Effectiveness of exercise therapy: a best-evidence summary of systematic reviews

Interventions to Improve Movement and Functional Outcomes in Adult Stroke Rehabilitation: Review and Evidence Summary

Background

Patients who have had a stroke may not be familiar with the terminology nor have the resources to efficiently search for evidence-based rehabilitation therapies to restore movement and functional outcomes. Recognizing that a thorough systematic review on this topic is beyond the scope of this article, we conducted a rapid review evidence summary to determine the level of evidence for common rehabilitation interventions to improve movement/motor and functional outcomes in adults who have had a stroke.

Objective

The objective of this study was to find evidence for common rehabilitation interventions to improve movement/motor and functional outcomes in adults who have had a stroke.

Methods

Medline Complete, PubMed, CINAHL Complete, Cochrane Database, Rehabilitation and Sports Medicine Source, Dissertation Abstracts International, and National Guideline Clearinghouse, from 1996 to April of 2016, were searched. From 348 articles, 173 met the following inclusion criteria: (1) published systematic reviews or meta-analyses, (2) outcomes target functional movement or motor skills of the upper and lower limbs, (3) non-pharmacological interventions that are commonly delivered to post-stroke population (acute and chronic), (4) human studies, and (5) English. Evidence tables were created to analyze the findings of systematic reviews and meta-analyses by category of interventions and outcomes.

Results

This rapid review found that the following interventions possess credible evidence to improve functional movement of persons with stroke: cardiorespiratory training, therapeutic exercise (ie, strengthening), task-oriented training (task-specific training), constraint-induced movement therapy (CIMT), mental practice, and mirror therapy. Neuromuscular electrical stimulation (NMES) (ie, functional electrical stimulation) shows promise as an intervention for stroke survivors.

Conclusions

Most commonly delivered therapeutic interventions to improve motor recovery after a stroke possess moderate quality evidence and are effective. Future research recommendations, such as optimal timing and dosage, would help rehabilitation professionals tailor interventions to achieve the best outcomes for stroke survivors.

The influence of dosing on effect size of exercise therapy for musculoskeletal foot and ankle disorders: a systematic review

OBJECTIVE

The purpose of this review was to identify doses of exercise therapy associated with greater treatment effect sizes in individuals with common musculoskeletal disorders of the foot and ankle, namely, achilles tendinopathy, ankle sprains and plantar heel pain.

METHODS

AMED, EMBASE and MEDLINE were searched from 2005 to August 2017 for randomized controlled trials related to exercise for these three diagnoses. The Physiotherapy Evidence Database scale was used for methodological quality assessment. Exercise dosing variables and outcome measures related to pain and function were extracted from the studies, and standardized mean differences were calculated for the exercise groups.

RESULTS

Fourteen studies met the final inclusion. A majority of the studies showed large effects and two small trends were identified. Patients with plantar heel pain may benefit more from a daily home exercise program than two supervised visits per week (SMD=3.82), but this recommendation is based on weak evidence. In achilles tendinopathy, a relationship was also seen when sets and repetitions of eccentric exercise were performed as tolerated (SMD=1.08 for function, -1.29 for pain).

CONCLUSIONS

Session duration, frequency, total number of visits, and overall length of care may all be dosing variables with limited value for determining effective exercise prescription. However, the limited number of studies prevents any definitive conclusions. Further investigation is warranted to improve our understanding of the influence exercise dosing has on treatment effect sizes. Future randomized controlled trials comparing specific exercise dose variables should be conducted to clarify the impact of these variables.

An observational study of Australian private practice physiotherapy consultations to explore the prescription of self-management strategies

OBJECTIVE

The aim of the study was to explore the types of self-management strategies prescribed; the number of strategies and the overall length of time allocated to self-management prescription, by consultation type and by injury location, in physiotherapy consultations.

METHODS

A cross-sectional, observational study of 113 physiotherapist-patient consultations was undertaken. Regression analyses were used to determine whether consultation type and injury location were associated with the number of strategies prescribed and the length/fraction of time spent on self-management.

RESULTS

A total of 108 patients (96%) were prescribed at least one self-management strategy - commonly exercise and advice. The mean length of time spent on self-management was 5.80 min. Common injury locations were the neck (n = 40) and lower back (n = 39). No statistically significant associations were observed between consultation type or injury location for either outcome (number of strategies and the length/fraction of time allocated to self-management prescription).

CONCLUSION

Physiotherapists regularly spend time prescribing self-management strategies such as exercise, advice, and the use of heat or ice to patients receiving treatment linked to a range of injury locations. This suggests that self-management is considered to be an important adjunct to in-clinic physiotherapy. The practice implications of this are that clinicians should reflect on how self-management strategies can be used to maximize patient outcomes, and whether the allocation of consultation time to self-management is likely to optimize patient adherence to each strategy.

Diagnosis and Treatment of Inflammatory Joint Disease

Arthritis damages the cartilage within joints, resulting in degenerative changes, including loss of function and joint instability. Ankylosing spondylitis (AS) is a chronic inflammatory condition affecting the spine and bone-to-tendon attachment area within the sacroiliac joint leading to back pain and progressive spinal stiffness. In the final stages, AS causes hyperkyphosis-a condition closely tied to the human leukocyte antigen-B27 gene. Rheumatoid arthritis is a chronic, systemic autoimmune disease characterized by the simultaneous inflammation of the synovium of multiple joints, leading to joint damage (e.g., destruction, deformation and disability). In the past, nonsteroidal anti-inflammatory drugs or conventional disease-modifying antirheumatic drug (DMARDs) have been used for the treatment of these autoimmune diseases, but biologic DMARDs have recently been introduced with excellent results. Gout is a chronic inflammatory disease that causes an alteration of joints resulting in severe pain. Specifically, gout is associated with an accumulation of uric acid within the body resulting from dysregulated purine metabolism, causing recurrent paroxysmal inflammation in the joints. Allopurinol and febuxostat are the primary treatment options for individuals with gout. It is necessary to have an accurate understanding of the pathogenesis, pathological ecology and treatment of AS, rheumatoid arthritis, and gouty arthritis, which are the representative diseases that may cause inflammatory arthritis.

Severe metallosis and elevated chromium in serum following implantation of the joint unloading implant system

In recent years, the minimally invasive joint-preserving implant system has been developed. The main goal of this device is to unload the medial knee compartment without affecting the lateral compartment. The current authors describe a severe metallosis and elevated chromium in serum following implantation of the joint unloading implant system of a 50-year-old male patient, presented to our hospital 3 years after implantation of a KineSpring System into his left knee due to unicompartmental medial osteoarthritis (OA) in an external hospital. Radiographs showed radiological signs for loosening of the screws in the tibia and a progressive OA on the medial and patellofemoral compartments. Revision surgery with removing of the unloading device was performed at our hospital. The intraoperative situs presented a severe metallosis around the device. Five days after revision surgery, the laboratory parameters revealed an elevated value for chromium in serum, while nickel and cobalt values in serum were normal. Reliable clinical data about the long-term results of the KineSpring System is desperately needed. Further studies are warranted to work out the effects of cobalt and chromium levels and further side effects following the implantation of the extra-articular absorber system.

The effect of an 8-week stabilization exercise program on the lumbopelvic rhythm and flexion-relaxation phenomenon

BACKGROUND

Lumbar stabilization exercise programs should normalize the aberrant movements patterns often observed in patients with low back pain. This study aimed to determine the effect of an 8-week lumbar stabilization program on EMG/kinematics measures of the aberrant movement patterns in such patients. A secondary goal was to assess the 8-week test-retest reliability of these measures.

METHODS

The patients followed an 8-week lumbar stabilization program while no intervention was carried out on the controls. Before and after this period, kinematics of the spine along with the EMG of paraspinal muscles were recorded during trunk maximal flexion-extension. ANOVAs tested the effect of the intervention in the patients, relative to the controls. Within the patients, correlation of the EMG/kinematics measures with the change in disability and pain following the intervention was investigated.

FINDINGS

A significant reduction in pain (Hedges's g effect size=2.31) and improvement in function (g=1.74) was reported in the patients. While EMG/kinematics measures disclosed impairments in the patients at baseline compared to the controls, no change was observed over the intervention. Nevertheless, the change of lumbar range of motion was positively correlated (r=0.42; P=0.015) with the change in disability.

INTERPRETATION

Although pain and disability decreased following the intervention, the EMG/kinematics measures did not change concomitantly suggesting that the patients learned to stiffen the lumbar spine during the treatment, and this technique was applied even if pain and disability unequivocally decreased after the treatment, which would not necessarily be beneficial to the patient.

Utilization of rehabilitation therapy services in Parkinson disease in the United States

OBJECTIVE

To examine rehabilitation therapy utilization for Parkinson disease (PD).

METHODS

We identified 174,643 Medicare beneficiaries with a diagnosis of PD in 2007 and followed them through 2009. The main outcome measures were annual receipt of physical therapy (PT), occupational therapy (OT), or speech therapy (ST).

RESULTS

Outpatient rehabilitation fee-for-service use was low. In 2007, only 14.2% of individuals with PD had claims for PT or OT, and 14.6% for ST. Asian Americans were the highest users of PT/OT (18.4%) and ST (18.4%), followed by Caucasians (PT/OT 14.4%, ST 14.8%). African Americans had the lowest utilization (PT/OT 7.8%, ST 8.2%). Using logistic regression models that accounted for repeated measures, we found that African American patients (adjusted odds ratio [AOR] 0.63 for PT/OT, AOR 0.63 for ST) and Hispanic patients (AOR 0.97 for PT/OT, AOR 0.91 for ST) were less likely to have received therapies compared to Caucasian patients. Patients with PD with at least one neurologist visit per year were 43% more likely to have a claim for PT evaluation as compared to patients without neurologist care (AOR 1.43, 1.30-1.48), and this relationship was similar for OT evaluation, PT/OT treatment, and ST. Geographically, Western states had the greatest use of rehabilitation therapies, but provider supply did not correlate with utilization.

CONCLUSIONS

This claims-based analysis suggests that rehabilitation therapy utilization among older patients with PD in the United States is lower than reported for countries with comparable health care infrastructure. Neurologist care is associated with rehabilitation therapy use; provider supply is not.

Markerless motion capture systems as training device in neurological rehabilitation: a systematic review of their use, application, target population and efficacy

Background

Client-centred task-oriented training is important in neurological rehabilitation but is time consuming and costly in clinical practice. The use of technology, especially motion capture systems (MCS) which are low cost and easy to apply in clinical practice, may be used to support this kind of training, but knowledge and evidence of their use for training is scarce. The present review aims to investigate 1) which motion capture systems are used as training devices in neurological rehabilitation, 2) how they are applied, 3) in which target population, 4) what the content of the training and 5) efficacy of training with MCS is.

Methods

A computerised systematic literature review was conducted in four databases (PubMed, Cinahl, Cochrane Database and IEEE). The following MeSH terms and key words were used: Motion, Movement, Detection, Capture, Kinect, Rehabilitation, Nervous System Diseases, Multiple Sclerosis, Stroke, Spinal Cord, Parkinson Disease, Cerebral Palsy and Traumatic Brain Injury. The Van Tulder’s Quality assessment was used to score the methodological quality of the selected studies. The descriptive analysis is reported by MCS, target population, training parameters and training efficacy.

Results

Eighteen studies were selected (mean Van Tulder score = 8.06 ± 3.67). Based on methodological quality, six studies were selected for analysis of training efficacy. Most commonly used MCS was Microsoft Kinect, training was mostly conducted in upper limb stroke rehabilitation. Training programs varied in intensity, frequency and content. None of the studies reported an individualised training program based on client-centred approach.

Conclusion

Motion capture systems are training devices with potential in neurological rehabilitation to increase the motivation during training and may assist improvement on one or more International Classification of Functioning, Disability and Health (ICF) levels. Although client-centred task-oriented training is important in neurological rehabilitation, the client-centred approach was not included. Future technological developments should take up the challenge to combine MCS with the principles of a client-centred task-oriented approach and prove efficacy using randomised controlled trials with long-term follow-up.

Trial registration

Prospero registration number 42016035582.

Electronic supplementary material

The online version of this article (doi:10.1186/s12984-017-0270-x) contains supplementary material, which is available to authorized users.

Exercise therapy for functional capacity in chronic diseases: an overview of meta-analyses of randomised controlled trials

OBJECTIVE

To summarise all meta-analyses of randomised controlled trials that have evaluated the effects of exercise therapy on functional capacity in patients with chronic diseases.

DESIGN

Umbrella review of meta-analyses of randomised controlled trials.

DATA SOURCES

We systematically searched the CENTRAL, CINAHL, DARE, Medline, OTSeeker, PEDro, SPORTDiscus, ProQuest Nursing & Allied Health Database, Web of Science, Scopus, OpenGrey and BMC Proceedings from database inception to 1 September 2016.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included meta-analyses that compared the effects of exercise therapy with no treatment or usual care in adults with non-communicable chronic diseases and included outcomes related to functional capacity. We excluded meta-analyses with less than 100 patients.

RESULTS

Eighty-five meta-analyses with 22 different chronic diseases were included. The exercise interventions resulted in statistically significant (p<0.05) improvements for 126 of 146 (86%) functional capacity outcomes, compared with the control group. The standardised mean differences were small in 64 (44%), moderate in 54 (37%) and large in 28 (19%) of the 146 functional capacity outcomes. The results were similar for aerobic exercise, resistance training, and aerobic and resistance training combined. There were no significant differences in serious adverse effects between the intervention and control groups in any of the meta-analyses.

CONCLUSION

Exercise therapy appears to be a safe way to improve functional capacity and reduce disability in individuals with chronic disease.

Physical activity and asthma: A longitudinal and multi-country study

OBJECTIVE

To investigate the impact of physical activity on asthma in middle-aged adults, in one longitudinal analysis, and one multi-centre cross-sectional analysis.

METHODS

The Respiratory Health in Northern Europe (RHINE) is a population-based postal questionnaire cohort study. Physical activity, height and weight were self-reported in Bergen, Norway, at RHINE II (1999-2001) and all centres at RHINE III (2010-2012). A longitudinal analysis of Bergen data investigated the association of baseline physical activity with follow-up asthma, incident asthma and symptoms, using logistic and zero-inflated Poisson regression (n = 1782). A cross-sectional analysis of all RHINE III centres investigated the association of physical activity with concurrent asthma and symptoms (n = 13,542) using mixed-effects models. Body mass index (BMI) was categorised (<20, 20-24.99, 25-29.99, 30+ kg/m²) and physical activity grouped by amount and frequency of lighter (no sweating/heavy breathing) and vigorous (sweating/heavy breathing) activity.

RESULTS

In the Bergen longitudinal analysis, undertaking light activity 3+ times/week at baseline was associated with less follow-up asthma (odds ratio [OR] 0.44, 95% confidence interval [CI] 0.22, 0.89), whilst an effect from undertaking vigorous activity 3+ times/week was not detected (OR 1.22, 95% CI 0.44, 2.76). The associations were attenuated with BMI adjustment. In the all-centre cross-sectional analysis an interaction was found, with the association between physical activity and asthma varying across BMI categories.

CONCLUSION

These findings suggest potential longer-term benefit from lighter physical activity, whilst improvement in asthma outcomes from increasing activity intensity was not evident. Additionally, it appears the benefit from physical activity may differ according to BMI.

Exercise, especially combined stretching and strengthening exercise, reduces myofascial pain: a systematic review

QUESTION

Among people with myofascial pain, does exercise reduce the intensity of the pain and disability?

DESIGN

Systematic review of randomised and quasi-randomised controlled trials.

PARTICIPANTS

People with myofascial pain of any duration.

INTERVENTION

Exercise versus minimal or no intervention and exercise versus other intervention.

OUTCOME MEASURES

Pain intensity and disability.

RESULTS

Eight studies involving 255 participants were included. Pooled estimates from six studies showed statistically significant effects of exercise when compared with minimal or no intervention (support and encouragement or no treatment) on pain intensity at short-term follow-up. The weighted mean difference in pain intensity due to exercise was -1.2 points (95% CI -2.3 to -0.1) on a 0 to 10 scale. Pooled estimates from two studies showed a non-significant effect of exercise when compared with other interventions (electrotherapy or dry needling) on pain intensity at short-term follow-up. The weighted mean difference in pain intensity due to exercise instead of other therapies was 0.4 points (95% CI -0.3 to 1.1) on a 0 to 10 scale. Individual studies reported no significant effects of exercise on disability compared with minimal intervention (-0.4, 95% CI -1.3 to 0.5) and other interventions (0.0, 95% CI -0.8 to 0.8) at short-term follow-up. Sensitivity analysis suggested that combining stretching and strengthening achieves greater short-term effects on pain intensity compared with minimal or no intervention (-2.3, 95% CI -4.1 to -0.5).

CONCLUSION

Evidence from a limited number of trials indicates that exercise has positive small-to-moderate effects on pain intensity at short-term follow-up in people with myofascial pain. A combination of stretching and strengthening exercises seems to achieve greater effects. These estimates may change with future high-quality studies. [Mata Diz JB, de Souza JRLM, Leopoldino AAO, Oliveira VC (2016) Exercise, especially combined stretching and strengthening exercise, reduces myofascial pain: a systematic review.Journal of Physiotherapy63: 17-22].

The effectiveness of specific exercise types on cardiopulmonary functions in patients with ankylosing spondylitis: a systematic review

The aim of this review was to assess the effectiveness of specific exercise types on pulmonary functions, aerobic and functional capacity in patients with ankylosing spondylitis (AS). A systematic search of Cochrane Database of Systematic Review, MEDLINE (EBSCO), Physiotherapy Evidence Database (PEDro), CINAHL (EBSCO), PUBMED, AMED, EMBASE (OVID) was conducted in January 2016. The outcome measures were spirometric measurements, chest expansion, 6 minute walk distance (6MWD), pVO₂, Bath Ankylosing Spondylitis Functional Index (BASFI) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). The search strategy was applied with limitation of date and language and this initial electronic search resulted in 143 relevant studies. After duplicates were removed, the titles and abstracts of 52 articles were screened. Of these, 14 full-text articles met initial criteria and were retrieved for review, with eight studies meeting final inclusion criteria. Both specific and conventional exercise groups showed significant improvements in BASDAI and BASFI scores (p < 0.05) in patients with AS, although there was no significant difference between two exercise groups. As for pulmonary functions, the specific exercise groups have greater improvements than conventional group in spirometric measurement, chest expansion (p < 0.05). However, there was no significant difference between specific conventional exercise types in 6MWD (p > 0.05). Specific exercises are an effective adjuvant therapy to enhance cardiopulmonary functions in patients with AS; therefore, it is assumed that in addition to the medical treatments, specific exercise therapy might reduce the cardiopulmonary complications related with AS.

Consensus on Exercise Reporting Template (CERT): Modified Delphi Study

BACKGROUND

Exercise interventions are often incompletely described in reports of clinical trials, hampering evaluation of results and replication and implementation into practice.

OBJECTIVE

The aim of this study was to develop a standardized method for reporting exercise programs in clinical trials: the Consensus on Exercise Reporting Template (CERT).

DESIGN AND METHODS

Using the EQUATOR Network's methodological framework, 137 exercise experts were invited to participate in a Delphi consensus study. A list of 41 items was identified from a meta-epidemiologic study of 73 systematic reviews of exercise. For each item, participants indicated agreement on an 11-point rating scale. Consensus for item inclusion was defined a priori as greater than 70% agreement of respondents rating an item 7 or above. Three sequential rounds of anonymous online questionnaires and a Delphi workshop were used.

RESULTS

There were 57 (response rate=42%), 54 (response rate=95%), and 49 (response rate=91%) respondents to rounds 1 through 3, respectively, from 11 countries and a range of disciplines. In round 1, 2 items were excluded; 24 items reached consensus for inclusion (8 items accepted in original format), and 16 items were revised in response to participant suggestions. Of 14 items in round 2, 3 were excluded, 11 reached consensus for inclusion (4 items accepted in original format), and 7 were reworded. Sixteen items were included in round 3, and all items reached greater than 70% consensus for inclusion.

LIMITATIONS

The views of included Delphi panelists may differ from those of experts who declined participation and may not fully represent the views of all exercise experts.

CONCLUSIONS

The CERT, a 16-item checklist developed by an international panel of exercise experts, is designed to improve the reporting of exercise programs in all evaluative study designs and contains 7 categories: materials, provider, delivery, location, dosage, tailoring, and compliance. The CERT will encourage transparency, improve trial interpretation and replication, and facilitate implementation of effective exercise interventions into practice.

Acceptability of physiotherapists as primary care practitioners and advanced practice physiotherapists for care of patients with musculoskeletal disorders: a survey of a university community within the province of Quebec

BACKGROUND

Musculoskeletal (MSK) disorders represent a great burden on the health care system. The use of physiotherapists in their autonomous roles and in advanced practice roles may help increase access to care. Thus, the aim of this survey was to assess the perceptions of a university community sample within the province of Quebec about physiotherapists as primary care practitioners and advanced practice physiotherapists (APPs) for the treatment of patients with musculoskeletal disorders.

METHODS

An electronic survey was sent in February 2014 via a web platform to members of the Laval University community (Québec City, Canada). The survey included questions about knowledge and perceptions on current physiotherapists' autonomous role in primary care and on APP future model of care for patients with MSK disorders. Survey results were synthetized with descriptive statistics. Differences in responses according to demographics, personal characteristics and previous physiotherapy care experience were evaluated using Chi-Square tests.

RESULTS

A total of 513 participants completed the online survey (1 % response rate). The majority of respondents were women (74 %) and aged 18 to 24 (39 % of all respondent). About 90 % of respondents believed that physiotherapists were skilled and competent and 91 % answered that they had trust in physiotherapists for the treatment of MSK disorders in primary care. A total of 90 % of respondents supported the idea of introducing APPs for the treatment of patients with MSK disorders. Over 90 % of respondents were in favour of the delegation of medical acts such as: communicating a medical diagnosis, ordering imaging tests, triaging surgical candidates or prescribing medication such as NSAIDS.

CONCLUSIONS

Respondents are satisfied and have confidence in physiotherapists as primary care practitioners; they also support the intended new roles of the APPs in the health care system. Caution should be taken in generalizing these results from this particular sample. These results need to be corroborated in the general population.

Effects of resistance training in individuals with knee osteoarthritis

Abstract Introduction: Osteoarthritis (OA), the most common form of arthritis, is considered the main cause of pain and disability in the elderly. Objective: To evaluate the effect of systematic muscle strength training on functional performance and quality of life in individuals with knee OA. Methods: Subjects with knee OA (n = 27, 46 - 76 years) completed the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Medical Outcomes Short-Form 36-item Health Survey (SF-36), and visual analog scale (VAS) questionnaires, musculoskeletal assessments, and 10-repetition maximum and timed 10-meter walk tests both before and after training. The training consisted of an exercise resistance program and stretches for 12 weeks (three sessions of 80 each per week). Results: Twenty-two subjects completed the training. Reduced overall scores and WOMAC physical function indicated improved functional performance (p < 0.001) as well as increased gait speed (p < 0.001). The perception of pain decreased after training, as evidenced by the VAS, WOMAC pain domain, and SF-36 scores (p < 0.001). Quality of life improvements occurred primarily in the areas of pain, functional capacity, and SF-36 physical aspects. No change in body mass index was noted (p = 0.93). Conclusion: Our results indicate that the combination of resistance training for the quadriceps, gluteus, and abdominal muscles could be a viable alternative to improving functionality and quality of life in patients with knee OA. However, more studies are necessary to confirm our findings.

Exercise after Stroke: Patient Adherence and Beliefs after Discharge from Rehabilitation

BACKGROUND

Most people complete post-stroke rehabilitation within the first 6 months after stroke even though benefits from exercise are believed to persist well beyond 6 months. Physical and Occupational therapists provide home exercise programs (HEP) to instruct patients on exercises to continue after discharge from rehabilitation. Unfortunately, there is little known about HEP adherence rates in adults with stroke.

OBJECTIVES

The objectives of this project were to (1) determine the adherence rate with post-rehabilitation HEP and reasons for non-adherence, (2) assess for interactions between HEP adherence and self-report of depression and fatigue, and (3) determine patient beliefs about the benefit of exercise during stroke recovery.

DESIGN

This was a cross-sectional, survey study.

METHODS

A survey was developed and distributed during stroke support group meetings to determine adherence rates with post rehabilitation HEP, reasons for non-adherence, and patient beliefs about the benefit of exercise.

RESULTS

Eighty-nine percent of participants reported receiving a HEP and 65.3% of those reported being adherent with at least part of the HEP. Several reasons for non-adherence were identified, including 'doing different exercises than the ones given by the physical therapist', as the most frequently given reason. Study participants identified positive roles of exercise in their recovery from stroke.

CONCLUSION

Patient adherence with HEP after discharge from rehabilitation is less than ideal. Reasons for non-adherence are varied. Rehabilitation therapists need to be able to identify and help patients manage barriers to HEP adherence to promote management of residual deficits.

Inter-rater Reliability of Sustained Aberrant Movement Patterns as a Clinical Assessment of Muscular Fatigue

BACKGROUND

The assessment of clinical manifestation of muscle fatigue is an effective procedure in establishing therapeutic exercise dose. Few studies have evaluated physical therapist reliability in establishing muscle fatigue through detection of changes in quality of movement patterns in a live setting.

OBJECTIVE

The purpose of this study is to evaluate the inter-rater reliability of physical therapists' ability to detect altered movement patterns due to muscle fatigue.

DESIGN

A reliability study in a live setting with multiple raters.

PARTICIPANTS

Forty-four healthy individuals (ages 19-35) were evaluated by six physical therapists in a live setting.

METHODS

Participants were evaluated by physical therapists for altered movement patterns during resisted shoulder rotation. Each participant completed a total of four tests: right shoulder internal rotation, right shoulder external rotation, left shoulder internal rotation and left shoulder external rotation.

RESULTS

For all tests combined, the inter-rater reliability for a single rater scoring ICC (2,1) was .65 (95%, .60, .71) This corresponds to moderate inter-rater reliability between physical therapists.

LIMITATIONS

The results of this study apply only to healthy participants and therefore cannot be generalized to a symptomatic population.

CONCLUSION

Moderate inter-rater reliability was found between physical therapists in establishing muscle fatigue through the observation of sustained altered movement patterns during dynamic resistive shoulder internal and external rotation.

Restrictions in ATP diffusion within sarcomeres can provoke ATP-depleted zones impairing exercise capacity in chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is characterized by the inability of patients to sustain a high level of ventilation resulting in perceived exertional discomfort and limited exercise capacity of leg muscles at average intracellular ATP levels sufficient to support contractility.

METHODS

Myosin ATPase activity in biopsy samples from healthy and COPD individuals was implemented as a local nucleotide sensor to determine ATP diffusion coefficients within myofibrils. Ergometric parameters clinically measured during maximal exercise tests in both groups were used to define the rates of myosin ATPase reaction and aerobic ATP re-synthesis. The obtained parameters in combination with AK- and CK-catalyzed reactions were implemented to compute the kinetic and steady-state spatial ATP distributions within control and COPD sarcomeres.

RESULTS

The developed reaction-diffusion model of two-dimensional sarcomeric space identified similar, yet extremely low nucleotide diffusion in normal and COPD myofibrils. The corresponding spatio-temporal ATP distributions, constructed during imposed exercise, predicted in COPD sarcomeres a depletion of ATP in the zones of overlap between actin and myosin filaments along the center axis at average cytosolic ATP levels similar to healthy muscles.

CONCLUSIONS

ATP-depleted zones can induce rigor tension foci impairing muscle contraction and increase a risk for sarcomere damages. Thus, intra-sarcomeric diffusion restrictions at limited aerobic ATP re-synthesis can be an additional risk factor contributing to the muscle contractile deficiency experienced by COPD patients.

GENERAL SIGNIFICANCE

This study demonstrates how restricted substrate mobility within a cellular organelle can provoke an energy imbalance state paradoxically occurring at abounding average metabolic resources.

Controlled Exercise in Equine Rehabilitation

Controlled exercise is a fundamental and critical component of any rehabilitation program for the equine athlete. The ideal controlled exercise program is designed to complement the normal tissue reparative process after injury. As a general rule, the program starts with complete rest followed by stall rest and short periods of walking. Over time, the intensity of the controlled exercise is gradually and systemically increased until complete healing has occurred. A well-designed, injury-directed, controlled exercise program enhances the healing process.

Clinical evidence in the treatment of rotator cuff tears with hyaluronic acid

PURPOSE

the aim of this quantitative review is to document potential benefit and adverse effects of hyaluronic acid (HA) injection into the shoulder with rotator cuff tears.

METHODS

a systematic literature search was performed in english PubMed, Medline, Ovid, Google Scholar and Embase databases using the combined key words "hyaluronic acid", "rotator cuff tear", "hyaluronate", "shoulder", "viscosupplementation", with no limit regarding the year of publication. Articles were included if they reported data on clinical and functional outcomes, complications in series of patients who had undergone HA injection for management of rotator cuff tears. Two Authors screened the selected articles for title, abstract and full text in accordance with predefined inclusion and exclusion criteria. The papers were accurately analyzed focusing on objective rating scores reported.

RESULTS

a total of 11 studies, prospective, 7 were randomized were included by full text. A total of 1102 patients were evaluated clinically after different HA injection compare with corticosteroid injection, physically therapies, saline solution injection and control groups. The use of HA in patients with rotator cuff tears improve VAS and functional score in all trials that we have analyzed.

CONCLUSION

intra-articular injection with HA is effective in reducing pain and improving function in shoulder with rotator cuff tears and without severe adverse reaction.

LEVEL OF EVIDENCE

Level I.

The effects of an 8-week stabilization exercise program on lumbar movement sense in patients with low back pain

Background

Lumbar stabilization exercises have gained popularity and credibility in patients with non-acute low back pain. Previous research provides more support to strength/resistance and coordination/stabilisation programs. Some authors also suggest adding strength/resistance training following motor control exercises. However, the effect of such a lumbar stabilization program on lumbar proprioception has never been tested so far. The present study investigated the effects of an 8-week stabilization exercise program on lumbar proprioception in patients with low back pain (LBP) and assessed the 8-week test-retest reliability of lumbar proprioception in control subjects.

Methods

Lumbar proprioception was measured before and after an 8-week lumbar stabilization exercise program for patients with LBP. Control subjects participated in the same protocol but received no treatment.

Results

The lumbar proprioception measure showed moderate reliability. Patients with LBP and control subjects demonstrated no differences in lumbar proprioception at baseline. Participants from both groups showed better proprioception following the 8-week interval, demonstrating the presence of learning between testing days.

Conclusions

The improvement of lumbar proprioception seen in both groups was ascribed to motor learning of the test itself. The effect of lumbar stabilization exercises on lumbar proprioception remains unknown because the LBP group did not show lumbar proprioception impairments.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-0875-4) contains supplementary material, which is available to authorized users.

The efficacy and safety of the Shaoyao Shujin tablet for knee osteoarthritis: study protocol for a randomized controlled trial

Background

Knee osteoarthritis (KOA) is a major public health issue causing chronic disability as well as a burden on healthcare resources. In China, a herbal drug tablet has been used as an effective and conventional therapy to alleviate clinical symptoms caused by KOA. However, evidence gathered from systematic reviews or randomized controlled trials that validated herbal drugs for the management of osteoarthritic pain is weak. The purpose of this study is to explore the efficacy and safety of the Shaoyao Shujin tablet for the management of KOA in a short-term study.

Methods/Design

This trial is a multicenter randomized, double-blind, placebo-controlled study. A total of 276 patients will be randomized into 3 groups: (1) the high-dose Shaoyao Shujin tablet group (HD group), (2) the low-dose Shaoyao Shujin tablet group (LD group), and (3) the placebo tablet group (control group). In the three groups, four tablets will be administered three times per day for 6 weeks. Follow-up will be at regular intervals during a 10-week period with the Western Ontario and McMaster Universities Index (WOMAC) score, visual analog scale (VAS) score, and rescue medication use assessed as outcome measures.

Discussion

This study will provide clinical evidence on the efficacy and safety of the Shaoyao Shujin tablet in treating KOA.

Trial registration

Chinese Cochrane Center ChiCTR-IPR-15006194, registered 4 April 2015.

Exercise Therapy for Parkinson's Disease: Pedaling Rate Is Related to Changes in Motor Connectivity

Forced-rate lower-extremity exercise has recently emerged as a potential safe and low-cost therapy for Parkinson's disease (PD). The efficacy is believed to be dependent on pedaling rate, with rates above the subjects' voluntary exercise rates being most beneficial. In this study, we use functional connectivity magnetic resonance imaging (MRI) to further elucidate the mechanism underlying this effect. Twenty-seven PD patients were randomized to complete 8 weeks of forced-rate exercise (FE) or voluntary-rate exercise (VE). Exercise was delivered using a specialized stationary bicycle, which can augment patients' voluntary exercise rates. The FE group received assistance from the cycle. Imaging was conducted at baseline, end of therapy, and after 4 weeks of follow-up. Functional connectivity (FC) was determined via seed-based correlation analysis, using activation-based seeds in the primary motor cortex (M1). The change in FC after exercise was compared using linear correlation with pedaling rate. Results of the correlation analysis showed a strong positive correlation between pedaling rate and change in FC from the most affected M1 to the ipsilateral thalamus. This effect persisted after 4 weeks of follow-up. These results indicate that a plausible mechanism for the therapeutic efficacy of high-rate exercise in PD is that it improves thalamo-cortical connectivity.

The association between arthritis and depression is intensified by excessive body weight: Findings from a US national survey, 2005-2012

OBJECTIVE

Obesity and arthritis are leading chronic conditions, but comorbidity of these conditions and their interaction leading to depression have not been fully investigated. The purpose of this study is to determine the degree to which excess body weight effect-modifies the relationship between arthritis and depressive symptoms.

METHODS

We used the data of 8677 men and 8820 women aged 20 or older, who completed a depression screening and general medical condition interview as a part of the National Health and Nutrition Examination Survey, 2005-2012. Depression was ascertained using the Patient Health Questionnaire-9 (PHQ-9); a PHQ-9 score of 15 or higher was defined as indicative of depression.

RESULTS

Arthritis was reported in 26.5% (SE=0.9) of men and 36.9% (SE=1.4) of women. The association between depression and arthritis was not significant among healthy weight women, but significant among overweight and obese women. The prevalence ratios (PRs) of depression among arthritis-free women were 1.00 (reference) for healthy weight, 1.43 (0.85-2.42) for overweight, and 1.99 (1.23-3.23) for obese women. For women with arthritis, the PRs were 1.16 (0.63-2.12) for healthy weight, 3.80 (2.24-6.45) for overweight and 3.73 (2.30-6.05) for obese women. The intensifying effect from excessive body weight on the association between arthritis and depression was less salient among men than women.

CONCLUSIONS

The association between arthritis and depression is intensified significantly by increased body weight, in particular, among women.

Operationalizing Pain Treatment in the Biopsychosocial Model: Take a Daily "SWEM"--Socialize, Work, Exercise, Meditate

In the United States, chronic pain is often poorly treated at an exceedingly high cost. The use of the biomedical model to manage pain is frequently ineffective, and evidence suggests that the biopsychosocial (BPS) model is a better choice. A problem with the BPS model is that it has not been operationalized in terms of patient behavior. This commentary addresses that issue by suggesting that people with chronic pain and illness participate daily in four self-management health behaviors: socialize, work, exercise, and meditation, and discusses evidence that supports these recommendations. These self-management behaviors may decrease pain and thus reduce the need for pain medications and other medical interventions. Additional topics include patient adherence and health coaching.

Standardised method for reporting exercise programmes: protocol for a modified Delphi study

INTRODUCTION

Exercise is integral to health across the lifespan and important for people with chronic health conditions. A systematic review of exercise trials for chronic conditions reported suboptimal descriptions of the evaluated interventions and concluded that this hinders interpretation and replication. The aim of this project is to develop a standardised method for reporting essential exercise programme details being evaluated in clinical trials.

METHODS AND ANALYSIS

A modified Delphi technique will be used to gain consensus among international exercise experts. We will use three sequential rounds of anonymous online questionnaires to refine a standardised checklist. A draft checklist of potentially relevant items was developed based on the results of a systematic review of exercise systematic reviews. An international panel of experts was identified by exercise systematic review authorship, established international profile in exercise research and practice and by peer referral. In round 1, the international panel of experts will be asked to rate the importance of each draft item and provide additional suggestions for revisions or new items. Consensus will be considered reached if at least 70% of the panel strongly agree/disagree that an item should be included or excluded. Where agreement is not reached or there are suggestions for altered or new items, these will be taken to round 2 together with an aggregated summary of round 1 responses. Following the second round, a ranking of item importance will be made to rationalise the number of items. The final template will be distributed to panel members for approval.

ETHICS AND DISSEMINATION

Ethics approval was received from The Cabrini Institute Ethics Committee, Melbourne, Australia (HREC 02-07-04-14). We plan to use a stepwise process to develop and refine a standardised and internationally agreed template for explicit reporting of exercise programmes. The template will be generalisable across all types of exercise interventions. The findings will be disseminated through peer-reviewed publications and conference presentations.

The influence of exercise on an unstable surface on the physical function and muscle strength of patients with osteoarthritis of the knee

[Purpose] This study investigated the influence of exercise on an unstable surface on ROM of the knee, muscle strength and the physical function of patients with osteoarthritis of the knee. [Subjects] The subjects were 30 patients diagnosed with degenerative osteoarthritis of the knee, they were divided into an experimental group (n=15) and a control group (n=15). [Methods] The experimental group performed exercise using an aero step XL (TOGU, Germany) 3 times a week, for 6 weeks. A control group performed the same exercise on a stable surface and without aero step XL. [Results] After the intervention, the experimental group showed statistically significant improvements in active knee flexion, knee joint manual muscle test (MMT), knee joint MMT hamstring and WOMAC score. [Conclusion] Exercise on the unstable surface improved the symptoms of patient with osteoarthritis. Exercise on an unstable surface might be helpful for improving the muscle strength and alignment of lower extremities as well as improving physical function related to the knee joint.

Treatment of ankylosing spondylitis with biologics and targeted physical therapy: positive effect on chest pain, diminished chest mobility, and respiratory function

OBJECTIVE

Biologics are highly effective in ankylosing spondylitis (AS). In this self-controlled study, we assessed the additive value of complex physiotherapy in decreasing chest pain and tenderness and improving respiratory function in AS patients treated with tumor necrosis factor α (TNF-α) inhibitors.

PATIENTS AND METHODS

The trial consisted of 2 parts. In study I, clinical data of AS patients with (n=55) or without biological therapy (n=20) were retrospectively analyzed and compared. Anthropometrical data, duration since diagnosis and patient assessment of disease activity, pain intensity, tender points, sacroiliac joint involvement determined by X-ray, functional condition, and physical activity level were recorded. Subjective, functional, and physical tests were performed. In study II, 10 voluntary patients (6 men and 4 women, age 52.4 ± 13.6 years) with definite AS and receiving anti-TNF therapy were recruited. It was a prospective, non-randomized physiotherapeutic trial. BASFI (Bath Ankylosing Spondylitis Functional Index), BASDAI (Bath Ankylosing Spondylitis Disease Activity Index), modified Schober Index, occiput-to-wall distance, and fingertip-to-floor distance were evaluated. Forced vital capacity, forced 1-s expiratory volume, peak expiratory flow, and maximum voluntary ventilation were recorded. Furthermore, typical tender points were recorded. A targeted physiotherapy program was conducted twice a week for 12 weeks and all above parameters were recorded at baseline and after 12 weeks.

RESULTS

Differences in patient assessment of disease activity (p=0.019) and pain intensity (p=0.017) were found in study I. Pain and tenderness of the thoracic spine were observed in both groups. Back pain without biologic therapy was slightly higher than other group. In study II, we found that patient assessment of disease activity and pain intensity significantly improved after the physical therapy program (p=0.002 and p<0.001). BASFI and BASDAI increased after treatment (p=0.004 and p<0.001). The finger-to-floor distance, chest expansion, and modified Schober index increased (p=0.008, p<0.001, and p=0.031, respectively). The respiratory functional parameters showed a tendency towards improvement.

CONCLUSION

AS patients already receiving biological therapy may benefit from additional targeted physiotherapy. Physical therapy may be of important additive value in AS patients being treated with biological. The exercise program presented here showed an improvement in functional parameters as well as spine and chest mobility, thereby enhancing the favorable effects of biological therapy.

Effect of the Frequency and Duration of Land-based Therapeutic Exercise on Pain Relief for People with Knee Osteoarthritis: A Systematic Review and Meta-analysis of Randomized Controlled Trials

[Purpose] This study aimed to investigate the influence of land-based exercise frequency and duration on pain relief for people with knee osteoarthritis (OA). [Subjects and Methods] The systematic review included randomized controlled trials that investigated this influence, which were identified by searches of PubMed, the Cochrane Central Register of Controlled Trials, the Physiotherapy Evidence Database, and the Cumulative Index to Nursing and Allied Health Literature. The exercise groups in the identified trials were categorized according to their type, frequency, and duration of exercise, and subgroup analyses were performed. [Results] Data integration of 17 studies (23 exercise groups) revealed a significant effect and a medium effect size. In subgroups involving strengthening exercise programs of ≥9 weeks duration, heterogeneity was found between subjects who performed up to 3 sessions/week and those who performed ≥4 sessions/week. In subgroups involving strengthening exercise programs of up to 3 sessions/week, there was heterogeneity between subjects who exercised for up to 8 weeks and those who exercised for ≥9 weeks. Heterogeneity was not confirmed in aerobic exercise subgroups. [Conclusion] Differences in exercise frequency and duration influence pain relief in effects of strengthening exercises but do not influence the effect size of aerobic exercise for people with knee OA.

A multicentre, pragmatic, parallel group, randomised controlled trial to compare the clinical and cost-effectiveness of three physiotherapy-led exercise interventions for knee osteoarthritis in older adults: the BEEP trial protocol (ISRCTN: 93634563)

BACKGROUND

Exercise is consistently recommended for older adults with knee pain related to osteoarthritis. However, the effects from exercise are typically small and short-term, likely linked to insufficient individualisation of the exercise programme and limited attention to supporting exercise adherence over time. The BEEP randomised trial aims to improve patients' short and long-term outcomes from exercise. It will test the overall effectiveness and cost-effectiveness of two physiotherapy-led exercise interventions (Individually Tailored Exercise and Targeted Exercise Adherence) to improve the individual tailoring of, and adherence to exercise, compared with usual physiotherapy care.

METHODS/DESIGN

Based on the learning from a pilot study (ISRCTN 23294263), the BEEP trial is a multi-centre, pragmatic, parallel group, individually randomised controlled trial, with embedded longitudinal qualitative interviews. 500 adults in primary care, aged 45 years and over with knee pain will be randomised to 1 of 3 treatment groups delivered by fully trained physiotherapists in up to 6 NHS services. These are: Usual Physiotherapy Care (control group consisting of up to 4 treatment sessions of advice and exercise), Individually Tailored Exercise (an individualised, supervised and progressed lower-limb exercise programme) or Targeted Exercise Adherence (supporting patients to adhere to exercise and to engage in general physical activity over the longer-term). The primary outcomes are pain and function as measured by the Western Ontario and McMaster Osteoarthritis index. A comprehensive range of secondary outcomes are also included. Outcomes are measured at 3, 6 (primary outcome time-point), 9, 18 and 36 months. Data on adverse events will also be collected. Semi-structured, qualitative interviews with a subsample of 30 participants (10 from each treatment group) will be undertaken at two time-points (end of treatment and 12 to 18 months later) and analysed thematically.

DISCUSSION

This trial will contribute to the evidence base for management of older adults with knee pain attributable to osteoarthritis in primary care. The findings will have important implications for healthcare commissioners, general practitioners and physiotherapy service providers and it will inform future education of healthcare practitioners. It may also serve to delay or prevent some individuals from becoming surgical candidates.

TRIAL REGISTRATION ISRCTN

ISRCTN93634563.

Role of rehabilitation medicine and physical agents in the treatment of cancer-associated pain

PURPOSE

To provide an overview of rehabilitation medicine- and physical modality-based approaches to cancer pain management, and to highlight the fact that these approaches are generally used in conjunction and that a majority are focused on minimizing pain during periods of mobility and the performance of activities of daily living.

METHODS

We performed a nonsystematic literature review and provide a description of the current standard of care.

RESULTS

Rehabilitative and physical modalities used to manage pain can be grouped into four categories: those that modulate nociception, stabilize or unload painful structures, influence physiological processes that indirectly influence nociception, or alleviate pain arising from the overloading of muscles and connective tissues that often occurs after surgery or with sarcopenia in late-stage cancer. Most modalities have been pragmatically refined over the years, and many have an evidence base, although few have been explicitly validated in the oncologic setting. With few exceptions, they are patient controlled and free of adverse effects.

CONCLUSION

Physical modalities and rehabilitation medicine offer a range of pain management approaches that may serve as beneficial adjuncts to the conventional systemic and interventional analgesic strategies used to control cancer-related pain. These approaches may be particularly beneficial to patients with movement-associated pain and those who are ambivalent regarding pharmacoanalgesia.

Development of comorbidity-adapted exercise protocols for patients with knee osteoarthritis

Background

Exercise therapy is generally recommended for patients with osteoarthritis (OA) of the knee. Comorbidity, which is highly prevalent in OA, may interfere with exercise therapy. To date, there is no evidence-based protocol for the treatment of patients with knee OA and comorbidity. Special protocols adapted to the comorbidity may facilitate the application of exercise therapy in patients with knee OA and one or more comorbidities.

Purpose

The purpose of this study was to develop comorbidity-adapted exercise protocols for patients with knee OA and comorbidity.

Method

Several steps were undertaken to develop comorbidity-adapted protocols: selection of highly prevalent comorbidities in OA, a literature search to identify restrictions and contraindications for exercise therapy for the various comorbid diseases, consultation of experts on each comorbid disease, and field testing of the protocol in eleven patients with knee OA and comorbidity.

Results

Based on literature and expert opinion, comorbidity-adapted protocols were developed for highly prevalent comorbidities in OA. Field testing showed that the protocols provided guidance in clinical decision making in both the diagnostic and the treatment phase. Because of overlap, the number of exercise protocols could be reduced to three: one for physiological adaptations (coronary disease, heart failure, hypertension, diabetes type 2, chronic obstructive pulmonary diseases, obesity), one for behavioral adaptations (chronic a-specific pain, nonspecific low back pain, depression), and one for environmental adaptations (visual or hearing impairments). Evaluation of patient outcome after treatment showed significant (P<0.05) and clinically relevant improvements in activity limitations and pain.

Conclusion

Comorbidity-adapted exercise protocols for patients with knee OA were developed, providing guidance in clinical reasoning with regard to diagnostics and treatment. To evaluate the effectiveness of treatment in line with our protocols, a randomized clinical trial should be performed.

Conservative interventions for treating work-related complaints of the arm, neck or shoulder in adults

BACKGROUND

Work-related upper limb disorder (WRULD), repetitive strain injury (RSI), occupational overuse syndrome (OOS) and work-related complaints of the arm, neck or shoulder (CANS) are the most frequently used umbrella terms for disorders that develop as a result of repetitive movements, awkward postures and impact of external forces such as those associated with operating vibrating tools. Work-related CANS, which is the term we use in this review, severely hampers the working population.

OBJECTIVES

To assess the effects of conservative interventions for work-related complaints of the arm, neck or shoulder (CANS) in adults on pain, function and work-related outcomes.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, 31 May 2013), MEDLINE (1950 to 31 May 2013), EMBASE (1988 to 31 May 2013), CINAHL (1982 to 31 May 2013), AMED (1985 to 31 May 2013), PsycINFO (1806 to 31 May 2013), the Physiotherapy Evidence Database (PEDro; inception to 31 May 2013) and the Occupational Therapy Systematic Evaluation of Evidence Database (OTseeker; inception to 31 May 2013). We did not apply any language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-randomised controlled trials evaluating conservative interventions for work-related complaints of the arm, neck or shoulder in adults. We excluded trials undertaken to test injections and surgery. We included studies that evaluated effects on pain, functional status or work ability.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data and assessed risk of bias of the included studies. When studies were sufficiently similar, we performed statistical pooling of reported results.

MAIN RESULTS

We included 44 studies (62 publications) with 6,580 participants that evaluated 25 different interventions. We categorised these interventions according to their working mechanisms into exercises, ergonomics, behavioural and other interventions.Overall, we judged 35 studies as having a high risk of bias mainly because of an unknown randomisation procedure, lack of a concealed allocation procedure, unblinded trial participants or lack of an intention-to-treat analysis.We found very low-quality evidence showing that exercises did not improve pain in comparison with no treatment (five studies, standardised mean difference (SMD) -0.52, 95% confidence interval (CI) -1.08 to 0.03), or minor intervention controls (three studies, SMD -0.25, 95% CI -0.87 to 0.37) or when provided as additional treatment (two studies, inconsistent results) at short-term follow-up or at long-term follow-up. Results were similar for recovery, disability and sick leave. Specific exercises led to increased pain at short-term follow-up when compared with general exercises (four studies, SMD 0.45, 95% CI 0.14 to 0.75)We found very low-quality evidence indicating that ergonomic interventions did not lead to a decrease in pain when compared with no intervention at short-term follow-up (three studies, SMD -0.07, 95% CI -0.36 to 0.22) but did decrease pain at long-term follow-up (four studies, SMD -0.76, 95% CI -1.35 to -0.16). There was no effect on disability but sick leave decreased in two studies (risk ratio (RR) 0.48, 95% CI 0.32 to 0.76). None of the ergonomic interventions was more beneficial for any outcome measures when compared with another treatment or with no treatment or with placebo.Behavioural interventions had inconsistent effects on pain and disability, with some subgroups showing benefit and others showing no significant improvement when compared with no treatment, minor intervention controls or other behavioural interventions.In the eight studies that evaluated various other interventions, there was no evidence of a clear beneficial effect of any of the interventions provided.

AUTHORS' CONCLUSIONS

We found very low-quality evidence indicating that pain, recovery, disability and sick leave are similar after exercises when compared with no treatment, with minor intervention controls or with exercises provided as additional treatment to people with work-related complaints of the arm, neck or shoulder. Low-quality evidence also showed that ergonomic interventions did not decrease pain at short-term follow-up but did decrease pain at long-term follow-up. There was no evidence of an effect on other outcomes. For behavioural and other interventions, there was no evidence of a consistent effect on any of the outcomes.Studies are needed that include more participants, that are clear about the diagnosis of work-relatedness and that report findings according to current guidelines.

Golden plaster for pain therapy in patients with knee osteoarthritis: study protocol for a multicenter randomized, double-blind, placebo-controlled trial

Background

Osteoarthritis is a relatively common musculoskeletal disorder that increases in prevalence with age. Worldwide, knee osteoarthritis is one of the leading causes of disability, particularly in the elderly. In numerous trials of agents for long-term pain therapy, no well-established and replicable results have been achieved. Complementary and alternative medical approaches have been employed for thousands of years to relieve knee osteoarthritis pain. Among herbal medicines, the golden plaster is the preferred and most commonlyused method in China to reduce pain in patients with knee osteoarthritis, as it causes few adverse effects. The purpose of this study will be to evaluate the efficacy and safety of golden plaster on pain in patients with knee osteoarthritis.

Methods/Design

This study will be a multicenter randomized, double-blind, placebo-controlled trial. A total of 320 participants aged 45 to 79 years with knee osteoarthritis, whose scores on a visual analog scale (VAS) are more than 20 mm,will be randomly allocated into a treatment group and a control group. A golden plaster will be administered externally to participants in the treatment group for 2 weeks, while the control group will receive a placebo plaster externally for 2 weeks. Follow-up will be at regular intervals during a 4-week period with a VAS score for pain, quality of life, and complications.

Discussion

This study will be a methodologically sound randomized controlled trial to assess pain relief after the intervention of golden plaster, compared to a placebo intervention in patients with knee osteoarthritis.

Trial registration

ClinicalTrials.gov identifier: ChiCTR-TRC-13003418

Failed joint unloading implant system in the treatment of medial knee osteoarthritis

In the setting of end-stage osteoarthritis of the knee, total knee arthroplasty is the gold-standard treatment. Recently, a minimally invasive, joint preserving treatment option in the treatment of medial osteoarthritis of the knee has been developed. It is called the KineSpring(®) (Moximed(®) International GmbH, Zurich, Switzerland). The goal of this novel device is to reduce medial compartment loading without significantly affecting the loading of the lateral compartment. In this context, the current authors present a case of device failure using these new implants, which at 7 months post-op necessitated revision surgery with complete removal of the device.