Knee pain and radiographic osteoarthritis interact in the prediction of levels of self‐reported disability

Objective

To determine predictors of disability depending on whether joint deformity and pain reporting exist independently or concurrently.

Methods

Subjects were 154 volunteers for an osteoarthritis screening examination. Eligible subjects completed questionnaires for physical function, pain, and depressive symptoms; underwent evoked pain testing for tenderness assessment; and had anteroposterior and lateral radiographs taken of both knees. Two blinded rheumatologists scored the images using Kellgren‐Lawrence criteria to determine presence of deformity.

Results

Subjects were divided into 3 subgroups based on radiographic evidence of deformity and self‐reported pain. Disability was greatest when pain and deformity occurred together (F[2,151] = 18.8, P < 0.0001). Self‐reported disability in the absence of deformity was predicted by body mass index, pain threshold, and anxiety symptoms; disability was predicted by the number of osteophytes and depressive symptoms when pain and deformity occurred together.

Conclusion

Self‐reported disability in osteoarthritis of the knee is greatest with concurrent pain and joint deformity. When pain and deformity do not cooccur, disability appears to be related to separate factors, including anxiety and pain threshold (e.g., tenderness).

     

Clinical effectiveness of a rehabilitation program integrating exercise,self‐management,and active coping strategies for chronic knee pain: A cluster randomized trial

Objective

Chronic knee pain is a major cause of disability and health care expenditure, but there are concerns about efficacy, cost, and side effects associated with usual primary care. Conservative rehabilitation may offer a safe, effective, affordable alternative. We compared the effectiveness of a rehabilitation program integrating exercise, self‐management, and active coping strategies (Enabling Self‐management and Coping with Arthritic Knee Pain through Exercise [ESCAPE‐knee pain]) with usual primary care in improving functioning in persons with chronic knee pain.

Methods

We conducted a single‐blind, pragmatic, cluster randomized controlled trial. Participants age ≥50 years, reporting knee pain for >6 months, were recruited from 54 inner‐city primary care practices. Primary care practices were randomized to continued usual primary care (i.e., whatever intervention a participant's primary care physician deemed appropriate), usual primary care plus the rehabilitation program delivered to individual participants, or usual primary care plus the rehabilitation program delivered to groups of 8 participants. The primary outcome was self‐reported functioning (Western Ontario and McMaster Universities Osteoarthritis Index physical functioning [WOMAC‐func]) 6 months after completing rehabilitation.

Results

A total of 418 participants were recruited; 76 (18%) withdrew, only 5 (1%) due to adverse events. Rehabilitated participants had better functioning than participants continuing usual primary care (?3.33 difference in WOMAC‐func score; 95% confidence interval [95% CI] ?5.88, ?0.78; P = 0.01). Improvements were similar whether participants received individual rehabilitation (?3.53; 95% CI ?6.52, ?0.55) or group rehabilitation (?3.16; 95% CI ?6.55, ?0.12).

Conclusion

ESCAPE‐knee pain provides a safe, relatively brief intervention for chronic knee pain that is equally effective whether delivered to individuals or groups of participants.

     

Acute low back pain self‐management intervention for urban primary care patients: Rationale,design, and predictors of participation

Objectives

To describe the rationale and design of a self‐management program for low‐income, urban, primary care patients with acute low back pain. Issues related to recruitment and protocol delivery, and attendance patterns and predictors of program attendance are described.

Methods

Two hundred eleven adult patients (73% female; 60% African American) were recruited from primary care neighborhood health centers. Focus groups were conducted for program development, and participants then completed a baseline interview and were randomized into groups receiving either usual care or a self‐management intervention.

Results

Twenty‐nine percent of the intervention group attended the self‐management class. Significant predictors of attendance included being older, reporting less income, and not working for pay. Attendees did not differ from nonattendees on back pain severity, symptoms, health‐related quality of life, self‐management processes, or satisfaction with care.

Conclusion

Effective minimal‐contact behavioral interventions are needed to reach larger portions of the patient population.

     

A comparison of strength training,self‐management,and the combination for early osteoarthritis of the knee

Objective

To assess the relative effectiveness of combining self‐management and strength training for improving functional outcomes in patients with early knee osteoarthritis.

Methods

We conducted a randomized intervention trial lasting 24 months at an academic medical center. Community‐dwelling middle‐aged adults (n = 273) ages 35–64 years with knee osteoarthritis, pain, and self‐reported physical disability completed a strength training program, a self‐management program, or a combined program. Outcomes included 5 physical function tests (leg press, range of motion, work capacity, balance, and stair climbing) and 2 self‐reported measures of pain and disability.

Results

A total of 201 participants (73.6%) completed the 2‐year trial. Overall, compliance was modest for the strength training (55.8%), self‐management (69.1%), and combined (59.6%) programs. The 3 groups showed a significant and large increase from pre‐ to posttreatment in all of the physical functioning measures, including leg press (d = 0.85), range of motion (d = 1.00), work capacity (d = 0.60), balance (d = 0.59), and stair climbing (d = 0.59). Additionally, all 3 groups showed decreased self‐reported pain (d = ?0.51) and disability (d = ?0.55). There were no significant differences among the groups.

Conclusion

Middle‐aged, sedentary persons with mild early knee osteoarthritis benefited from strength training, self‐management, and the combination program. These results suggest that both strength training and self‐management are suitable treatments for the early onset of knee osteoarthritis in middle‐aged adults. Self‐management alone may offer the least burdensome treatment for early osteoarthritis.

     

Racial differences in social network experience and perceptions of benefit of arthritis treatments among New York City Medicare beneficiaries with self‐reported hip and knee pain

Objective

To determine whether social network experience and perceptions of benefit of arthritis treatments influence the decision to seek diagnosis and treatment.

Methods

A population‐based telephone survey of 515 black and 455 white Medicare beneficiaries was conducted. Validated questionnaires adapted for use in a telephone interview were used to identify people with self‐reported symptoms of hip or knee pain. Treatment history for arthritis‐related pain and perceptions of benefit of treatment were also assessed.

Results

Forty‐two percent of blacks and 31% of whites reported hip or knee pain. Forty‐two percent of blacks and 65% of whites reported knowing someone who had surgery for hip or knee pain (P < 0.0001). Blacks were less likely than whites to report that surgery had helped someone they knew with hip or knee pain (not significant).

Conclusion

Blacks know fewer people who have had surgical treatment of hip and knee pain than whites and appear to be less likely to perceive that such treatment is beneficial.

     

Arthritis self‐management education programs: A meta‐analysis of the effect on pain and disability

Objective

Some reports suggest that education programs help arthritis patients better manage their symptoms and improve function. This review of the published literature was undertaken to assess the effect of such programs on pain and disability.

Methods

Medline and HealthSTAR were searched for the period 1964–1998. The references of each article were then hand‐searched for further publications. Studies were included in the meta‐analysis if the intervention contained a self‐management education component, a concurrent control group was included, and pain and/or disability were assessed as end points. Two authors reviewed each study. The methodologic attributes and efficacy of the interventions were assessed using a standardized abstraction tool, and the magnitude of the results was converted to a common measure, the effect size. Summary effect sizes were calculated separately for pain and disability.

Results

The search strategy yielded 35 studies, of which 17 met inclusion criteria. The mean age of study participants was 61 years, and 69% were female. On average, 19% of patients did not complete followup (range 0–53%). The summary effect size was 0.12 for pain (95% confidence interval [95% CI] 0.00, 0.24) and 0.07 for disability (95% CI 0.00, 0.15). Funnel plots indicated no significant evidence of bias toward the publication of studies with findings that showed reductions in pain or disability.

Conclusion

The summary effect sizes suggest that arthritis self‐management education programs result in small reductions in pain and disability.

     

Changes in self‐efficacy and health status over 5 years: A longitudinal observational study of 306 patients with rheumatoid arthritis

Objective

To investigate changes in self‐efficacy and health status over 5 years in patients with rheumatoid arthritis (RA), the relationships between these changes, and the influence of baseline values on subsequent changes.

Methods

306 adult patients with RA, born in 1926 or later, were examined by questionnaire in 1994 and again in 1999. We analyzed data regarding pain (visual analogue scale [VAS], Arthritis Impact Measurement Scale [AIMS2] symptom scale, Short Form‐36 [SF‐36] pain scale), fatigue (VAS, SF‐36 vitality scale), mental distress (AIMS2 affect scale, SF‐36 mental health scale) and self‐efficacy (Arthritis Self‐Efficacy Scales for pain and for other symptoms).

Results

On group level, all health status measures were numerically somewhat improved, and self‐efficacy slightly reduced. Changes in self‐efficacy and in corresponding health status measures were significantly correlated. For patients with above average educational level self‐efficacy for pain at baseline was positively correlated to improvement in pain measures. Good mental health at baseline was correlated to improvement in self‐efficacy for other symptoms, but only for patients with below average educational level.

Conclusion

Baseline self‐efficacy seems to influence future level of perceived pain and baseline mental health status seems to influence future self‐efficacy. These associations seem to be affected by level of education.

     

Effectiveness of self‐management of low back pain: Systematic review with meta‐analysis

Objective

To determine the effectiveness of self‐management for nonspecific low back pain (LBP).

Methods

We performed a systematic review searching the Medline, Embase, CINAHL, PsycINFO, LILACS, PEDro, AMED, SPORTDiscus, and Cochrane databases from earliest record to April 2011. Randomized controlled trials evaluating self‐management for nonspecific LBP and assessing pain and disability were included. The PEDro scale was used to assess the methodologic quality of included trials. Data were pooled where studies were sufficiently homogenous. Analyses were conducted separately for short‐ (less than 6 months after randomization) and long‐term (at least 12 months after randomization) followup. Six criteria for self‐management were used to assess the content of the intervention.

Results

The search identified 2,325 titles, of which 13 original trials were included. Moderate‐quality evidence showed that self‐management is effective for improving pain and disability for people with LBP. The weighted mean difference at short‐term followup for pain was ?3.2 points on a 0–100 scale (95% confidence interval [95% CI] ?5.1, ?1.3) and for disability was ?2.3 points (95% CI ?3.7, ?1.0). The long‐term effects were ?4.8 (95% CI ?7.1, ?2.5) for pain and ?2.1 (95% CI ?3.6, ?0.6) for disability.

Conclusion

There is moderate‐quality evidence that self‐management has small effects on pain and disability in people with LBP. These results challenge the endorsement of self‐management in treatment guidelines.

     

Long-term outcomes and costs of an integrated rehabilitation program for chronic knee pain: a pragmatic, cluster randomized, controlled trial

Objective

Chronic joint pain is a major cause of pain and disability. Exercise and self‐management have short‐term benefits, but few studies follow participants for more than 6 months. We investigated the long‐term (up to 30 months) clinical and cost effectiveness of a rehabilitation program combining self‐management and exercise: Enabling Self‐Management and Coping of Arthritic Knee Pain Through Exercise (ESCAPE‐knee pain).

Methods

In this pragmatic, cluster randomized, controlled trial, 418 people with chronic knee pain (recruited from 54 primary care surgeries) were randomized to usual care (pragmatic control) or the ESCAPE‐knee pain program. The primary outcome was physical function (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] function), with a clinically meaningful improvement in physical function defined as a ≥15% change from baseline. Secondary outcomes included pain, psychosocial and physiologic variables, costs, and cost effectiveness.

Results

Compared to usual care, ESCAPE‐knee pain participants had large initial improvements in function (mean difference in WOMAC function ?5.5; 95% confidence interval [95% CI] ?7.8, ?3.2). These improvements declined over time, but 30 months after completing the program, ESCAPE‐knee pain participants still had better physical function (difference in WOMAC function ?2.8; 95% CI ?5.3, ?0.2); lower community‐based health care costs (£?47; 95% CI £?94, £?7), medication costs (£?16; 95% CI £?29, £?3), and total health and social care costs (£?1,118; 95% CI £?2,566, £?221); and a high probability (80–100%) of being cost effective.

Conclusion

Clinical and cost benefits of ESCAPE‐knee pain were still evident 30 months after completing the program. ESCAPE‐knee pain is a more effective and efficient model of care that could substantially improve the health, well‐being, and independence of many people, while reducing health care costs.

     

Exercise,self‐efficacy,and mobility performance in overweight and obese older adults with knee osteoarthritis

Objective

To examine changes in mobility‐related self efficacy following exercise and dietary weight loss interventions in overweight and obese older adults with knee osteoarthritis (OA), and to determine if self efficacy and pain mediate the effects of the interventions on mobility task performance.

Methods

The Arthritis, Diet, and Activity Promotion Trial was an 18‐month, single‐blind, randomized, controlled trial comparing the effects of exercise alone, dietary weight loss alone, a combination of exercise plus dietary weight loss, and a healthy lifestyle control intervention in the treatment of 316 overweight or obese older adults with symptomatic knee OA. Participants completed measures of stair‐climb time and 6‐minute walk distance, self efficacy for completing each mobility task, and self‐reported pain at baseline, 6 months, and 18 months during the trial.

Results

Mixed model analyses of covariance of baseline adjusted change in the outcomes demonstrated that the exercise + dietary weight loss intervention produced greater improvements in mobility‐related self efficacy (P = 0.0035), stair climb (P = 0.0249) and 6‐minute walk performance (P = 0.00031), and pain (P = 0.09) when compared with the healthy lifestyle control intervention. Mediation analyses revealed that self efficacy and pain served as partial mediators of the beneficial effect of exercise + dietary weight loss on stair‐climb time.

Conclusion

Exercise + dietary weight loss results in improved mobility‐related self efficacy; changes in these task‐specific control beliefs and self‐reported pain serve as independent partial mediators of the beneficial effect of exercise + dietary weight loss on stair‐climb performance.

     

Responsiveness of observational and self‐report methods for assessing disability in mobility in patients with osteoarthritis

Objective

To establish the responsiveness of observational and self‐report methods for the assessment of disability in mobility in patients with osteoarthritis (OA).

Methods

Data from 186 patients with hip OA or knee OA were used. Data from 1 observational method and 4 self‐report methods for the assessment of disability in mobility were collected at week 0 and again 12 weeks later. Using correlations and factor analysis, the relationships among changes in these 5 methods were established.

Results

Intercorrelations between change scores of the self‐report methods ranged from 0.12 to 0.34. Correlations between the observational method and the self‐report methods ranged from 0.14 to 0.26. In the factor analysis, both the self‐report methods and the observational method loaded on the same factor.

Conclusion

In a longitudinal design, no evidence for differential responsiveness of observational and self‐report methods was obtained. Because of the advantages of questionnaires (they are easier to use, less time‐consuming, and less of a burden to subjects), this implies that the use of self‐report methods is to be preferred over observational methods. Arthritis Care Res 45:56–61, 2001. © 2001 by the American College of Rheumatology.

     

Efficacy and safety of four doses of lumiracoxib versus diclofenac in patients with knee or hip primary osteoarthritis: A phase II,four‐week,multicenter, randomized,double‐blind,placebo‐controlled trial

Objective

To compare the efficacy and tolerability of the novel cyclooxygenase 2‐selective inhibitor lumiracoxib with placebo and diclofenac in osteoarthritis (OA).

Methods

Adults (n = 583) with knee or hip OA were randomized to receive for 4 weeks lumiracoxib 50, 100, or 200 mg twice daily or 400 mg once daily; placebo; or diclofenac 75 mg twice daily. Efficacy assessments included overall joint pain intensity and Western Ontario and McMaster Universities Osteoarthritis Index subscales; tolerability was evaluated by adverse event and physician reporting.

Results

All lumiracoxib doses were superior to placebo in relieving pain, improving stiffness, and improving physical function after 4 weeks. At study endpoint, pain relief was comparable among all lumiracoxib dosages and similar to diclofenac. Lumiracoxib tolerability was superior to diclofenac and comparable to placebo.

Conclusion

Lumiracoxib provides predictable and sustained relief from pain, stiffness, and impaired physical function in OA. Lumiracoxib shows clinically comparable efficacy and superior tolerability to diclofenac.

     

Thalamic atrophy associated with painful osteoarthritis of the hip is reversible after arthroplasty: A longitudinal voxel‐based morphometric study

Objective

Voxel‐based morphometry (VBM) is a method of assessing brain gray matter volume that has previously been applied to various chronic pain conditions. From this previous work, it appears that chronic pain is associated with altered brain morphology. The present study was undertaken to assess these potential alterations in patients with painful hip osteoarthritis (OA).

Methods

We studied 16 patients with unilateral right‐sided hip pain, before and 9 months after hip arthroplasty. This enabled comparison of gray matter volume in patients with chronic musculoskeletal pain versus healthy controls, as well as identification of any changes in volume following alleviation of pain (after surgery). Assessment involved self‐completion questionnaires to assess pain, function, and psychosocial variables, and magnetic resonance imaging scanning of the brain for VBM analysis.

Results

Significant differences in brain gray matter volume between healthy controls and patients with painful hip arthritis were seen. Specifically, areas of the thalamus in patients with chronic OA pain exhibited decreased gray matter volume. Furthermore, when these preoperative changes were compared with the brain morphology of the patients 9 months after surgery, the areas of reduced thalamic gray matter volume were found to have “reversed” to levels seen in healthy controls.

Conclusion

Our findings confirm that gray matter volume decreases within the left thalamus in the presence of chronic pain and disability in patients with hip OA. The results also show that these thalamic volume changes reverse after hip arthroplasty and are associated with decreased pain and increased function. These findings have potential implications with regard to optimizing the timing of orthopedic interventions such as arthroplasty.

     

Attentional functioning in fibromyalgia,rheumatoid arthritis,and musculoskeletal pain patients

Objectives

To investigate whether chronic pain patients have deficits in attentional functioning compared with pain‐free controls, and whether fibromyalgia patients have larger deficits in attentional functioning compared with rheumatoid arthritis and musculoskeletal pain patients.

Methods

Sixty patients (20 in each of 3 patient groups) and 20 pain‐free controls completed measures assessing pain intensity, mood, pain‐related disability, somatic awareness, and catastrophic thinking about pain. Attentional functioning was assessed using an age‐standardized, ecologically valid test battery. Analyses were made of between‐group differences.

Results

Sixty percent of patients had at least one score in the clinical range of neuropsychological impairment, independent of demography and mood. Fibromyalgia patients were more anxious and somatically aware than rheumatoid arthritis or musculoskeletal pain patients, but did not show larger attentional deficits than other patient groups.

Conclusion

All 3 groups of chronic pain patients, regardless of diagnosis, had impaired cognitive functioning on an ecologically sensitive neuropsychological test of everyday attention.

     

Efficacy of multicomponent treatment in fibromyalgia syndrome: A meta‐analysis of randomized controlled clinical trials

Objective

To systematically review the efficacy of multicomponent treatment of fibromyalgia syndrome (FMS).

Methods

We screened Medline, PsychINFO, Scopus, and the Cochrane Library (through December 2007), as well as reference sections of original studies, reviews, and evidence‐based guidelines. Randomized controlled trials (RCTs) on the multicomponent treatment (at least 1 educational or other psychological therapy with at least 1 exercise therapy) of FMS were analyzed.

Results

We included 9 (of 14) RCTs with 1,119 subjects (median treatment time 24 hours) in the meta‐analysis. Effects were summarized using standardized mean differences (SMDs) or weighted mean differences (WMDs). There was strong evidence that multicomponent treatment reduces pain (SMD ?0.37; 95% confidence interval [95% CI] ?0.62, ?0.13), fatigue (WMD ?0.85; 95% CI ?1.50, ?0.20), depressive symptoms (SMD ?0.67; 95% CI ?1.08, ?0.26), and limitations to health‐related quality of life (HRQOL) (SMD ?0.59; 95% CI ?0.90, ?0.27) and improves self‐efficacy pain (SMD 0.54; 95% CI 0.26, 0.82) and physical fitness (SMD 0.30; 95% CI 0.02, 0.57) at posttreatment. There was no evidence of its efficacy on pain, fatigue, sleep disturbances, depressive symptoms, HRQOL, or self‐efficacy pain in the long term. There was strong evidence that positive effects on physical fitness (SMD 0.30; 95% CI 0.09, 0.51) can be maintained in the long term (median followup 7 months).

Conclusions

There is strong evidence that multicomponent treatment has beneficial short‐term effects on the key symptoms of FMS. Strategies to maintain the benefits of multicomponent treatment in the long term need to be developed.

     

Arthritis beliefs and self‐care in an urban American Indian population

Objective

To describe beliefs and self‐care strategies of American Indians with chronic arthritis joint pain.

Method

In‐depth interviews were conducted with a convenience sample of urban‐dwelling American Indians (n = 56) concerning self‐care and beliefs about arthritis; objective measures of arthritis disease activity were obtained through standardized interview protocols.

Results

Joint pain was not generally assumed to be arthritis nor directly related to aging. Belief that chronic pain affecting multiple joints was a serious and unexpected condition oriented American Indians' decisions to seek medical attention. However, verbal communications about pain may be subtle or under emphasized. Few coping strategies were used to control either chronic or episodic pain.

Conclusions

Chronic arthritis pain may not be optimally managed in this population. Cultural assessment should recognize that American Indian patients may understate serious symptoms. Community educational interventions should target this population to enhance self‐care, pain management, and communication of arthritis symptoms to physicians.

     

Variation in perceptions of treatment and self‐care practices in elderly with osteoarthritis: a comparison between African American and white patients

Objective

To compare elderly African American and white patients with osteoarthritis of the knee or hip with respect to their perceptions of the efficacy of traditional and complementary treatments and their self‐care practices.

Methods

An observational, cross‐sectional study design using structured questionnaires was employed.

Results

The sample consisted of 593 patients (44% African American and 56% white). The 2 groups were comparable with respect to age, disease severity or functional status, and comorbidities. African Americans were more likely than whites to report lower educational level and household income. African Americans were also more likely than whites to perceive various traditional and complementary care modalities as efficacious. However, they were less likely than whites to perceive joint replacement therapy as efficacious (odds ratio 0.52, 95% confidence interval 0.28–0.98). African American patients were more likely than white patients to rely on self‐care measures for their arthritis.

Conclusion

African American and white patients with osteoarthritis of the knee or hip differ with respect to their perceptions of traditional and complementary treatments for arthritis and their self‐care practices.

     

The relationship between self‐report and performance‐related measures: Questioning the content validity of timed tests

Objective

To examine the determinants of the modest correlation between self‐report and performance‐related measures in patients with osteoarthritis of the hip or knee.

Methods

Measures included the Lower Extremity Functional Scale (LEFS), the self paced walk, timed up‐and‐go, and stair test. Each performance measure consisted of 3 domains: time, pain (visual analog scale), and exertion (Borg scale). Activity specificity was assessed by examining correlations between the LEFS with single activity and multiple activity time scores. Domain specificity was examined by comparing correlations between the LEFS and single and multiple domain scores. The impact of measurement error was considered.

Results

Increasing the number of activity time scores had no effect. Forming a composite performance score based on time, pain, and exertion substantially increased the correlation from 0.44 (composite timed score) to 0.59 (pooled domain and activity score) (P = 0.009).

Conclusion

Performance scores based on time alone appear to inadequately represent the breadth of health concepts associated with functional status.

     

Identification of modifiable work‐related factors that influence the risk of work disability in rheumatoid arthritis

Objective

To define work‐related factors associated with increased risk of work disability (WD) in people with rheumatoid arthritis (RA).

Methods

Questionnaires were mailed to all RA patients who used a province‐wide arthritis treatment program between 1991 and 1998 (n = 1,824). The association between risk factors and WD (defined as no paid work due to RA for at least 6 months) was assessed using multiple logistic regression analysis, controlling for significant sociodemographic and disease‐related variables.

Results

Of the original 1,824 patients, 581 were eligible and responded to the questionnaire. Work survival analysis revealed a steady rate of WD starting early, with 7.5%, 18%, and 27% work disabled at 1, 5, and 10 years, respectively. Significant determinants in multiple logistic regression were physical function (Health Assessment Questionnaire), pain (visual analog scale), and 6 work‐related factors: self employment, workstation modification, work importance, family support toward employment, commuting difficulty, and comfort telling coworkers about RA.

Conclusion

Work disability occurs early in RA. Novel work‐related factors were identified, which are potentially modifiable, to help RA patients stay employed.

     

Cost effectiveness of a two‐year home exercise program for the treatment of knee pain

Objective

To assess the cost effectiveness of a 2‐year home exercise program for the treatment of knee pain.

Methods

A total of 759 adults aged ≥45 years were randomized to receive exercise therapy, monthly telephone contact, exercise therapy and telephone contact, or no intervention. Efficacy was measured using self‐reported knee pain at 2 years. Costs to both the National Health Service and to the patient were included.

Results

Exercise therapy was associated with higher costs and better effectiveness. Direct costs for the interventions were £112 for the exercise program and £61 for the monthly telephone support. Participants allocated to receive exercise therapy were significantly more likely to incur higher medical costs than those in the no‐exercise groups (mean difference £225; 95% confidence interval £218, £232; P < 0.001).

Conclusion

Exercise therapy is associated with improvements in knee pain, but the cost of delivering the exercise program is unlikely to be offset by any reduction in medical resource use.