Evidence summary (Updated 2022)
A large body of good quality randomised controlled trial data shows consistent reduction in pain due to osteoarthritis, with benefits reported in strengthening, weight-bearing and aerobic exercise(8,10,11,15–20). This benefit is comparable with other treatment modalities, including many oral and topical analgesics(18). Effect size diminishes with time from structured physical activity intervention with no sustained benefit seen >6 months after a 3 month intervention in 5222 participants reported in a good quality meta-analysis of 54 RCTs suggesting physical activity needs to be sustained to maintain effect(11). A Cochrane review found moderate quality evidence of an absolute reduction in pain by 6% (in 9 studies of 1058 patients).(3)
All exercise types improved pain. Strengthening exercises alone have been shown to have the greatest effect on pain according to systematic reviews(21), although a combination of strengthening, aerobic and flexibility exercises is advised due to this combination still adequately improving pain and having a greater effect on function and general health(19). Goh et al, however found strength exercise had a moderate effect on pain while the greatest effect was seen on aerobic and mind-body exercises(10) and reviews focusing on stationary cycling have also found significant improvement in pain (p<0.0001)(14).
Yoga(5), Tai-chi and aquatic based exercises have been shown to have a significant improvement on pain compared to controls(4). Despite study heterogeneity a study looking at traditional Chinese exercises confirmed this finding and found a significant improvement in pain in intervention groups (p<0.001)(7).
A systematic review looking at the safety of physical activity interventions in those with knee osteoarthritis found that no studies reported an increase in pain in the physical activity group versus controls(22).
Quality of evidence
A – High quality
Strength of recommendation
1 – Strong
Physical activity can be recommended for the treatment of pain to most people with osteoarthritis and is consistently recommended across clinical guidelines.(23)
- JM S, TB B, HF A, Woehrle E, CA P, MJ L, et al. Are we missing the target? Are we aiming too low? What are the aerobic exercise prescriptions and their effects on markers of cardiovascular health and systemic inflammation in patients with knee osteoarthritis? A systematic review and meta-analysis. Br J Sports Med [Internet]. 2020 Jul 1 [cited 2022 Jan 5];54(13):771–5. Available from: https://pubmed.ncbi.nlm.nih.gov/31848152/
- Umehara T, Tanaka R. Effective exercise intervention period for improving body function or activity in patients with knee osteoarthritis undergoing total knee arthroplasty: a systematic review and meta-analysis. Brazilian J Phys Ther. 2018 Jul 1;22(4):265–75.
- Hurley M, Dickson K, Hallett R, Grant R, Hauari H, Walsh N, et al. Exercise interventions and patient beliefs for people with hip, knee or hip and knee osteoarthritis: a mixed methods review. Cochrane database Syst Rev [Internet]. 2018 Apr 17 [cited 2022 Jan 5];4(4):CD010842. Available from: https://pubmed.ncbi.nlm.nih.gov/29664187/
- Zampogna B, Papalia R, Papalia GF, Campi S, Vasta S, Vorini F, et al. The Role of Physical Activity as Conservative Treatment for Hip and Knee Osteoarthritis in Older People: A Systematic Review and Meta-Analysis. J Clin Med [Internet]. 2020 Apr 1 [cited 2022 Jan 5];9(4). Available from: https://pubmed.ncbi.nlm.nih.gov/32325775/
- Lauche R, Hunter DJ, Adams J, Cramer H. Yoga for Osteoarthritis: a Systematic Review and Meta-analysis. Curr Rheumatol Rep. 2019 Sep 1;21(9).
- SL G, MSM P, Stocks J, Hou Y, NJ W, Lin J, et al. Relative Efficacy of Different Exercises for Pain, Function, Performance and Quality of Life in Knee and Hip Osteoarthritis: Systematic Review and Network Meta-Analysis. Sports Med [Internet]. 2019;49(5):743–61. Available from: https://pubmed.ncbi.nlm.nih.gov/30830561/
- Li R, Chen H, Feng J, Xiao Y, Zhang H, Lam CWK, et al. Effectiveness of Traditional Chinese Exercise for Symptoms of Knee Osteoarthritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Int J Environ Res Public Health [Internet]. 2020 Nov 1 [cited 2022 Jan 5];17(21):1–18. Available from: https://pubmed.ncbi.nlm.nih.gov/33121082/
- Raposo F, Ramos M, A LC, Lúcia Cruz A. Effects of exercise on knee osteoarthritis: A systematic review. Musculoskeletal Care [Internet]. 2021 Dec 1 [cited 2022 Jan 5];19(4):399–435. Available from: https://pubmed.ncbi.nlm.nih.gov/33666347/
- Leyland KM, Gates LS, Sanchez-Santos MT, Nevitt MC, Felson D, Jones G, et al. Knee osteoarthritis and time-to all-cause mortality in six community-based cohorts: an international meta-analysis of individual participant-level data. Aging Clin Exp Res. 2021 Mar 1;33(3):529–45.
- Goh SL, Persson MSM, Stocks J, Hou Y, Lin J, Hall MC, et al. Efficacy and potential determinants of exercise therapy in knee and hip osteoarthritis: A systematic review and meta-analysis. Ann Phys Rehabil Med [Internet]. 2019 Sep 1 [cited 2022 Jan 5];62(5):356–65. Available from: https://pubmed.ncbi.nlm.nih.gov/31121333/
- Fransen M, Mcconnell S, Harmer AR, Van Der Esch M, Simic M, Bennell KL, et al. Exercise for osteoarthritis of the knee: a Cochrane systematic review This review is an abridged version of a Cochrane Review previously published in the Cochrane Database of. Available from: http://dx.doi.org/10.1136/bjsports-2015-095424
- Fransen M, Mcconnell S, Hernandez-Molina G, Reichenbach S. Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev. 2014 Apr 22;2014(4).
- Sampath KK, Mani R, Miyamori T, Tumilty S. The effects of manual therapy or exercise therapy or both in people with hip osteoarthritis: a systematic review and meta-analysis. Clin Rehabil [Internet]. 2016;30(12):1141–55. Available from: https://doi.org/10.1177/0269215515622670
- Luan L, Bousie J, Pranata A, Adams R, Han J. Stationary cycling exercise for knee osteoarthritis: A systematic review and meta-analysis. Clin Rehabil [Internet]. 2021 Apr 1 [cited 2022 Jan 5];35(4):522–33. Available from: https://pubmed.ncbi.nlm.nih.gov/33167714/
- Tanaka R, Ozawa J, Kito N, Moriyama H. CLINICAL REHABILITATION Efficacy of strengthening or aerobic exercise on pain relief in people with knee osteoarthritis: a systematic review and meta-analysis of randomized controlled trials. Clin Rehabil. 27(12):1059–71.
- Hall J, Swinkels A, Briddon J, McCabe CS. Does Aquatic Exercise Relieve Pain in Adults With Neurologic or Musculoskeletal Disease? A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Arch Phys Med Rehabil [Internet]. 2008 May 1 [cited 2022 Jun 17];89(5):873–83. Available from: http://www.archives-pmr.org/article/S0003999308000543/fulltext
- O’Keeffe M, Hayes A, McCreesh K, Purtill H, O’Sullivan K. Are group-based and individual physiotherapy exercise programmes equally effective for musculoskeletal conditions? A systematic review and meta-analysis. Br J Sports Med [Internet]. 2017 Jan 1 [cited 2022 Jun 17];51(2):126–32. Available from: https://pubmed.ncbi.nlm.nih.gov/27343238/
- Babatunde OO, Jordan JL, Van Der Windt DA, Hill JC, Foster NE, Protheroe J. Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence. PLoS One [Internet]. 2017 Jun 1 [cited 2022 Jun 17];12(6). Available from: https://pubmed.ncbi.nlm.nih.gov/28640822/
- Uthman OA, Van Der Windt DA, Jordan JL, Dziedzic KS, Healey EL, Peat GM, et al. Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis. BMJ [Internet]. 2013 Oct 12 [cited 2022 Jun 17];347(7928). Available from: https://pubmed.ncbi.nlm.nih.gov/24055922/
- Denham-Jones L, Gaskell L, Spence N, Pigott T. A systematic review of the effectiveness of Pilates on pain, disability, physical function, and quality of life in older adults with chronic musculoskeletal conditions. Musculoskeletal Care [Internet]. 2021 May 24 [cited 2022 Jan 5]; Available from: http://www.ncbi.nlm.nih.gov/pubmed/34028164
- Zhang Q, Young L, Li F. Network Meta-Analysis of Various Nonpharmacological Interventions on Pain Relief in Older Adults With Osteoarthritis. Am J Phys Med Rehabil [Internet]. 2019 Jun 1 [cited 2022 Jan 5];98(6):469–78. Available from: https://pubmed.ncbi.nlm.nih.gov/31094857/
- Quicke JG, Foster NE, Thomas MJ, Holden MA. Is long-term physical activity safe for older adults with knee pain?: a systematic review. Osteoarthr Cartil [Internet]. 2015 Sep 1 [cited 2022 Jun 17];23(9):1445–56. Available from: https://pubmed.ncbi.nlm.nih.gov/26003947/
- Masud S, Sheehan B, Rousseau-Saine A, Tucker A, Sandman E, Wong I, et al. Arthroscopy Association of Canada Position Statement on Exercise for Knee Osteoarthritis: A Systematic Review of Guidelines. Orthop J Sport Med [Internet]. 2021 Jun [cited 2022 Jan 5];9(6):23259671211016900. Available from: http://www.ncbi.nlm.nih.gov/pubmed/34179210
- Li Y, Su Y, Chen S, Zhang Y, Zhang Z, Liu C, et al. The effects of resistance exercise in patients with knee osteoarthritis: a systematic review and meta-analysis. Clin Rehabil [Internet]. 2016 Oct 1 [cited 2022 Jun 17];30(10):947–59. Available from: https://pubmed.ncbi.nlm.nih.gov/26471972/