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REVIEW ARTICLE
Relationship Between Number of Different Lower-Limb
Resistance Exercises Prescribed in a Program and Exercise
Outcomes in People With Knee Osteoarthritis: A Systematic
Review With Meta-Regression
Belinda J. Lawford,
1
Kim L. Bennell,
1
Libby Spiers,
1
Alexander J. Kimp,
1
Andrea Dell’Isola,
2
Alison R. Harmer,
3
Martin Van der Esch,
4
Michelle Hall,
3
and Rana S. Hinman
1
Objective. We determine whether there is a relationship between the number of different lower-limb resistance
exercises prescribed in a program and outcomes for people with knee osteoarthritis.
Methods. We used a systematic review with meta-regression. We searched the Cochrane Central Register of
Controlled Trials, MEDLINE, and Embase up to January 4, 2024. We included randomized controlled trials that evalu-
ated land-based resistance exercise for knee osteoarthritis compared with nonexercise interventions. We conducted
meta-regressions between number of different exercises prescribed and standardized mean differences (SMDs) for
pain and function. Covariates (intervention duration, frequency per week, use of resistance exercise machine[s], and
comparator type) were applied to attempt to reduce between-study heterogeneity.
Results. Forty-four trials (3,364 participants) were included. The number of resistance exercises ranged from 1 to
12 (mean ± SD 5.0 ± 3.0). Meta-regression showed no relationship between the number of prescribed exercises and
change in pain (slope coefficient: −0.04 SMD units [95% confidence interval {95% CI} −0.14 to 0.05]) or self-reported
function (SMD −0.04 [95% CI −0.12 to 0.05]). There was substantial heterogeneity and evidence of publication bias.
However, even after removing 31 trials that had overall unclear/high risk of bias, there was no change in relationships.
Conclusion. There was no relationship between the number of different lower-limb resistance exercises prescribed
in a program and change in knee pain or self-reported function. However, given that we were unable to account for all
differences in program intensity, progression, and adherence, as well as the heterogeneity and overall low quality of
included studies, our results should be interpreted with caution.
INTRODUCTION
Knee osteoarthritis (OA) affects >654 million people aged
≥40 years worldwide.
1
All current clinical guidelines advocate exer-
cise for management of knee OA, irrespective of age, comorbidity,
pain severity, or disability.
2–6
Although numerous systematic
reviews support the effectiveness of exercise for knee OA, effect
sizes are small to moderate and decline over time.
7,8
New ways of
enhancing the effectiveness of exercise are needed, such as by
identifying the optimal content and dosage of exercise programs.
Muscle weakness is common in people with OA, often evi-
dent in muscles surrounding the affected joint,
9–11
and is associ-
ated with pain and physical dysfunction.
12
Improving muscle
strength via resistance training is therefore a common focus of
exercise for knee OA management and is hypothesized to be
one of the mechanisms by which exercise leads to improvements
in symptoms.
13–16
The American College of Sports Medicine
(ACSM) provides specific recommendations for prescription of
resistance exercise programs for people with arthritis, including
the frequency, intensity, and duration of the program.
17
However,
Drs Bennell and Hinman’s work was supported by the National Health
and Medical Research Council (grants 1174431 and 2025733).
1
Belinda J. Lawford, PhD, Kim L. Bennell, PhD, Libby Spiers, BPhysio, Alex-
ander J. Kimp, DPT, Rana S. Hinman, PhD: The University of Melbourne, Mel-
bourne, Victoria, Australia;
2
Andrea Dell’Isola, PhD: Lund University, Lund,
Sweden;
3
Alison R. Harmer, PhD, Michelle Hall, PhD: The University of Sydney,
Sydney, New South Wales, Australia;
4
Martin Van der Esch, PhD: Amsterdam
University of Applied Sciences, Amsterdam, The Netherlands.
Drs Hall and Hinman contributed equally to this work.
Additional supplementary information cited in this article can be found
online in the Supporting Information section (https://acrjournals.
onlinelibrary.wiley.com/doi/10.1002/acr.25476).
Author disclosures are available at https://onlinelibrary.wiley.com/doi/10.
1002/acr.25476.
Address correspondence via email to Belinda J. Lawford, PhD, at belinda.
lawford@unimelb.edu.au.
Submitted for publication July 1, 2024; accepted in revised form
November 22, 2024.
1
Arthritis Care & Research
Vol. 0, No. 0, Month 2025, pp 1–10
DOI 10.1002/acr.25476
© 2024 American College of Rheumatology