***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background H and exercises are recommended for patients with h and osteoarthritis ( HOA ) , though evidence for their effect is conflicting . Objective To evaluate , in a r and omised controlled trial , the effect of HOA information plus home-based h and exercises ( exercise group ) compared with information only ( control group ) in women with HOA . Methods Interventions were delivered by two occupational therapists . Exercise group participants received eight follow-up calls over the 3-month study and recorded adherence , pain after exercises and adverse events in a diary . Primary outcome was activity performance measured after 3 months by the Patient-Specific Functional Scale ( PSFS ) , with a range of 0–10 . Secondary outcomes were measurements of h and function , disease activity , symptoms and number of responders to treatment according to the OMERACT-OARSI criteria . Results Of 80 women r and omised ( 40 : 40 ) ( mean age ( SD ) 60.8 years ( 7.0 ) ) , follow-up was 89 % ( n=71 ) . An intention-to-treat analysis was performed . The adjusted mean difference for the exercise versus control group was 1.4 points ( 95 % CI 0.6 to 2.2 , effect size 1.0 ) for the PSFS score .  Thirteen patients in the  exercise  group versus three participants in the control group reached a positive minimal clinical important difference of 2.2 points in the PSFS total score , while none versus two , respectively , had a negative change ( p=0.007 ) . For secondary outcomes , significant mean differences were found in grip strength and thumb web space , in fatigue , joint pain and the Functional Index for HOA activity performance scores . Sixteen exercise-group participants fulfilled the OMERACT-OARSI response criteria versus two control-group participants ( p<0.001 ) . Conclusions H and exercises were well tolerated and significantly improved activity performance , grip strength , pain and fatigue in women with HOA . Trial registration number : ISRTCN79019063 Background Osteoarthritis is the leading cause of disability in older adults . Evidence of effectiveness for self-management of h and osteoarthritis is lacking . Methods In this r and omised , factorial trial , we evaluated the effectiveness of joint protection versus no joint protection , and h and exercise versus no h and exercise in adults , 50 years of age or older , with h and osteoarthritis . Following a population survey ( n=12 297 ) , eligible individuals were r and omly assigned ( 1:1:1:1 ) to : leaflet and advice ; joint protection ; h and exercise ; joint protection plus h and exercise . Joint protection and h and exercises were delivered by nine occupational therapists , over four group sessions . The primary outcome was the OARSI/OMERACT responder criteria at 6 months . Outcomes were collected blind to allocation ( 3 , 6 , 12 m ) . Analysis was by intention to treat . Results Of 257 participants r and omised ( 65:62:65:65 ) ( mean age ( SD ) 66 years ( 9.1 ) ; female 66 % ) follow-up was 85 % at 6 m ( n=212 ) . Baseline characteristics and loss to follow-up were similar between groups . There were no reported treatment side effects . At 6 m 33 % assigned joint protection were responders compared with 21 % with no joint protection ( p=0.03 ) . Of those assigned h and exercises , 28 % were responders compared with 25 % with no exercises ( n.s . ) . Differences in secondary outcomes were not statistically significant , except for improvement in pain self-efficacy with joint protection ( 3 m p=0.002 ; 6 m p=0.001 ; 12 m p=0.03 ) . Conclusions These findings show that occupational therapists can support self-management in older adults with h and osteoarthritis , and that joint protection provides an effective intervention for medium term outcome . ( Funded by the Arthritis Research UK IS RCT N 33870549 ) OBJECTIVE To evaluate the clinical effectiveness of manual physiotherapy and /or exercise physiotherapy in addition to usual care for patients with osteoarthritis ( OA ) of the hip or knee . DESIGN In this 2 × 2 factorial r and omized controlled trial , 206 adults ( mean age 66 years ) who met the American College of Rheumatology criteria for hip or knee OA were r and omly allocated to receive manual physiotherapy ( n = 54 ) , multi-modal exercise physiotherapy ( n = 51 ) , combined exercise and manual physiotherapy ( n = 50 ) , or no trial physiotherapy ( n = 51 ) . The primary outcome was change in the Western Ontario and McMaster osteoarthritis index ( WOMAC ) after 1 year . Secondary outcomes included physical performance tests . Outcome assessors were blinded to group allocation . RESULTS Of 206 participants recruited , 193 ( 93.2 % ) were retained at follow-up . Mean ( SD ) baseline WOMAC score was 100.8 ( 53.8 ) on a scale of 0 - 240 . Intention to treat analysis showed adjusted reductions in WOMAC scores at 1 year compared with the usual care group of 28.5 ( 95 % confidence interval ( CI ) 9.2 - 47.8 ) for usual care plus manual therapy , 16.4 ( -3.2 to 35.9 ) for usual care plus exercise therapy , and 14.5 ( -5.2 to 34.1 ) for usual care plus combined exercise therapy and manual therapy . There was an antagonistic interaction between exercise therapy and manual therapy ( P = 0.027 ) . Physical performance test outcomes favoured the exercise therapy group . CONCLUSIONS Manual physiotherapy provided benefits over usual care , that were sustained to 1 year . Exercise physiotherapy also provided physical performance benefits over usual care . There was no added benefit from a combination of the two therapies . TRIAL REGISTRATION NUMBER Australian New Zeal and Clinical Trials Registry ACTRN12608000130369 IMPORTANCE There is debate about benefits of acupuncture for  knee pain . OBJECTIVE To determine the efficacy of laser and needle acupuncture for  chronic knee pain . DESIGN , SETTING , AND PARTICIPANTS Zelen- design clinical trial ( r and omization occurred before informed consent ) , in Victoria , Australia ( February 2010-December 2012 ) . Community volunteers ( 282 patients aged ≥50 years with chronic knee pain ) were treated by family physician acupuncturists . INTERVENTIONS No acupuncture ( control group , n = 71 ) and needle ( n = 70 ) , laser ( n = 71 ) , and sham laser ( n = 70 ) acupuncture . Treatments were delivered for 12 weeks . Participants and acupuncturists were blinded to laser and sham laser acupuncture . Control participants were unaware of the trial . MAIN OUTCOMES AND MEASURES Primary outcomes were average knee pain ( numeric rating scale , 0 [ no pain ] to 10 [ worst pain possible ] ; minimal clinical ly important difference [ MCID ] , 1.8 units ) and physical function ( Western Ontario and McMaster Universities Osteoarthritis Index , 0 [ no difficulty ] to 68 [ extreme difficulty ] ; MCID , 6 units ) at 12 weeks . Secondary outcomes included other pain and function measures , quality of life , global change , and 1-year follow-up . Analyses were by intention-to-treat using multiple imputation for missing outcome data . RESULTS At 12 weeks and 1 year , 26 ( 9 % ) and 50 ( 18 % ) participants were lost to follow-up , respectively . Analyses showed neither needle nor laser acupuncture  significantly improved pain ( mean difference ; -0.4 units ; 95 % CI , -1.2 to 0.4 , and -0.1 ; 95 % CI , -0.9 to 0.7 , respectively ) or function ( -1.7 ; 95 % CI , -6.1 to 2.6 , and 0.5 ; 95 % CI , -3.4 to 4.4 , respectively ) compared with sham at 12 weeks . Compared with control , needle and laser acupuncture result ed in modest improvements in pain ( -1.1 ; 95 % CI , -1.8 to -0.4 , and -0.8 ; 95 % CI , -1.5 to -0.1 , respectively ) at 12 weeks , but not at 1 year . Needle acupuncture result ed in modest improvement in function compared with control at 12 weeks ( -3.9 ; 95 % CI , -7.7 to -0.2 ) but was not significantly different from sham ( -1.7 ; 95 % CI , -6.1 to 2.6 ) and was not maintained at 1 year . There were no differences for most secondary outcomes and no serious adverse events . CONCLUSIONS AND RELEVANCE In patients older than 50 years with moderate or severe chronic knee pain , neither laser nor needle acupuncture conferred benefit over sham for pain or function . Our findings do not support acupuncture for these patients . TRIAL REGISTRATION anzctr.org.au Identifier : ACTRN12609001001280 Background Exercise treatment is recommended for all patients with hip osteoarthritis ( OA ) , but its effect on the long-term need for total hip replacement ( THR ) is unknown . Methods We conducted a long-term follow-up of a r and omised trial investigating the efficacy of exercise therapy and patient education versus patient education only on the 6-year cumulative survival of the native hip to THR in 109 patients with symptomatic and radiographic hip OA . Results regarding the primary outcome measure of the trial , self-reported pain at 16 months follow-up , have been reported previously . Results There were no group differences at baseline . The response rate at follow-up was 94 % . 22 patients in the group receiving both exercise therapy and patient education and 31 patients in the group receiving patient education only underwent THR during the follow-up period , giving a 6-year cumulative survival of the native hip of 41 % and 25 % , respectively ( p=0.034 ) . The HR for survival of the native hip was 0.56 ( CI 0.32 to 0.96 ) for the exercise therapy group compared with the control group . Median time to THR was 5.4 and 3.5 years , respectively . The exercise therapy group had better self-reported hip function prior to THR or end of study , but no significant differences were found for pain and stiffness . Conclusions Our findings in this explanatory study suggest that exercise therapy in addition to patient education can reduce the need for THR by 44 % in patients with hip OA . Clinical Trials.gov number NCT00319423 ( original project protocol ) and NCT01338532 ( additional protocol for long-term follow-up ) OBJECTIVE To investigate whether an exercise program , initially focusing on knee stabilization and subsequently on muscle strength and performance of daily activities is more effective than an exercise program focusing on muscle strength and performance of daily activities only , in reducing activity limitations in patients with knee osteoarthritis ( OA ) and instability of the knee joint . DESIGN A single-blind , r and omized , controlled trial involving 159 knee OA patients with self-reported and /or biomechanically assessed knee instability , r and omly assigned to two treatment groups . Both groups received a supervised exercise program for 12 weeks , consisting of muscle strengthening exercises and training of daily activities , but only in the experimental group specific knee joint stabilization training was provided . Outcome measures included activity limitations ( Western Ontario and McMaster Universities Osteoarthritis Index - WOMAC physical function , primary outcome ) , pain , global perceived effect and knee stability . RESULTS Both treatment groups demonstrated large ( ∼20 - 40 % ) and clinical ly relevant reductions in activity limitations , pain and knee instability , which were sustained 6 months post-treatment . No differences in effectiveness between experimental and control treatment were found on WOMAC physical function ( B ( 95 % confidence interval - CI ) = -0.01 ( -2.58 to 2.57 ) ) or secondary outcome measures , except for a higher global perceived effect in the experimental group ( P = 0.04 ) . CONCLUSIONS Both exercise programs were highly effective in reducing activity limitations and pain and restoring knee stability in knee OA patients with instability of the knee . In knee OA patients suffering from knee instability  , specific knee joint stabilization training , in addition to muscle strengthening and functional exercises , does not seem to have any additional value . Dutch Trial Register ( NTR ) registration number : NTR1475 OBJECTIVES To determine the effectiveness of exercise therapy ( ET ) compared with ET with adjunctive manual therapy ( MT ) for people with hip osteoarthritis ( OA ) ; and to identify if immediate commencement of treatment ( ET or ET+MT ) was more beneficial than a 9-week waiting period for either intervention . DESIGN Assessor-blind r and omized controlled trial with a 9-week and 18-week follow-up . SETTING Four academic teaching hospitals in Dublin , Irel and . PARTICIPANTS Patients ( N=131 ) with hip OA recruited from general practitioners , rheumatologists , orthopedic surgeons , and other hospital consultants were r and omized to 1 of 3 groups : ET ( n=45 ) , ET+MT ( n=43 ) , and waitlist controls ( n=43 ) . INTERVENTIONS Participants in both the ET and ET+MT groups received up to 8 
    Output:
    
Recent trials have also found no or uncertain clinical benefits of  transcutaneous electrical nerve stimulation ( TENS ) or acupuncture  , or of valgus braces or lateral wedge insoles for pain and function in knee osteoarthritis .
Available evidence suggests a small to moderate effect of exercise in comparison with not exercising for hip or knee osteoarthritis , although optimum exercise prescription and dosage are unclear .
SUMMARY Other than exercise , recent data suggest that the role of physical therapies in the treatment of osteoarthritis appears limited