Exercise vs. NSAIDs/Tylenol for Hip or Knee Osteoarthritis

Two middle aged adults cycling outdoors

Osteoarthritis (OA) is the most common form of joint disease and the leading cause of pain in older adults.  Oral non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol (or acetaminophen/Tylenol) are the most frequently prescribed analgesics in this population, with 10-35% of patients with OA reporting oral NSAID use. It is important to note that oral NSAIDs and paracetamol are associated with gastrointestinal and cardiovascular complications, including increased risk of death, especially in older adults with comorbidities. 

Current National Institution for Health and Care Excellence and international guidelines strongly recommend exercise as a core therapy for the management of hip and knee OA, however, implementation in clinical practice is often limited and suboptimal, likely due to the time required, lack of standard protocols, and/or lack of confidence or concerns in those with OA.  Given the current evidence directly comparing exercise and oral NSAIDs/paracetamol is sparse, it is difficult to ascertain whether exercise has an analgesic effect equivalent to those medications. Studying the comparative efficacy of exercise and oral NSAIDs/paracetamol will help to confirm the analgesic effect of exercise, which may help to enhance public education regarding its utility as an intervention. These studies could help to inform patient-practitioner discussion and shared decision-making. 

Given there are few head-to-head randomized controlled trials (RCT), the authors undertook a network meta-analysis (NMA) to gather all RCT that directly compared exercise with oral NSAIDs/paracetamol or indirectly compared the two treatments with a common comparison. They estimated the comparative effect size for pain and function in people with knee or hip OA.

Note: In a network meta-analysis (NMA), researchers can incorporate data from RCTs that do not necessarily have the same comparator group in a network of studies.  This allows the authors to include studies that tested two or more kinds of treatment, with or without a control and allows for direct comparison of treatment and indirect comparisons with the network. This approach allows researchers to rank interventions as comparably more or less effective, which can be very helpful for clinicians and policy makers.

RESEARCH REVIEW: Comparative Efficacy of Exercise and Oral NSAIDs and Paracetamol for Knee or Hip Osteoarthritis

This paper was published in the British Journal of Sports Medicine (2023). 

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