and one of the leading causes of pain and disability worldwide.1 The lifetime prevalence of symptomatic hip osteoarthritis is estimated at 25.3%, 2 while that of knee osteoarthritis is even higher at 44.7%. 3 The economic burden of osteoarthritis is substantial and consists of both direct costs (such as drugs, Between 1999 and 2000 in the United Kingdom, about 36 million working days were lost because of osteoarthritis alone, leading to an estimated £3.2bn (€3.8bn, $5.1bn) in productivity losses, with the total cost to the UK economy being estimated at 1% of gross national product per year. 1 In the United States, the estimated incremental cost of medical care expenditures and earnings losses for people ...

Depression and pain: primary data and meta-analysis among 237 952 people across 47 low- and middle-income countries

“…Related to the inflammatory hypothesis, sedentary behaviour is also associated with inflammation (Hamer et al, 2012a, Hamer et al, 2012b and both pain (Stubbs et al, 2014) and depression are associated with sedentary behaviour . Given that physical activity can improve inflammatory markers (Hamer et al, 2014), interventions increasing activity levels may improve pain symptoms (Uthman et al, 2013) and depression (Schuch et al, 2016a, Schuch et al, 2016b and at a population level may be a particularly viable option in LMICs. Another potential option is that areas of the brain linked to mood dysregulation (e.g.…”

Effects of resistance training in individuals with knee osteoarthritis

“…Muscular endurance training has been explored as an intervention to prevent or delay OA onset (10,16). Considering the lower limb as an integrated unit, the use of exercises for developing strength of the quadriceps, hamstrings, abdominals, and gluteus medius and maximus can lead to normal biomechanical restoration of the lower limb and promote OA symptom control.…”

Effectiveness of Exercise Therapy and its Variations in Lower Limb Osteoarthritis: A Literature Review

“…While certain authors suggest that a simple flexion-extension exercise program is sufficient to achieve positive results in treatment, 16 there is stronger evidence to suggest that a combination of various forms of exercises is most beneficial, although it is still unclear which exercise combinations work best. 13,31 Furthermore, most functional outcome parameters are seen to improve with these interventions except pain and knee adduction moment, that show little improvement at long-term follow-up. More high quality systemic reviews addressing exercise therapy interventions are needed for narrowing down optimum interventions, and would make it easier for healthcare professionals to design the most effective intervention programs.…”

“…Ni et al 30 demonstrated similar results in a study demonstrating the efficacy of Tai Chi on improving function in cases of Knee OA. However in both these studies the control groups did not undergo any form of physical exercises, and since studies have shown benefits of physical exercises in OA 13,31 it is difficult to say whether Tai Chi is more effective than standard exercises. Nonetheless it is a safe and controlled form of training and can be incorporated in a rehabilitation program, as it has not shown any adverse effects.…”

“…A quantitative systemic review by Uthman et al also concluded that prescribing an effective strength and flexibility program in combination with aerobic exercises had significantly positive results on pain and functional limitations in patients with OA of knees. 13 It is believed that stretching exercises may be beneficial in conjunction with strengthening exercises in patients with knee OA. A clinical trial conducted by Weng et al investigated the effects of combining stretching with strength training in patients suffering from mild to moderate OA.…”