Recent highlights and uncertainties in exercise management of knee osteoarthritis

INTRODUCTION: This narrative review outlines recent research highlights and uncertainties in the exercise management of knee osteoarthritis (OA) published between January 2020 and February 2025. METHODS: To identify studies for inclusion, these electronic databases were searched: Medline, CINAHL Plus, Cochrane Central Trial Register of Controlled Trials and Cochrane Database of Systematic Reviews. Search results were screened and article selection was discussed among the entire research team. Studies that were deemed to be of significant clinical importance, particularly high-quality and/or controversial were selected for inclusion. Study findings were summarised according to overarching themes and future research directions were suggested for each thematic area. FINDINGS: This review highlighted six themes formulated as questions: Is exercise as effective as previously thought? How does exercise work and who might benefit the most? Is there an optimal exercise dose and type? Can patient adherence be improved - and does it matter? Do patients need to be seen in person to deliver exercise? How does communication about osteoarthritis influence patient beliefs about exercise? There were several key findings related to these themes. First, there was reduced certainty in the effectiveness of exercise for knee OA. Additionally, the mechanisms by which exercise improves clinical outcomes are largely unknown and it is unclear which individuals benefit the most from exercise. Research has failed to demonstrate a dose-response relationship between exercise and clinical outcomes and improving patient adherence to exercise may not lead to improved clinical outcomes. Nonetheless, exercise therapy can be effectively delivered remotely via a variety of methods. Communicating about OA using an impairment-based approach has been causally linked to negative beliefs about exercise.