Adjunctive therapies in addition to land‐based exercise therapy for osteoarthritis of the hip or knee

Background Land‐based exercise therapy is recommended in clinical guidelines for hip or knee osteoarthritis. Adjunctive non‐pharmacological therapies are commonly used alongside exercise in hip or knee osteoarthritis management, but cumulative evidence for adjuncts to land‐based exercise therapy is lacking. Objectives To evaluate the benefits and harms of adjunctive therapies used in addition to land‐based exercise therapy compared with placebo adjunctive therapy added to land‐based exercise therapy, or land‐based exercise therapy only for people with hip or knee osteoarthritis. Search methods We searched CENTRAL, MEDLINE, PsycINFO, EMBASE, CINAHL, Physiotherapy Evidence Database (PEDro) and clinical trials registries up to 10 June 2021. Selection criteria We included randomised controlled trials (RCTs) or quasi‐RCTs of people with hip or knee osteoarthritis comparing adjunctive therapies alongside land‐based exercise therapy (experimental group) versus placebo adjunctive therapies alongside land‐based exercise therapy, or land‐based exercise therapy (control groups). Exercise had to be identical in both groups. Major outcomes were pain, physical function, participant‐reported global assessment, quality of life (QOL), radiographic joint structural changes, adverse events and withdrawals due to adverse events. We evaluated short‐term (6 months), medium‐term (6 to 12 months) and long‐term (12 months onwards) effects. Data collection and analysis Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias and certainty of evidence for major outcomes using GRADE. Main results We included 62 trials (60 RCTs and 2 quasi‐RCTs) totalling 6508 participants. One trial included people with hip osteoarthritis, one hip or knee osteoarthritis and 60 included people with knee osteoarthritis only. Thirty‐six trials evaluated electrophysical agents, seven manual therapies, four acupuncture or dry needling, or taping, three psychological therapies, dietary interventions or whole body vibration, two spa or peloid therapy and one foot insoles. Twenty‐two trials included a placebo adjunctive therapy. We presented the effects stratified by different adjunctive therapies along with the overall results. We judged most trials to be at risk of bias, including 55% at risk of selection bias, 74% at risk of performance bias and 79% at risk of detection bias. Adverse events were reported in 11 (18%) trials. Comparing adjunctive therapies plus