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

BMJ 2013; 347 doi: (Published 20 September 2013) Cite this as: BMJ 2013;347:f5555
  1. Olalekan A Uthman, assistant professor in applied research, systematic reviewer12,
  2. Danielle A van der Windt, professor of primary care epidemiology1,
  3. Joanne L Jordan, research information manager1,
  4. Krysia S Dziedzic, Arthritis Research UK professor of musculoskeletal therapies1,
  5. Emma L Healey, research fellow1,
  6. George M Peat, professor of clinical epidemiology1,
  7. Nadine E Foster, NIHR professor of musculoskeletal health in primary care1
  1. 1Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire ST5 5BG, UK
  2. 2Warwick-Centre for Applied Health Research and Delivery (WCAHRD), Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL UK
  1. Correspondence to: D van der Windt d.van.der.windt{at}
  • Accepted 16 August 2013


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 ( No CRD42012002267.


  • We thank Mark Porcheret for his advice during the preparation of this paper and Kelvin Jordan for critical reading of this manuscript.

  • Contributors: OAU, DAvdW, JLJ, KSD, ELH, and NEF were responsible for study concept and design, acquisition of data, and analysis and interpretation of data. All authors drafted or wrote the manuscript and critically revised it for important intellectual content. OAU, DAvdW, and JLJ were responsible for statistical analysis. DAvdW, KSD, and NEF supervised the study. OAU is guarantor.

  • Funding: This study was funded by the National Institute for Health Research (NIHR) under its programme grants for applied research programme (grant reference No RP-PG-0407-10386). The NIHR had no role in the conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review of the manuscript. The conclusions and views expressed in this article are those of the authors and not necessarily those of the NHS, NIHR, or Department of Health.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: DAvdW, KSD, ELH, GMP, and NEF are involved in the design and conduct of publicly funded trials on the effectiveness or exercise approaches for osteoarthritis or other musculoskeletal conditions.

  • Ethical approval: Not required.

  • Data sharing: No additional data available.

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