This document summarizes a network meta-analysis of randomized controlled trials examining the effectiveness of exercise interventions for lower limb osteoarthritis. The analysis included 60 RCTs with 8,218 patients. It found that exercise programs combining strengthening, flexibility, and aerobic exercises were most effective at improving pain and physical function outcomes. The analysis provides evidence that a structured exercise program targeting multiple domains is the best exercise option clinicians can recommend to patients for treating lower limb osteoarthritis.

1. By
Hasan & Hamza
MA Physical Activity and Health
Institute of Sport Sciences

2.  Under
the Keyword of “Arthritis ”
244,309 Articles on PubMed.
“Osteoarthritis AND Physical Activity”
2242 on PubMed
“Meta-Analysis of 5 Year older”
13 Results
<After Review>
9 were related to effectiveness of some
modalities intervention.
4 were found relevant.

3.  Title
of the Article:
“Exercise for lower limb osteoarthritis:
systematic review incorporating trial
sequential analysis and network metaanalysis”
Authors:
Olalekan , Danielle and all.
Published: 20 September 2013.

4. 
Osteoarthritis is the most common form of arthritis and one of
the leading cause of pain and disability worldwide.

*Prevalence of Hip OA is 25.3% & Knee OA is 45.7%
Economic Burden: Direct & Indirect
 Uk† (1990 to 2000) 36M working days were Lost OA
Which cost €3.8bn ($5.1bn)
Productivity loss to UK economy is being estimated about 1% of total
GNP(gross national product)/ Year.


USA total(direct and indirect) economical losses in 2003 is
€95.8bn ($128 Bn)
* Murphy et al. One in four people may develop symptomatic hip
osteoarthritis in his or her lifetime.2010
† National Collaborating Centre for Chronic Conditions 2008

5. Network Meta-analysis of RCTs
 Information sources and search strategy
One Inf.Specialist develop strategies. And Six
Reviewer in pairs study the articles form data
bases.
Exercise interventions were defined as any type of
therapeutic exercise (land or water
based), regardless of content, duration,
frequency, or intensity.
 Data Bases:
Medline, Embase, CINAHL, AMED, HMIC, CENTRAL
, DARE and NHS EED.
 From Inception to March 2012
 No language restriction and bibliography is also
studied.


6.  Study
population: Adult of
clinical/Radiographical diagnosis of OA of hip
or Knee.
 Interventions: Therapeutic Exercise
 Comparator:other form of Ex or Control Group.
 Outcome measure: the core set of outcome
measures for clinical trials in osteoarthritis.
include assessment of at least one of self
reported pain and function
 Study Design: RCT, Trials were excluded if they
concerned pre-operative exercise therapy
(immediately before or after surgery

7.  They
used the Cochrane Collaboration’s tool
for assessing risk of bias for quality
assessment of the included trials. The trials
were graded (unclear, high, or low risk of
bias) based on sequence
generation, allocation concealment, blinding
of outcome assessor, incomplete outcome
data, and selective outcome reporting.

8. 
Number of Studies: 3796  full text articles 177
(Critical Reading)115(did not match inclusion
criteria)  60 RCT selected (8218 patients).

Time Frame: The trials were published between 1989
and 2012. The maximum length of follow-up ranged
from 4 weeks to 79 weeks (median 15 weeks).
Risk of bias of included trials:
The potential risk of bias likely to be introduced by
incomplete data was high in 10 trials (18%). The risk
of selective reporting bias was low in most trials
(n=53,88%).


9. Fig 1 Study selection of trials examining exercise in treatment of
lower limb osteoarthritis

10.  Implications
for practice:
> It also shows that some therapeutic
intervention are more beneficial to others.
>Exercise programs that combine
strengthening exercise with exercise aimed
at increasing flexibility and aerobic capacity
seem to be the “best” exercise option that
clinicians can offer to patients as a
“core” treatment.

11. Implications for research:
Further research is required in
How? adhere people to exercise and PA
Which? patients with lower limb osteoarthritis
benefit most from exercise.
What? mode of delivery is beneficial for
Intervention.


12.  What
this study adds
As of the year 2002, there was enough
evidence to show significant benefit of
exercise interventions versus no exercise in
lower limb osteoarthritis, indicating that
further trials of exercise versus no exercise
are unlikely to overturn this positive result.
Evidence from the network metaanalysis, largely based on studies in knee
osteoarthritis, indicates that a programmed
combining flexibility, strengthening, and
aerobic exercise is most likely to improve
outcomes of pain and function

13. Fig 2 Forest plots for network meta-analysis for pain and physical
function outcomes with no exercise as reference group. SUCRA=1 when
exercise intervention is certain to be best (that is, always ranks first)
and 0 when exercise intervention is certain to be worst

14. Fig 3 Scatter plot presenting ranking of exercise interventions for pain
reduction and physical function based on cumulative probability of being
most effective intervention

15.  All
studies shows The greatest improvements
were found in pain, quality of life, and
functional status.

16.  1-http:
//www.ncbi.nlm.nih.gov/pmc/articles/PMC3
779121/pdf/bmj.f5555.pdf
 2-www.scopus.com
 3- http://www.ncbi.nlm.nih.gov