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Are we missing the target? Are we aiming too low? What are the aerobic exercise prescriptions and their effects on markers of cardiovascular health and systemic inflammation in patients with knee osteoarthritis? A systematic review and meta-analysis
  1. Jenna M Schulz1,2,
  2. Trevor B Birmingham1,2,
  3. Hayden F Atkinson1,2,
  4. Emilie Woehrle3,
  5. Codie A Primeau1,2,
  6. Michael J Lukacs1,2,
  7. Baraa K Al-Khazraji2,3,
  8. Michaela C M Khan2,3,
  9. Bryn O Zomar1,2,
  10. Robert J Petrella2,4,
  11. Frank Beier2,5,
  12. C Thomas Appleton2,6,
  13. J Kevin Shoemaker2,3,
  14. Dianne M Bryant1,2
  1. 1Health and Rehabilitation Sciences, Western University Faculty of Health Sciences, London, Ontario, Canada
  2. 2Bone and Joint Institute, Western University, London, Ontario, Canada
  3. 3Kinesiology, Western University Faculty of Health Sciences, London, Ontario, Canada
  4. 4Family Medicine, Western University Schulich School of Medicine and Dentistry, London, Ontario, Canada
  5. 5Physiology and Pharmacology, Western University Schulich School of Medicine and Dentistry, London, Ontario, Canada
  6. 6Medicine, Western University Schulich School of Medicine and Dentistry, London, Ontario, Canada
  1. Correspondence to Dr Trevor B Birmingham, Faculty of Health Sciences, Bone and Joint Institute, London, ON N6G 1H1, Canada; tbirming{at}


Objectives We systemically reviewed published studies that evaluated aerobic exercise interventions in patients with knee osteoarthritis (OA) to: (1) report the frequency, intensity, type and time (FITT) of exercise prescriptions and (2) quantify the changes in markers of cardiovascular health and systemic inflammation.

Data sources PubMed, CINAHL, Scopus; inception to January 2019.

Eligibility criteria Randomised clinical trials (RCT), cohort studies, case series.

Design We summarised exercise prescriptions for all studies and calculated effect sizes with 95% CIs for between-group (RCTs that compared exercise and control groups) and within-group (pre-post exercise) differences in aerobic capacity (VO2), heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and inflammatory markers (interleukin-6 (IL-6), tumour necrosis factor-alpha). We pooled results where possible using random effects models.

Results Interventions from 49 studies were summarised; 8% (4/49) met all FITT guidelines; 16% (8/49) met all or most FITT guidelines. Fourteen studies (10 RCTs) reported at least one marker of cardiovascular health or systemic inflammation. Mean differences (95% CI) indicated a small to moderate increase in VO2 (0.84 mL/min/kg; 95% CI 0.37 to 1.31), decrease in HR (−3.56 beats per minute; 95% CI −5.60 to −1.52) and DBP (−4.10 mm Hg; 95% CI −4.82 to −3.38) and no change in SBP (−0.36 mm Hg; 95% CI −3.88 to 3.16) and IL-6 (0.37 pg/mL; 95% CI −0.11 to 0.85). Within-group differences were also small to moderate.

Conclusions In studies of aerobic exercise in patients with knee OA, very few interventions met guideline-recommended dose; there were small to moderate changes in markers of cardiovascular health and no decrease in markers of systemic inflammation. These findings question whether aerobic exercise is being used to its full potential in patients with knee OA.

PROSPERO registration number CRD42018087859.

  • knee osteoarthritis
  • aerobic exercise
  • inflammation
  • cardiovascular
  • cardiometabolic
  • meta-analyses

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  • Twitter @jennaschulz_1

  • Contributors JMS conceptualised the project, analysed the data, and drafted and edited the manuscript. TBB, RJP, FB and DMB contributed to conception and design and critical revision of the article. DMB provided statistical expertise. HFA, EW, CAP, MJL, BKA, MCMK and BOZ contributed to data collection and synthesis. CTA and JKS provided critical analysis of the data and critical revision of the article. All authors edited and approved the final version of the manuscript.

  • Funding JMS is funded by a Transdisciplinary Training Award from the Collaborative Training Specialization in Musculoskeletal Health Research, Bone and Joint Institute, Western University. TBB, JKS and FB are funded in part by the Canada Research Chairs Program. Support for this study was provided by the Canadian Institutes of Health Research and The Arthritis Society, Canada.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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