Thorlund JB, Simic M, Pihl K, et al. Similar Effects of Exercise Therapy, Nonsteroidal Anti-inflammatory Drugs, and Opioids for Knee Osteoarthritis Pain: A Systematic Review with Network Meta-analysis. J Orthop Sports Phys Ther. 2022 Apr;52(4):207-216. doi: 10.2519/jospt.2022.10490. (Systematic review)

OBJECTIVE: To compare the effectiveness of opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and exercise therapy for knee osteoarthritis pain.

DESIGN: Systematic review with network meta-analysis.

LITERATURE SEARCH: We searched the databases MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials from inception to April 15, 2021. Web of Science was used for citation tracking.

STUDY SELECTION CRITERIA: Randomized controlled trials comparing exercise therapy, NSAIDs, and opioids in any combination for knee osteoarthritis pain.

DATA SYNTHESIS: Network meta-analysis comparing exercise therapy, NSAIDs, opioids, and placebo/control for knee osteoarthritis pain. Additional trials from previous reviews were included to create the external placebo/control anchor.

RESULTS: We included 13 trials (1398 patients) with direct comparisons, supplemented with data from 101 additional trials. The treatment effect of NSAIDs for knee osteoarthritis pain was similar to that of opioids (standardized mean difference [SMD], 0.02; 95% confidence interval [CI], -0.14 to 0.18; Grading of Recommendations, Assessment, Development and Evaluations [GRADE]: low certainty). Exercise therapy had a larger effect than NSAIDs (SMD, 0.54; 95% CI, 0.19 to 0.89; GRADE: very low certainty). No estimate could be made for exercise vs opioids due to the lack of studies. Exercise therapy ranked as the "best" intervention in the network meta-analysis, followed by NSAIDs, opioids, and placebo/control intervention (GRADE: low certainty).

CONCLUSION: Exercise therapy ranked as the best treatment for knee osteoarthritis pain, followed by NSAIDs and opioids. The difference between treatments was small and likely not clinically relevant, and the overall confidence in the ranking was low. The results highlight the limited evidence for comparative effectiveness between exercise therapy, NSAIDs, and opioids for knee osteoarthritis pain. J Orthop Sports Phys Ther 2022;52(4):207-216. doi:10.2519/jospt.2022.10490.

Discipline Area Score
Rehab Clinician (OT/PT) 6 / 7
Physician 5 / 7
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Comments from MORE raters

Physician rater

I suspect that most doctors, while aware that exercise helps with OA knee pain, wouldn't know that it is not inferior (and it may be better) than analgesics for this indication.

Physician rater

The ranking of exercise as best for pain is a surprise. Not enough information to lead me to have high expectations for implementation in practice.

Physician rater

The study was well conducted, but, unfortunately, limited by the small number of good-quality studies.

Physician rater

There are some inconsistencies amongst these MSK pain reviews, particularly as to whether opioids have any clinically important benefit at all.

Rehab Clinician (OT/PT) rater

Another article highlighting the importance of exercise. The results show that exercise therapy as the best treatment for knee OA pain, followed by NSAIDs; although, differences between treatments are likely not clinically relevant.

Rehab Clinician (OT/PT) rater

The content of this article helps to support exercise therapy in management of OA, which is highly relevant to my profession.
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