Abstract
Background
In recent years, an increasing number of studies have demonstrated the potential therapeutic effects of traditional Chinese exercises in the treatment of knee osteoarthritis (KOA). However, the effectiveness of Wuqinxi (WQX) for patients with KOA remains a subject of debate. This study aimed to systematically evaluate the effects of WQX on joint function, muscle strength, balance function, and pain in patients with KOA.
Methods
A systematic search was conducted in seven electronic databases, including PubMed, Cochrane, EMBASE, Web of Science, CNKI, Wanfang, and VIP, from database inception to November 2025 to identify all randomized controlled trials (RCTs) on WQX for the treatment of KOA. Two reviewers independently extracted data and assessed the risk of bias using the Cochrane tool. Outcome measures included joint function scores [Lysholm and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)], peak torque of the flexor and extensor muscles of the knee, balance function [including dynamic fall index (DFI), time to contact test (TCT), and overall stability index (OSI)], and Visual Analog Scale (VAS) scores. Subgroup, sensitivity, and publication-bias analyses were also performed. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
Results
A total of 9 trials involving 809 participants were included. The results showed that WQX significantly improved Lysholm scores [mean difference (MD) = 6.34, 95% confidence interval (CI): 2.32 to 10.36, p = 0.002], WOMAC scores (standardized MD (SMD) = −0.67, 95% CI: −1.08 to −0.27, p = 0.001), peak torque of the flexor and extensor muscles of the knee (SMD = 0.50, 95% CI: 0.36 to 0.65, p < 0.00001), and DFI scores (SMD = −0.95, 95% CI: −1.15 to −0.75, p < 0.00001). However, WQX showed no significant effects on TCT, OSI, or VAS scores. Overall, the certainty of evidence ranged from low to high.
Conclusion
WQX may be an effective complementary and alternative therapy for KOA, improving joint function and muscle strength in patients with KOA. However, the available evidence is limited by geographic concentration, clinical heterogeneity, risk of bias, and low-to-moderate certainty for several outcomes. Therefore, further high-quality RCTs are needed to validate these findings.
Systematic review registration
https://www.crd.york.ac.uk/PROSPERO/view/CRD420251268070, identifier (CRD420251047102).
Keywords: meta-analysis, muscle strength, osteoarthritis, knee, postural balance, Qigong, systematic review
1. Introduction
Knee osteoarthritis (KOA), the most common degenerative joint disorder among the elderly, is characterized by chronic pain and functional disorders (1). As a chronic progressive disease with diverse etiologies, KOA affects over 600 million people worldwide (2). With population growth and aging, its prevalence continues to rise, and the global number of patients is projected to reach 642 million by 2050 (3). Currently, there is no curative treatment for KOA, and treatment is primarily symptomatic and aims to alleviate pain (4). Common treatments include physical therapy, pharmacological approaches, rehabilitation training, and surgery (5). However, long-term medication use may lead to adverse reactions such as renal toxicity, gastrointestinal disturbances, and cardiovascular events (6).
Exercise therapy is widely recognized as a cornerstone of non-pharmacological management (7). A substantial body of research has confirmed its efficacy in alleviating pain, improving joint mobility, and delaying disease progression (8). A systematic review on exercise therapy for KOA concluded that patients can achieve significant improvements in physical function, overall quality of life, and joint pain. Exercise not only exerts positive molecular-level effects on KOA but also shows potential for symptom relief and quality-of-life enhancement, positioning it as an effective and safe non-pharmacological management strategy (9).
Traditional Chinese Medicine (TCM) emphasizes the holistic concept of “the unity of body and mind,” positing that the maintenance of life activities relies on the harmony between physical form and spirit (10). Traditional Chinese Exercise (TCE), integrating the TCM holistic view, the theories of Yin–Yang and the Five Elements, and the doctrines of meridians and viscera, has gradually developed into a unique system that combines movement and stillness, facilitates meridian flow, regulates Qi and blood, and strengthens the body for disease prevention (11, 12). Compared to general physical exercise, TCE places greater emphasis on the simultaneous regulation of body and mind. Through interventions encompassing emotional management and lifestyle adjustment, it aims to enhance immunity, harmonize Qi and blood, and improve visceral function, thereby playing an active role in disease prevention and treatment (13, 14).
In recent years, a growing number of studies have confirmed the unique value of TCE in the management of KOA (15). Tai Chi, as the most representative form, has been shown in several high-quality randomized controlled trials (RCTs) to improve pain and physical function (16). Wuqinxi (Five-Animal Exercises, WQX), an ancient Chinese health-preserving practice that advocates the principle of “the unity of form and spirit, external movement with internal stillness,” focuses not only on physical movements but also on the internal harmony of Qi and blood and mental tranquility (17, 18). Currently, the efficacy of WQX in complementary and alternative medicine remains a topic of considerable interest.
Existing meta-analyses indicate that WQX has beneficial effects on pain and joint function in KOA, but its effects on muscle strength and balance have not been fully explored (19). Therefore, we conducted a systematic review and meta-analysis to address this evidence gap.
2. Methods
2.1. Study protocol and registration
This review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (20), and the protocol was registered with PROSPERO under registration number CRD420251268070.
2.2. Search strategy and study selection
We conducted a systematic search across seven electronic databases from their inception to 18 November 2025, including PubMed, Cochrane Library, EMBASE, Web of Science, CNKI, Wanfang Data, and VIP Database. We applied a combination of Medical Subject Headings and free-text terms related to the two concepts, KOA and WQX.
The search strategy for PubMed was as follows: ((“Osteoarthritis, Knee”[Mesh]) OR (Knee Osteoarthritides[Title/Abstract] OR Knee Osteoarthritis[Title/Abstract] OR Osteoarthritis of Knee[Title/Abstract] OR Osteoarthritis of the Knee[Title/Abstract])) AND (wuqinxi[Title/Abstract] OR “wu qin xi”[Title/Abstract] OR “wuqinxi qigong”[Title/Abstract] OR “five animal exercise”[Title/Abstract]).
Similar search strategies were used for the other databases.
The inclusion criteria were defined according to the PICOS framework:
Patients: adults diagnosed with KOA, accompanied by symptomatic knee pain (21–23);
Intervention: WQX exercise;
Comparison: blank control or other functional exercises;
Outcomes: included any of the following: Lysholm knee score (24), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) (25), peak torque of the flexor and extensor muscles of the knee (26), dynamic fall index (DFI) (27), time to contact test (TCT), overall stability index (OSI), and the Visual Analogue Scale (VAS) for pain (28);
Study design: RCTs.
2.3. Data extraction and quality assessment
Data extraction and quality assessment were performed independently by two authors (S-ZT and Y-TA). When information regarding any of the above was unclear, we attempted to contact the trial authors for further details. Any discrepancies were resolved by a third investigator (LO).
The extracted items included: (1) author, (2) year of publication, (3) study location, (4) sample size, (5) mean age, (6) duration of KOA, (7) grade of KOA, (8) interventions, (9) controls, (10) intervention duration, (11) follow-up time, and (12) outcome measures.
The primary outcome indicators for our meta-analysis included Lysholm and WOMAC scores, and peak torque of the flexor and extensor muscles of the knee, and the secondary outcomes included DFI, TCT, OSI, and VAS scores.
The quality of the included literature was assessed using the Cochrane Risk of Bias tool (29). This tool evaluates seven domains concerning methodology, assessment, reporting, and other biases. Each domain was rated as “high risk,” “unclear risk,” or “low risk.” For some items rated as unclear, we contacted the authors to request further data for clarification.
2.4. Statistical analysis
Review Manager version 5.4 (Cochrane Collaboration, United Kingdom, 2020) was used to conduct all meta-analyses of the outcomes in the included studies, and the results were illustrated by forest plots.
In this review, the mean difference (MD) or standardized mean difference (SMD) was used to pool effect sizes, depending on whether the outcome measures shared the same measurement tool or unit. All pooled effects were expressed with 95% confidence intervals (CIs).
Heterogeneity was assessed using the Cochran Q test and the I2 statistic. An I2 value > 50% was considered to represent high heterogeneity. Subsequently, subgroup or sensitivity analyses were performed to explore sources of heterogeneity when substantial heterogeneity was present.
Random-effects or fixed-effects models were selected depending on the level of heterogeneity. Publication bias was assessed using Begg’s and Egger’s tests, which were conducted using Stata version 18. A p-value of <0.05 was considered statistically significant.
3. Results
3.1. Study selection
Through the literature search, we retrieved 111 relevant papers from 7 databases. After removing duplicates, 50 papers remained. Of these, 39 were excluded after preliminary screening because they did not include RCTs, KOA, or WQX. After further screening, two studies were excluded because their control groups involved other traditional exercises. Finally, nine studies (30–38) met the inclusion criteria. The complete screening process is shown in Figure 1.
Figure 1.
PRISMA flow diagram of the study selection process.
3.2. Characteristics of the included studies
All studies were published within the last 14 years (2012–2025). All trials were conducted in China, and all participants were of Chinese ethnicity. The total sample size was 809, with 411 participants in the experimental group and 398 in the control group.
Most participants were diagnosed with KOA and had chronic pain lasting over 6 months and were aged over 50 years. Only seven studies reported the classification of KOA, all based on the Kellgren–Lawrence scale. Among these, four studies included participants classified as grade I/II, and three studies included participants classified as grade II/III.
All studies used WQX exercise as the intervention, with two studies also including massage (a form of Chinese physical therapy) and isokinetic muscle strength training. The control groups were either no intervention (blank control) or other forms of physical therapy. Most trials lasted between 3 and 6 months, with similar follow-up periods. The main characteristics of the extracted studies are shown in Table 1.
Table 1.
Characteristics of data extracted from the included studies.
| References | Study location | Participant characteristics | Intervention protocol | Outcome measure | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Sample size | Mean age (year) | KOA duration (months) | Grade of KOA (K–L scale) | Intervention group | Control group | Duration | Follow-up | |||
| Li et al. (30) | Fujian, China | 55/53 | EG: 58.51 ± 1.20 | EG: 17.64 ± 1.13 | II/III | WQX + TuiNa + isokinetic training | TuiNa + isokinetic training | 20 days (WQX 6 months) | 6 months | A, C, D |
| CG: 57.09 ± 1.22 | CG: 19.26 ± 1.23 | |||||||||
| Tian et al. (31) | Sichuan, China | 20/20 | EG: 63.0 ± 4.0 | EG/CG ≥ 6 | I/II | WQX | None | 6 months | 6 months | B, E, F, G |
| CG: 62.0 ± 3.9 | ||||||||||
| Tu and Liao (32) | Sichuan, China | 20/20 | EG/CG ≥ 50 | EG/CG ≥ 6 | I/II | WQX | Standing exercise | 16 weeks | 16 weeks | B, C |
| Wang et al. (33) | Tianjin, China | 18/10 | EG: 65.00 ± 5.18 | EG: 5.31 ± 4.31 | II/III | WQX | None | 12 weeks | 12 weeks | B, C, D |
| CG: 66.20 ± 5.33 | CG: 5.27 ± 3.07 | |||||||||
| Xiao et al. (34) | Beijing, China | 34/34 | EG: 70.7 ± 9.36 | EG: 12.21 ± 7.38 | I/II | WQX | Physical therapy | 12 weeks | 12 weeks | B |
| CG: 70.2 ± 10.35 | CG: 12.81 ± 5.24 | |||||||||
| Xiao et al. (35) | Hubei, China | 132/134 | EG: 71 ± 2.92 | EG: 28.3 ± 18.10 | None | WQX | None | 24 weeks | 24 weeks | B, E |
| CG: 69 ± 3.72 | CG: 27.9 ± 17.98 | |||||||||
| Yin and Li (36) | Anhui, China | 59/59 | EG: 68.6 ± 2.3 | None | None | WQX | None | 3 months | 3 months | B, E, F, G |
| CG: 69.6 ± 2.3 | ||||||||||
| Tang et al. (37) | Fujian, China | 28/28 | EG: 60.36 ± 4.73 | EG: 19.86 ± 8.50 | II/III | WQX + TuiNa + isokinetic training | TuiNa + isokinetic training | 20 days | 20 days | A, C, D |
| CG: 59.86 ± 5 0.92 | CG: 18.79 ± 8.53 | |||||||||
| Xiao et al. (38) | Beijing, China | 45/40 | EG: 70.7 ± 9.36 | None | I/II | WQX | Physical therapy | 6 months | 6 months | B |
| CG: 70.2 ± 10.35 | ||||||||||
A, Lysholm; B, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC); C, peak torque of flexor and extensor muscles; D, visual analogue scale (VAS); E, dynamic fall index (DFI); F, time to contact (TCT); G, overall stability index (OSI).
KOA, knee osteoarthritis; K–L, Kellgren–Lawrence; EG, experimental group; CG, control group; WQX, Wuqinxi.
3.3. Risk of bias assessment
The results are shown in Figures 2, 3. Six studies reported appropriate randomization methods and avoided selection bias. One study did not report the allocation method, and two studies did not report the methods used to generate and conceal the allocation sequence.
Figure 2.
Risk-of-bias summary of the included studies assessed using the Cochrane Risk of Bias tool.
Figure 3.
Risk-of-bias graph showing the overall distribution of judgments across the included studies.
Regarding performance bias, all studies were judged to be at high risk because participants inevitably knew whether the experimental intervention was performed. Therefore, the overall methodological quality of the included trials was limited, reducing confidence in the pooled estimates.
3.4. Outcomes of meta-analysis
3.4.1. Lysholm knee function scores
A total of 2 studies (30, 37) involving 140 participants were included. Both studies compared WQX plus conventional therapies with conventional therapies alone.
The meta-analysis showed that, compared with the control group, the intervention group showed improved Lysholm scores (MD = 6.34, 95% CI: 2.32 to 10.36, p = 0.002, I2 = 20%), with low heterogeneity; therefore, a fixed-effects model was used (Figure 4).
Figure 4.
Forest plot of the effect of WQX on Lysholm knee function scores.
3.4.2. WOMAC scores
A total of 7 studies (31–36, 38) involving 645 participants were included. Due to differences in the versions and scoring methods of the WOMAC scores, the effect size was presented as standardized MD (SMD).
The pooled results showed that WQX significantly reduced WOMAC scores compared with the control group (SMD = −0.67, 95% CI: −1.08 to −0.27, p = 0.001), with high heterogeneity (I2 = 81%); therefore, a random-effects model was used (Figure 5).
Figure 5.
Forest plot of the effect of WQX on WOMAC scores.
Considering differences in control interventions (no intervention, physical therapy, and standing exercise), subgroup analysis was performed. The results showed that WQX significantly improved WOMAC scores compared with no intervention (SMD = −0.91, 95% CI: −1.40 to −0.41, p = 0.0004; I2 = 78%) and standing exercise (SMD = −1.03, 95% CI: −1.70 to −0.37, p = 0.002).
However, no significant difference was observed between WQX and physical therapy (SMD = −0.08, 95% CI: −0.65 to 0.50, p = 0.79; I2 = 69%). A borderline significant difference was observed among subgroups (p = 0.05) (Figure 6).
Figure 6.
Subgroup analysis of WOMAC scores according to the type of control intervention.
3.4.3. Peak torque of flexor and extensor muscles
Four studies (30, 32, 33, 37) reported peak torque of knee flexor and extensor muscles. Considering the differences in intervention and control conditions across studies, subgroup analyses at 60°/s were conducted according to treatment design, including WQX versus no intervention, WQX versus standing exercise, and WQX plus conventional therapies versus conventional therapies alone.
At 60°/s, four studies were included (30, 32, 33, 37). The pooled results showed that both flexor and extensor peak torque were significantly higher in the WQX group than in the control group (flexors: SMD = 0.59, 95% CI: 0.32 to 0.85, p < 0.0001, I2 = 0%; extensors: SMD = 0.42, 95% CI: 0.15 to 0.68, p = 0.002, I2 = 76%).
Subgroup analysis showed that, for flexor peak torque, significant effects were observed in the standing exercise subgroup (p = 0.005) and the combined conventional therapy subgroup (p = 0.0005), but not in the no-intervention subgroup (p = 0.46), with no significant difference among subgroups (p = 0.41).
For extensor peak torque, a significant effect was found only in the combined conventional therapy subgroup (p < 0.0001), whereas no significant effects were found in the no-intervention subgroup (p = 0.25) or standing exercise subgroup (p = 0.06); a significant difference was observed among subgroups (p = 0.002) (Figures 7, 8).
Figure 7.
Forest plot of the effect of WQX on knee flexor peak torque at 60°/s.
Figure 8.
Forest plot of the effect of WQX on knee extensor peak torque at 60°/s.
At 180°/s, two studies (30, 37) were included. The pooled results showed significantly higher peak torque in the WQX group than the control group for both flexor muscles (SMD = 0.41, 95% CI: 0.10 to 0.72, p = 0.009, I2 = 0%) and extensor muscles (SMD = 0.59, 95% CI: 0.28 to 0.91, p = 0.0002, I2 = 0%) (Figures 9, 10).
Figure 9.
![Forest plot summarizing two studies comparing experimental and control groups, with standardized mean differences and confidence intervals shown as squares and lines. Overall effect favors the experimental group, 0.41 [0.10, 0.72], with low heterogeneity indicated.](https://www.ncbi.nlm.nih.gov/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Click%20on%20image%20to%20zoom&p=PMC3&id=13237677_fmed-13-1810683-g009.jpg)
Forest plot of the effect of WQX on knee flexor peak torque at 180°/s.
Figure 10.
Forest plot of the effect of WQX on knee extensor peak torque at 180°/s.
3.4.4. Balance function
3.4.4.1. DFI
A total of 3 studies (31, 35, 36) involving 424 participants were included. Considering differences in DFI score interpretation, SMD was used to pool the results.
The meta-analysis showed that, compared with the control group, the WQX group had better balance (SMD = −0.95, 95% CI: −1.15 to −0.75, p < 0.00001, I2 = 0%) (Figure 11).
Figure 11.
Forest plot of the effect of WQX on dynamic fall index.
3.4.4.2. TCT
A total of 2 studies (31, 36) involving 158 participants were included. The meta-analysis showed that, compared with the control group, the WQX group had a slight increase in TCT, but the difference was not significant (MD = 6.46, 95% CI: −3.25 to 16.17, p = 0.19, I2 = 80%) (Figure 12).
Figure 12.
Forest plot of the effect of WQX on time to contact test.
3.4.4.3. Overall stability index (OSI)
A total of 2 studies (31, 36) involving 158 participants were included. The meta-analysis showed no significant difference in OSI between the WQX and control groups (MD = 0.05, 95% CI: −0.05 to 0.16, p = 0.32, I2 = 0%) (Figure 13).
Figure 13.
Forest plot of the effect of WQX on overall stability index.
3.4.5. VAS scores
A total of 3 studies (30, 33, 37) involving 192 participants were included. The meta-analysis showed that, compared with the control group, the WQX group reduced pain intensity, but the difference was not significant (MD = −0.69, 95% CI: −1.51 to 0.13, p = 0.10, I2 = 84%) (Figure 14).
Figure 14.
Forest plot of the effect of WQX on VAS scores.
3.5. Sensitivity analysis
To verify the stability of the main results, sensitivity analyses were performed for outcomes including WOMAC scores and peak torque of the flexor and extensor muscles at 60°/s. The leave-one-out method was used to conduct the sensitivity analysis.
The results showed that excluding any single study did not substantially change the direction or statistical significance of the pooled effect size, indicating that the results of the meta-analysis are robust (Figures 15–17).
Figure 15.
Sensitivity analysis of WOMAC scores using the leave-one-out method.
Figure 17.
Sensitivity analysis of knee extensor peak torque at 60°/s using the leave-one-out method.
Figure 16.
Sensitivity analysis of knee flexor peak torque at 60°/s using the leave-one-out method.
3.6. Publication bias
Publication bias was assessed only for outcomes with more than five included studies; only WOMAC scores met this criterion. The funnel plot showed no obvious asymmetry, suggesting a low risk of publication bias (Figure 18).
Figure 18.
Funnel plot assessing publication bias for WOMAC scores.
Furthermore, Begg’s and Egger’s tests did not identify significant publication bias (Egger’s test, p = 0.662; Begg’s test, p = 0.293) (Figures 19, 20).
Figure 19.
Begg’s funnel plot assessing publication bias for WOMAC scores.
Figure 20.
Egger’s publication bias plot for WOMAC scores.
3.7. Evidence quality assessment
The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.
The summary of findings indicated low certainty for WOMAC and VAS scores, moderate certainty for peak torque outcomes, and high certainty for Lysholm, DFI, TCT, and OSI (Table 2).
Table 2.
GRADE assessment of the certainty of evidence for all outcomes.
| Variable | No. of studies | No. of participants | Effect estimate (95% CI) | I2 heterogeneity, % | GRADE |
|---|---|---|---|---|---|
| Lysholm | 2 | 140 | 6.34 (2.32 to 10.36) | 20 | High |
| WOMAC scores | 7 | 645 | −0.67 (−1.08 to −0.27) | 81 | Low |
| Peak torque | |||||
| Flexion peak torque (60°/s) | 4 | 232 | 0.59 (0.32 to 0.85) | 0 | Moderate |
| Flexion peak torque (180°/s) | 2 | 164 | 0.41 (0.1 to 0.72) | 0 | High |
| Extension peak torque (60°/s) | 4 | 232 | 0.42 (0.15 to 0.68) | 76 | Moderate |
| Extension peak torque (180°/s) | 2 | 164 | 0.59 (0.28 to 0.91) | 0 | High |
| DFI | 3 | 424 | −0.95 (−1.15 to −0.75) | 0 | High |
| TCT | 2 | 158 | 6.46 (−3.25 to 16.17) | 80 | High |
| OSI | 2 | 158 | 0.05 (−0.05 to 0.16) | 0 | High |
| VAS scores | 3 | 192 | −0.69 (−1.51 to 0.13) | 84 | Low |
CI, confidence interval; I2, inconsistency statistic; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index; DFI, dynamic fall index; TCT, time to contact test; OSI, overall stability index; VAS, visual analogue scale.
4. Discussion
4.1. Joint function
Exercise therapy, as a supplementary and adjunctive physical treatment, can prevent cartilage degeneration, suppress inflammation, and prevent the loss of subchondral bone and trabecular bone (39). Studies have shown that exercise therapy can increase muscle cross-sectional area, reduce muscle fiber density, alter tendon structure, and delay musculoskeletal atrophy, thereby improving joint stability, reducing inflammation, improving synovial cell function, and preventing cartilage degeneration and subchondral bone loss (40). Therefore, exercise therapy plays a crucial role in improving knee joint function in patients with KOA.
Pooled results from two studies demonstrated that WQX, when added to conventional therapies, improved Lysholm scores with low heterogeneity, suggesting a potential adjunctive benefit on knee function. However, this result reflects the additional effect of WQX on top of conventional treatment, rather than its isolated effect.
For WOMAC, seven studies suggested an overall benefit of WQX, but substantial heterogeneity remained. In the subgroup analysis, the benefit was more evident when WQX was compared with no intervention or standing exercise, whereas no significant difference was found when compared with physical therapy. This suggests that the comparator type may partly explain the heterogeneity. In addition, differences in exercise frequency, intervention duration, and home-based adherence may also have contributed to variability in WOMAC outcomes. Therefore, the WOMAC findings should be interpreted cautiously.
4.2. Muscle strength
Many studies, both domestic and international, recognize that muscle strength plays an important role in the onset and progression of KOA (41). Scholars worldwide agree that decreased knee muscle strength has many negative effects on the daily life of patients with KOA (42, 43).
Knee extensor muscles are essential for joint stabilization and shock absorption during gait, and reduced extensor strength may compromise tibial control, increasing the risk of structural knee damage and contributing to disease progression. Although knee flexors are generally considered less influential than extensors in osteoarthritis progression, emerging evidence suggests that reduced flexor strength is associated with an increased risk of tibiofemoral osteoarthritis deterioration, highlighting the importance of flexor function for joint health in patients with KOA and at-risk populations (44).
The present meta-analysis demonstrated that WQX was associated with improved peak torque of both knee flexor and extensor muscles in patients with KOA. At 180°/s, the pooled effects for both flexor and extensor peak torque were significant, with no observed heterogeneity, indicating a relatively consistent benefit under this testing condition.
At 60°/s, the pooled results also favored WQX for both flexor and extensor strength. However, the included studies differed in treatment design. Some studies evaluated WQX as a standalone intervention, whereas others assessed its additional effect on top of conventional therapies.
In the subgroup analysis, no significant subgroup difference was observed for flexor peak torque, suggesting that the beneficial effect on flexor strength was relatively stable across different comparison settings. In contrast, a significant subgroup difference was observed in extensor peak torque, indicating that the treatment design may have contributed to the heterogeneity in the extensor analysis.
This interpretation is supported by the included trials: WQX showed greater improvement than standing exercise in one study, whereas in the trial using physical therapy as an active comparator, between-group differences in knee flexor and extensor strength were not significant.
Therefore, WQX may improve knee muscle strength in patients with KOA, but the magnitude of benefit may vary depending on the comparator type and whether WQX is used alone or as an adjunct to conventional therapy.
4.3. Balance function
Balance refers to the ability of a system to control its center of gravity within a given environment (static or dynamic), thereby maintaining posture without falling (45). The quality of balance directly affects the safety of daily activities and mobility in patients with KOA (46).
This meta-analysis explored the effects of WQX on balance using three indicators: DFI, TCT, and OSI. The pooled results demonstrated that WQX significantly reduced DFI, with no observed heterogeneity across studies. This finding suggests that WQX may enhance dynamic balance control in patients with KOA.
The slow, coordinated, and continuous movement patterns characteristic of WQX may improve proprioceptive input and neuromuscular regulation, thereby facilitating postural adjustments during movement and reducing fall risk, which is clinically relevant for rehabilitation.
In contrast, no statistically significant improvements were observed for TCT or OSI. The pooled estimate for TCT showed substantial heterogeneity, whereas OSI showed low heterogeneity but no significant effect.
The heterogeneity in TCT may be related to differences in intervention duration, study setting, participant characteristics, and testing procedures, even though both included studies used no-exercise controls. Therefore, while WQX appears to reduce dynamic fall risk, its effects on TCT and OSI remain inconclusive.
4.4. VAS scores
For VAS scores, this study found that the pooled effect did not reach statistical significance, which differs from previous studies. The evaluation of the analgesic effect of WQX should therefore be interpreted cautiously.
The study by Guo et al. (19) reported statistically significant improvements in VAS scores, whereas the present analysis did not. This discrepancy may be due to the inclusion of additional studies with different effect sizes [such as Tang (37)], which may have influenced the pooled results.
Differences in treatment duration, follow-up design, and exercise adherence may also have contributed to heterogeneity. Therefore, the analgesic effect of WQX should be interpreted cautiously.
Several limitations should be noted. First, all included studies were conducted in China, which limits the generalizability of the findings. Second, there was substantial clinical heterogeneity across studies in terms of intervention format (WQX alone versus WQX combined with other treatments).
Third, several outcomes, including WOMAC, VAS, and TCT, showed substantial statistical heterogeneity, and the small number of studies for some outcomes limited further exploration of heterogeneity sources.
Fourth, the methodological quality of the included trials was limited, particularly with respect to randomization reporting and allocation concealment.
Finally, adverse events were not systematically reported; therefore, the safety of WQX could not be reliably assessed in this review.
5. Conclusion
This systematic review and meta-analysis suggest that WQX may provide benefits for joint function, muscle strength, and balance function in patients with KOA.
However, the current evidence is limited by geographic concentration, clinical heterogeneity, and methodological limitations. The findings should be regarded as preliminary rather than definitive.
More rigorous and internationally representative RCTs are still needed before firm clinical conclusions can be drawn.
Acknowledgments
All authors have significantly contributed to the conception and design of the research, as well as the acquisition, analysis, and interpretation of data. They participated in drafting or critically revising the manuscript and have approved the final version.
Funding Statement
The author(s) declared that financial support was received for this work and/or its publication. This study received funding from the following projects: the National Natural Science Foundation of China (82405447), the Hunan Provincial Natural Science Foundation of China (2025JJ60762; 2024JJ8125), the Evidence-Based Project of Hunan Provincial Hospital of Integrated Traditional Chinese and Western Medicine, and the NATCM Initiative for Strengthening TCM Evidence-Based (NATCM-STER).
Footnotes
Edited by: Karuppasamy Govindasamy, Symbiosis International (Deemed University), India
Reviewed by: Ayşegül Yetişir, Cukurova University, Türkiye
Lei Guo, Xinjiang Medical University, China
Data availability statement
The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.
Author contributions
S-ZT: Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft. Y-TA: Data curation, Validation, Writing – review & editing. Y-sL: Data curation, Validation, Writing – review & editing. W-JH: Formal analysis, Software, Visualization, Writing – review & editing. YT: Formal analysis, Software, Visualization, Writing – review & editing. T-TZ: Funding acquisition, Methodology, Supervision, Writing – review & editing. LO: Funding acquisition, Methodology, Supervision, Writing – review & editing.
Conflict of interest
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Generative AI statement
The author(s) declared that Generative AI was not used in the creation of this manuscript.
Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
References
- 1.Cai Z, Cui Y, Wang J, Qi X, He P, Bu P, et al. A narrative review of the progress in the treatment of knee osteoarthritis. Ann Transl Med. (2022) 10:373. doi: 10.21037/atm-22-818, [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Wiggers TG, Winters M, Van den Boom NA, Haisma HJ, Moen MH. Autologous stem cell therapy in knee osteoarthritis: a systematic review of randomised controlled trials. Br J Sports Med. (2021) 55:1161–9. doi: 10.1136/bjsports-2020-103671, [DOI] [PubMed] [Google Scholar]
- 3.GBD 2021 Osteoarthritis Collaborators . Global, regional, and national burden of osteoarthritis, 1990-2020 and projections to 2050: a systematic analysis for the global burden of disease study 2021. Lancet Rheumatol. (2023) 5:e508–22. doi: 10.1016/S2665-9913(23)00163-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Liu Y, Shah KM, Luo J. Strategies for articular cartilage repair and regeneration. Front Bioeng Biotechnol. (2021) 9:770655. doi: 10.3389/fbioe.2021.770655, [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Yetişir A, Öztürk GY. Effects of low-level laser therapy on acupuncture points on knee pain and function in knee osteoarthritis. Rev Assoc Med Bras. (2023) 70:e20230264. doi: 10.1590/1806-9282.20230264, [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Singh JA. Making the current non-surgical treatments for knee osteoarthritis more effective: solutions from a diverse patient group. Joint Bone Spine. (2023) 90:105535. doi: 10.1016/j.jbspin.2022.105535 [DOI] [PubMed] [Google Scholar]
- 7.Brophy RH, Fillingham YA. AAOS clinical practice guideline summary: management of osteoarthritis of the knee (nonarthroplasty), third edition. J Am Acad Orthop Surg. (2022) 30:e721–9. doi: 10.5435/JAAOS-D-21-01233, [DOI] [PubMed] [Google Scholar]
- 8.Mo L, Jiang B, Mei T, Zhou D. Exercise therapy for knee osteoarthritis: a systematic review and network meta-analysis. Orthop J Sports Med. (2023) 11:23259671231172773. doi: 10.1177/23259671231172773, [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Yang Y, Li S, Cai Y, Zhang Q, Ge P, Shang S, et al. Effectiveness of telehealth-based exercise interventions on pain, physical function and quality of life in patients with knee osteoarthritis: a meta-analysis. J Clin Nurs. (2023) 32:2505–20. doi: 10.1111/jocn.16388, [DOI] [PubMed] [Google Scholar]
- 10.Mo H, Lu W, Wang T, Chai D, Zhao L, Zhang Q, et al. The "mind-cognition-emotion" system model from the perspective of traditional Chinese medicine and its clinical applications. Integr Psychol Behav Sci. (2025) 59:79. doi: 10.1007/s12124-025-09933-4, [DOI] [PubMed] [Google Scholar]
- 11.Yin H. Research on Chinese Traditional Sports Health-Preservation Theory and Methods [Dissertation]. Changsha: Hunan University of Chinese Medicine; (2019). [Google Scholar]
- 12.Zeng L, Zhou G, Yang W, Liu J. Guidelines for the diagnosis and treatment of knee osteoarthritis with integrative medicine based on traditional Chinese medicine. Front Med. (2023) 10:1260943. doi: 10.3389/fmed.2023.1260943, [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Wang C, Schmid CH, Iversen MD, Harvey WF, Fielding RA, Driban JB, et al. Comparative effectiveness of tai chi versus physical therapy for knee osteoarthritis: a randomized trial. Ann Intern Med. (2016) 165:77–86. doi: 10.7326/M15-2143, [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Ye J, Simpson MW, Liu Y, Lin W, Zhong W, Cai S, et al. The effects of Baduanjin qigong on postural stability, proprioception, and symptoms of patients with knee osteoarthritis: a randomized controlled trial. Front Med. (2020) 6:307. doi: 10.3389/fmed.2019.00307, [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Qiu B, Wang W, Tang G, Chai S, Zhang X, Zhou P, et al. Long- and short-term effectiveness of traditional Chinese exercises in improving the overall physical capacity of patients with knee osteoarthritis: a systematic review and meta-analysis. Medicine. (2024) 103:e39520. doi: 10.1097/MD.0000000000039520, [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Wang W, Lu H, Yan C, Shan Y. Home-based traditional Chinese exercise for knee osteoarthritis: a systematic review and meta-analysis of randomized controlled trials. Front Med. (2025) 12:1665680. doi: 10.3389/fmed.2025.1665680, [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Hartley L, Lee MS, Kwong JS, Flowers N, Todkill D, Ernst E, et al. Qigong for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev. (2015) 2015:CD010390. doi: 10.1002/14651858.CD010390.pub2, [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Song T, Liu L, Sun Y, Li H. Effects and mechanisms of traditional Chinese medicine guiding technique five-animal exercises on coronary heart disease. Chin J Cardiovasc Rehabil Med. (2025) 34:728–35. doi: 10.3969/j.issn.1008-0074.2025.05.24 [DOI] [Google Scholar]
- 19.Guo J, Peng C, Hu Z, Guo L, Dai R, Li Y. Effect of Wu Qin xi exercises on pain and function in people with knee osteoarthritis: a systematic review and meta-analysis. Front Med. (2022) 9:979207. doi: 10.3389/fmed.2022.979207, [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. (2021) 372:n71. doi: 10.1136/bmj.n71 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Runhaar J, Kloppenburg M, Boers M, Bijlsma JWJ, Bierma-Zeinstra SMA, and the CREDO expert group . Towards developing diagnostic criteria for early knee osteoarthritis: data from the CHECK study. Rheumatology (Oxford). (2021) 60:2448–55. doi: 10.1093/rheumatology/keaa643, [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Kohn MD, Sassoon AA, Fernando ND. Classifications in brief: Kellgren-Lawrence classification of osteoarthritis. Clin Orthop Relat Res. (2016) 474:1886–93. doi: 10.1007/s11999-016-4732-4, [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Luyten FP, Bierma-Zeinstra S, Dell’Accio F, Kraus VB, Nakata K, Sekiya I, et al. Toward classification criteria for early osteoarthritis of the knee. Semin Arthritis Rheum. (2018) 47:457–63. doi: 10.1016/j.semarthrit.2017.08.006, [DOI] [PubMed] [Google Scholar]
- 24.Eshuis R, Lentjes GW, Tegner Y, Wolterbeek N, Veen MR. Dutch translation and cross-cultural adaptation of the Lysholm score and Tegner activity scale for patients with anterior cruciate ligament injuries. J Orthop Sports Phys Ther. (2016) 46:976–83. doi: 10.2519/jospt.2016.6566, [DOI] [PubMed] [Google Scholar]
- 25.Ackerman I. Western Ontario and McMaster universities osteoarthritis index (WOMAC). Aust J Physiother. (2009) 55:213. doi: 10.1016/s0004-9514(09)70088-1, [DOI] [PubMed] [Google Scholar]
- 26.Timmins RG, Shield AJ, Williams MD, Opar DA. Is there evidence to support the use of the angle of peak torque as a marker of hamstring injury and re-injury risk? Sports Med. (2016) 46:7–13. doi: 10.1007/s40279-015-0378-8, [DOI] [PubMed] [Google Scholar]
- 27.Klenk J, Becker C, Palumbo P, Schwickert L, Rapp K, Helbostad JL, et al. Conceptualizing a dynamic fall risk model including intrinsic risks and exposures. J Am Med Dir Assoc. (2017) 18:921–7. doi: 10.1016/j.jamda.2017.08.001, [DOI] [PubMed] [Google Scholar]
- 28.Price DD, McGrath PA, Rafii A, Buckingham B. The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain. (1983) 17:45–56. doi: 10.1016/0304-3959(83)90126-4, [DOI] [PubMed] [Google Scholar]
- 29.Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane collaboration's tool for assessing risk of bias in randomised trials. BMJ. (2011) 343:d5928. doi: 10.1136/bmj.d5928, [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Li C, Tang L, Lin BQ, Zhang KM, Li ZR, Zhou GF, et al. Effect of isokinetic training combined with Wuqinxi on muscle strength of knee osteoarthritis and long-term effect. Clin J Tradit Chin Med. (2021) 33:157–61. doi: 10.16448/j.cjtcm.2021.0138 [DOI] [Google Scholar]
- 31.Tian B. A Study on the Effect of Wuqinxi Exercise on the Proprioception and Balance Function of Elderly Female Patients With KOA [Dissertation]. Beijing: Beijing Sport University; (2012). [Google Scholar]
- 32.Tu P, Liao Y. Effect of Wuqinxi and Zhanzhuang on knee flexor and extensor strength and WOMAC scores of female patients with KOA. J Chengdu Sport Univ. (2014) 40:68–71. doi: 10.15942/j.jcsu.2014.06.001 [DOI] [Google Scholar]
- 33.Wang D. A Study on the Rehabilitation Effect of 12 Weeks of Five-Animal Exercise on Patients With Knee Osteoarthritis and Its Influencing Factors [Master’s Thesis]. Tianjin: Tianjin Institute of Physical Education; (2019). [Google Scholar]
- 34.Xiao CM, Li JJ, Kang Y, Zhuang YC. Follow-up of a Wuqinxi exercise at home programme to reduce pain and improve function for knee osteoarthritis in older people: a randomised controlled trial. Age Ageing. (2021) 50:570–5. doi: 10.1093/ageing/afaa179, [DOI] [PubMed] [Google Scholar]
- 35.Xiao Z, Li G. The effect of Wuqinxi exercises on the balance function and subjective quality of life in elderly female patients with knee osteoarthritis. Am J Transl Res. (2021) 13:6710–6. [PMC free article] [PubMed] [Google Scholar]
- 36.Yin X, Li H. Influence of Wuqinxi on proprioceptive sensation and balance function in female patients with knee osteoarthritis. J Jianghan Univ Nat Sci Ed. (2017) 45:355–8. doi: 10.16389/j.cnki.cn42-1737/n.2017.04.011 [DOI] [Google Scholar]
- 37.Tang LZ, Li CH, Zhang KM, Xiao AD, Pan ZW, Lin Y. Clinical efficacy observation of massage combined with isokinetic training and Wuqinxi on knee osteoarthritis. J Hunan Univ Chin Med. (2019) 39:879–84. doi: 10.3969/j.issn.1674-070X.2019.07.020 [DOI] [Google Scholar]
- 38.Xiao C, Zhuang Y, Kang Y. Effects of Wu Qin xi Qigong exercise on physical functioning in elderly people with knee osteoarthritis: a randomized controlled trial. Geriatr Gerontol Int. (2020) 20:899–903. doi: 10.1111/ggi.14007, [DOI] [PubMed] [Google Scholar]
- 39.Hu HY, Jia LN, Zhao WY, Guo SJ, Fang ZM, Li XY, et al. Clinical effect and mechanism of aerobic exercise for knee osteoarthritis: a mini review. Front Physiol. (2025) 16:1708750. doi: 10.3389/fphys.2025.1708750, [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Zeng CY, Zhang ZR, Tang ZM, Hua FZ. Benefits and mechanisms of exercise training for knee osteoarthritis. Front Physiol. (2021) 12:794062. doi: 10.3389/fphys.2021.794062, [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41.Cecchi F, Molino-Lova R, Di Iorio A, Conti AA, Mannoni A, Lauretani F, et al. Measures of physical performance capture the excess disability associated with hip pain or knee pain in older persons. J Gerontol A Biol Sci Med Sci. (2009) 64:1316–24. doi: 10.1093/gerona/glp125 19797345, [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Hong H, Wei X, Chen Y, Zhang M, Xu Y, Zhu S, et al. Study on the relationship between quadriceps femoris muscle tone and knee function in patients with knee osteoarthritis. J Tradit Chin Orthop Traumatol. (2014) 26:32–4. [Google Scholar]
- 43.Patterson BE, Girdwood MA, West TJ, Bruder AM, Øiestad BE, Juhl C, et al. Muscle strength and osteoarthritis of the knee: a systematic review and meta-analysis of longitudinal studies. Skeletal Radiol. (2023) 52:2085–97. doi: 10.1007/s00256-022-04266-4, [DOI] [PubMed] [Google Scholar]
- 44.Pollock AS, Durward BR, Rowe PJ, Paul JP. What is balance? Clin Rehabil. (2000) 14:402–6. doi: 10.1191/0269215500cr342oa, [DOI] [PubMed] [Google Scholar]
- 45.Wang X, Chen Z, Liang Y, Su H, Wang T, Lv Y, et al. Effects of exercise on balance function in people with knee osteoarthritis: a systematic review and meta-analysis of randomized controlled trials. Healthcare (Basel). (2025) 13:1312. doi: 10.3390/healthcare13111312, [DOI] [PMC free article] [PubMed] [Google Scholar]
- 46.Chen L, Zhou H, Gong Y, Tang Y, Su H, Jin Z, et al. How do muscle function and quality affect the progression of KOA? A narrative review. Orthop Surg. (2024) 16:802–10. doi: 10.1111/os.14022, [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.