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

Long-term effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review

OBJECTIVE

To determine the long-term effectiveness (>/=6 months after treatment) of exercise therapy on pain, physical function, and patient global assessment of effectiveness in patients with osteoarthritis (OA) of the hip and/or knee.

METHODS

We conducted an extensive literature search in PubMed, EMBase, CINAHL, SciSearch, PEDro, and the Cochrane Central Register of Controlled Trials. Both randomized clinical trials and controlled clinical trials on the long-term effectiveness of exercise therapy were included. The followup assessments were at least 6 months after treatment ended. Methodologic quality was independently assessed by 2 reviewers. Effect estimates were calculated and a best evidence synthesis was performed based on design, methodologic quality, and statistical significance of findings.

RESULTS

Five high-quality and 6 low-quality randomized clinical trials were included. Strong evidence was found for no long-term effectiveness on pain and self-reported physical function, moderate evidence for long-term effectiveness on patient global assessment of effectiveness, and conflicting evidence for observed physical function. For exercise programs with additional booster sessions, moderate evidence was found for long-term effectiveness on pain, self-reported physical function, and observed physical function.

CONCLUSION

The positive posttreatment effects of exercise therapy on pain and physical function in patients with OA of the hip and/or knee are not sustained in the long term. Long-term effectiveness was only found for patient global assessment of effectiveness. However, additional booster sessions after the treatment period positively influenced maintenance of beneficial posttreatment effects on pain and physical function in the long term.

Repetitive task training for improving functional ability after stroke

BACKGROUND

The active practice of task-specific motor activities is a component of current approaches to stroke rehabilitation.

OBJECTIVES

To determine if repetitive task training after stroke improves global, upper or lower limb function, and if treatment effects are dependent on the amount, type or timing of practice.

SEARCH STRATEGY

We searched the Cochrane Stroke Trials Register (October 2006), The Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED, SportDiscus, Science Citation Index, Index to Theses, ZETOC, PEDro, and OT Seeker (to September 2006), and OT search (to March 2006). We also searched for unpublished/non-English language trials, conference proceedings, combed reference lists, requested information on bulletin boards, and contacted trial authors.

SELECTION CRITERIA

Randomised/quasi-randomised trials in adults after stroke, where the intervention was an active motor sequence performed repetitively within a single training session, aimed towards a clear functional goal, and where the amount of practice could be quantified.

DATA COLLECTION AND ANALYSIS

Two authors independently screened abstracts, extracted data and appraised trials. Assessment of methodological quality was undertaken for allocation concealment, blinding, loss to follow up and equivalence of treatment. We contacted trial authors for additional information.

MAIN RESULTS

Fourteen trials with 17 intervention-control pairs and 659 participants were included.

PRIMARY OUTCOMES

results were statistically significant for walking distance (mean difference (MD) 54.6, 95% CI 17.5 to 91.7); walking speed (standardised mean difference (SMD) 0.29, 95% CI 0.04 to 0.53); sit-to-stand (standard effect estimate 0.35, 95% CI 0.13 to 0.56); and of borderline statistical significance for functional ambulation (SMD 0.25, 95% CI 0.00 to 0.51), and global motor function (SMD 0.32, 95% CI -0.01 to 0.66). There were no statistically significant differences for hand/arm function, or sitting balance/reach.

SECONDARY OUTCOMES

results were statistically significant for activities of daily living (SMD 0.29, 95% CI 0.07 to 0.51), but not for quality of life or impairment measures. There was no evidence of adverse effects. Follow-up measures were not significant for any outcome at six or twelve months. Treatment effects were not modified by intervention amount or timing, but were modified by intervention type for lower limbs.

AUTHORS' CONCLUSIONS

Repetitive task training resulted in modest improvement in lower limb function, but not upper limb function. Training may be sufficient to impact on daily living function. However, there is no evidence that improvements are sustained once training has ended. The review potentially investigates task specificity rather more than repetition. Further research should focus on the type and amount of training, and how to maintain functional gain.

Physical activity interventions among adults with arthritis: meta-analysis of outcomes

OBJECTIVE

Due to reduced physical activity, adults with arthritis experience significant disability and comorbidities including cardiovascular disease. This meta-analytic review integrates results from primary research studies testing interventions to increase physical activity in arthritis patients.

METHODS

Extensive literature searching strategies were employed to locate published and unpublished empirical studies testing physical activity interventions. Results were coded for studies that had at least 5 participants. Effect sizes (ESs) were calculated for measures of physical activity, pain, and objective and subjective measures of functional ability.

RESULTS

Twenty-eight research studies with 4111 subjects were synthesized. The mean ES for 2-group comparisons (treatment versus control) was 0.69 for physical activity, 0.21 for pain, 0.49 for objectively measured function, and 0.14 for subjectively measured function. This average effect on subjective function is consistent with a Health Assessment Questionnaire mean of 0.64 for treatment subjects as compared with 0.70 for control subjects. For pain assessed using the 0 to 10 visual analog scale, the average effect amounts to a mean of 3.78 for treatment subjects versus 4.33 for control subjects. Control group subjects experienced statistically significant improvements in pain and, to a lesser extent, objectively measured functional ability during study participation.

CONCLUSIONS

Physical activity interventions resulted in moderate positive effects on physical activity behavior and small positive effects on pain and physical function outcomes. Future research should examine specific intervention characteristics that result in optimal results, such as frequency, type, and intensity of exercise.

Acupuncture as an adjunct to exercise based physiotherapy for osteoarthritis of the knee: randomised controlled trial

OBJECTIVE

To investigate the benefit of adding acupuncture to a course of advice and exercise delivered by physiotherapists for pain reduction in patients with osteoarthritis of the knee.

DESIGN

Multicentre, randomised controlled trial.

SETTING

37 physiotherapy centres accepting primary care patients referred from general practitioners in the Midlands, United Kingdom.

PARTICIPANTS

352 adults aged 50 or more with a clinical diagnosis of knee osteoarthritis.

INTERVENTIONS

Advice and exercise (n=116), advice and exercise plus true acupuncture (n=117), and advice and exercise plus non-penetrating acupuncture (n=119).

MAIN OUTCOME MEASURES

The primary outcome was change in scores on the Western Ontario and McMaster Universities osteoarthritis index pain subscale at six months. Secondary outcomes included function, pain intensity, and unpleasantness of pain at two weeks, six weeks, six months, and 12 months.

RESULTS

Follow-up rate at six months was 94%. The mean (SD) baseline pain score was 9.2 (3.8). At six months mean reductions in pain were 2.28 (3.8) for advice and exercise, 2.32 (3.6) for advice and exercise plus true acupuncture, and 2.53 (4.2) for advice and exercise plus non-penetrating acupuncture. Mean differences in change scores between advice and exercise alone and each acupuncture group were 0.08 (95% confidence interval -1.0 to 0.9) for advice and exercise plus true acupuncture and 0.25 (-0.8 to 1.3) for advice and exercise plus non-penetrating acupuncture. Similar non-significant differences were seen at other follow-up points. Compared with advice and exercise alone there were small, statistically significant improvements in pain intensity and unpleasantness at two and six weeks for true acupuncture and at all follow-up points for non-penetrating acupuncture.

CONCLUSION

The addition of acupuncture to a course of advice and exercise for osteoarthritis of the knee delivered by physiotherapists provided no additional improvement in pain scores. Small benefits in pain intensity and unpleasantness were observed in both acupuncture groups, making it unlikely that this was due to acupuncture needling effects.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN88597683 [controlled-trials.com] .

Evidence-based analysis of physical therapy in Parkinson's disease with recommendations for practice and research

Physical therapy is often prescribed in Parkinson's disease. To facilitate the uniformity and efficacy of this intervention, we analyzed current evidence and developed practice recommendations. We carried out an evidence-based literature review. The results were supplemented with clinical expertise and patient values and translated into practice recommendations, developed according to international standards for guideline development. A systematic literature search yielded 6 systematic reviews and 23 randomized controlled trials of moderate methodological quality with sufficient data. Six specific core areas for physical therapy were identified: transfers, posture, reaching and grasping, balance, gait, and physical capacity. We extracted four specific treatment recommendations that were based on evidence from more than two controlled trials: cueing strategies to improve gait; cognitive movement strategies to improve transfers; exercises to improve balance; and training of joint mobility and muscle power to improve physical capacity. These practice recommendations provide a basis for current physical therapy in Parkinson's disease in everyday clinical practice, as well as for future research in this field.

US national prevalence and correlates of low back and neck pain among adults

OBJECTIVE

To estimate the US prevalence and psychological and health behavior correlates of low back pain and/or neck pain. No current US national prevalence estimates of low back and neck pain exist and few studies have investigated the associations between low back and neck pain, psychological factors, and health behaviors in a representative sample of US community dwellers.

METHODS

We analyzed data obtained from adults ages 18 years or older (n = 29,828) who participated in the 2002 National Health Interview Survey, a cross-sectional, population-based survey of US adults.

RESULTS

The 3-month US prevalence of back and/or neck pain was 31% (low back pain: 34 million, neck pain: 9 million, both back and neck pain: 19 million). Generally, adults with low back and/or neck pain reported more comorbid conditions, exhibited more psychological distress (including serious mental illness), and engaged in more risky health behaviors than adults without either condition.

CONCLUSION

Low back and neck pain are critical public health problems. Our study supports the idea of a multidimensional approach to examining low back and neck problems and suggests the need for further research to address potentially modifiable psychological factors and health behaviors in these populations.

Therapeutic exercise in physiotherapy practice is beneficial: a summary of systematic reviews 2002-2005

QUESTION

Is therapeutic exercise of benefit?

DESIGN

A summary of systematic reviews on therapeutic exercise published from 2002 to September 2005.

PARTICIPANTS

People with neurological, musculoskeletal, cardiopulmonary, and other conditions who would be expected to consult a physiotherapist.

INTERVENTION

Therapeutic exercise was defined as the prescription of a physical activity program that involves the client undertaking voluntary muscle contraction and/or body movement with the aim of relieving symptoms, improving function or improving, retaining or slowing deterioration of health.

OUTCOME MEASURES

Effect of therapeutic exercise in terms of impairment, activity limitations, or participation restriction.

RESULTS

The search yielded 38 systematic reviews of reasonable or good quality. The results provided high level evidence that therapeutic exercise was beneficial for patients across broad areas of physiotherapy practice, including people with conditions such as multiple sclerosis, osteoarthritis of the knee, chronic low back pain, coronary heart disease, chronic heart failure, and chronic obstructive pulmonary disease. Therapeutic exercise was more likely to be effective if it was relatively intense and there were indications that more targeted and individualised exercise programs might be more beneficial than standardised programs. There were few adverse events reported. However, in many areas of practice there was no evidence that one type of exercise was more beneficial than another.

CONCLUSION

Therapeutic exercise was beneficial for patients across broad areas of physiotherapy practice. Further high quality research is required to determine the effectiveness of therapeutic exercise in emerging areas of practice.

Exercise therapy and the additional effect of supervision on exercise therapy in patients with intermittent claudication. Systematic review of randomised controlled trials

OBJECTIVE

To review the evidence for the effectiveness of exercise therapy and to estimate the additional effect of supervision on exercise therapy in patients with intermittent claudication.

MATERIALS AND METHODS

A systematic review was performed of all randomised controlled trials (RCTs) comparing supervised exercise therapy to unsupervised exercise regimens or observation in patients with intermittent claudication. Main endpoints were pain free walking distance (PWD) and absolute walking distance (AWD). Quality assessment and data extraction were performed independently by two observers.

RESULTS

Fifteen manuscripts, published between 1990 and May 2006, were eligible for analysis, evaluating 761 patients. In the studies comparing supervised exercise to standard care the weighted mean difference in pain free walking distance (PWD) and absolute walking distance (AWD) was 81.3meters (95% CI; 35.5-127.1) and 155.8meters (95% CI; 80.8-230.7), respectively. In the studies comparing supervised to unsupervised exercise therapy, the weighted mean difference in PWD and AWD was 143.8meters (95% CI; 5.8-281.8) and 250.4meters (95% CI; 192.4-308.5).

CONCLUSION

Exercise therapy increases the PWD and AWD in patients with intermittent claudication. Supervised exercise therapy increases the PWD and AWD more than standard care. However, the additional value of supervision over unsupervised exercise regimens needs further clarification.

Validation of a modified Thai version of the Western Ontario and McMaster (WOMAC) osteoarthritis index for knee osteoarthritis

The aim of this study was to evaluate the psychometric properties (validity and reliability) of the Thai version of the Western Ontario and McMaster (WOMAC) index in knee osteoarthritis (OA) patients. After permission from the copyright holder of the WOMAC index was obtained, the questionnaire was translated into Thai, backtranslated, tested for face and content validities, and then modified. A convergent validity was evaluated in 114 patients with knee OA by comparing the scores of a modified Thai WOMAC index to those of the algofunctional Lequesne index. A test-retest reliability was evaluated in 89 patients who answered the modified Thai WOMAC index twice at 3-week intervals. The statistical analyses for the content validity were index of content validity (ICV), floor and ceiling effects, and skewness of distribution; for the convergent validity was Spearman's correlation; for the test-retest reliability were Spearman's correlation and intraclass correlation; and for the internal consistency was Chronbach's alpha. The Thai WOMAC index had face validity. The ICV of the content validity ranged from 0.25-1.00. Two items (F05 and F12 of the original 24-item WOMAC index) that had an ICV of 0 were removed from the modified Thai version. The modified 22-item Thai WOMAC index had convergent validity to the algofunctional Lequesne index in pain and function dimensions (Spearman's correlation coefficients were 0.66 and 0.69, respectively). The test-retest reliability had correlation coefficients ranging from 0.65 to 0.71. The internal consistency had an alpha ranging from 0.85 to 0.97. In conclusion, the modified Thai WOMAC index had acceptable psychometric properties for Thai patients with knee OA.

Comparison of customized versus standard exercises in rehabilitation of shoulder disorders

OBJECTIVE(S)

(1) To compare the effectiveness of customized exercises with that of standard exercises for the treatment of patients with shoulder disorders. (2) To determine whether four weeks or eight weeks would be needed to see improvement in outcome measures.

DESIGN

A single-blinded randomized clinical trial.

SETTING

An outpatient physical therapy clinic affiliated with an academic institution.

SUBJECTS

Thirty patients with shoulder disorders were tested and treated between February 2003 and December 2004.

INTERVENTIONS

Patients were randomized to a customized or standard exercise group. Each patient first underwent a standardized physical therapy assessment. Based on the results of the assessment, a classification was determined and a classification-specific exercise programme was instructed to the patients in the customized exercise group. The standard exercise group, regardless of classification, received preselected standard exercises. Both groups were followed for eight weeks.

MAIN MEASURES

Shoulder range of motion, strength, pain intensity and function were assessed three times (weeks 0, 4 and 8).

RESULTS

There were no significant differences between the customized and standard exercise groups in measures of shoulder range of motion, strength, pain intensity and function after four or eight weeks of exercise. Patients in both groups had significant improvements in shoulder strength, pain intensity and function. Significant improvements occurred at week 8, but not at week 4.

CONCLUSION

The customized shoulder exercises did not provide additional benefit to our shoulder patients than the standard exercises.

Effectiveness of behavioral graded activity in patients with osteoarthritis of the hip and/or knee: A randomized clinical trial

OBJECTIVE

To determine the effectiveness of a behavioral graded activity program (BGA) compared with usual care (UC; exercise therapy and advice) according to the Dutch guidelines for physiotherapy in patients with osteoarthritis (OA) of the hip and/or knee. The BGA intervention is intended to increase activity in the long term and consists of an exercise program with booster sessions, using operant treatment principles.

METHODS

We conducted a cluster randomized trial involving 200 patients with hip and/or knee OA. Primary outcome measures were pain (visual analog scale [VAS] and Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]), physical function (WOMAC), and patient global assessment, assessed at weeks 0, 13, 39, and 65. Secondary outcome measures comprised tiredness (VAS), patient-oriented physical function (McMaster Toronto Arthritis Patient Preference Disability Questionnaire [MACTAR]), 5-meter walking time, muscle strength, and range of motion. Data were analyzed according to intent-to-treat principle.

RESULTS

Both treatments showed short-term and long-term beneficial within-group effects. The mean differences between the 2 groups for pain and functional status were not statistically significant. Significant differences in favor of BGA were found for the MACTAR functional scale and 5-meter walking test at week 65.

CONCLUSION

Because both interventions resulted in beneficial long-term effects, the superiority of BGA over UC has not been demonstrated. Therefore, BGA seems to be an acceptable method to treat patients with hip and/or knee OA, with equivalent results compared with UC.

Tennis elbow: blending basic science with clinical practice

Tennis elbow defines a condition of varying degrees of pain or point tenderness on or near the lateral epicondyle. It is prevalent in individuals who perform a combination of forceful and repetitive activities including athletes and wheelchair users. The most common work-related disorder at the elbow is tennis elbow. Histopathological findings indicate that tennis elbow is a degenerative condition, called tendinosis, of the common extensor tendon, with the extensor carpi radialis brevis tendon more commonly implicated as the primary location of tendinosis. Despite the absence of inflammation, patients with tennis elbow still present with pain. Neurochemicals including glutamate, substance P, and calcitonin gene-related peptide have been identified in patients with chronic tennis elbow and in animal models of tendinopathy. Their presence provides an alternative mechanism for pain mediation. Based on what is known about tissue changes within chronic tendinopathies, implications for therapy including examination and interventions are discussed.

Effectiveness of physiotherapy in Parkinson's disease: the feasibility of a randomised controlled trial

To study the feasibility of a large randomised controlled trial (RCT) evaluating the effectiveness of physiotherapy in Parkinson's disease (PD), 173 patients were asked to participate in a study with random allocation to best practice physiotherapy, or to no physiotherapy. The primary outcome measures were the Parkinson's disease questionnaire-39, the Parkinson activity scale, and a patient preference outcome scale (PPOS). Only 14% of the patients could be included in the study. The PPOS showed the largest effect size (0.74) with a significant group effect (p<0.05). Specific alterations to the study design to ensure successful RCTs in this field are recommended.

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

BACKGROUND

Conservative interventions such as physiotherapy and ergonomic adjustments (such as keyboard adjustments or ergonomic advice) play a major role in the treatment of most work-related complaints of the arm, neck or shoulder (CANS).

OBJECTIVES

This systematic review aims to determine whether conservative interventions have a significant impact on outcomes for work-related CANS in adults.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2005) and Cochrane Rehabilitation and Related Therapies Field Specialised Register (March 2005), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2005), PubMed, EMBASE, CINAHL, AMED and reference lists of articles. The date of the last search was March 2005. No language restrictions were applied.

SELECTION CRITERIA

We included randomised and non-randomised controlled trials studying conservative interventions (e.g. exercises, relaxation, physical applications, biofeedback, myofeedback and work-place adjustments) for adults suffering CANS.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials from the search yield, assessed the methodological quality using the Delphi list, and extracted relevant data. We pooled data or, in the event of clinical heterogeneity or lack of data, we used a rating system to assess levels of evidence.

MAIN RESULTS

For this update we included six additional studies; 21 trials in total. Seventeen trials included people with chronic non-specific neck or shoulder complaints, or non-specific upper extremity disorders. Over 25 interventions were evaluated; five main subgroups of interventions could be determined: exercises, manual therapy, massage, ergonomics, and energised splint. Overall, the quality of the studies was poor. In 14 studies a form of exercise was evaluated, and contrary to the previous review we now found limited evidence about the effectiveness of exercises when compared to massage and conflicting evidence when exercises are compared to no treatment. In this update there is limited evidence for adding breaks during computer work; massage as add-on treatment on manual therapy, manual therapy as add-on treatment on exercises; and some keyboard designs when compared to other keyboards or placebo in participants with carpal tunnel syndrome.

AUTHORS' CONCLUSIONS

There is limited evidence for the effectiveness of keyboards with an alternative force-displacement of the keys or an alternative geometry, and limited evidence for the effectiveness of exercises compared to massage; breaks during computer work compared to no breaks; massage as an add-on treatment to manual therapy; and manual therapy as an add-on treatment to exercises.

Shedding light into the role of BDNF in the pharmacotherapy of Parkinson's disease

Parkinson's disease (PD) is a chronic, neurodegenerative disease with a 1% incidence in the population over 55 years of age. Movement impairments represent undoubtedly the hallmark of the disorder; however, extensive evidence implicates cognitive deficits as concomitant peculiar features. Brain-derived neurotrophic factor (BDNF) colocalizes with dopamine neurons in the substantia nigra, where dopaminergic cell bodies are located, and it has recently garnered attention as a molecule crucial for cognition, a function that is also compromised in PD patients. Thus, due to its colocalization with dopaminergic neurons and its role in cognition, BDNF might possess a dual role in PD, both as a neuroprotective molecule, since its inhibition leads to loss of nigral dopaminergic neurons, and as a neuromodulator, as its enhanced expression ameliorates cognitive processes. In this review, we discuss the mechanism of action of established as well as novel drugs for PD with a particular emphasis to those interfering with BDNF biosynthesis.