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Research · Therapies

Physical therapy and exercise therapy

Exercise therapy eased chronic low back pain about 15 points on a 100-point scale against no treatment, usual care or placebo, and eased knee and hip osteoarthritis pain against no exercise. Two sham-controlled trials of physical therapy packages found no difference from sham. Results matched surgery for some knee and spine conditions. Minor flare-ups rose, serious events did not.

Checked 2026-11-13
Status
Physical therapists are licensed by each state's licensing authority, each with its own eligibility criteria, and candidates take the National Physical Therapy Examination [1].
Also called
physical therapy, physiotherapy, PT, physio, exercise therapy, therapeutic exercise, rehabilitation, rehab, physical therapist, physiotherapist, manual therapy, Pilates for back pain, motor control exercise, prehab
Used for
low back pain, knee osteoarthritis, hip osteoarthritis, arthritis pain, knee pain, meniscus tear, spinal stenosis, ACL tear, recovery after knee replacement, recovery after surgery, recovery after injury, avoiding surgery, mobility, strength

Strong several reviews agree · Moderate one review or consistent trials · Limited one or a few small studies · Untested no study in people, listed with what it rests on

Shown to help5

Reported risks1

What it is used for, and what was found

Shown to help5

Strong

Chronic low back pain, compared with no treatment, usual care or placebo

Shown to ease chronic low back pain about 15 points on a 100-point scale against no treatment, usual care or placebo, with a smaller gain in function.

Compared with no treatment, usual care or placebo [2]; no-exercise true control [3]

The numbers and sources
Effect
Exercise lowered pain by 15.2 points on a 100-point scale at earliest follow-up (95% CI -18.3 to -12.2), a difference the reviewers called clinically important, and functional limitation by 6.8 points (95% CI -8.3 to -5.3), short of their clinical threshold [2]. In a network meta-analysis against true control, Pilates had the largest pain effect (SMD -1.86), and resistance and stabilization or motor control exercise the largest function effects (SMD -1.14 and -1.13). Stretching and McKenzie exercise did not differ from true control for pain or function [3].
Population
249 trials of adults with chronic low back pain, mean age 43.7, 59% women [2]. 5,578 patients in 89 trials [3].
Sources
[2], [3]
Caveats
Most trials were at risk of performance bias because exercise cannot be blinded, and heterogeneity and publication bias lowered certainty [2]. The network meta-analysis rated its evidence low quality [3].
Moderate

Knee osteoarthritis, compared with no exercise

Shown to ease knee osteoarthritis pain about 12 points on a 100-point scale and improve function about 10 points against no exercise, right after treatment.

Compared with non-exercise or no-treatment control groups [4]

The numbers and sources
Effect
Exercise reduced pain (SMD -0.49, 44 trials, 3,537 participants), equal to 12 points on a 0 to 100 scale, and improved physical function by 10 points (SMD -0.52), both immediately after treatment. Quality of life improved by 4 points. Two to six months after treatment ended, pain was 6 points lower and function 3 points better [4].
Population
54 trials of people with knee osteoarthritis [4].
Sources
[4]
Caveats
Only 4 trials blinded participants, and pain and function were self-reported [4].
Moderate

Hip osteoarthritis, compared with no exercise

Shown to ease hip osteoarthritis pain and improve function about 8 and 7 points on a 100-point scale against no exercise, sustained 3 to 6 months later.

Compared with non-exercise control groups [5]

The numbers and sources
Effect
Exercise reduced pain (SMD -0.38, 9 trials, 549 participants), equal to 8 points on a 0 to 100 scale, and improved function by 7 points, with a number needed to treat of 6 for both. The pain reduction held 3 to 6 months after supervised treatment ended. Quality of life did not change (3 small studies) [5].
Population
10 trials of people with hip osteoarthritis [5].
Sources
[5]
Caveats
No trial could blind participants, and outcomes were self-reported [5].
Limited

Knee osteoarthritis, compared with a steroid injection

One trial of 156 adults found less knee pain and disability at 1 year with physical therapy than with a glucocorticoid injection.

Compared with intra-articular glucocorticoid injection [8]

The numbers and sources
Effect
At 1 year, WOMAC scores (0 to 240) were 37.0 with physical therapy and 55.8 with injection, a difference of 18.8 points (95% CI 5.0 to 32.6) [8].
Population
156 patients with knee osteoarthritis, mean age 56, in the US Military Health System [8].
Sources
[8]
Caveats
One trial, without blinding of participants.
Moderate

Recovery after knee replacement

Shown to improve function and pain modestly 3 to 4 months after knee replacement, compared with minimal physiotherapy. No long-term benefit was found.

Compared with minimal physiotherapy [13]; home-based physiotherapy [13]

The numbers and sources
Effect
Against minimal physiotherapy, physiotherapy exercise improved function (SMD -0.37, 95% CI -0.62 to -0.12) and pain (SMD -0.45, 95% CI -0.85 to -0.06) at 3 to 4 months. Outpatient and home-based programs did not differ for function or pain, and adding balance or cycling made no difference [13].
Population
1,739 patients with recent total knee replacement in 18 trials [13].
Sources
[13]
Caveats
Studies were small and underpowered individually and combined [13].

Mixed results2

Moderate

Chronic low back pain, compared with other treatments

Mixed results: exercise eased pain about 9 points on a 100-point scale more than other conservative treatments, below the clinical threshold, and did not differ from manual therapy.

Compared with other conservative treatments [2]; education alone [2]; non-exercise physical therapy [2]; manual therapy [2]

The numbers and sources
Effect
Against all other conservative treatments, pain fell 9.1 points more (95% CI -12.6 to -5.6) and functional limitation 4.1 points more, neither meeting the reviewers' threshold for clinical importance. By subgroup, pain fell more than with education alone (-12.2) and non-exercise physical therapy (-10.4), and did not differ from manual therapy (1.0, 95% CI -3.1 to 5.1) [2].
Population
249 trials of adults with chronic low back pain [2].
Sources
[2]
Caveats
Low-certainty evidence for these comparisons [2].
Moderate

Compared with surgery

Mixed results: trials found outcomes similar to surgery for degenerative meniscus tears, spinal stenosis and ACL tears, and smaller gains than knee replacement.

Compared with arthroscopic partial meniscectomy [9]; surgical decompression [10]; early ACL reconstruction [11]; total knee replacement followed by nonsurgical treatment [12]

The numbers and sources
Effect
For degenerative meniscus tears, knee scores at 2 years differed by 0.9 points between 12 weeks of supervised exercise and surgery (95% CI -4.3 to 6.1), and 19% of the exercise group crossed over to surgery [9]. For lumbar spinal stenosis, physical function improved by 19.2 points with physical therapy and 22.4 with surgery, with no difference at 2 years, and 57% crossed over from therapy to surgery [10]. For acute ACL tears, knee scores rose 39.4 points with rehabilitation plus optional later reconstruction and 39.2 with rehabilitation plus early reconstruction, and 36 of 59 never had surgery [11]. For knee osteoarthritis, knee replacement plus nonsurgical treatment improved scores by 32.5 points against 16.0 with nonsurgical treatment alone, and had more serious adverse events (24 against 6) [12].
Population
140 adults aged 35 to 60 with degenerative meniscal tears [9]. 169 surgical candidates aged 50 or older with lumbar spinal stenosis [10]. 121 young, active adults with acute ACL tears [11]. 100 patients eligible for knee replacement [12].
Sources
[9], [10], [11], [12]
Caveats
Each condition rests on one trial, and crossover to surgery was common [9][10]. The spinal stenosis trial had no untreated group [10].

Not shown to help1

Limited

Hip and knee osteoarthritis, compared with sham treatment

Two small trials found physical therapy programs did not ease hip or knee osteoarthritis pain more than sham ultrasound with inert gel.

Compared with sham ultrasound and inert gel [6][7]

The numbers and sources
Effect
In hip osteoarthritis, pain at week 13 fell from 58.8 to 40.1 mm with physical therapy and from 58.0 to 35.2 mm with sham, a difference of 6.9 mm favoring sham (95% CI -3.9 to 17.7). Function did not differ [6]. In knee osteoarthritis, pain fell by 2.2 cm with physiotherapy and 2.0 cm with placebo at 12 weeks, and global improvement was reported by 70% and 72% [7].
Population
102 adults with painful hip osteoarthritis [6]. 140 adults with knee osteoarthritis, 119 completing [7].
Sources
[6], [7]
Caveats
The sham involved regular contact with a therapist, so both groups received attention. The authors of [7] wrote that the program did no more than regular contact with a therapist.

Protocols studied

Back pain trials compared many exercise types, including Pilates, resistance, stabilization or motor control, aerobic, stretching and McKenzie exercise [3]. Osteoarthritis trials used land-based therapeutic exercise [4][5]. The sham-controlled hip trial gave 10 sessions over 12 weeks of education, manual therapy, home exercise and a walking aid where needed, then 24 weeks of home exercise [6]. The knee trial gave 12 weeks of exercise, massage, taping and mobilization, then 12 weeks of self-management [7]. In both, sham treatment was inactive ultrasound and an inert gel [6][7].

The meniscus trial used 12 weeks of supervised exercise [9]. The knee replacement trial gave 12 weeks of nonsurgical treatment by physiotherapists and dietitians, including exercise, education and dietary advice [12]. Programs after knee replacement were delivered at home, in outpatient clinics, in pools or in gyms [13].

Risks

Reported risks1

ModerateVery common

Pain flare-ups and soreness

Shown to raise minor adverse events by 19% in pooled trials, about one extra for every 6 people. Most were increased pain or muscle soreness.

The numbers and sources
How common
Very common: more than 1 in 10 people.
Effect
Across exercise therapy trials, non-serious adverse events rose (RR 1.19, 95% CI 1.09 to 1.30), with one extra event for every 6 people treated [14]. In the hip osteoarthritis trial, 19 of 46 people (41%) on physical therapy and 7 of 49 (14%) on sham reported mild adverse effects [6]. In back pain trials that measured harms systematically, there was a median of 0.14 adverse effects per participant with exercise and 0.12 with comparison treatments, mostly minor, such as muscle soreness [2]. In knee and hip osteoarthritis trials, reported adverse events were increased knee, hip or low back pain [4][5].
Population
38,517 participants in 375 trials [14]. 95 adults with hip osteoarthritis [6]. 249 back pain trials [2]. Osteoarthritis trials [4][5].
Sources
[14], [6], [2], [4], [5]
Caveats
The 41% comes from one trial of a multi-part program [6]. Many trials did not report adverse events [2].

Checked, no increase found1

Moderate

Serious adverse events

Not shown to raise serious adverse events in pooled exercise therapy trials.

The numbers and sources
How common
How often is not known: the sources give no rate.
Effect
Serious adverse events did not rise with exercise therapy (RR 0.96, 95% CI 0.90 to 1.02) [14]. No knee osteoarthritis exercise study reported a serious adverse event [4], and none occurred in either group of the meniscus trial over 2 years [9].
Population
38,368 participants in 378 trials [14]. 54 knee osteoarthritis trials [4]. 140 adults [9].
Sources
[14], [4], [9]
Caveats
Trials enroll people judged fit to exercise.

Claims tested and not found

  1. That a physical therapy program eases hip osteoarthritis pain beyond sham. Pain at 13 weeks did not differ, with a 6.9 mm difference favoring sham [6].
  2. That a physiotherapy program eases knee osteoarthritis pain beyond placebo contact. Pain fell by similar amounts with physiotherapy and placebo [7].
  3. That stretching or McKenzie exercises ease chronic low back pain. Neither differed from true control for pain or function [3].
  4. That early reconstruction of a torn ACL gives better knee scores at 2 years than rehabilitation first. Rehabilitation with optional later surgery gave the same knee scores, and most in that group never had surgery [11].

Sources

  1. Federation of State Boards of Physical Therapy. State Licensure. 2026. https://www.fsbpt.org/
  2. Hayden JA, Ellis J, Ogilvie R, et al. Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews. 2021. https://doi.org/10.1002/14651858.CD009790.pub2
  3. Owen PJ, Miller CT, Mundell NL, et al. Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis. British Journal of Sports Medicine. 2019. https://doi.org/10.1136/bjsports-2019-100886
  4. Fransen M, McConnell S, Harmer AR, et al. Exercise for osteoarthritis of the knee. Cochrane Database of Systematic Reviews. 2015. https://doi.org/10.1002/14651858.CD004376.pub3
  5. Fransen M, McConnell S, Hernandez-Molina G, et al. Exercise for osteoarthritis of the hip. Cochrane Database of Systematic Reviews. 2014. https://doi.org/10.1002/14651858.CD007912.pub2
  6. Bennell KL, Egerton T, Martin J, et al. Effect of physical therapy on pain and function in patients with hip osteoarthritis: a randomized clinical trial. JAMA. 2014. https://doi.org/10.1001/jama.2014.4591
  7. Bennell KL, Hinman RS, Metcalf BR, et al. Efficacy of physiotherapy management of knee joint osteoarthritis: a randomised, double blind, placebo controlled trial. Annals of the Rheumatic Diseases. 2005. https://doi.org/10.1136/ard.2004.026526
  8. Deyle GD, Allen CS, Allison SC, et al. Physical Therapy versus Glucocorticoid Injection for Osteoarthritis of the Knee. New England Journal of Medicine. 2020. https://doi.org/10.1056/nejmoa1905877
  9. Kise NJ, Risberg MA, Stensrud S, et al. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ. 2016. https://doi.org/10.1136/bmj.i3740
  10. Delitto A, Piva SR, Moore CG, et al. Surgery versus nonsurgical treatment of lumbar spinal stenosis: a randomized trial. Annals of Internal Medicine. 2015. https://doi.org/10.7326/M14-1420
  11. Frobell RB, Roos EM, Roos HP, et al. A randomized trial of treatment for acute anterior cruciate ligament tears. New England Journal of Medicine. 2010. https://doi.org/10.1056/nejmoa0907797
  12. Skou ST, Roos EM, Laursen MB, et al. A Randomized, Controlled Trial of Total Knee Replacement. New England Journal of Medicine. 2015. https://doi.org/10.1056/NEJMoa1505467
  13. Artz N, Elvers KT, Lowe CM, et al. Effectiveness of physiotherapy exercise following total knee replacement: systematic review and meta-analysis. BMC Musculoskeletal Disorders. 2015. https://doi.org/10.1186/s12891-015-0469-6
  14. Niemeijer A, Lund H, Stafne SN, et al. Adverse events of exercise therapy in randomised controlled trials: a systematic review and meta-analysis. British Journal of Sports Medicine. 2019. https://doi.org/10.1136/bjsports-2018-100461

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