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

Objective To investigate the effective exercise prescription in randomized controlled trials (RCTs) for patellofemoral pain (PFP). Design A network meta-analysis. Data sources PubMed (including Medline), Embase, Web of Science, PEDro, [Clinicaltrials.gov][1] and other resourses for RCTs. Eligibility criteria for selecting studies RCTs of exercise interventions for PFP with outcomes of pain intensity or functional improvement. Primary outcome measure Pain intensity is measured by ‘worst pain in the past week’ on a Visual Analogue Scale (VAS) or Numerical Rating Pain Scale (NRS). Data extraction Two 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. Results A 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. Conclusion The 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?) ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was funded by Science & Technology Department of Sichuan Province found (Grant number:2021YJ0463 and 2021YF0070) and Office of Science & Technology and Talent Work of LU ZHOU found (Grant number:2020LZXNYDJ10 and 2020LZXNYDJ14). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors. [1]: http://Clinicaltrials.gov