Exercise for Lower Limb Osteoarthritis
Exercise for Lower Limb Osteoarthritis
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).
Conclusions. As 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.
Protocol Registration. PROSPERO (www.crd.york.ac.uk/prospero/) No CRD42012002267.
Osteoarthritis is the most common form of arthritis and one of the leading causes of pain and disability worldwide. The lifetime prevalence of symptomatic hip osteoarthritis is estimated at 25.3%, while that of knee osteoarthritis is even higher at 44.7%. The economic burden of osteoarthritis is substantial and consists of both direct costs (such as drugs, hospital care) and indirect costs (such as loss in productivity). 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. In the United States, the estimated incremental cost of medical care expenditures and earnings losses for people with arthritis or other rheumatological conditions was $128 billion (£80.5bn, €95.8bn) in 2003. In Canada, time lost from employment and leisure by people with disabling hip or knee osteoarthritis and their unpaid caregivers has been estimated at $C12,200 (£7400, €8800, US$11,800) per person per year.
The main goal of treatment for patients with osteoarthritis is to relieve the common symptoms of joint pain and improve everyday physical function. Current international guidelines recommend therapeutic exercise (land or water based) as "core" and effective management, given its beneficial effects, ease of application, few adverse effects, and relatively low costs. Regular exercise can reduce physical impairments and improve participation in social, domestic, occupational, and recreational activities. Additional benefits of exercise include improvements in mobility, risk of falls, body weight, mental health, and metabolic abnormalities. Recent guidance recommends both strengthening and aerobic exercise, but there are multiple other approaches to exercise such as stretching/flexibility, endurance training, aquatic exercise, and increasing general physical activity.
Several systematic reviews, including meta-analyses, have examined the effectiveness of exercise interventions for osteoarthritis. Since these reviews were published, many new trials have been conducted. Previous reviews have primarily focused on pairwise comparisons of the different exercise interventions within individual trials. One recent systematic review and network meta-analysis compared the effectiveness of acupuncture with other relevant physical treatments for alleviating pain from osteoarthritis. To our knowledge no review has yet compared different exercise approaches relative to each other by using network meta-analysis in which all interventions are compared equally by drawing on both direct evidence (comparing treatments within the same trial) and indirect evidence (comparing treatments from different trials). This approach deals with a critical research gap highlighted by recent Cochrane Reviews, which is the need for further studies to help provide evidence of the optimal types of exercise interventions and support decision making by patients, clinicians, and service commissioners. In this review, we first examined whether the required amount of information has been reached to confidently conclude that exercise is more effective than no exercise and that future trials need no longer examine this question. Secondly, we conducted a comprehensive synthesis using network meta-analysis methods to compare the effectiveness of different exercise interventions for pain and function in patients with lower limb osteoarthritis and to support evidence based recommendations regarding the content of these exercise programmes.
Abstract and Introduction
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).
Conclusions. As 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.
Protocol Registration. PROSPERO (www.crd.york.ac.uk/prospero/) No CRD42012002267.
Introduction
Osteoarthritis is the most common form of arthritis and one of the leading causes of pain and disability worldwide. The lifetime prevalence of symptomatic hip osteoarthritis is estimated at 25.3%, while that of knee osteoarthritis is even higher at 44.7%. The economic burden of osteoarthritis is substantial and consists of both direct costs (such as drugs, hospital care) and indirect costs (such as loss in productivity). 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. In the United States, the estimated incremental cost of medical care expenditures and earnings losses for people with arthritis or other rheumatological conditions was $128 billion (£80.5bn, €95.8bn) in 2003. In Canada, time lost from employment and leisure by people with disabling hip or knee osteoarthritis and their unpaid caregivers has been estimated at $C12,200 (£7400, €8800, US$11,800) per person per year.
The main goal of treatment for patients with osteoarthritis is to relieve the common symptoms of joint pain and improve everyday physical function. Current international guidelines recommend therapeutic exercise (land or water based) as "core" and effective management, given its beneficial effects, ease of application, few adverse effects, and relatively low costs. Regular exercise can reduce physical impairments and improve participation in social, domestic, occupational, and recreational activities. Additional benefits of exercise include improvements in mobility, risk of falls, body weight, mental health, and metabolic abnormalities. Recent guidance recommends both strengthening and aerobic exercise, but there are multiple other approaches to exercise such as stretching/flexibility, endurance training, aquatic exercise, and increasing general physical activity.
Several systematic reviews, including meta-analyses, have examined the effectiveness of exercise interventions for osteoarthritis. Since these reviews were published, many new trials have been conducted. Previous reviews have primarily focused on pairwise comparisons of the different exercise interventions within individual trials. One recent systematic review and network meta-analysis compared the effectiveness of acupuncture with other relevant physical treatments for alleviating pain from osteoarthritis. To our knowledge no review has yet compared different exercise approaches relative to each other by using network meta-analysis in which all interventions are compared equally by drawing on both direct evidence (comparing treatments within the same trial) and indirect evidence (comparing treatments from different trials). This approach deals with a critical research gap highlighted by recent Cochrane Reviews, which is the need for further studies to help provide evidence of the optimal types of exercise interventions and support decision making by patients, clinicians, and service commissioners. In this review, we first examined whether the required amount of information has been reached to confidently conclude that exercise is more effective than no exercise and that future trials need no longer examine this question. Secondly, we conducted a comprehensive synthesis using network meta-analysis methods to compare the effectiveness of different exercise interventions for pain and function in patients with lower limb osteoarthritis and to support evidence based recommendations regarding the content of these exercise programmes.
