An umbrella review and pooled analysis published in BMJ’s open-access journal RMD Open concludes that exercise therapy—widely promoted as a first-line treatment for osteoarthritis—delivers, at most, small and short-term improvements in pain and function compared with placebo or no treatment, with benefits appearing smaller in larger and longer-term trials.
A sweeping umbrella systematic review and pooled analysis has raised questions about how much exercise therapy helps people with osteoarthritis, a condition for which exercise is commonly recommended as an initial treatment.
The study, published in RMD Open (a BMJ open-access journal), assessed evidence from existing systematic reviews and added randomized controlled trials where review evidence was incomplete. Across the combined evidence base, the authors reported data from clinical trials involving more than 13,000 participants with osteoarthritis.
What the analysis found
The researchers included five prioritized systematic reviews comprising 8,631 patients and 100 unique randomized trials within those reviews. They also incorporated evidence from 28 additional randomized trials involving 4,360 participants.
When results were pooled, knee osteoarthritis outcomes showed small and short-lived reductions in pain for exercise compared with placebo or no treatment, and the authors rated the overall certainty of this evidence as very low. They also reported that, in larger studies and those with longer follow-up, estimated benefits tended to be smaller.
For hip osteoarthritis, the authors reported negligible improvement with moderate-certainty evidence. For hand osteoarthritis, the available data suggested small effects.
Comparisons with other treatments
The review found that exercise generally performed about the same as several other commonly used approaches, including patient education, manual therapy, pain medications, steroid or hyaluronic acid injections, and arthroscopic (keyhole) knee surgery, though the certainty of evidence varied depending on the comparison.
In some individual trials focused on specific patient groups, exercise was reported to be less effective over the long term than procedures such as knee osteotomy (bone realignment surgery) or joint replacement.
Caveats and conclusions
The authors noted limitations, including that they prioritized specific reviews for inclusion (meaning some relevant studies may not have been part of the main synthesis), that many studies lacked direct head-to-head comparisons, that patient symptom severity varied, and that some trials allowed additional treatments alongside exercise.
Even with these caveats, the authors wrote: "We found largely inconclusive evidence on exercise for osteoarthritis, suggesting negligible or, at best, short-lasting small effects on pain and function across different types of osteoarthritis compared with placebo or no treatment. These effects appear less pronounced in larger and longer-term trials."
They added: "Our findings question the universal promotion of exercise therapy as the sole focus in first-line treatment to improve pain and physical function in all patients with osteoarthritis."
The researchers emphasized that exercise can still offer broader health benefits and encouraged shared decision-making between clinicians and patients when weighing likely symptom relief, safety, cost, the stage of care, and alternative treatment options.
