Osteoarthritis (OA) is the most prevalent joint disease in the world, affecting more than 500 million people globally and representing the main cause of chronic musculoskeletal pain in adults over 45 years of age. The guidelines of the main rheumatology societies — EULAR, ACR, OARSI, and the Brazilian Society of Rheumatology — recommend physical exercise as a first-line intervention, before any pharmacologic or surgical treatment. But what is the real magnitude of this benefit? And how long does it last after the suspension of the exercise program?
An umbrella review published in RMD Open (BMJ Group) answered these questions with the highest level of evidence synthesis available: the analysis of multiple systematic reviews and pooled randomized clinical trials. The main result — small to moderate beneficial effects, with a tendency to decrease after exercise suspension — does not weaken the clinical recommendation, but requires that physicians and patients establish realistic expectationsand plan continuity of exercise as a permanent component of treatment, not as a temporary cycle.
What is an umbrella review and why does it matter
An umbrella review (or overview of reviews) is the synthesis of multiple systematic reviews that evaluate the same clinical question. While an isolated systematic review compiles clinical trials, the umbrella review compiles systematic reviews, offering a panoramic view of the totality of available evidence. In the field of osteoarthritis and exercise, where dozens of systematic reviews exist with slightly different results, this approach allows identification of robust patterns and conflicting evidence.
Methodology of the review
The review (DOI: 10.1136/rmdopen-2025-006275) included systematic reviews and meta-analyses published that evaluated physical exercise for osteoarthritis of the knee and/or hip, with pain and physical function outcomes. The authors applied the AMSTAR-2 methodology to assess the quality of the included reviews and GRADE to rank the certainty of the evidence by outcome.
UMBRELLA REVIEW OVERVIEW
Results: exercise is effective, but the benefit is not permanent on its own
The review confirms that physical exercise — both aerobic and muscle strengthening — produces clinically significant reductions in pain and improvements in physical function in osteoarthritis of the knee and hip. The effects are consistent across different types of exercise (water, dry land, resistance, aerobic) and across different populations.
EXERCISE FOR OA — SYNTHESIS OF MAIN FINDINGS
| DIMENSION EVALUATED | FINDING OF THE REVIEW |
|---|---|
| Effect on pain | Small to moderate (SMD ≈ 0.3-0.6) · statistically significant · superior to control without exercise |
| Effect on physical function | Small to moderate · improvement in functional questionnaires (WOMAC, KOOS) · significant for daily activities |
| Persistence of benefit | Tends to decrease after suspension of the program · studies with 6-12 month follow-up show attenuation of gains |
| Water exercise vs. land exercise | Comparable effect magnitudes · aquatic exercise preferable in patients with high pain burden or severe functional limitation |
The central message — that benefits tend to decrease after suspension of exercise — does not mean that exercise "does not work". It means that, like medication, exercise is a treatment that needs continuity. The analogy with antihypertensive therapy is direct: when the patient stops exercising, blood pressure rises again. The same occurs with pain and function in osteoarthritis.
What guidelines recommend about exercise for OA
- ACR 2021: strong and unconditional recommendation for aerobic and strengthening exercise in osteoarthritis of the knee, hip, and hand
- EULAR 2019: terrestrial and aquatic exercise as central first-line interventions for OA of the knee and hip
- OARSI 2019: exercise recommended for all patients with OA, regardless of age, comorbidities, or radiographic severity
- SBR 2020: exercise as a pillar of the multimodal treatment of OA — recommendation with high level of evidence
Frequently Asked Questions
No. Physical exercise does not reverse the structural cartilage alterations of osteoarthritis — there is no evidence of significant cartilage regeneration with any non-surgical intervention available. What exercise does is: reduce pain through endogenous analgesia mechanisms (release of endorphins, improvement of the descending inhibitory system), improve periarticular muscle function (which protects the joint from overload), and reduce low-grade chronic synovial inflammation. Osteoarthritis is managed, not cured.
The umbrella review confirms that aerobic, muscle-strengthening, and aquatic exercise have comparable effect magnitudes. The individualized recommendation should consider: (1) current pain burden — patients with very high pain better tolerate water exercise; (2) cardiovascular comorbidities — they influence aerobic prescription; (3) preferences and adherence — the best modality is the one the patient can maintain; (4) access — swimming and aquatic gymnastics have lower availability in interior cities.
Yes, and exercise has two functions in this context: pré-rehabilitation (maintaining muscle strength before surgery improves postoperative results and reduces recovery time) and as a therapeutic test (many patients with relative indication for arthroplasty who adhere to a structured exercise program significantly delay surgery). OARSI guidelines recommend that surgery be considered only after adequate trial of conservative treatment, including supervised exercise.
Yes. A network meta-analysis published in the BMJ with 80 randomized clinical trials and knee osteoarthritis demonstrated that acupuncture is superior to control (sham and no treatment) for pain and function. When directly compared, exercise and acupuncture have similar effect magnitudes, but act through distinct mechanisms: exercise acts mainly on periarticular musculature and local metabolism, while acupuncture modulates central pain circuits (descending inhibitory system, HPA axis). The combination potentiates both effects.
The guidelines recommend as a goal 150 minutes per week of moderate-intensity aerobic activity, complemented by 2 sessions of lower-limb muscle strengthening. For patients with intense pain, start with 10-15 minutes three times a week and progress gradually. Programs supervised by a physical therapist or physical educator in the first 8-12 weeks significantly improve adherence and reduce the risk of pain exacerbation.
Sources consulted
- Umbrella review on exercise for osteoarthritis. RMD Open. 2026;12(1):e006275. DOI: 10.1136/rmdopen-2025-006275.
- Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Care Res. 2020.
- Bannuru RR, Osani MC, Vaysbrot EE, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019.
- Lin X, Huang K, Zhu G, et al. The effects of acupuncture on chronic knee pain due to osteoarthritis: a meta-analysis. J Bone Joint Surg Am. 2016.
- Bidonde J, Busch AJ, Bath B, Milosavljevic S. Exercise for adults with fibromyalgia: an umbrella systematic review with synthesis of best evidence. Curr Rheumatol Rev. 2014.
Founded in 1989 by physicians trained at the University of São Paulo (USP) and specialized in China, CEIMEC is a Brazilian national reference in the teaching and practice of medical acupuncture. With more than 3,000 physicians trained over 35 years, it collaborates with HC-FMUSP and is recognized by the Brazilian Medical College of Acupuncture (CMBA/AMB).