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Osteoarthritis: Best Timing for Prescribing Exercise Therapy

Due to an aging population and increasing obesity, the prevalence of knee osteoarthritis (KOA) has more than doubled in the past ten years, pointing to an impending endemic state.1,2

As the world’s tenth largest contributor to years lived with disabilities, KOA surgeries and hospitalisations cost world healthcare systems billions of dollars yearly.3,4 This scenario heightens the importance of focusing on the most effective treatments delivered in the most effective way. The research showing the efficacy of exercise therapy for KOA is definitive.

Physiotherapy ameliorates KOA progression while quickly reducing pain and improving function with effects comparable to surgery.5-7 In November, this bulletin reported on new research evaluating predictors of clinically important treatment success with physiotherapy. By far, the strongest predictor of treatment success in physiotherapy was the number of supervised therapeutic exercise visits.

Lieberz et al. demonstrated that patients receiving eighteen sessions of supervised exercise therapy proved more than six times more likely to have treatment success.8 While their research measured several possible predictors of physiotherapy success, they did not address the timing of the referral to exercise therapy. As with most studies regarding KOA, the preponderance of their subjects had suffered KOA symptoms for greater than two years. Interestingly, a team of researchers from the Netherlands, the United Kingdom, and Australia recently analysed the results of 31 studies covering 4,241 patients to evaluate timing.9

The research team concludes that initiating exercise therapy early—such as within the first year of pain or reduced function—gives patients improved pain scores and better function. At long-term assessments, compared to patients who initiate exercise therapy after two years of symptoms, patients referred to physiotherapy within their first year of symptoms achieved 21% better scores for pain and 28% better scores for function.

The results provide strong encouragement to recommend physiotherapy when patients first report pain or reduced function resulting from osteoarthritis. In a separate commentary, researchers noted that it was even difficult to recruit patients for studies within their first year of KOA symptoms. Now, clinicians can explain to patients that exercise therapy proves effective for long-standing and painful cases of KOA, but it is even more effective when initiated early in the course of the disease


1. Englund M, Turkiewicz A. Osteoarthritis increasingly common public disease. Lakartidningen. 2014;111(21):930.

2. Kyu HH, Abate D, Abate KH, Abay SM, Abbafati C, Abbasi N, Abbastabar H, Abd-Allah F, Abdela J, Abdelalim A, Abdollahpour I. Global, regional, and national disability-adjusted life-years (DALYs) for 359 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. The Lancet. 2018 Nov 10;392(10159):1859-922.

3. Hawker GA. Osteoarthritis is a serious disease. Clin Exp Rheumatol. 2019 Sep 1;37(Suppl 120):3-6.

4. Palazzo C, Nguyen C, Lefevre-Colau MM, Rannou F, Poiraudeau S. Risk factors and burden of osteoarthritis. Annals of Physical and Rehabilitation Medicine. 2016 Jun 1;59(3):134-8.

5. Katz J, Brophy R, Chaisson C, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. NEJM. Mar 19 2013; DOI: 10.1056/NEJMoa1301408.

6. Pinto D, Robertson M, Abbott J, et al. Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee. 2: economic evaluation alongside a randomized controlled trial. Osteoarthritis and Cartilage. 2013; joca.2013.06.014.

7. Fransen M, McConnell S, Harmer A, et al. Exercise for osteoarthritis of the knee. Br J Sports Med. 2015; 49 (24): 1554-1557.

8. Lieberz D, Regal R, Conway P. Observational study: predictors of a successful functional outcome in persons who receive physical therapy for knee osteoarthritis. Evaluation & the Health Professions. 2022 Jun;45(2):137-46.

9. van Middelkoop M, Schiphof D, Hattle M, Simkins JM, Bennell K, Hinman RS, Allen KD, Knoop J, van Baar ME, Bossen D, Wallis J. Exercise Therapy Compared To Usual Care In People With Early-Stage Knee Oa: An Individual Patient Data Meta-Analysis From The Oa Trial Bank. Osteoarthritis and Cartilage. 2023 Mar 1;31:S17.

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