A network meta-analysis of 139 RCTs finds that knee bracing, hydrotherapy, and exercise provide the greatest improvement in pain, stiffness, and function for adults with mild to moderate KOA.
A network meta-analysis of randomized clinical trials has identified knee bracing, hydrotherapy, and exercise as the most effective physical therapy interventions for improving symptoms of knee osteoarthritis (KOA). The findings are based on 139 randomized controlled trials involving 9,644 adults with mild to moderate KOA.
The study evaluated 12 non-pharmacologic treatment options: low-level laser therapy (LLLT), high-intensity laser therapy (HILT), transcutaneous electrical nerve stimulation (TENS), interferential current (IFC), short wave diathermy, ultrasound, lateral wedged insole, knee brace, exercise, hydrotherapy, kinesio taping (KT), and extracorporeal shock wave therapy (ESWT). The control intervention was placebo.
Outcomes were assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)—which measures pain, stiffness, function, and total symptom burden—and the visual analog scale (VAS) for pain at rest and during activity.
Knee bracing was associated with the highest probability of reducing pain, improving physical function, and relieving stiffness on the WOMAC scale. It also ranked highest for reducing activity-related pain on the VAS. Hydrotherapy demonstrated the greatest likelihood of improving total WOMAC scores and VAS scores at rest. Exercise consistently ranked among the top interventions across multiple outcomes, particularly for pain and function.
Compared with placebo, knee bracing and exercise were more effective for pain relief. Knee bracing also outperformed lateral wedge insoles and ultrasound, which consistently ranked among the least effective modalities. Hydrotherapy, HILT, and LLLT also outperformed placebo in select outcomes. Ultrasound ranked lowest across several measures, including pain, function, and activity-related scores.
The network meta-analysis used a frequentist model and Surface Under the Cumulative Ranking (SUCRA) curves to integrate direct and indirect comparisons and probabilistically rank each intervention. Most comparisons were statistically consistent, and inconsistency testing indicated no significant differences across closed loops.
The study adhered to PRISMA 2020 guidelines and AMSTAR-2 criteria and included only randomized controlled trials with adult participants diagnosed with KOA using standardized radiographic and clinical criteria. Patients with recent joint surgery or intra-articular injection, or those receiving other physical therapy interventions within the past year, were excluded.
The authors emphasized the clinical importance of non-pharmacologic therapies for patients who are at increased risk for adverse effects from long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs). Physical therapy interventions such as knee bracing, hydrotherapy, and exercise may provide symptom relief with fewer systemic risks.
These findings provide an evidence-based hierarchy of physical therapy interventions for KOA and may assist clinicians in selecting safe and effective non-drug strategies for symptom management.
The authors reported no conflicts of interest.
Source: PLOS One