Overview

• Pooled evidence from 217 randomized trials with 15,684 participants conducted between 1990 and 2024 underpinned the analysis.
• Walking, cycling and swimming were most likely to reduce pain and enhance function, gait performance and quality of life.
• Findings reached moderate-certainty levels, with pain improvements in the short to mid term and functional gains extending to long-term follow-up.
• No exercise modality increased adverse events compared with controls, supporting the safety of exercise therapy.
• Mind–body, neuromotor, strengthening and mixed programs offered targeted benefits but are advised as complements rather than replacements, with noted limits including indirect comparisons and limited long-term data.