Therapeutics
Review: Strength training, with or without flexibility and aerobic training, reduces pain in lower limb osteoarthritis
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;347:f5555.
Clinical impact ratings: F ★★★★★✩✩ R ★★★★★✩✩ Question
Main results
What is the effectiveness of different exercise therapies for reducing pain and improving function in lower limb osteoarthritis (OA)?
Results for network meta-analyses of exercise compared with no exercise are shown in the Table. Exercise therapies did not differ for reducing pain or improving function.
Review scope Included studies compared land- or water-based exercise therapies with another exercise therapy or no exercise in adults with clinical or radiographic knee or hip OA. Exclusion criteria were perioperative exercise therapy or use of the same exercise therapy in both study groups. Outcomes were self-reported pain and function.
Review methods MEDLINE, EMBASE/Excerpta Medica, CINAHL, AMED, Cochrane CENTRAL, Web of Science, DARE, NHSEED, and Health Management Information Consortium to Mar 2012; and reference lists were searched for randomized controlled trials (RCTs). 60 RCTs (n = 8218, median follow-up 15 wk) met the inclusion criteria: 44 were done in patients with knee OA, 2 in patients with hip OA, and 14 included a mix of patients. 45 RCTs evaluated land-based therapies, 6 water-based therapies, and 9 both. Therapies focused on ≥ 1 of flexibility, strength, and aerobic capacity/general health, with most RCTs comparing land-based strengthening exercise (16 alone, 11 combined with flexibility exercise, and 12 combined with aerobic and flexibility exercises) with no exercise; other comparisons were evaluated in ≤ 3 RCTs. 25 RCTs had adequate allocation concealment, 31 had blinded outcome assessors, and 44 had adequate follow-up data. Data from direct and indirect treatment comparisons were pooled using random-effects Bayesian network meta-analysis.
Conclusion Strength training, alone or with flexibility and aerobic training, reduces pain compared with no exercise therapy in patients with lower limb osteoarthritis. Source of funding: National Institute for Health Research. For correspondence: Dr. D.A. van der Windt, Keele University, Keele, Staffordshire, England, UK. E-mail [email protected]. ■
Commentary
One in 4 persons may develop symptomatic hip OA, and knee OA occurs in almost 1 in 2 persons. Pain and disability are frequent and substantial, and impact on quality of life, lost working days, and health care costs is immense. Surgery is invasive, complicated, and a last resort, and drugs often have low efficacy, toxicity, or both. Therefore, proven nonpharmacologic interventions are of utmost value. Exercises for lower limb OA have been found to be useful and recommended before (1) but not with the robustness and scope of the review by Uthman and colleagues, who used state-of-the-art methodology in meta-analysis. For the first time in this setting, network meta-analysis was used, which allowed indirect comparisons of multiple interventions that have not been studied head-to-head. Although such analyses are susceptible to the effects of heterogeneity and inconsistency (2), meta-regression did not reveal substantial differences. 3 pairs of reviewers evaluated Network meta-analysis of exercise vs no exercise therapy in lower limb OA* each trial, risk for bias was assessed, and trial sequenOutcomes Exercise therapy focus Type of exercise therapy tial analysis confirmed the reliability and conclusiveLand-based (unadjusted Water-based (unadjusted ness of findings. Most exercise programs reduced pain, SMD [95% CrI])† SMD [CrI])† with no additional advantage of aquatic performance. As safe, noninvasive, and inexpensive interventions, Pain reduction Flexibility −0.66 (−1.33 to 0.00) — these should be implemented. Concurrent positive Strength −0.81 (−1.13 to −0.50) −0.75 (−1.42 to −0.07)‡ effects on function may accrue, especially with Aerobic −0.41 (−1.13 to 0.30) — combined land-based programs, although function Flexibility + strength −0.50 (−0.85 to −0.16) −0.96 (−1.64 to −0.27) was less affected by exercise than pain. Flexibility + aerobic −0.26 (−1.00 to 0.47) −0.07 (−0.98 to 0.83) There are several caveats to the results of the netStrength + aerobic −0.13 (−0.88 to 0.61) −0.92 (−2.08 to 0.25) work meta-analysis. First, results apply mainly to knee OA; data were limited in hip OA. Second, Flexibility + strength + aerobic −0.69 (−1.04 to −0.35) −0.45 (−1.02 to 0.11) the efficacy of exercise was confirmed, but its Improved function Flexibility −0.17 (−1.26 to 0.93) — maintenance in the long term remains unknown. Strength −0.37 (−0.84 to 0.09) −0.43 (−1.42 to 0.56) Third, the effects of exercise programs on use of Aerobic −0.30 (−1.53 to 0.92) — drugs or surgery, their cost-effectiveness (which is likely), and the crucial question of patient acceptFlexibility + strength −0.40 (−0.92 to 0.12) −0.61 (−1.75 to 0.52) ance are currently unknown. However, I will now Flexibility + aerobic −0.18 (−1.24 to 0.89) 0.07 (−1.23 to 1.36) be more adamant about enrolling my patients with Strength + aerobic −0.17 (−1.25 to 0.91) −0.86 (−2.52 to 0.79) OA in continuing supervised exercise programs Flexibility + strength + aerobic −0.63 (−1.16 to −0.10)§ −0.49 (−1.32 to 0.33) and telling them about the results of the study by Uthman and colleagues—their chances of *CrI = credible interval; OA = osteoarthritis; SMD = standardized mean difference. Data were pooled using randomadherence may well increase. effects Bayesian network meta-analysis with direct and indirect treatment comparisons.
†SMD < 0 indicates benefit with exercise therapy. Bayesian CrIs are similar to classic frequentist CIs. Results of analyses adjusted for study-level covariates (follow-up period, publication year, and number of exercise sessions) using meta-regression are similar unless otherwise indicated. ‡Covariate-adjusted SMD −0.68 (95% CrI −1.38 to 0.02). §Covariate-adjusted SMD −0.57 (95% CrI −1.17 to 0.03).
17 December 2013 | ACP Journal Club | Volume 159 • Number 12
Ami Schattner, MD Nuffield Orthopaedic Centre Oxford, England, UK References 1. Baker KR, Nelson ME, Felson DT, et al. J Rheumatol. 2001;28:1655-65. 2. Jansen JP, Naci H. BMC Med. 2013;11:159. © 2013 American College of Physicians
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/929454/ by a NYU Medical Center Library User on 03/17/2017
JC7
Review: Strength training, with or without flexibility and aerobic training, reduces pain in lower limb osteoarthritis
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;347:f5555.
Clinical impact ratings: F ★★★★★✩✩ R ★★★★★✩✩ Question
Main results
What is the effectiveness of different exercise therapies for reducing pain and improving function in lower limb osteoarthritis (OA)?
Results for network meta-analyses of exercise compared with no exercise are shown in the Table. Exercise therapies did not differ for reducing pain or improving function.
Review scope Included studies compared land- or water-based exercise therapies with another exercise therapy or no exercise in adults with clinical or radiographic knee or hip OA. Exclusion criteria were perioperative exercise therapy or use of the same exercise therapy in both study groups. Outcomes were self-reported pain and function.
Review methods MEDLINE, EMBASE/Excerpta Medica, CINAHL, AMED, Cochrane CENTRAL, Web of Science, DARE, NHSEED, and Health Management Information Consortium to Mar 2012; and reference lists were searched for randomized controlled trials (RCTs). 60 RCTs (n = 8218, median follow-up 15 wk) met the inclusion criteria: 44 were done in patients with knee OA, 2 in patients with hip OA, and 14 included a mix of patients. 45 RCTs evaluated land-based therapies, 6 water-based therapies, and 9 both. Therapies focused on ≥ 1 of flexibility, strength, and aerobic capacity/general health, with most RCTs comparing land-based strengthening exercise (16 alone, 11 combined with flexibility exercise, and 12 combined with aerobic and flexibility exercises) with no exercise; other comparisons were evaluated in ≤ 3 RCTs. 25 RCTs had adequate allocation concealment, 31 had blinded outcome assessors, and 44 had adequate follow-up data. Data from direct and indirect treatment comparisons were pooled using random-effects Bayesian network meta-analysis.
Conclusion Strength training, alone or with flexibility and aerobic training, reduces pain compared with no exercise therapy in patients with lower limb osteoarthritis. Source of funding: National Institute for Health Research. For correspondence: Dr. D.A. van der Windt, Keele University, Keele, Staffordshire, England, UK. E-mail [email protected]. ■
Commentary
One in 4 persons may develop symptomatic hip OA, and knee OA occurs in almost 1 in 2 persons. Pain and disability are frequent and substantial, and impact on quality of life, lost working days, and health care costs is immense. Surgery is invasive, complicated, and a last resort, and drugs often have low efficacy, toxicity, or both. Therefore, proven nonpharmacologic interventions are of utmost value. Exercises for lower limb OA have been found to be useful and recommended before (1) but not with the robustness and scope of the review by Uthman and colleagues, who used state-of-the-art methodology in meta-analysis. For the first time in this setting, network meta-analysis was used, which allowed indirect comparisons of multiple interventions that have not been studied head-to-head. Although such analyses are susceptible to the effects of heterogeneity and inconsistency (2), meta-regression did not reveal substantial differences. 3 pairs of reviewers evaluated Network meta-analysis of exercise vs no exercise therapy in lower limb OA* each trial, risk for bias was assessed, and trial sequenOutcomes Exercise therapy focus Type of exercise therapy tial analysis confirmed the reliability and conclusiveLand-based (unadjusted Water-based (unadjusted ness of findings. Most exercise programs reduced pain, SMD [95% CrI])† SMD [CrI])† with no additional advantage of aquatic performance. As safe, noninvasive, and inexpensive interventions, Pain reduction Flexibility −0.66 (−1.33 to 0.00) — these should be implemented. Concurrent positive Strength −0.81 (−1.13 to −0.50) −0.75 (−1.42 to −0.07)‡ effects on function may accrue, especially with Aerobic −0.41 (−1.13 to 0.30) — combined land-based programs, although function Flexibility + strength −0.50 (−0.85 to −0.16) −0.96 (−1.64 to −0.27) was less affected by exercise than pain. Flexibility + aerobic −0.26 (−1.00 to 0.47) −0.07 (−0.98 to 0.83) There are several caveats to the results of the netStrength + aerobic −0.13 (−0.88 to 0.61) −0.92 (−2.08 to 0.25) work meta-analysis. First, results apply mainly to knee OA; data were limited in hip OA. Second, Flexibility + strength + aerobic −0.69 (−1.04 to −0.35) −0.45 (−1.02 to 0.11) the efficacy of exercise was confirmed, but its Improved function Flexibility −0.17 (−1.26 to 0.93) — maintenance in the long term remains unknown. Strength −0.37 (−0.84 to 0.09) −0.43 (−1.42 to 0.56) Third, the effects of exercise programs on use of Aerobic −0.30 (−1.53 to 0.92) — drugs or surgery, their cost-effectiveness (which is likely), and the crucial question of patient acceptFlexibility + strength −0.40 (−0.92 to 0.12) −0.61 (−1.75 to 0.52) ance are currently unknown. However, I will now Flexibility + aerobic −0.18 (−1.24 to 0.89) 0.07 (−1.23 to 1.36) be more adamant about enrolling my patients with Strength + aerobic −0.17 (−1.25 to 0.91) −0.86 (−2.52 to 0.79) OA in continuing supervised exercise programs Flexibility + strength + aerobic −0.63 (−1.16 to −0.10)§ −0.49 (−1.32 to 0.33) and telling them about the results of the study by Uthman and colleagues—their chances of *CrI = credible interval; OA = osteoarthritis; SMD = standardized mean difference. Data were pooled using randomadherence may well increase. effects Bayesian network meta-analysis with direct and indirect treatment comparisons.
†SMD < 0 indicates benefit with exercise therapy. Bayesian CrIs are similar to classic frequentist CIs. Results of analyses adjusted for study-level covariates (follow-up period, publication year, and number of exercise sessions) using meta-regression are similar unless otherwise indicated. ‡Covariate-adjusted SMD −0.68 (95% CrI −1.38 to 0.02). §Covariate-adjusted SMD −0.57 (95% CrI −1.17 to 0.03).
17 December 2013 | ACP Journal Club | Volume 159 • Number 12
Ami Schattner, MD Nuffield Orthopaedic Centre Oxford, England, UK References 1. Baker KR, Nelson ME, Felson DT, et al. J Rheumatol. 2001;28:1655-65. 2. Jansen JP, Naci H. BMC Med. 2013;11:159. © 2013 American College of Physicians
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/929454/ by a NYU Medical Center Library User on 03/17/2017
JC7
