Osteoarthritis of the Knee/Hip Therapeutic Exercise Preferred/OTC Oral Analgesic

Currently, guidelines from the Osteoarthritis Research Society International (OARSI) recommend therapeutic exercise and education as a core component of any management plan for OA of the knee or hip.2 This and multiple other guidelines variably recommend paracetamol (Panadol, etc.) and non-steroidal anti-inflammatories (NSAIDs), most of which are available to patients over the counter.

However, the recommendations vary and can be somewhat contradictory.3 Similarly, research shows conflicting conclusions on the comparative efficacy between therapeutic exercise and these common analgesics.4 Further complicating care planning, one must also consider the well-known adverse effects of the common analgesics among elderly patients, such as increased mortality, cardiovascular disease, and gastrointestinal bleeding.3

Fortunately, a recently published study provides some needed clarity that can facilitate shared decision-making between patients and practitioners. Earlier this year, the British Medical Journal / British Journal of Sports Medicine published the largest-to-date network meta-analysis comparing therapeutic exercise with NSAIDs and paracetamol.4 The analysis combined 152 randomised controlled trials, covering 17, 431 participants.

The current study removes some heterogeneity of conflicting previous network meta-analyses, where data mixed placebo, usual care, and therapeutic ultrasound into control groups.

The largest network meta-analysis to date finds that therapeutic exercise proves more effective than usual care in terms of both pain relief and function improvement at 4, 8, and 24 weeks. On the other hand, for both functio and pain, therapeutic exercise, paracetamol, and oral NSAIDS all show similar efficacy at all time points up to 24 weeks. The best evidence to date demonstrates that therapeutic exercise provides the same, short-term relief and functional improvements as oral analgesics. The authors of the current study conclude that therapeutic exercise should be prescribed preferentially, given its superior safety profile and the age and comorbidities often associated with OA pain of the knees and hips.

References

1. Katz JN, Arant KR, Loeser RF. Diagnosis and treatment of hip and knee osteoarthritis: a review. JAMA. 2021 Feb 9;325(6):568-78.

2. Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SM, Kraus VB, Lohmander LS, Abbott JH, Bhandari M, Blanco FJ. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis and Cartilage. 2019 Nov 1;27(11):1578-89.

3. Zeng C, Doherty M, Persson MS, Yang Z, Sarmanova A, Zhang Y, Wei J, Kaur J, Li X, Lei G, Zhang W. Comparative efficacy and safety of acetaminophen, topical and oral non-steroidal anti-inflammatory drugs for knee osteoarthritis: evidence from a network meta-analysis of randomized controlled trials and real-world data. Osteoarthritis and Cartilage. 2021 Sep 1;29(9):1242-51.

4. Weng Q, Goh SL, Wu J, Persson MS, Wei J, Sarmanova A, Li X, Hall M, Doherty M, Jiang T, Zeng C. Comparative efficacy of exercise therapy and oral non-steroidal anti-inflammatory drugs and paracetamol for knee or hip osteoarthritis: a network meta-analysis of randomised controlled trials. British Journal of Sports Medicine. 2023 Jan 2