Effect of exercise and/or educational interventions on physical activity and pain in patients with hip/knee osteoarthritis: A systematic review with meta-analysis

Abstract

Objective: To investigate the effectiveness of exercise and/or educational intervention on physical activity and pain in patients with hip/knee osteoarthritis (OA) using systematic review and meta-analysis.

Methods: We searched randomized controlled trials that investigated physical activity and pain and compared exercise and/or educational intervention with usual care in patients with hip/knee OA in MEDLINE (PubMed), ProQuest, Scopus, and the Physiotherapy Evidence Database (PEDro), including all those published by April 30, 2022 and written in English. Studies that newly applied analgesics after onset of the intervention were excluded. The revised Cochrane risk-of-bias tool for randomized trials was used to assess the methodological qualities. The random-effects model was used for meta-analysis with standard mean differences using RevMan version 5.4. The body of evidence for each study was synthesized using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.

Results: Twenty studies including 2,350 patients were included (7 exercise studies, 8 educational intervention studies and 5 combination studies). The meta-analysis demonstrated that there is very low evidence that combination therapy of exercise and educational intervention improve the physical activity level at the endpoint (4 articles; SMD 0.33, 95% CI 0.04 to 0.51, P = 0.03). Low evidence was observed for combination therapy reducing pain (4 articles; SMD -0.15, 95% CI -0.29 to -0.02, P = 0.03).

Discussion: The current evidence indicated that combination therapy of exercise and educational intervention leads to improved physical activity and pain reduction in hip/knee OA patients, but the risk of bias in each study, especially in allocation concealment, downgraded the evidence level. These findings support the use of a combination therapy of exercise and educational intervention to promote physical activity levels in patients with hip/knee OA.

Trail registration: There was no financial support for this research. The protocol was registered at the International Prospective Register of Systematic Reviews (registration code: CRD42020205804).

Fig 1. PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources.

*Consider, if feasible to do so, reporting the number of records identified from each database or register searched (rather than the total number across all databases/registers). **If automation tools were used, indicate how many records were excluded by a human and how many were excluded by automation tools. From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71. For more information, visit: http://www.prisma-statement.org/.

Fig 2. Summary in risk of bias 2.

(A) Outcomes on physical activity. (B) Outcomes on pain. Green, Low risk of bias; Yellow, Some concerns; Red, High risk of bias.

Fig 3. The mean difference and 95% CI values in physical activities.

Results from each study. Interv., intervention; Std Mean Difference, standardized mean difference; IV, inverse variance; 95% CI, 95% confidence interval; PASE, Physical Activity Scale for the Elderly; SQUASH, short questionnaire to assess health-enhancing physical activity; LTPA, average monthly leisure time physical activity; MVPA, moderate to vigorous physical activity; METs, metabolic equivalents; LEE, Lower-extremity exercise; Accel, accelerometer.

Fig 4. The mean difference and 95% CI values in pain.

Results from each study. Interv., intervention; Std Mean Difference, standardized mean difference; IV, inverse variance; 95% CI, 95% confidence interval; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index; VAS, visual analogue scale; HOOS, Hip disability and Osteoarthritis Outcome Scale; KOOS, Knee injury and Osteoarthritis Outcome Scale; NRS, numerical rating scale; BPI, brief pain inventory.