Time to revisit the therapeutic benefits of exercise for osteoarthritis?

Clinical guidelines for management of hip and knee osteoarthritis universally recommend therapeutic exercise as a core treatment. In 2013 and 2019, the osteoarthritis community was assured that exercise was clinically effective for managing symptoms of hip or knee osteoarthritis and that new clinical trials would be unlikely to change this conclusion. 1 Uthman OA van der Windt DA Jordan JL et al. Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis. BMJ. 2013; 347f5555 Crossref PubMed Scopus (238) Google Scholar , 2 Verhagen AP Ferreira M Reijneveld-van de Vendel EAE et al. Do we need another trial on exercise in patients with knee osteoarthritis?: No new trials on exercise in knee OA. Osteoarthritis Cartilage. 2019; 27: 1266-1269 Summary Full Text Full Text PDF PubMed Scopus (35) Google Scholar Today, however, even the staunchest advocate for the use of exercise to manage osteoarthritis symptoms should question the clinical effectiveness of exercise as a core treatment. Why? In The Lancet Rheumatology, a systematic review and individual patient data (IPD) meta-analysis by Melanie Holden and colleagues 3 Holden MA Hattle M Runhaar J et al. Moderators of the effect of therapeutic exercise for knee and hip osteoarthritis: a systematic review and individual participant data meta-analysis. Lancet Rheumatol. 2023; (published online June 12.)https://doi.org/10.1016/S2665-9913(23)00122-4 Summary Full Text Full Text PDF Scopus (2) Google Scholar of 31 trials (n=4241 participants) demonstrates that although exercise has a significant benefit in individuals with hip or knee osteoarthritis, the magnitude of this overall effect on pain (–6·36 points [95% CI –8·45 to –4·27]; on a standardised 0–100 scale, with higher scores meaning worse pain), and physical function (–4·46 points [95% CI –5·95 to –2·98]; on a standardised 0–100 scale, with higher scores meaning worse physical function), compared with non-exercise controls, is small and of questionable clinical importance, with further diminishing returns beyond 12 weeks. Moderators of the effect of therapeutic exercise for knee and hip osteoarthritis: a systematic review and individual participant data meta-analysisThere was evidence of a small, positive overall effect of therapeutic exercise on pain and physical function compared with non-exercise controls. However, this effect is of questionable clinical importance, particularly in the medium and long term. As individuals with higher pain severity and poorer physical function at baseline benefited more than those with lower pain severity and better physical function at baseline, targeting individuals with higher levels of osteoarthritis-related pain and disability for therapeutic exercise might be of merit. Full-Text PDF Open Access