Comparative efficacy of exercise therapy for patellofemoral pain: A network meta-analysis of randomized controlled trials

ObjectiveTo investigate the effective exercise prescription in randomized controlled trials (RCTs) for patellofemoral pain (PFP). DesignA network meta-analysis. Data sourcesPubMed (including Medline), Embase, Web of Science, PEDro, Clinicaltrials.gov and other resourses for RCTs. Eligibility criteria for selecting studiesRCTs of exercise interventions for PFP with outcomes of pain intensity or functional improvement. Primary outcome measurePain intensity is measured by worst pain in the past week on a Visual Analogue Scale (VAS) or Numerical Rating Pain Scale (NRS). Data extractionTwo researchers independently extracted data and assessed the bias of risks. We used Grading of Recommendations, Assessment, Development, and Evaluation to appraise the strength of the evidence. ResultsA total of 45 trials with 42,319 patients were included in this network meta-analysis (NMA). For the primary outcomes, all included treatments were superior to a wait-and-see approach: PNF + exercise (SMD -2.88, 95%CIs -4.75 to -1.02), whole body exercise (-1.57, -3.15 to -0.00), hip-and knee-focused exercise therapy (-1.32, -2.57 to -0.06), foot orthoses + exercise (-1.06, -2.92 to -0.06), hip exercise (-1.10, -2.44 to 0.24), knee brace + exercise(-0.91, -2.54 to 0.72), gait retraining exercise (-2.55, -4.72 to -0.37), knee exercise (-0.92, -2.16 to 0.33), knee arthroscopy + exercise (-0.61, -2.44 to 1.22), target exercise (-0.52, -2.38 to 1.33), kinesiotaping + exercise (-0.54, -2.07 to 0.99), education + exercise (-0.47, -2.31 to 1.38), feedback exercise (-0.22, -1.86 to 1.43). Exercise therapy with education (SMD -0.25, 95%CIs -1.76 to 1.26) was better than exercise alone in alleviating pain intensity. ConclusionThe knee and hip combination strength training is highly effective in muscle strength improvement. All treatments in our NMA were superior to nontreatment, we recommend avoiding a wait-and-see approach. Comprehensive therapy based on individual evaluation can effectively improve the symptoms of patients. Key points (what are the new findings?)O_LIThe combination of knee and hip strength training is highly effective in pain relief and function improvement for PFP. C_LIO_LIThe exercise therapy with biomechanical devices, such as foot orthoses, braces, and kinesiotaping can improve knee function. C_LIO_LIEducation with exercise therapy shows a great effect on pain relief and function improvement than exercise alone. C_LIO_LITarget exercise based on individual evaluation is superior to general exercise therapy for keen function. C_LI