Table 4.
Systematic Reviews summaries (n = 57).
| Interventions | Authors (A to Z; year) | No of included RCTs (subjects; grade) | Results/Conclusions |
|---|---|---|---|
| Athletic tape | |||
| Li et al. [68] | 11 (n = 168; B) | Statistical significance was found in self-reported pain during activity (MD = −0.85; 95% CI: −1.55 to −0.14; p = 0.02), knee flexibility (MD = 7.59; 95% CI: 0.61 to 14.57; p = 0.03), knee-related health status (WOMAC scale, MD = −4.10; 95% CI: −7.75 to −0.45; p = 0.03), and proprioceptive sensibility (MD = −4.69; 95% CI: −7.75 to −1.63; p = 0.003). However, no significant enhancement was reported regarding knee muscle strength (MD = 1.25; 95% CI: −0.03 to 2.53; p = 0.06). | |
| Lin et al. [72] | 15 (n = 546; A) | The study suggests that physical therapy combined with kinesio taping is more effective than physical therapy alone, as indicated by a greater reduction in pain scores (MD = −0.70; 95% CI: −1.14 to −0.26; p = 0.002) and functional improvement (MD = −5.45; 95% CI: −10.23 to −0.66; p = 0.03). The results also show significant pain reduction (MD = −0.72; 95% CI: −1.18 to −0.26; p = 0.002) and functional improvement (MD = −6.05; 95% CI: −11.18 to −0.93; p = 0.02) within six weeks after initial treatments. | |
| Lu et al. [75] | 5 (n = 363; B) | Kinesio taping is effective in improving for pain (VAS at rest, WMD = −0.394; 95% CI: −0.759 to −0.029; p = 0.034; VAS during walking, WMD = −0.429; 95% CI: −0.752 to −0.105; p = 0.009), WOMAC index score (WMD = −5.026; 95% CI: −7.649 to −2.403; p < 0.001), and knee flexion ROM (WMD = 6.193; 95% CI: 2.678 to 9.709; p = 0.001). However, it does not improve muscle strenght (WMD = 3.205; 95% CI: −3.141 to 9.550; p = 0.322). | |
| Melese et al. [77] | 18 (n = 876; B) | Differences were found between Kinesio Taping groups and control groups in terms of VAS, WOMAC index scale and flexion ROM. | |
| Wu et al. [96] | 16 (n = 642; A) | There was a significant difference between the Kinesio taping plus exercise group and the exercise-only group in terms of VAS score after the intervention (MD = −0.86; 95% CI: −1.32 to −0.40; p = 0.0003). However, no significant differences were found in terms of VAS at the follow-up period (MD = −0.58; 95% CI: −1.41 to 0.25; p = 0.17), WOMAC score (MD = 0.28; 95% CI: −9.16 to 9.71; p = 0.95), and TUG after the intervention (MD = −0.74; 95% CI: −1.72 to 0.24; p = 0.14). | |
| Ye et al. [101] | 11 (n = 490; B) | The study found statistically significant differences in pain (SMD = −0.78; 95% CI: 1.07 to −0.50; p < 0.00001), physical function (SMD = 0.73; 95% CI: −1.03 to −0.43; p < 0.00001), ROM (MD = 2.04; 95% CI: 0.14 to 3.94; p = 0.04), and quadriceps muscle strength (MD = 2.42; 95% CI: 1.09 to 3.74; p = 0.0004). No significant differences were found for the hamstring muscle strength. | |
| Balneology | |||
| Antonelli et al. [45] | 17 (n = 1599; B) | When comparing balneological interventions with standard treatment, the results showed that the former were more effective in terms of long-term overall QOL (SMD = −1.03; 95% CI: −1.66 to −0.40; p < 0.00001). Additionally, when comparing balneological interventions with sham interventions, the results showed that the former were more effective in terms of long-term pain improvement (SMD = −0.38; 95% CI: −0.74 to −0.02; p = 0.04), while no significant difference was found when considering social function (SMD = −0.16; 95% CI: −0.52 to 0.19; p = 0.36). | |
| Hou et al. [62] | 11 (n = 1106; B) | The study found significant differences in VAS score (SMD = −0.74; 95% CI: −1.08 to −0.41; p < 0.0001) and WOMAC Index (pain, SMD = −0.53; 95% CI: −0.71 to −0.36; p < 0.00001; stiffness, SMD = −0.50; 95% CI: −0.68 to −0.31; p < 0.00001; function, SMD = −0.43; 95% CI: −0.57 to −0.29; p < 0.00001). | |
| Exercise therapies | |||
| Aquatic therapy | Dong et al. [55] | 8 (n = 579; B) | The study found no significant difference in pain relief, physical function, and improvement in QOL between aquatic exercise and land-based exercise for short- and long-term interventions in patients with KOA. However, patients reported higher adherence and satisfaction levels with aquatic exercise compared to land-based exercise. Compared to no intervention, aquatic exercise had a mild effect on elevating activities of daily living (SMD = −0.55; 95% CI: −0.94 to −0.16; p = 0.005) and a high effect on improving sports and recreational activities (SMD = −1.03; 95% CI: −1.82 to −0.25; p = 0.01). |
| Ma et al. [76] | 13 (n = 883; B) | Aquatic physical therapy has been found to significantly reduce pain based on the WOMAC index (SMD = −1.09; 95% CI: −1.97 to −0.21; p = 0.02) and VAS (SMD = −0.55; 95% CI: −0.98 to −0.12; p = 0.01). Additionally, it effectively improved physical function based on the WOMAC physical function score (SMD = −0.57; 95% CI: −1.14 to −0.01; p = 0.05). However, there were no significant improvements in joint symptoms, QOL, flexibility, or body composition for KOA. Aquatic physical therapy has been found to improve knee extension muscle strength (MD = 2.11; 95% CI: 0.02 to 4.20; p = 0.05) and TUG (MD = −0.89; 95% CI: −1.25 to −0.53; p < 0.05), thereby improving walking ability. | |
| Balance training | Pirayeh et al. [80] | 15 (n = 919; B) | The studies revealed that balance training can significantly improve physical function in KOA patients. However, the effect of balance training on muscle strength of the quadriceps and the hamstring remains unclear due to conflicting results. Additionally, the balance training group showed more significant improvement in postural stability and balance compared to the control group. |
| Wang et al. [94] | 24 (n = 1275; A) | In comparison with no intervention, proprioceptive training significantly improved pain, stiffness, physical function, joint position sense, muscle strength, mobility, and knee ROM (P < 0.05) in people with KOA. When compared to other non-proprioceptive training, proprioceptive training yielded superior results in terms of joint position sense (SMD = −1.28; 95% CI: −1.64 to −0.92; p < 0.00001) and mobility (timed walk over spongy surface) (SMD = −0.76; 95% CI: −1.33 to −0.18; p = 0.01), while other outcomes were comparable. When comparing proprioceptive training plus other non-proprioceptive training to other non-proprioceptive training, both groups showed similar outcomes. However, the proprioceptive training group showed greater improvement in joint position sense (SMD −1.54; 95% CI: −2.74 to −0.34; p = 0.01), physical function (SMD -0.34; 95% CI: −0.56 to −0.12; p = 0.003), and knee ROM (p < 0.05). When comparing proprioceptive training plus conventional physiotherapy to conventional physiotherapy alone, both groups demonstrated similar outcomes. However, the proprioceptive training plus conventional physiotherapy group showed a significant improvement in joint position sense (SMD −0.95; 95% CI: −1.73 to −0.18; p = 0.02). | |
| Blood flow restriction therapy | Grantham et al. [58] | 5 (n = 199; A) | There was no statistical difference (p: 0.329–0.880) found between blood flow restriction therapy and traditional resistance training in terms of pain reduction, functional improvement, and TUG improvement. |
| Pitsillides et al. [81] | 3 (n = 117; B) | The blood flow restriction and high intensity training groups demonstrated significant improvements in quadriceps strength in the strength outcome, with an increase from baseline to post-intervention. Additionally, the blood flow restriction and high intensity training groups showed significant strength gains in leg press and leg extension exercises, while the low intensity training group showed minimal improvements. In terms of the pain outcome, all groups experienced a reduction in pain. However, blood flow restriction training was found to be more effective in reducing compared to high-intensity training. While blood flow restriction resulted in decreased scores on physical function scales compared to baseline, there were no significant changes observed in the TUG test among the three groups. Regarding the QOL outcome, there were few studies to draw conclusions from. However, it appears that all three groups can improve WOMAC scores, with no statistically significant differences found in SF-36. | |
| Circuit-based exercise | Al-Mhanna et al. [44] | 7 (n = 346; B) | The intervention group showed a significant improvement in pain level (SMD = −0.96; 95% CI: −1.77 to −0.14; p = 0.02). However, no significant improvement was found in physical function (SMD = 0.03; 95% CI: −0.44 to 0.50; p = 0.89), QOL (SMD = −0.25; 95% CI: −1.18 to 0.68; p = 0.60), activity of daily living (SMD = 0.81; 95% CI: −0.85 to 2.48; p = 0.34), or knee stiffness (SMD = −0.65, 95% CI: −1.96 to 0.66; p = 0.33). |
| Resistance training | Kus and Yeldan [65] | 10 (n = 759; B) | When comparing different exercises to strengthen the quadriceps femoris muscle, no significant difference was found between the training groups. However, exercise training to strengthen the quadriceps femoris muscle was found to be superior to proprioceptive training. Additionally, the use of hot packs along with shortwave diathermy, ultrasound, or transcutaneous electrical nerve stimulation was found to be superior to isokinetic strengthening of the quadriceps femoris muscle alone. Only the additional use of Russian electrical stimulation showed a significant difference compared to the strengthening of the quadriceps femoris muscle exercise. Most of the studies included in this analysis showed that exercises aimed at strengthening the quadriceps femoris muscle have a positive effect on reducing pain and improving function. |
| Liao et al. [69] | 19 (n = 1195; A) | Muscle strength exercise training resulted in a significantly higher gain in lean mass (SMD = 0.49; 95% CI: 0.28 to 0.71; p < 0.00001), muscle thickness (SMD = 0.82; 95% CI: 0.20 to 1.43; p = 0.009), and cross-sectional area (SMD = 0.80; 95% CI: 0.25 to 1.35; p = 0.004) compared to non-exercise controls. No significant effects in favor of muscle strength exercise training were observed for any muscle outcome compared to exercise controls. | |
| Neelapala et al. [78] | 5 (n = 331; B) | Strong, high-quality evidence demonstrated the effectiveness of hip muscle strengthening was assessed in isolation, combination, and comparison with other lower extremity exercise. Overall, the studies reported clear benefits of hip muscle strengthening on knee pain, physical function, and hip muscle strength. However, hip muscle strengthening was ineffective in improving the biomechanical measures such as dynamic alignment and knee adduction moment. | |
| Thomas et al. [87] | 7 (n = 428; B) | Hip abductor strengthening interventions were found to be superior to the control groups. Specifically, hip abductor strengthening significantly reduced the VAS (SMD = −0.60; 95% CI: −0.88 to −0.33; p < 0.0001) and improved the WOMAC scores (SMD = −0.75; 95% CI: −1.05 to −0.45; p < 0.0001). All of the included studies concluded that strengthening the hip abductor muscle had a positive impact on knee pain and functional outcomes. | |
| Thorlund et al. [88] | 13 (n = 1398; A) | The study found that the treatment effect of NSAIDs for KOA pain was comparable to that of opioids (SMD = 0.02; 95% CI: −0.14 to 0.18). Exercise therapy had a larger effect than NSAIDs (SMD = 0.54; 95% CI: 0.19 to 0.89). No estimate could be made for exercise vs opioids due to the lack of studies. | |
| Turner et al. [91] | 12 (n = 1428; B) | Resistance training has been shown to improve pain, QOL, and physical function in individuals with KOA. The study found that 24 total sessions over an 8- to 12-week period had large effect sizes. No optimal number of repetitions, maximum strength, or frequency of sets or repetitions was found. | |
| Whole-body vibration | Qiu et al. [82] | 14 (n = 559; B) | Whole-body vibration combined with strengthening exercises has a significant positive effect on pain score (SMD = 0.46; 95% CI: 0.20 to 0.71; p = 0.0004), WOMAC Index (WOMAC-function, SMD = 0.51; 95% CI: 0.27 to 0.75; p < 0.0001), TUG (SMD = 0.82; 95% CI: 0.46 to 1.18; p < 0.00001), extensor isokinetic peak torque (SMD = 0.65; 95% CI: 0.00 to 1.29; p = 0.05), peak power (SMD = 0.68; 95% CI: 0.26 to 1.10; p = 0.001), and extensor isometric strength (SMD = 0.44; 95% CI: 0.13 to 0.75; p = 0.006). Both low-frequency (10–30 Hz) and high-frequency (30–40 Hz) whole-body vibration resulted in significant changes in pain, physical function, and knee extensor strength (p < 0.05). Whole-body vibration was not associated with significant changes in stiffness, balance, QOL, and knee flexor strength. |
| Mind-body therapies | |||
| Baduanjin | Zeng et al. [103] | 7 (n = 424; A) | Statistically significant differences were found between Baduanjin exercise and waiting list control on WOMAC index scores (pain, MD = −4.40; 95% CI: −7.16 to −1.64; p < 0.01; stiffness, MD = −1.34; 95% CI: −1.64, −1.04; p < 0.01; function, MD = −2.44; 95% CI: −4.33 to −0.55; p < 0.01). Furthermore, when used in isolation, the Baduanjin exercise demonstrated a statistically significant improvement on three domains of WOMAC index scores (pain, MD = −1.69; 95 % CI: −2.03 to −1.35; p < 0.01; stiffness, MD = −0.86; 95 % CI: −1.13 to −0.58; p < 0.01; function, MD = −2.23; 95 % CI: −3.65 to −0.82; p < 0.01) compared to health education. In addition, the combination of Baduanjin exercise and NSAID therapies led to a significant improvement in the total WOMAC score (MD = −10.26; 95% CI: −13.41 to −7.11; p < 0.01) and a reduction in VAS (MD = −1.65; 95% CI: −1.83 to −1.48; p < 0.01) compared to NSAID therapies alone. |
| Tai Ji | Hu et al. [63] | 16 (n = 986; B) | Tai Ji significantly improved patients' outcomes, including pain (SMD = −0.69; 95% CI: −0.95 to −0.44; p < 0.001), stiffness (SMD = −0.59; 95% CI: −0.91 to −0.27, p < 0.001), physical function (SMD = −0.92; 95% CI: −1.16 to −0.69, p < 0.001), dynamic balance (SMD = 0.69; 95% CI: 0.38 to 0.99; P < 0.001), and physiological and psychological health (SF-36 physical, SMD = 0.48; 95% CI: 0.28 to 0.68; p < 0.001; SF-36 mental, SMD = 0.26; 95% CI: 0.06 to 0.45; p = 0.01). |
| You et al. [102] | 11 (n = 603; B) | The results showed that the Tai Ji group was associated with better performance in 6-MWT (MD = 46.67; 95% CI: 36.91 to 56.43; p < 0.001), TUG (MD = −0.89; 95% CI: −1.16 to −0.61; p < 0.001]), and WOMAC Index function score (MD = −11.28; 95% CI: −13.33 to −9.24; p < 0.001) than the control group. | |
| Wu Qin Xi | Guo et al. [59] | 7 (n = 668; B) | Wu Qin Xi exercise showed a significant improvement in WOMAC total score regardless of the intervention of control group (MD = −105.76; 95% CI: −161.38 to −50.14; p < 0.01). Furthermore, Wu Qin Xi exercise significantly improved the pain symptoms (MD = −17.00; 95% CI: −21.41 to −12.58; p < 0.00001), joint stiffness (MD = −3.43; 95% CI: −5.50 to −1.37; p = 0.001), and joint function (MD = −33.45; 95% CI: −48.74 to −18.17; p < 0.0001). Wu Qin Xi can also decrease pain, as VAS scores revealed an improvement (MD = −1.07; 95% CI: −1.97 to −0.17; p = 0.02). |
| Yoga | Lauche et al. [66] | 9 (n = 640; B) | The studies revealed effects of yoga on pain (vs. exercise, SMD = −1.07; 95% CI: −1.92 to −0.21; p = 0.01; vs. non-exercise, SMD = −0.75; 95% CI: −1.18 to −0.31; p < 0.001), physical function (vs. exercise, SMD = 0.80; 95% CI: 0.36 to 1.24; p < 0.001; vs. non-exercise, SMD = 0.60; 95% CI: 0.30 to 0.98; p < 0.001), and stiffness (vs. exercise, SMD = −0.92; 95% CI: −1.69 to −0.14; p = 0.008; vs. non-exercise, SMD = −0.76; 95% CI −1.26 to −0.26; p = 0.003) in KOA individuals. |
| Musculoskeletal manual manipulations | |||
| Anwer et al. [46] | 11 (n = 494; B) | The results indicated a statistically insignificant reduction of VAS score with orthopaedic manual therapy compared with the control group was (SMD = −0.59; 95% CI: −1.54 to −0.36; p = 0.224). However, there was a statistically significant reduction in VAS score with orthopaedic manual therapy compared to exercise therapy (SMD = −0.78; 95% CI: −1.42 to −0.17; p = 0.013). There was a statistically significant reduction in WOMAC pain (SMD = −0.79; 95% CI: −1.14 to −0.43; p = 0.001) and function (SMD = −0.85; 95% CI: −1.20 to −0.50; p = 0.001) with orthopaedic manual therapy compared to the exercise therapy group. However, the reduction in WOMAC global score with orthopaedic manual therapy compared to the exercise therapy group was statistically insignificant (SMD = −0.23; 95% CI: −0.54 to −0.09; p = 0.164). A statistically significant reduction was found in the time taken to ascend and descend stairs in the orthopaedic manual therapy group compared to the exercise therapy group (SMD = −0.88; 95% CI: −1.48 to −0.29; p = 0.004). | |
| Runge et al. [83] | 19 (n = 1394; B) | There was very low- to moderate-certainty evidence that manual therapy when added to exercise, provided benefit in the short-term for pain (SMD = −0.82; 95% CI: −1.22 to −0.43) and WOMAC global score (SMD = −1.05; 95% CI: −1.52 to −0.59), but not for TUG (MD = −0.12; 95% CI: −0.27 to 0.03) and WOMAC function (SMD = −0.27; 95% CI: −0.85 to 0.30). In the medium-term, there was low- to very-low-certainty evidence that MT added benefit for TUG (MD = −2.20; 95% CI: −2.89 to −1.51) and WOMAC global score (MD = −7.40; 95% CI: −10.31 to −4.49), but not for pain (MD = −0.97; 95% CI: −2.02 to 0.09) and WOMAC physical function (MD = 0.23; 95% CI: −6.36 to 6.82). There was high-certainty evidence that manual therapy did not provided any additional benefit in the long-term for pain (MD = −0.14; 95% CI: −0.48 to 0.21), TUG (MD = 0.39; 95% CI: −0.30 to 1.08) and WOMAC global score (MD = 0.56; 95% CI: −8.45 to 9.57; p = 0.90). | |
| Weleslassie et al. [95] | 15 (n = 704; B) | The results suggests that there were significant differences between mobilization with movement groups and control groups in terms of VAS, WOMAC Index scale, and flexion ROM. | |
| Needle-based therapies | |||
| Acupuncture therapy | Gong et al. [57] | 17 (n = 4774; B) | Acutherapy had a significant effect on knee pain (SMD = −0.73; 95% CI: −0.98 to −0.47; p < 0.001), knee stiffness (SMD = −0.66; 95% CI: −0.85 to −0.47; p < 0.001), and physical function (SMD = −1.56; 95% CI: −2.17 to −0.95; p < 0.001) compared to a control condition without any acutherapy intervention. Additionally, acutherapy was found to be more effective than a corresponding sham intervention applied on nonacupoints (SMD = −0.16; 95% CI: −0.32 to −0.01; p = 0.04). However, there were no significant differences found in treatment effects between acutherapy and sham acutherapy at the same acupoints (SMD = −0.09; 95% CI: −0.40 to 0.21; p = 0.55). |
| Sun et al. [86] | 8 (n = 2106; B) | Compared with low- and medium-dosage acupuncture treatments, strong evidence showed that there was a positive correlation between high-dosage acupuncture treatment and positive outcomes. | |
| Dry needling | Jiménez-del-Barrio et al. [64] | 7 (n = 291; A) | In the short-term, dry needling demonstrated significant improvements in pain intensity (SMD = −0.76; 95% CI: −1.24 to −0.29; p = 0.002) and physical function (SMD = −0.98; 95% CI: −1.54 to −0.42; p = 0.0006). However, no significant differences were observed in the medium- or long-term. |
| Ughreja and Prem [92] | 9 (n = 779; A) | Subgroup analysis of moderate-quality evidence shows that periosteal stimulation technique has short-term effects on pain (post-treatment, MD = −1.13; 95% CI: −1.31 to −0.95; p < 0.00001; 3-month follow-up, MD = −1.46; 95% CI: −2.43 to −0.50; p = 0.003) and WOMAC function (post-treatment, MD = −5.47; 95% CI: −7.56 to −3.37; p < 0.00001; 3-month follow-up, MD = −4.95; 95% CI: −9.69 to −0.21; p = 0.04). Intramuscular electrical stimulation has a significant effect on pain (MD = −2.30; 95% CI: −4.4 to 0.20; p = 0.03) in KOA. The myofascial trigger point needling technique showed significant within-group differences in pain and knee function, but no significant differences were found between the dry needling and sham dry needling groups. A meta-analysis was not performed for this technique due to the lack of studies that could be compared. | |
| Nutrition therapies | |||
| Diet therapy | Chu et al. [52] | 7 (n = 1105; B) | The study results indicate that weight loss had a significant positive effect on pain (SMD = 0.33; 95% CI: 0.17 to 0.48; p < 0.0001), self-reported disability (SMD = 0.42; 95% CI: 0.25 to 0.59; p < 0.00001), QOL (physical) (SMD = 0.39; 95% CI: 0.24 to 0.54; p < 0.00001), WOMAC index (SMD = 0.37; 95% CI: 0.11 to 0.62; p = 0.004), and 6-MWT (SMD = 0.23; 95% CI: 0.06 to 0.40; p = 0.009). However, no significant improvements were observed in the timed stair climb test (p = 0.20). |
| Hall et al. [60] | 16 (n = 2142; A) | The study found that diet-only treatments did not result in a reduction of pain (SMD = −0.13; 95% CI: −0.37 to 0.10; p = 0.10). However, a combination of diet and exercise treatments did moderately reduce pain (SMD = −0.37; 95% CI: −0.69 to −0.04; p = 0.112). Physical function showed moderate improvement with both diet treatments (SMD = −0.30; 95% CI: −0.52 to −0.08; p = 0.08) and combined diet and exercise treatments (SMD = −0.32; 95% CI: −0.56 to −0.08; p = 0.265). Of all the inflammatory markers that were assessed, only interleukin-6 showed a reduction with diet-only treatments (SMD = −0.23; 95% CI: −0.45 to −0.02; p = 0.38). | |
| Dietary supplements | Liao et al. [71] | 6 (n = 242; B) | The group that received protein supplementation combined with exercise training showed significant improvements in muscle mass (SMD = 1.13; 95% CI: 0.72 to 1.53; p < 0.00001), pain (SMD = 1.36; 95% CI: 0.68 to 2.03; p < 0.00001), and muscle strength (involved leg, SMD = 0.44; 95% CI: 0.03 to 0.85; p = 0.04; uninvolved leg, SMD = 0.54; 95% CI: 0.13 to 0.95; p = 0.01). |
| Patient education | |||
| Goff et al. [56] | 29 (n = 4107; A) | Patient education was found to be more effective than usual care in improving pain (SMD = 20.35; 95% CI: 20.56 to 20.14) and function in the short-term (SMD = 20.31; 95% CI: 20.62 to 0.00). However, it was less effective than exercise therapy in reducing pain in the short-term (SMD = 0.77; 95% CI: 0.07 to 1.47). Combining patient education with exercise therapy resulted in better outcomes for pain in the short-term (SMD = 0.44; 95% CI: 0.19 to 0.69) and function in the short- (SMD = 0.81; 95% CI: 0.54 to 1.08) and medium-term (SMD = 0.39; 95% CI: 0.15 to 0.62). When comparing results using the WOMAC Index, it was found that exercise therapy was more effective than patient education for short-term pain relief (MD = 1.56; 95% CI: 0.14 to 2.98). Additionally, a combination of patient education and exercise therapy was found to be more effective than patient education alone for short-term improvement in function (MD = 8.94; 95% CI: 6.05 to 11.82). | |
| Safari et al. [84] | 8 (n = 2687; B) | Studies reported that digital-based structured self-management programs compared with the treatment as usual control group resulted in a significant medium reduction in pain (SMD = −0.28; 95% CI: −0.38 to −0.18) and improvement in physical function (SMD = −0.26; 95% CI: −0.35 to −0.16) at post-treatment. Although the effect of digital-based structured self-management programs on pain and function reduced slightly at the 12-month follow-up, it remained medium and significant. The effect of digital-based structured self-management programs after treatment was small and significant for disability (SMD = −0.10; 95% CI: −0.17 to 0.03), but not significant for QOL (SMD = −0.17; 95% CI: −0.47 to 0.14). The intervention's effect at the 12-month follow-up was very small for both disability and QOL. | |
| Uritani et al. [93] | 7 (n = 1123; B) | Group-based and face-to-face self-management education programmes have been found to have beneficial effects on self-efficacy for managing pain and other symptoms, as well as for self-regulating KOA. However, due to the wide range of clinical heterogeneity, most of the information in the systematic review was inconclusive. | |
| Wu et al. [98] | 13 (n = 1610; B) | Meta-analysis revealed significant differences between the self-management and control groups in pain (SMD = −1.51; 95% CI: 2.41 to 0.62; p = 0.001), function (SMD = −0.24; 95% CI: −0.45 to 0.04; p = 0.02), arthritis self-efficacy (pain, MD = 2.82; 95% CI: 0.35 to 5.29; p = 0.03; other symptoms, SMD = 3.99; 95% CI: 1.55 to 6.43; p = 0.001), and mental health (MD = 3.82; 95% CI: 3.31 to 4.32; p < 0.00001). However, no statistically significant differences were found in the WOMAC index. | |
| Xie et al. [99] | 6 (n = 791; B) | The study found that internet-based rehabilitation programs can significantly reduce osteoarthritic pain in patients compared to conventional rehabilitation (SMD = −0.21; 95% CI: −0.4 to −0.01; p = 0.04). However, there was no significant difference in physical function improvement between patients with KOA who underwent internet-based rehabilitation and those who underwent conventional rehabilitation within 2–12 months (SMD = −0.08; 95% CI; −0.27 to 0.12; p = 0.43). | |
| Physical agents | |||
| Cryotherapy | Dantas et al. [53] | 5 (n = 202; B) | Low-quality evidence showed improvements in pain control and functional outcomes. |
| Electric stimulation therapy | Chen et al. [49] | 10 (n = 493; B) | The groups that received interferential current therapy showed significant improvements in short-term pain scores (SMD = −0.64; 95% CI: −1.04 to −0.25; p = 0.001), long-term pain scores (SMD = −0.36; 95% CI: −0.60 to −0.11; p = 0.005), and short-term WOMAC index scores (SMD = −0.39; 95% CI: −0.77 to −0.02; p = 0.04) compared to the control groups. |
| Extracorporeal shockwave therapy | Avendano-Coy et al. [47] | 14 (n = 782; A) | Extracorporeal shockwave therapy caused a decrease on the pain VAS (MD = 1.7; 95% CI: 1.1 to 2.3) and WOMAC (MD = 13.9; 95%CI: 6.9 to 20.8). The effect of extracorporeal shockwave therapy using medium energetic density was greater than with low or high density in the WOMAC (X2 = 9.8; p = 0.002) and bordered statistical significance on the VAS (X2 = 3.8; p = 0.05). Extracorporeal shockwave therapy causes moderate improvement in the knee ROM (MD = 17.5; 95% CI: 9.4 to 25.5) and walking test (SMD = 0.58; 95% CI: 0.35 to 0.81). |
| Chen et al. [51] | 32 (n = 2408; B) | Extracorporeal shockwave therapy demonstrated significant improvement in pain reduction and functional improvement compared to placebo, corticosteroid, hyaluronic acid, medication, and ultrasound (p < 0.05). In terms of functional improvement, shockwave therapy showed statistically significant improvement compared to kinesiotherapy and moxibustion (p < 0.05), but not with acupotomy surgery (p = 0.24). A statistically significant difference was observed in pain reduction (p < 0.05) between shockwave therapy and platelet-rich plasma, but not in functional improvement (p = 0.89). Similarly, a statistical difference was found in functional improvement (p < 0.05) between extracorporeal shockwave therapy and fumigation, but not in pain reduction (p = 0.26). Furthermore, there was no statistically significant difference between extracorporeal shockwave therapy and manipulation in both pain reduction (p = 0.21) and functional improvement (p = 0.45). | |
| Li et al. [67] | 7 (n = 366; B) | The extracorporeal shockwave therapy group exhibited a lower VAS score (MD = −2.35; 95% CI: −2.92 to −1.79; p < 0.00001), larger ROM (MD = 17.58; 95% CI: 12.88 to 22.28; p < 0.00001) and a better Lequesne index (MD = −3.06; 95% CI: −3.90 to −2.21; p < 0.00001) than the placebo group after 1 month of therapy. At 1 month post-therapy, the group that received extracorporeal shockwave therapy had a lower VAS score (MD = −1.98; 95% CI: −2.93 to −1.03; p < 0.00001), a larger ROM (MD = 11.69; 95% CI: 6.40 to 16.98; p < 0.00001), and better WOMAC scores (MD = −15.38; 95% CI: −18.87 to −11.89; p < 0.00001) compared to the group that received physical therapy. | |
| Liao et al. [70] | 50 (n = 4844; B) | Results indicate a significant improvement in the success rate of shockwave therapy (OR = 3.22; 95% CI: 2.21 to 4.69; p < 0.00001), pain reduction (SMD = −2.02; 95% CI: −2.38 to −1.67; p < 0.00001), and WOMAC Index function outcome (SMD = −2.71; 95% CI: −3.50 to −1.92; p < 0.00001). | |
| Laser therapy | Ahmad et al. [43] | 10 (n = 495; B) | Statistically significant improvements were observed in the VAS (SMD = −0.67; 95% CI: −1.05 to −0.29; p < 0.05) and WOMAC function (SMD = −0.70; 95% CI: −1.36 to −0.04; p < 0.05) scores of patients treated with low-level laser therapy plus exercise compared to the control group. However, no significant difference was found between the two groups in the WOMAC pain and stiffness scores. High-level laser therapy was found to be superior to the control group in terms of VAS (SMD = −2.06; 95% CI: −3.14 to −0.98; p < 0.05), WOMAC pain (SMD = −2.03; 95% CI: −3.81 to −0.26; p = 0.02), stiffness (SMD = −0.84; 95% CI: −1.43 to −0.24, p < 0.05), and function (SMD = −3.11; 95% CI: −5.59 to −0.62; p < 0.05) when compared to the control group. |
| Stausholm et al. [85] | 22 (n = 1063; B) | Overall, low-level laser therapy significantly reduced VAS compared to placebo at the end of therapy (MD = 14.23; 95% CI: 7.31 to 21.14; p < 0.0001) and during follow-ups 1–12 weeks later (MD = 15.92; 95% CI: 6.47 to 25.37; p = 0.001). The results of the subgroup analysis indicate that the recommended low-level laser therapy doses significantly reduced pain compared to placebo at the end of therapy (MD = 18.71; 95% CI: 9.42 to 27.99; p < 0.0001) and during follow-ups 1–12 weeks after the end of therapy (MD = 23.23; 95% CI: 10.60 to 35.86; p = 0.0003). The greatest reduction in pain from the recommended low-level laser therapy doses was observed during follow-ups 2–4 weeks after the end of therapy (MD = 31.87; 95% CI: 18.18 to 45.56; p ≤ 0.01). Low-level laser therapy significantly reduced disability compared to placebo at the end of therapy (MD = 0.59; 95% CI: 0.33 to 0.86; p < 0.00001) and during follow-ups 1–12 weeks later (MD = 0.66; 95% CI: 0.23 to 1.09; p = 0.003). The subgroup analysis showed that the recommended low-level laser therapy doses significantly increased disability compared to placebo at the end of therapy (MD = 0.75; 95% CI: 0.46 to 1.03; p < 0.00001) and during follow-ups 1–12 weeks after the end of therapy (MD = 1.31; 95% CI: 0.92 to 1.69; p < 0.00001). | |
| Wu et al. [97] | 10 (n = 580; B) | High-intensity laser demonstrated the highest probability of being among the most effective treatments, compared to a control (placebo laser, exercise, or a combination of both) in the VAS (WMD = 1.66; 95% CI: 1.48 to 1.84; p < 0.00001) and WOMAC (WMD = 10.87; 95% CI: 8.85 to 12.88; p < 0.00001). Comparing low- to high-intensity laser, differences were found in WOMAC (WMD = 6.48; 95% CI: 4.07 to 8.89; p < 0.00001) and pain (WMD = 0.81; 95% CI: 0.44 to 1.18; p < 0.00001), favoring high-intensity laser. | |
| Magnetic field therapy | Chen et al. [50] | 8 (n = 421; B) | Pulsed electromagnetic field therapy improved physical function (WMD = −5.28; 95% CI: −9.45 to −1.11, p = 0.01), but did not show advantage in reducing WOMAC total score (WMD = −7.80; 95% CI: −16.08 to 0.47; p = 0.06), WOMAC pain score (WMD = −1.06; 95% CI −2.30 to 0.17, p = 0.09), VAS pain score (WMD = −0.88; 95% CI: −2.06 to 0.31, p = 0.15), or WOMAC stiffness score (WMD = −0.50; 95% CI: −1.09 to 0.09; p = 0.1). |
| Tong et al. [89] | 11 (n = 614; B) | Compared to the control groups, pulsed electromagnetic field therapy yielded more favorable results. It alleviated pain (SMD = 0.71; 95% CI: 0.08 to 1.34; p = 0.03), improved stiffness (SMD = 1.34; 95% CI: 0.45 to 2.23; p = 0.003), and restored physical function (SMD = 1.52; 95% CI: 0.49 to 2.55; p = 0.004). | |
| Yang et al. [100] | 16 (n = 1078; B) | Compared to the placebo group, electromagnetic field therapy was found to have a beneficial effect on pain (SMD = 1.06; 95% CI = 0.61 to 1.51; p < 0.00001), stiffness (SMD = 0.37; 95% CI: 0.07 to 0.67; p = 0.02), and function (SMD = 0.46; 95% CI: 0.14 to 0.78; p = 0.005). However, no statistically significant differences were found for QOL (SMD = 1.49; 95% CI: −0.06 to 3.04; p = 0.06). Electromagnetic field therapy parameters, such as duration of treatment, may not be a critical factor to influence symptoms. | |
| Ultrasonic therapy | Chen et al. [48] | 13 (n = 807; B) | Low-intensity pulsed ultrasound significantly improved the VAS (MD = −0.95, 95% CI: −1.43 to −0.48; p < 0.001), WOMAC index score (MD = −4.35; 95% CI: −8.30 to −0.40; p = 0.0309), Lysholm score (SMD = 1.59; 95% CI: 1.29 to 1.90; p < 0.001), Lequesne index (MD = −1.33; 95% CI: −1.69 to −0.96; p < 0.001), ROM (MD = 2.43; 95% CI: 0.39 to 4.46; p = 0.0197) and 50-m walking time (SMD = 1.48; 95% CI: 0.46 to 2.49; p = 0.0044). Subgroup analyses revealed that low-intensity pulsed ultrasound monotherapy was more effective in reducing VAS (p = 0.0213), while a shorter therapeutic period (≤4 weeks) was more effective in increasing the WOMAC score (p = 0.0083). |
| Dantas et al. [54] | 5 (n = 234; B) | Therapeutic ultrasonic therapy resulted in statistically significant pain relief (SMD = −0.33; 95% CI: −0.60 to −0.07; p = 0.01) and improved self-reported function (SMD = −0.33; 95% CI: −0.65 to −0.01; p = 0.05) compared to sham treatment. | |
| Liu et al. [73] | 14 (n = 1080; B) | Both pulsed (SMD = 1.11; 95% CI: 0.86 to 1.36; p < 0.00001) and continuous ultrasound (SMD = 1.18; 95% CI: 0.78 to 1.57; p < 0.00001) therapy were found to have significant pain relief effects. High-intensity ultrasound (>1.5 W/cm2) appeared to be more effective than other intensities (SMD = 1.34; 95% CI: 0.94 to 1.73; p < 0.00001). Additionally, therapeutic ultrasound was effective in improving joint function as measured by WOMAC (SMD = 8.18; 95% CI: 5.88 to 10.48; p < 0.00001). |
Abbreviations: 6-MWT, 6-min Walk Test; KOA, knee osteoarthritis; MD, mean difference; NSAID, non-steroidal anti-inflammatory drug; OR, odds ratio; QOL, quality of life; ROM, range of motion; SF-36, Short Form Health Survey 36-item; SMD, standardized mean difference; TUG, Timed Up and Go test; VAS, Visual Analogic Scale; WMD, weighted mean difference; WOMAC, Western Ontario and McMaster Universities Arthritis.