Aquatic exercise for the treatment of knee and hip osteoarthritis

Progress and Challenges of Topical Delivery Technologies Meditated Drug Therapy for Osteoarthritis

Osteoarthritis (OA) is a degenerative disease commonly seen in middle-aged and elderly people. Multiple cytokines are involved in the local tissue damage in OA. Currently, non-pharmacologic and surgical interventions are the main conventional approaches for the treatment of OA. In terms of pharmaceutical drug therapy, NSAIDs and acetaminophen are mainly used to treat OA. However, it is prone to various adverse reactions such as digestive tract ulcer, thromboembolism, prosthesis loosening, nerve injury and so on. With the in-depth study of OA, more and more novel topical drug delivery strategies and vehicles have been developed, which can make up for the shortcomings of traditional dosage forms, improve the bioavailability of drugs, and significantly reduce drug side effects. This review summarizes the immunopathogenesis, treatment guidelines, and progress and challenges of topical delivery technologies of OA, with some perspectives on the future pharmacological treatment of OA proposed.

Supervised Exercise in Water: Is It a Viable Alternative in Overweight/Obese People with or without Type 2 Diabetes? A Pilot Study

The study of the effects of a water-based exercise program in overweight/obese people with or without type 2 diabetes is a topic of relatively recent interest. This type of exercise presents some advantages in reducing the risk of injury or trauma, and it can be a valuable therapeutic card to play for sedentary or physically inactive patients who have chronic metabolic diseases. This work aims to make a contribution showing the effects of a water-based exercise intervention, supervised by graduates in sports sciences, in a group of overweight/obese people with or without type 2 diabetes. In total, 93 adults (age 60.59 ± 10.44 years), including 72 women (age 60.19 ± 10.97 years) and 21 men (age 61.95 ± 8.48 years), were recruited to follow a water-based exercise program (2 sessions/week, for 12 weeks) at the C.U.R.I.A.Mo. Healthy Lifestyle Institute of Perugia University. Results showed an improvement in body mass index (−0.90 ± 1.56, p = 0.001), waist circumference (−4.32 ± 6.03, p < 0.001), and systolic (−7.78 ± 13.37, p = 0.001) and diastolic (−6.30 ± 10.91, p = 0.001) blood pressure. The supervised water-based intervention was useful in managing patients with metabolic diseases who often present with other health impairments, such as musculoskeletal problems or cardiovascular or rheumatic disease that could contraindicate gym-based exercise.

Antidepressants for hip and knee osteoarthritis

BACKGROUND

Although pain is common in osteoarthritis, most people fail to achieve adequate analgesia. Increasing acknowledgement of the contribution of pain sensitisation has resulted in the investigation of medications affecting pain processing with central effects. Antidepressants contribute to pain management in other conditions where pain sensitisation is present.

OBJECTIVES

To assess the benefits and harms of antidepressants for the treatment of symptomatic knee and hip osteoarthritis in adults.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search was January 2021.

SELECTION CRITERIA

We included randomised controlled trials of adults with osteoarthritis that compared use of antidepressants to placebo or alternative comparator. We included trials that focused on efficacy (pain and function), treatment-related adverse effects and had documentation regarding discontinuation of participants. We excluded trials of less than six weeks of duration or had participants with concurrent mental health disorders.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Major outcomes were pain; responder rate; physical function; quality of life; and proportion of participants who withdrew due to adverse events, experienced any adverse events or had serious adverse events. Minor outcomes were proportion meeting the OARSI (Osteoarthritis Research Society International) Response Criteria, radiographic joint structure changes and proportion of participants who dropped out of the study for any reason. We used GRADE to assess certainty of evidence.

MAIN RESULTS

Nine trials (2122 participants) met the inclusion criteria. Seven trials examined only knee osteoarthritis. Two also included participants with hip osteoarthritis. All trials compared antidepressants to placebo, with or without non-steroidal anti-inflammatory drugs. Trial sizes were 36 to 388 participants. Most participants were female, with mean ages of 54.5 to 65.9 years. Trial durations were 8 to 16 weeks. Six trials examined duloxetine. We combined data from nine trials in meta-analyses for knee and hip osteoarthritis. One trial was at low risk of bias in all domains. Five trials were at risk of attrition and reporting bias. High-certainty evidence found that antidepressants resulted in a clinically unimportant improvement in pain compared to placebo. Mean reduction in pain (0 to 10 scale, 0 = no pain) was 1.7 points with placebo and 2.3 points with antidepressants (mean difference (MD) -0.59, 95% confidence interval (CI) -0.88 to -0.31; 9 trials, 2122 participants). Clinical response was defined as achieving a 50% or greater reduction in 24-hour mean pain. High-certainty evidence demonstrated that 45% of participants receiving antidepressants had a clinical response compared to 28.6% receiving placebo (RR 1.55, 95% CI 1.32 to 1.82; 6 RCTs, 1904 participants). This corresponded to an absolute improvement in pain of 16% more responders with antidepressants (8.9% more to 26% more) and a number needed to treat for an additional beneficial effect (NNTB) of 6 (95% CI 4 to 11). High-certainty evidence showed that the mean improvement in function (on 0 to 100 Western Ontario and McMaster Universities Arthritis Index, 0 = best function) was 10.51 points with placebo and 16.16 points with antidepressants (MD -5.65 points, 95% CI -7.08 to -4.23; 6 RCTs, 1909 participants). This demonstrates a small, clinically unimportant response. Moderate-certainty evidence (downgraded for imprecision) showed that quality of life measured using the EuroQol 5-Dimension scale (-0.11 to 1.0, 1.0 = perfect health) improved by 0.07 points with placebo and 0.11 points with antidepressants (MD 0.04, 95% CI 0.01 to 0.07; 3 RCTs, 815 participants). This is clinically unimportant. High-certainty evidence showed that total adverse events increased in the antidepressant group (64%) compared to the placebo group (49%) (RR 1.27, 95% CI 1.15 to 1.41; 9 RCTs, 2102 participants). The number needed to treat for an additional harmful outcome (NNTH) was 7 (95% CI 5 to 11). Low-certainty evidence (downgraded twice for imprecision for very low numbers of events) found no evidence of a difference in serious adverse events between groups (RR 0.94, 95% CI 0.46 to 1.94; 9 RCTs, 2101 participants). The NNTH was 1000.  Moderate-certainty evidence (downgraded for imprecision) showed that 11% of participants receiving antidepressants withdrew from trials due to an adverse event compared to 5% receiving placebo (RR 2.15, 95% CI 1.56 to 2.97; 6 RCTs, 1977 participants). The NNTH was 17 (95% CI 10 to 35).

AUTHORS' CONCLUSIONS

There is high-certainty evidence that use of antidepressants for knee osteoarthritis leads to a non-clinically important improvement in mean pain and function. However, a small number of people will have a 50% or greater important improvement in pain and function. This finding was consistent across all trials. Pain in osteoarthritis may be due to a variety of causes that differ between individuals. It may be that the cause of pain that responds to this therapy is only present in a small number of people. There is moderate-certainty evidence that antidepressants have a small positive effect on quality of life with heterogeneity between trials. High-certainty evidence indicates antidepressants result in more adverse events and moderate-certainty evidence indicates more withdrawal due to adverse events. There was little to no difference in serious adverse events (low-certainty evidence due to low numbers of events). This suggests that if antidepressants were being considered, there needs to be careful patient selection to optimise clinical benefit given the known propensity for adverse events with antidepressant use. Future trials should include alternative antidepressant agents or phenotyping of pain in people with osteoarthritis, or both.

A pilot study of aquatic prehabilitation in adults with knee osteoarthritis undergoing total knee arthroplasty - short term outcome

BACKGROUND

Knee osteoarthritis (KOA) is increasingly more prevalent and significant number of patients require knee arthroplasty. Although knee arthroplasty is generally successful, it takes months to recover physical function. Preoperative physical function is known to predict postoperative outcomes and exercise can improve preoperative physical function. However, patients with KOA have difficulty exercise on land due to pain and stiffness, while water exercise can be better tolerated. We hypothesized that preoperative water exercise to improve preoperative physical function will improve postoperative outcomes after total knee arthroplasty (TKA).

METHODS

We enrolled 43 participants who were scheduled for elective TKA in 4-8 weeks and scored at or below 50th percentile in mobility assessment tool-sf (MAT-sf). All enrolled participants were assessed on 1) clinical osteoarthritis symptom severity using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), 2) physical function using Short Physical Performance Battery (SPPB), 3) self-reported mobility using Mobility Assessment Tool-short form (MAT-sf), 4) depression using Geriatric Depression Scale-short form (GDS-sf), 5) cognitive function using Montreal Cognitive Assessment (MoCA). Blood samples for high-sensitivity-C-reactive protein (hs-CRP), tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) were stored at - 80 °C then all samples were analyzed together. All the enrolled participants were randomly assigned to the aquatic exercise intervention (AEI) or usual care group. Sixty minute sessions of AEI was conducted three times a week for 4-8 weeks. Participants in both groups were evaluated within 1 week before their scheduled surgery, as well as 4 weeks after the surgery.

RESULTS

The mean age was 67.1 (±6.2), 44% were female, 74% were White. There is no statistically significant difference in combined outcome of any complication, unscheduled ER visit, and disposition to nursing home or rehab facility by AEI. However, AEI was associated with more favorable outcomes: WOMAC scores (p < 0.01), chair-stand (p = 0.019), MAT-sf as well as improved depression (p = 0.043) and cognition (p = 0.008).

CONCLUSION

4-8 weeks of aquatic exercise intervention resulted in improved functional outcomes as well as improved depression and cognition in elderly patients undergoing TKA. A larger study is warranted to explore the role of water exercise in clinical and functional outcomes of TKA.

Effects of hydrotherapy and land-based exercise on mobility and quality of life in patients with knee osteoarthritis: a randomized control trial

[Purpose] To determine the effects of hydrotherapy and land-based exercises on functional mobility and quality of life among patients with knee osteoarthritis. [Participants and Methods] We conducted a randomized controlled trial with knee osteoarthritis patients randomly allocated into land-based (n=17) and hydrotherapy groups (n=17). The Time-Up and Go (TUG), Five Times Sit-to-Stand (5STS), Stair Climbing Test (SCT), and Quality of Life by questionnaires including the Modified Western Ontario and McMaster Universities Osteoarthritis Index questionnaire Thai version (Thai WOMAC) were assessed at baseline and 6 weeks. The World Health Organization Quality of Life BREF Thai version (WHOQOL-BREF-THAI) questionnaire were assessed at baseline and six weeks and 6 months. [Results] There was no significant difference in outcomes between the groups after 6-weeks and 6-months of follow-up. After 6 weeks, Thai WOMAC score improved in both groups. Only 5STS was improved in the land-based group, while the hydrotherapy group showed significant TUG, 5STS, and SCT improvement. Furthermore, only hydrotherapy showed significant improvement in WHOQOL-BREF-THAI scores in the mental, social, quality of health, and total domains after six months. [Conclusion] Both exercises equally improved functional mobility and quality of life. Hydrotherapy and land-based exercise could improve functional mobility and quality of life in patients with knee osteoarthritis.

Outpatient Evaluation of Knee Pain

Knee pain is present in up to 20% of the adult general population and can be significantly debilitating to patients. A thorough history and physical examination can help localize the source of inflammation or injury to further determine if imaging, physical therapy, specialty referral, or surgery is necessary. By following a systematic approach to evaluating knee pain, primary care physicians can make the correct diagnosis and formulate an appropriate therapeutic strategy for patients.

The safety and feasibility of a Halliwick style of aquatic physiotherapy for falls and balance dysfunction in people with Parkinson's Disease: A single blind pilot trial

BACKGROUND

There is growing evidence that aquatic physiotherapy may be effective for people with Parkinson's Disease (PD) but most studies have investigated land based type exercises in the aquatic environment. Few studies have examined customised aquatic therapies such as the Halliwick concept which focuses on trunk rotation and core stabilisation.

OBJECTIVE

The primary aim was to determine the feasibility of a Halliwick style aquatic physiotherapy intervention for people with PD. The secondary aim was to compare the Halliwick intervention with traditional aquatic and land based physiotherapy in terms of disease severity, balance and fear of falling.

METHODS

Halliwick style aquatic, traditional aquatic and land based physiotherapy were trialled in a single blind pilot study. All interventions ran for 60 minutes per week over 12 weeks. Feasibility outcomes were safety, adherence and attrition. Secondary outcomes included the Unified Parkinson's Disease Rating Scale motor subsection (UPDRS-III), Berg Balance Scale (BBS), Mini BESTest and modified Falls Efficacy Scale (mFES).

RESULTS

30 participants with moderate PD were recruited. Participant mean age was 72 years (SD 8.4; range 51-86) with moderate disease severity (median Hoehn & Yahr score 3; IQR 1).No falls occurred during intervention sessions, however ten participants reported falls during the study period. No other adverse consequences were reported. All groups had adherence over 85%. No within group significant differences were found in UPDRS-III, BBS or mFES scores post-intervention for all groups, but the Halliwick aquatic group improved significantly in the Mini BESTest post-intervention (p = 0.011, 95% CI -7.36,-1.31, t (10) = -2.98).

CONCLUSIONS

Despite people with PD being a vulnerable population, aquatic physiotherapy, including the Halliwick style is a safe treatment option. Promising results for balance in the Halliwick aquatic group were observed, but further studies with larger sample sizes is required to increase confidence in the results.

Internet of Things (IoT) System and Field Sensors for Exercise Intensity Measurements

Although exercise training according to individual peak aerobic capacity ( V ˙ o_2peak ) has been recommended at all ages, sensors available in the field are limited. The most popular sensors in the field are pedometers, but they cannot be used to monitor exercise intensity. Instead, although heart rate (HR) monitors are broadly available in the field to estimate exercise intensity, HR responses to exercise vary by individual according to physical fitness and environmental conditions, which hinders the precise measurement of energy expenditure. These issues make it difficult for exercise physiologists to collaborate with geneticists, nutritionists, and clinicians using the internet of things (IoT). To conquer these problems, we have developed a device that is equipped with a triaxial accelerometer and a barometer to measure energy expenditure during interval walking training (IWT) in the field with inclines. IWT is a training regimen to repeat fast and slow walking for 3 min each, equivalent to greater than 70% and approximately 40% of individual V ˙ o_2peak , respectively. Additionally, we developed an IoT system that enables users to receive instructions from trainers according to their walking records even if they live far away. Since the system is available at low cost with minimum personnel, we can investigate any factors affecting the adherence to and effects of IWT in a large population for a long period. This system was also used to verify any effects of nutritional supplements during IWT and to examine the value of applying IWT to clinical medicine. © 2020 American Physiological Society. Compr Physiol 10:1207-1240, 2020.

Design of an Underwater Treadmill System for rehabilitation of older obese adults: a pre-post study

Background

Patients with knee osteoarthritis (OA) who are obese have problems performing land-based exercises. The reduced joint stress associated with aquatic exercise may benefit these patients. This study aimed to develop an underwater treadmill (UTM) machine that is affordable and suitable for use in developing countries, and to evaluate its efficacy in decreasing pain and increasing functional improvement.

Methods

Clinical testing of the UTM machine was performed in an outpatient setting at Siriraj Hospital during January–June 2017. Patients with knee OA, aged 50–85 years, numerical rating scale (NRS) ≥5/10, and body mass index (BMI) ≥25 kg/m ² were recruited. The UTM exercise protocol was 30 min/session, 3 days/week, for 4 weeks. The main outcomes were NRS pain score, 6-min walk distance (6MWD), quadriceps strength (QS) and body weight. Those outcomes were evaluated at baseline and at week 4.

Results

The UTM was constructed with safety, ergonomically designed and user-friendly control panel with push button for emergency stopping. Thirty patients were included for clinical testing. The mean age was 62.8 years, and almost all were female. The mean BMI was 28.9 kg/m ². Most patients (65.0%) developed bilateral knee OA, used pain medication (56.7%), and engaged in regular knee exercise (73.3%). Of the 30 enrolled patients, 6 withdrew. All of the remaining 24 patients attended all 12 sessions. The mean difference between baseline and the end of the study was − 2.3 (95% CI: − 3.0, − 1.5; p < 0.001) for NRS pain; 34.9 m (95% CI: 14.1, 55.8; p = 0.002) for 6MWD; and, 1.8 kg (95% CI, 1.1, 2.6; p < 0.001) for QS. Concerning adverse events, 4 patients (15.4%) developed muscle pain, 2 patients (7.7%) had joint pain, and 1 patient (3.9%) withdrew due to severe knee pain. Two-thirds of patients described themselves as being ‘very satisfied’ with UTM exercise, and approximately 90% of participants rated their symptoms as ‘improved’ or ‘much improved’.

Conclusions

4-week exercise with UTM can significantly improve NRS pain, 6MWD, and QS. UTM could be an alternative treatment for patients with knee OA who are obese due to small size, durability, and ecofriendly design as an exercise modality.

Osteoarthritis, Exercise, and Tissue Engineering: A Stimulating Triad for Health Professionals

Osteoarthritis (OA) is a degenerative disease, promoted by abnormal chronic mechanical loading over the joint, for instance, due to excessive body mass. Patients frequently report pain, fatigue, and limitations in specific functional daily activities. Regarding the treatment of OA, two nonpharmacological options are available. However, it is not clear which type and intensity of exercise have better outcomes in treatment and how tissue engineering can be a promising field due to the mechanical load implants will suffer. The aims of this work were to investigate (1) the main characteristics, prevalence, and consequences of OA; (2) the exercise prescription guidelines and whether exercise interventions have a positive effect on OA treatment; and (3) the novel improvements on tissue engineering for OA treatment. Both patients and practitioners should be aware that benefits may come from prescribed and supervised exercise. Recent studies have highlighted that an optimal balance between exercise and nutritional income should be widely recommended. Regarding tissue engineering, significant steps towards the development of implants that mimic the native tissue have been taken. Thus, further studies should focus on the impact that exercise (repetitive loading) might have on cartilage regeneration. Finally, suggestions for future research were proposed.

Exercise-induced hypoalgesia: A meta-analysis of exercise dosing for the treatment of chronic pain

OBJECTIVE

Increasing evidence purports exercise as a first-line therapeutic for the treatment of nearly all forms of chronic pain. However, knowledge of efficacious dosing respective to treatment modality and pain condition is virtually absent in the literature. The purpose of this analysis was to calculate the extent to which exercise treatment shows dose-dependent effects similar to what is seen with pharmacological treatments.

METHODS

A recently published comprehensive review of exercise and physical activity for chronic pain in adults was identified in May 2017. This report reviewed different physical activity and exercise interventions and their effectiveness in reducing pain severity and found overall modest effects of exercise in the treatment of pain. We analyzed this existing data set, focusing specifically on the dose of exercise intervention in these studies. We re-analyzed data from 75 studies looking at benefits of time of exercising per week, frequency of exercise per week, duration of intervention (in weeks), and estimated intensity of exercise.

RESULTS

Analysis revealed a significant positive correlation with exercise duration and analgesic effect on neck pain. Multiple linear regression modeling of these data predicted that increasing the frequency of exercise sessions per week is most likely to have a positive effect on chronic pain patients.

DISCUSSION

Modest effects were observed with one significant correlation between duration and pain effect for neck pain. Overall, these results provide insufficient evidence to conclude the presence of a strong dose effect of exercise in pain, but our modeling data provide tes predictions that can be used to design future studies to explicitly test the question of dose in specific patient populations.

Aquatic versus land-based exercise for cardiorespiratory endurance and quality of life in obese patients with knee osteoarthritis: a randomized controlled trial

Background: Obesity with knee osteoarthritis (OA) is related to chronic pain causing physical inactivity that leads to decreased cardiorespiratory endurance and quality of life. Aquatic and land-based exercises are effective in improving physical activity. The aim of this study is to compare between aquatic and land-based exercise to improve cardiorespiratory endurance and quality of life in obese patients with knee osteoarthritis.Methods: A single-blind, randomized, controlled trial was conducted on thirty three obese patients with knee OA who visited Obesity Clinic of Medical Rehabilitation Cipto Mangunkusumo Hospital, from October 2016 to January 2017, subjects were divided into aquatic or land-based exercise group. Aerobic and knee-strengthening exercises were given. Cardiorespiratory endurance was assessed using the Borg Scale, whereas both the BORG CR-10 and SF-36 questionnaires were used to assess quality of life.Results: After intervention, there were significant improvements in the land-based exercise group in the rating of perceived exertion (p=0.02), role limitations due to physical health (p=0.024), role limitations due to emotional problems (p=0.041), energy/fatigue (p=0.016), and the decline in pain (p=0.049) parameters. While in the aquatic exercise, there were significant improvements in leg fatigue (p=0.016), energy/fatigue (p=0.025), emotional well-being (p<0.001), and general health (p=0.045) parameters. Despite this, there were no significant differences between two groups regarding cardiorespiratory endurance and quality of life.Conclusion: This study found that patients could start aquatic exercise to reduce leg fatigue and enhanced general health and energy. After that, exercise could be continued in land-based settings to improve cardiorespiratory endurance and quality of life.

[Physical therapy options in rheumatic diseases: what is evidence-based?]

Rheumatic diseases usually progress towards morphological and functional deficits and thus cause impairment of physical health and function. Based on this fact, physiotherapeutic options are elementary and indispensable. This article focuses on the significance and importance of physiotherapy in inflammatory and degenerative rheumatic diseases. Furthermore, an overview is presented on the consequences of rheumatic diseases, the reality of supply of physiotherapy, the principles and therapeutic options, and the evidence.

2017 update of the Turkish League Against Rheumatism (TLAR) evidence-based recommendations for the management of knee osteoarthritis

In a Turkish League Against Rheumatism (TLAR) project, evidence-based recommendations for the management of knee osteoarthritis (OA) was developed for the first time in our country in 2012 (TLAR-2012). In accordance with developing medical knowledge and scientific evidence, recommendations were updated. The committee was composed of 22 physical medicine and rehabilitation specialists (4 have rheumatology subspeciality also) and an orthopaedic surgeon. Systematic literature search were applied on Pubmed, Embase, Cochrane and Turkish Medical Index for the dates between January the 1st 2012 and January the 29th of 2015. The articles were assessed for quality and classified according to hierarchy for the level of evidence, and the selected ones sent to committee members electronically. They were asked to develop new recommendations. In the meeting in 2015, the format of the recommendations was decided to be patient-based and considering the grade and the severity of the disease. By the discussion of the each item under the light of new evidences, the final recommendations were developed. Each item was voted electronically on a 10-cm visual analogue scale (VAS) and the strength of recommendation (SoR) was calculated. In the light of evidences, totally 11 titles of recommendations were developed; the first 7 were applicable to each patient in every stages of the disease, remaining were for defined specific clinical situations. The mean SoR value of the recommendations was between 7.44 and 9.93. TLAR-2012 recommendations were updated in a new format. We think that, present recommendations will be beneficial for the physicians who manage, as well as the patients who suffer from the disease.

[Knee school as a secondary preventive approach : The sustainable treatment of occupational gonarthrosis]

BACKGROUND

2-6 months after successful medical rehabilitation in gonarthrosis, the positive effects remit without the implementation of adequate aftercare strategies.

OBJECTIVES

A prospective comparative study aimed to investigate whether and to what extent the sustainability model of knee school for the secondary preventive treatment of occupational gonarthrosis is able to maintain positive treatment effects in the medium term.

MATERIAL AND METHODS

A total of 292 male employees from the building trade went through the three-week phase 1 of the biopsychosocial knee college with a focus on ergonomics and muscle strength training. In the following 12 months (Phase 2), the participants were contacted several times by telephone in order to motivate them to continue the training. While 178 employees voluntarily and locally continued their training in selected fitness centers with financial support (VG 1), and 38 employees opted for an individual home program (VG 2), 76 participants stopped all training (KG).

RESULTS

After Phase 1, all groups showed significant improvements in the parameters mobility, as well as stretch ability and strength endurance of the thigh muscles, complaints of the knee and quality of life. While the parameters in VG 1 continued to develop positively after 12 months, the measured values in VG 2, with the exception of muscle strength, moderately remitted. By contrast, a significant decline in the measurement values partly below the status quo ante was observed for the KG.

CONCLUSIONS

As part of the aftercare, financially supported training in a fitness center with accompanying regular telephone contacts for male construction workers with knee discomforts shows positive effects if the participation is voluntary. Organized training in the fitness center is superior to individual home programs.

A Research Agenda for Advancing Non-pharmacological Management of Chronic Musculoskeletal Pain: Findings from a VHA State-of-the-art Conference

Chronic pain is widely prevalent among Veterans and can have serious negative consequences for functional status and quality of life among other domains. The Veterans Health Administration (VHA) convened a state-of-the-art (SOTA) conference to develop research priorities for advancing the science and clinical practice of non-pharmacological management of chronic musculoskeletal pain. In this perspective article, we present the methods and consensus recommendations for research priorities emanating from the SOTA. In the months leading up to the SOTA, a core group of researchers defined four areas of focus: psychological/behavioral therapies; exercise/movement therapies; manual therapies; and models for delivering multi-modal pain care and divided into workgroups. Each workgroup, in their respective areas of focus, identified seminal studies capturing the state of the evidence. Herein, we present consensus recommendations ranging from efficacy to effectiveness to implementation/dissemination research depending on the state of the evidence as assessed by participants, including commentary on common elements across workgroups and future areas of innovation in study design, measurement, and outcome ascertainment.

Exercise interventions and patient beliefs for people with hip, knee or hip and knee osteoarthritis: a mixed methods review

BACKGROUND

Chronic peripheral joint pain due to osteoarthritis (OA) is extremely prevalent and a major cause of physical dysfunction and psychosocial distress. Exercise is recommended to reduce joint pain and improve physical function, but the effect of exercise on psychosocial function (health beliefs, depression, anxiety and quality of life) in this population is unknown.

OBJECTIVES

To improve our understanding of the complex inter-relationship between pain, psychosocial effects, physical function and exercise.

SEARCH METHODS

Review authors searched 23 clinical, public health, psychology and social care databases and 25 other relevant resources including trials registers up to March 2016. We checked reference lists of included studies for relevant studies. We contacted key experts about unpublished studies.

SELECTION CRITERIA

To be included in the quantitative synthesis, studies had to be randomised controlled trials of land- or water-based exercise programmes compared with a control group consisting of no treatment or non-exercise intervention (such as medication, patient education) that measured either pain or function and at least one psychosocial outcome (self-efficacy, depression, anxiety, quality of life). Participants had to be aged 45 years or older, with a clinical diagnosis of OA (as defined by the study) or self-reported chronic hip or knee (or both) pain (defined as more than six months' duration).To be included in the qualitative synthesis, studies had to have reported people's opinions and experiences of exercise-based programmes (e.g. their views, understanding, experiences and beliefs about the utility of exercise in the management of chronic pain/OA).

DATA COLLECTION AND ANALYSIS

We used standard methodology recommended by Cochrane for the quantitative analysis. For the qualitative analysis, we extracted verbatim quotes from study participants and synthesised studies of patients' views using framework synthesis. We then conducted an integrative review, synthesising the quantitative and qualitative data together.

MAIN RESULTS

Twenty-one trials (2372 participants) met the inclusion criteria for quantitative synthesis. There were large variations in the exercise programme's content, mode of delivery, frequency and duration, participant's symptoms, duration of symptoms, outcomes measured, methodological quality and reporting. Comparator groups were varied and included normal care; education; and attention controls such as home visits, sham gel and wait list controls. Risk of bias was high in one and unclear risk in five studies regarding the randomisation process, high for 11 studies regarding allocation concealment, high for all 21 studies regarding blinding, and high for three studies and unclear for five studies regarding attrition. Studies did not provide information on adverse effects.There was moderate quality evidence that exercise reduced pain by an absolute percent reduction of 6% (95% confidence interval (CI) -9% to -4%, (9 studies, 1058 participants), equivalent to reducing (improving) pain by 1.25 points from 6.5 to 5.3 on a 0 to 20 scale and moderate quality evidence that exercise improved physical function by an absolute percent of 5.6% (95% CI -7.6% to 2.0%; standardised mean difference (SMD) -0.27, 95% CI -0.37 to -0.17, equivalent to reducing (improving) WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) function on a 0 to 100 scale from 49.9 to 44.3) (13 studies, 1599 participants)). Self-efficacy was increased by an absolute percent of 1.66% (95% CI 1.08% to 2.20%), although evidence was low quality (SMD 0.46, 95% CI 0.34 to 0.58, equivalent to improving the ExBeliefs score on a 17 to 85 scale from 64.3 to 65.4), with small benefits for depression from moderate quality evidence indicating an absolute percent reduction of 2.4% (95% CI -0.47% to 0.5%) (SMD -0.16, 95% CI -0.29 to -0.02, equivalent to improving depression measured using HADS (Hospital Anxiety and Depression Scale) on a 0 to 21 scale from 3.5 to 3.0) but no clinically or statistically significant effect on anxiety (SMD -0.11, 95% CI -0.26 to 0.05, 2% absolute improvement, 95% CI -5% to 1% equivalent to improving HADS anxiety on a 0 to 21 scale from 5.8 to 5.4; moderate quality evidence). Five studies measured the effect of exercise on health-related quality of life using the 36-item Short Form (SF-36) with statistically significant benefits for social function, increasing it by an absolute percent of 7.9% (95% CI 4.1% to 11.6%), equivalent to increasing SF-36 social function on a 0 to 100 scale from 73.6 to 81.5, although the evidence was low quality. Evidence was downgraded due to heterogeneity of measures, limitations with blinding and lack of detail regarding interventions. For 20/21 studies, there was a high risk of bias with blinding as participants self-reported and were not blinded to their participation in an exercise intervention.Twelve studies (with 6 to 29 participants) met inclusion criteria for qualitative synthesis. Their methodological rigour and quality was generally good. From the patients' perspectives, ways to improve the delivery of exercise interventions included: provide better information and advice about the safety and value of exercise; provide exercise tailored to individual's preferences, abilities and needs; challenge inappropriate health beliefs and provide better support.An integrative review, which compared the findings from quantitative trials with low risk of bias and the implications derived from the high-quality studies in the qualitative synthesis, confirmed the importance of these implications.

AUTHORS' CONCLUSIONS

Chronic hip and knee pain affects all domains of people's lives. People's beliefs about chronic pain shape their attitudes and behaviours about how to manage their pain. People are confused about the cause of their pain, and bewildered by its variability and randomness. Without adequate information and advice from healthcare professionals, people do not know what they should and should not do, and, as a consequence, avoid activity for fear of causing harm. Participation in exercise programmes may slightly improve physical function, depression and pain. It may slightly improve self-efficacy and social function, although there is probably little or no difference in anxiety. Providing reassurance and clear advice about the value of exercise in controlling symptoms, and opportunities to participate in exercise programmes that people regard as enjoyable and relevant, may encourage greater exercise participation, which brings a range of health benefits to a large population of people.

Effects of aquatic exercise and land-based exercise on postural sway in elderly with knee osteoarthritis

Background: Knee Osteoarthritis (knee OA) is the most common joint disease in the elderly. It is a major cause of walking disability and balance impairment. The balance impairment or increase postural sway may result in increased risk of fall. Objectives: Compare effects of aquatic exercise and land-based exercise on postural sway and physical performance (pain, quality of life, leg muscle strength and leg muscle flexibility) in the elderly with knee OA. Subjects and methods: Fifty elderly women with knee OA were recruited for this study. They were randomized into aquatic exercise (n=25) and land-based exercise group (n=25). Postural sway views by anterior-posterior amplitude, medio-lateral amplitude, and total area were measured in subjects with eye opened or closed during double and single leg stance after six-week training, using the Force platform. Functional outcome was tested by the modified WOMAC. Knee injury and Osteoarthritis Outcome Score (KOOS), and pain scale were tested by Visual Analog Scale (VAS). Leg muscle strength was measured by chair stand, and leg muscle flexibility was measured by sit-andreach test. Aquatic group exercised at King Chulalongkorn Memorial Hospital therapeutic pool, while landbased group exercised at home. Results: In comparing postural sway before and after exercise, reduction in postural sway and pain, and increase in strength, the aquatic group were significantly better than those for land-based group (p <0.05). WOMAC, KOOS scores, and sit-and-reach test after six-weeks training were improved after exercise, but these were not significantly different between groups (p >0.05). Conclusion: Elderly patients with knee OA need exercise to improve balance and reduce sway. Six-week aquatic exercise was better than land-based exercise in sway reduction.

Predictors of Swimming Ability among Children and Adolescents in the United States

Swimming is an important source of physical activity and a life skill to prevent drowning. However, little research has been conducted to understand predictors of swimming ability. The purpose of this study was to understand factors that predict swimming ability among children and adolescents in the United States (US). This was a cross-sectional survey conducted between February and April of 2017 across five geographically diverse cities. Participants were accessed through the Young Christian Men's Association (YMCA) and included parents of children aged 4⁻11 years old and adolescents aged 12⁻17 years old. Independent t-test, analysis of variance (ANOVA), and univariate and multivariate analyses were conducted. Several factors were significant (p ≤ 0.05) predictors of swimming ability and explained 53% of the variance in swimming ability. Variables that were positively associated with swimming ability included: ability of parent(s) to swim, child/adolescent age, a best friend who enjoys swimming, water-safety knowledge, pool open all year, and encouragement to swim from parent(s). Variables that were negatively associated with swimming ability included: fear of drowning, being African American, and being female. Interventions and programs to improve the swimming ability of children and adolescents could be developed with these predictors in mind.

Models and applications for measuring the impact of health research: update of a systematic review for the Health Technology Assessment programme

BACKGROUND

This report reviews approaches and tools for measuring the impact of research programmes, building on, and extending, a 2007 review.

OBJECTIVES

(1) To identify the range of theoretical models and empirical approaches for measuring the impact of health research programmes; (2) to develop a taxonomy of models and approaches; (3) to summarise the evidence on the application and use of these models; and (4) to evaluate the different options for the Health Technology Assessment (HTA) programme.

DATA SOURCES

We searched databases including Ovid MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature and The Cochrane Library from January 2005 to August 2014.

REVIEW METHODS

This narrative systematic literature review comprised an update, extension and analysis/discussion. We systematically searched eight databases, supplemented by personal knowledge, in August 2014 through to March 2015.

RESULTS

The literature on impact assessment has much expanded. The Payback Framework, with adaptations, remains the most widely used approach. It draws on different philosophical traditions, enhancing an underlying logic model with an interpretative case study element and attention to context. Besides the logic model, other ideal type approaches included constructionist, realist, critical and performative. Most models in practice drew pragmatically on elements of several ideal types. Monetisation of impact, an increasingly popular approach, shows a high return from research but relies heavily on assumptions about the extent to which health gains depend on research. Despite usually requiring systematic reviews before funding trials, the HTA programme does not routinely examine the impact of those trials on subsequent systematic reviews. The York/Patient-Centered Outcomes Research Institute and the Grading of Recommendations Assessment, Development and Evaluation toolkits provide ways of assessing such impact, but need to be evaluated. The literature, as reviewed here, provides very few instances of a randomised trial playing a major role in stopping the use of a new technology. The few trials funded by the HTA programme that may have played such a role were outliers.

DISCUSSION

The findings of this review support the continued use of the Payback Framework by the HTA programme. Changes in the structure of the NHS, the development of NHS England and changes in the National Institute for Health and Care Excellence's remit pose new challenges for identifying and meeting current and future research needs. Future assessments of the impact of the HTA programme will have to take account of wider changes, especially as the Research Excellence Framework (REF), which assesses the quality of universities' research, seems likely to continue to rely on case studies to measure impact. The HTA programme should consider how the format and selection of case studies might be improved to aid more systematic assessment. The selection of case studies, such as in the REF, but also more generally, tends to be biased towards high-impact rather than low-impact stories. Experience for other industries indicate that much can be learnt from the latter. The adoption of researchfish^® (researchfish Ltd, Cambridge, UK) by most major UK research funders has implications for future assessments of impact. Although the routine capture of indexed research publications has merit, the degree to which researchfish will succeed in collecting other, non-indexed outputs and activities remains to be established.

LIMITATIONS

There were limitations in how far we could address challenges that faced us as we extended the focus beyond that of the 2007 review, and well beyond a narrow focus just on the HTA programme.

CONCLUSIONS

Research funders can benefit from continuing to monitor and evaluate the impacts of the studies they fund. They should also review the contribution of case studies and expand work on linking trials to meta-analyses and to guidelines.

FUNDING

The National Institute for Health Research HTA programme.

[The feasibility of the application of cryotherapy and radonotherapy for the treatment of the patients presenting with osteoarthritis]

Osteoarthritis (OA) is currently considered to be one of the most widespread diseases. Its main clinical symptoms include pain and dysfunction of joints. In the present review of the foreign and domestic literature, the questions of pathogenesis and risk factors underlying the development of osteoarthritis are discussed. The understanding of OA pathogenesis have altered essentially in the recent years which made necessary the search for the novel approaches to the treatment of this pathology. According to the modern views of OA origin and progression, its therapy should be based on the application of the combination of medicamentous and non-medicamentous modalities including, in particular, collective and individual activities focused on the implementation of the programs of therapeutic physical training as an obligatory component of ОА prophylaxis and treatment. The present review gives evidence of the feasibility of the application of the methods of cryotherapy and radonotherapy for the management of the patients suffering from osteoarthritis. It is emphasized that many recent publications report extensive investigations of the clinical and pathogenetic aspects of the application of these methods for the combined regenerative treatment of the patients presenting with gonarthrosis. The influence of cryotherapy and radonotherapy on the neuroendocrine and immune systems is discussed with special reference to the possibility of regulation of the metabolic processes and retardation of inflammation. It is concluded that the introduction of the above methods into the compulsory individual program for the regenerative treatment of patients presenting with osteoarthritis is pathologically substantiated since it greatly contributes to the reduction of pain and retardation of the progress of the disease. The main pharmaceutical preparations for the OA treatment remain to be slow-acting symptomatic medicines possessed of the chondro-protective effect.

Treatment of musculo-skeletal pain in haemophilia

Musculo-skeletal pain treatment is inadequate in many haemophilic patients. Analgesics are used only by 36% of adult patients. FVIII/FIX intravenous infusion is mainly used to lessen pain, followed in frequency by usage of NSAIDS (primarily COX-2 inhibitors). In about 30% of patients, pain continues after infusion of F VIII/IX. In acute haemarthroses pain treatment must continue until total disappearance (checked by ultrasonography) and include haematologic treatment, short-term rest of the involved joint, cryotherapy, joint aspiration and analgesic medication (paracetamol in mild pain, metamizole for more intense pain, and in a few precise patients, soft opioids such as codeine or tramadol). In the circumstance of intolerable pain we should use morphine hydrochloride either by continual infusion or a patient-controlled analgesia (PCA) pump, determined by the age, mental condition and grade of observance of the patient. Epidural blocks utilizing bupivacaine and fentanyl may be very efficacious as well. Three main strategies to alleviate chronic musculo-skeletal pain secondary to haemophilic arthropathy (joint degeneration) exist: pharmacologic management, physical medicine and rehabilitation, and intra-articular injections. As for pharmacologic management, NSAIDs (ibuprofen, diclofenac, celecoxib, robecoxib) are better than paracetamol. The advantages of tramadol or tramadol/paracetamol and non-tramadol opioids are scanty. With respect to physical medicine and rehabilitation, there is insufficient confirmation that a brace has supplementary favourable effect compared with isolated pharmacologic management. Land-based curative exercise and watery exercise have at the minimum a tiny short-run benefit. Curative ultrasound can be helpful (poor quality of evidence). The efficacy of transcutaneous electrostimulation (TENS) for pain mitigation has not been proved. Electrical stimulation treatment can procure notable ameliorations. With respect to intra-articular injections, viscosupplementation appears to be a useful method for pain alleviation in the short-run (months). The short-run (weeks) advantage of intra-articular corticosteroids in the treatment of joint pain has been shown.

Quantifying kinematic differences between land and water during squats, split squats, and single-leg squats in a healthy population

Aquatic exercises can be used in clinical and sporting disciplines for both rehabilitation and sports training. However, there is limited knowledge on the influence of water immersion on the kinematics of exercises commonly used in rehabilitation and fitness programs. The aim of this study was to use inertial sensors to quantify differences in kinematics and movement variability of bodyweight squats, split squats, and single-leg squats performed on dry land and whilst immersed to the level of the greater trochanter. During two separate testing sessions, 25 active healthy university students (22.3±2.9 yr.) performed ten repetitions of each exercise, whilst tri-axial inertial sensors (100 Hz) recorded their trunk and lower body kinematics. Repeated-measures statistics tested for differences in segment orientation and speed, movement variability, and waveform patterns between environments, while coefficient of variance was used to assess differences in movement variability. Between-environment differences in segment orientation and speed were portrayed by plotting the mean difference ±95% confidence intervals (CI) throughout the tasks. The results showed that the depth of the squat and split squat were unaffected by the changed environment while water immersion allowed for a deeper single leg squat. The different environments had significant effects on the sagittal plane orientations and speeds for all segments. Water immersion increased the degree of movement variability of the segments in all exercises, except for the shank in the frontal plane, which showed more variability on land. Without compromising movement depth, the aquatic environment induces more upright trunk and shank postures during squats and split squats. The aquatic environment allows for increased squat depth during the single-leg squat, and increased shank motions in the frontal plane. Our observations therefore support the use of water-based squat tasks for rehabilitation as they appear to improve the technique without compromising movement depth.

Effect of aquatic physical therapy on pain perception, functional capacity and quality of life in older people with knee osteoarthritis: study protocol for a randomized controlled trial

Background

Aquatic therapy promotes short-term benefits for patients with knee osteoarthritis (OA), and it may be the first therapeutic option for this pathological condition. The objective of this study was to investigate the effects of an aquatic therapy program on pain intensity, functional ability, and quality of life in older people with knee OA.

Methods/design

This is a parallel, two-arm, open, randomized controlled clinical trial with older people with knee OA. Volunteers will be allocated to an aquatic intervention group (WG), subjected to the intervention, or to a control group, not be subjected to any kind of intervention. Data collection pre- and postintervention will be composed of the evaluation of the perception of pain by visual analogue scale with application of nociceptive stimuli in four anatomical points of the knee, functional fitness tests, and application of the World Health Organization Quality of Life Scale abbreviated version and Western Ontario and McMaster Universities Osteoarthritis Index. The program will last 12 weeks, consisting of aerobic and functional exercises in the form of circuit training.

Discussion

The objective of this clinical trial is to evaluate the effect of aquatic therapy in elderly patients with knee OA. The study is guided by practice-based scientific evidence for the use of aquatic rehabilitation exercises. It is expected that the WG volunteers will show reduced pain intensity, increased flexibility, and improved functional capacity and quality of life. It is believed that the desired results can be attributed to physical and physiological effects of immersion in warm water associated with the exercise protocol proposed. The data will be published after completion of the study.

Trial registration

Brazilian Registry of Clinical Trials (ReBEC) registration number: RBR-78h48d. Registered on 19 August 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2061-x) contains supplementary material, which is available to authorized users.

Post-exercise hypotension and heart rate variability response after water- and land-ergometry exercise in hypertensive patients

BACKGROUND

systemic arterial hypertension is the most prevalent cardiovascular disease; physical activity for hypertensive patients is related to several beneficial cardiovascular adaptations. This paper evaluated the effect of water- and land-ergometry exercise sessions on post-exercise hypotension (PEH) of healthy normotensive subjects versus treated or untreated hypertensive patients.

METHODS

Forty-five older women composed three experimental groups: normotensive (N, n = 10), treated hypertensive (TH, n = 15) and untreated hypertensive (UH, n = 20). The physical exercise acute session protocol was performed at 75% of maximum oxygen consumption (VO2max) for 45 minutes; systolic (SBP), diastolic (DBP) and mean (MBP) blood pressure were evaluated at rest, peak and at 15, 30, 45, 60, 75 and 90 minutes after exercise cessation. Additionally, the heart rate variability (HRV) was analyzed by R-R intervals in the frequency domain for the assessment of cardiac autonomic function.

RESULTS

In both exercise modalities, equivalent increases in SBP were observed from rest to peak exercise for all groups, and during recovery, significant PEH was noted. At 90 minutes after the exercise session, the prevalence of hypotension was significantly higher in water- than in the land-based protocol. Moreover, more pronounced reductions in SBP and DBP were observed in the UH patients compared to TH and N subjects. Finally, exercise in the water was more effective in restoring HRV during recovery, with greater effects in the untreated hypertensive group.

CONCLUSION

Our data demonstrated that water-ergometry exercise was able to induce expressive PEH and improve cardiac autonomic modulation in older normotensive, hypertensive treated or hypertensive untreated subjects when compared to conventional land-ergometry.

The effect of Ai Chi aquatic therapy on individuals with knee osteoarthritis: a pilot study

[Purpose] To examine the efficacy of Ai Chi in relieving the pain and stiffness of knee osteoarthritis and improving, physical functioning, proprioception and quality of life. [Subjects and Methods] Twenty-five persons with knee osteoarthritis completed 5 weeks Ai Chi practice (60 minutes per session, twice per week, 10 sessions in total). Knee pain and stiffness were measured before and after the intervention program. [Results] Significant improvements in pain, self-perceived physical functioning and self-perceived stiffness were observed after the Ai-Chi intervention. On average, no significant change in knee range of motion, 6-minute walk test distances or proprioception was observed. [Conclusion] A five-week Ai Chi intervention can improve the pain and stiffness of knee osteoarthritis and self-perceived physical functions and quality of life improvement. Ai Chi may be another treatment choice for people with knee OA to practice in the community.

Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews

BACKGROUND

Chronic pain is defined as pain lasting beyond normal tissue healing time, generally taken to be 12 weeks. It contributes to disability, anxiety, depression, sleep disturbances, poor quality of life, and healthcare costs. Chronic pain has a weighted mean prevalence in adults of 20%.For many years, the treatment choice for chronic pain included recommendations for rest and inactivity. However, exercise may have specific benefits in reducing the severity of chronic pain, as well as more general benefits associated with improved overall physical and mental health, and physical functioning.Physical activity and exercise programmes are increasingly being promoted and offered in various healthcare systems, and for a variety of chronic pain conditions. It is therefore important at this stage to establish the efficacy and safety of these programmes, and furthermore to address the critical factors that determine their success or failure.

OBJECTIVES

To provide an overview of Cochrane Reviews of adults with chronic pain to determine (1) the effectiveness of different physical activity and exercise interventions in reducing pain severity and its impact on function, quality of life, and healthcare use; and (2) the evidence for any adverse effects or harm associated with physical activity and exercise interventions.

METHODS

We searched theCochrane Database of Systematic Reviews (CDSR) on the Cochrane Library (CDSR 2016, Issue 1) for systematic reviews of randomised controlled trials (RCTs), after which we tracked any included reviews for updates, and tracked protocols in case of full review publication until an arbitrary cut-off date of 21 March 2016 (CDSR 2016, Issue 3). We assessed the methodological quality of the reviews using the AMSTAR tool, and also planned to analyse data for each painful condition based on quality of the evidence.We extracted data for (1) self-reported pain severity, (2) physical function (objectively or subjectively measured), (3) psychological function, (4) quality of life, (5) adherence to the prescribed intervention, (6) healthcare use/attendance, (7) adverse events, and (8) death.Due to the limited data available, we were unable to directly compare and analyse interventions, and have instead reported the evidence qualitatively.

MAIN RESULTS

We included 21 reviews with 381 included studies and 37,143 participants. Of these, 264 studies (19,642 participants) examined exercise versus no exercise/minimal intervention in adults with chronic pain and were used in the qualitative analysis.Pain conditions included rheumatoid arthritis, osteoarthritis, fibromyalgia, low back pain, intermittent claudication, dysmenorrhoea, mechanical neck disorder, spinal cord injury, postpolio syndrome, and patellofemoral pain. None of the reviews assessed 'chronic pain' or 'chronic widespread pain' as a general term or specific condition. Interventions included aerobic, strength, flexibility, range of motion, and core or balance training programmes, as well as yoga, Pilates, and tai chi.Reviews were well performed and reported (based on AMSTAR), and included studies had acceptable risk of bias (with inadequate reporting of attrition and reporting biases). However the quality of evidence was low due to participant numbers (most included studies had fewer than 50 participants in total), length of intervention and follow-up (rarely assessed beyond three to six months). We pooled the results from relevant reviews where appropriate, though results should be interpreted with caution due to the low quality evidence. Pain severity: several reviews noted favourable results from exercise: only three reviews that reported pain severity found no statistically significant changes in usual or mean pain from any intervention. However, results were inconsistent across interventions and follow-up, as exercise did not consistently bring about a change (positive or negative) in self-reported pain scores at any single point. Physical function: was the most commonly reported outcome measure. Physical function was significantly improved as a result of the intervention in 14 reviews, though even these statistically significant results had only small-to-moderate effect sizes (only one review reported large effect sizes). Psychological function and quality of life: had variable results: results were either favourable to exercise (generally small and moderate effect size, with two reviews reporting significant, large effect sizes for quality of life), or showed no difference between groups. There were no negative effects. Adherence to the prescribed intervention: could not be assessed in any review. However, risk of withdrawal/dropout was slightly higher in the exercising group (82.8/1000 participants versus 81/1000 participants), though the group difference was non-significant. Healthcare use/attendance: was not reported in any review. Adverse events, potential harm, and death: only 25% of included studies (across 18 reviews) actively reported adverse events. Based on the available evidence, most adverse events were increased soreness or muscle pain, which reportedly subsided after a few weeks of the intervention. Only one review reported death separately to other adverse events: the intervention was protective against death (based on the available evidence), though did not reach statistical significance.

AUTHORS' CONCLUSIONS

The quality of the evidence examining physical activity and exercise for chronic pain is low. This is largely due to small sample sizes and potentially underpowered studies. A number of studies had adequately long interventions, but planned follow-up was limited to less than one year in all but six reviews.There were some favourable effects in reduction in pain severity and improved physical function, though these were mostly of small-to-moderate effect, and were not consistent across the reviews. There were variable effects for psychological function and quality of life.The available evidence suggests physical activity and exercise is an intervention with few adverse events that may improve pain severity and physical function, and consequent quality of life. However, further research is required and should focus on increasing participant numbers, including participants with a broader spectrum of pain severity, and lengthening both the intervention itself, and the follow-up period.

Does aquatic exercise reduce hip and knee joint loading? In vivo load measurements with instrumented implants

Aquatic exercises are widely used for rehabilitation or preventive therapies in order to enable mobilization and muscle strengthening while minimizing joint loading of the lower limb. The load reducing effect of water due to buoyancy is a main advantage compared to exercises on land. However, also drag forces have to be considered that act opposite to the relative motion of the body segments and require higher muscle activity. Due to these opposing effects on joint loading, the load-reducing effect during aquatic exercises remains unknown. The aim of this study was to quantify the joint loads during various aquatic exercises and to determine the load reducing effect of water. Instrumented knee and hip implants with telemetric data transfer were used to measure the resultant joint contact forces in 12 elderly subjects (6x hip, 6x knee) in vivo. Different dynamic, weight-bearing and non-weight-bearing activities were performed by the subjects on land and in chest-high water. Non-weight-bearing hip and knee flexion/extension was performed at different velocities and with additional Aquafins. Joint forces during aquatic exercises ranged between 32 and 396% body weight (BW). Highest forces occurred during dynamic activities, followed by weight-bearing and slow non-weight-bearing activities. Compared to the same activities on land, joint forces were reduced by 36–55% in water with absolute reductions being greater than 100%BW during weight-bearing and dynamic activities. During non-weight-bearing activities, high movement velocities and additional Aquafins increased the joint forces by up to 59% and resulted in joint forces of up to 301%BW. This study confirms the load reducing effect of water during weight-bearing and dynamic exercises. Nevertheless, high drag forces result in increased joint contact forces and indicate greater muscle activity. By the choice of activity, movement velocity and additional resistive devices joint forces can be modulated individually in the course of rehabilitation or preventive therapies.

Knee osteoarthritis: Therapeutic alternatives in primary care

AIM

To discusses pharmacological and non-pharmacological therapeutic alternatives for managing knee osteoarthritis in primary care by primary health care nurse practitioners.

METHODS

A case example is presented, the evidence-based guideline recommendations of the Osteoarthritis Research Society International and the American Academy of Orthopaedic Surgeons are reviewed, and a plan of care is developed.

RESULTS

Osteoarthritis is the most common form of arthritis seen in primary care, and it is a major public health issue because the aging population and widespread obesity have drastically increased incidence. Osteoarthritis is clinically associated with escalating chronic pain, physical disability, and decreased quality of life. Early diagnosis of mild osteoarthritis in relatively young patients presents an opportunity for primary health care providers to manage pain, increase quality of life, and decrease risk of disability.

CONCLUSION

Primary health care providers can implement these recommendations in their own practices to provide care to patients with knee osteoarthritis based on current best evidence.

Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews

BACKGROUND

Chronic pain is defined as pain lasting beyond normal tissue healing time, generally taken to be 12 weeks. It contributes to disability, anxiety, depression, sleep disturbances, poor quality of life, and healthcare costs. Chronic pain has a weighted mean prevalence in adults of 20%.For many years, the treatment choice for chronic pain included recommendations for rest and inactivity. However, exercise may have specific benefits in reducing the severity of chronic pain, as well as more general benefits associated with improved overall physical and mental health, and physical functioning.Physical activity and exercise programmes are increasingly being promoted and offered in various healthcare systems, and for a variety of chronic pain conditions. It is therefore important at this stage to establish the efficacy and safety of these programmes, and furthermore to address the critical factors that determine their success or failure.

OBJECTIVES

To provide an overview of Cochrane Reviews of adults with chronic pain to determine (1) the effectiveness of different physical activity and exercise interventions in reducing pain severity and its impact on function, quality of life, and healthcare use; and (2) the evidence for any adverse effects or harm associated with physical activity and exercise interventions.

METHODS

We searched theCochrane Database of Systematic Reviews (CDSR) on the Cochrane Library (CDSR 2016, Issue 1) for systematic reviews of randomised controlled trials (RCTs), after which we tracked any included reviews for updates, and tracked protocols in case of full review publication until an arbitrary cut-off date of 21 March 2016 (CDSR 2016, Issue 3). We assessed the methodological quality of the reviews using the AMSTAR tool, and also planned to analyse data for each painful condition based on quality of the evidence.We extracted data for (1) self-reported pain severity, (2) physical function (objectively or subjectively measured), (3) psychological function, (4) quality of life, (5) adherence to the prescribed intervention, (6) healthcare use/attendance, (7) adverse events, and (8) death.Due to the limited data available, we were unable to directly compare and analyse interventions, and have instead reported the evidence qualitatively.

MAIN RESULTS

We included 21 reviews with 381 included studies and 37,143 participants. Of these, 264 studies (19,642 participants) examined exercise versus no exercise/minimal intervention in adults with chronic pain and were used in the qualitative analysis.Pain conditions included rheumatoid arthritis, osteoarthritis, fibromyalgia, low back pain, intermittent claudication, dysmenorrhoea, mechanical neck disorder, spinal cord injury, postpolio syndrome, and patellofemoral pain. None of the reviews assessed 'chronic pain' or 'chronic widespread pain' as a general term or specific condition. Interventions included aerobic, strength, flexibility, range of motion, and core or balance training programmes, as well as yoga, Pilates, and tai chi.Reviews were well performed and reported (based on AMSTAR), and included studies had acceptable risk of bias (with inadequate reporting of attrition and reporting biases). However the quality of evidence was low due to participant numbers (most included studies had fewer than 50 participants in total), length of intervention and follow-up (rarely assessed beyond three to six months). We pooled the results from relevant reviews where appropriate, though results should be interpreted with caution due to the low quality evidence. Pain severity: several reviews noted favourable results from exercise: only three reviews that reported pain severity found no statistically significant changes in usual or mean pain from any intervention. However, results were inconsistent across interventions and follow-up, as exercise did not consistently bring about a change (positive or negative) in self-reported pain scores at any single point. Physical function: was the most commonly reported outcome measure. Physical function was significantly improved as a result of the intervention in 14 reviews, though even these statistically significant results had only small-to-moderate effect sizes (only one review reported large effect sizes). Psychological function and quality of life: had variable results: results were either favourable to exercise (generally small and moderate effect size, with two reviews reporting significant, large effect sizes for quality of life), or showed no difference between groups. There were no negative effects. Adherence to the prescribed intervention: could not be assessed in any review. However, risk of withdrawal/dropout was slightly higher in the exercising group (82.8/1000 participants versus 81/1000 participants), though the group difference was non-significant. Healthcare use/attendance: was not reported in any review. Adverse events, potential harm, and death: only 25% of included studies (across 18 reviews) actively reported adverse events. Based on the available evidence, most adverse events were increased soreness or muscle pain, which reportedly subsided after a few weeks of the intervention. Only one review reported death separately to other adverse events: the intervention was protective against death (based on the available evidence), though did not reach statistical significance.

AUTHORS' CONCLUSIONS

The quality of the evidence examining physical activity and exercise for chronic pain is low. This is largely due to small sample sizes and potentially underpowered studies. A number of studies had adequately long interventions, but planned follow-up was limited to less than one year in all but six reviews.There were some favourable effects in reduction in pain severity and improved physical function, though these were mostly of small-to-moderate effect, and were not consistent across the reviews. There were variable effects for psychological function and quality of life.The available evidence suggests physical activity and exercise is an intervention with few adverse events that may improve pain severity and physical function, and consequent quality of life. However, further research is required and should focus on increasing participant numbers, including participants with a broader spectrum of pain severity, and lengthening both the intervention itself, and the follow-up period.

Evaluation of the efficacy of a short-course, personalized self-management and intensive spa therapy intervention as active prevention of musculoskeletal disorders of the upper extremities (Muska): a research protocol for a randomized controlled trial

Background

Musculoskeletal disorders (MSDs) constitute a major occupational health problem in the working population, substantially impacting the quality of life of employees. They also cause considerable economic cost to the healthcare system, with, notably, the reimbursement of treatments and compensation for lost income. MSDs manifest as localized pain or functional difficulty in one or more anatomical areas, such as the cervical spine, shoulder, elbow, hand, and wrist. Although prevalence varies depending on the region considered and the method of assessment, a prevalence of 30% is found in different epidemiological studies. The disease needs to be prevented, not only for medical and economic reasons, but also for legal reasons, owing to the requirement of assessing occupational risks. The strategy envisaged may thus revolve around active, multimodal prevention that has employees fully involved at the heart of their care. Although physical exercise is widely recommended, few studies with a good level of evidence have enabled us to base a complete, well-constructed intervention on exercise that can be offered as secondary prevention in these disorders.

Methods

A prospective, multicenter, comparative (intervention arm vs. control arm), randomized (immediate vs. later treatment) study using Zelen’s design. This study falls under active prevention of MSDs of the upper extremities (UE-MSDs). Participants are workers aged between 18 and 65 years with latent or symptomatic MSDS, with any type of job or workstation, with or without an history of sick leave. The primary aim is to show the superiority at 3 months of a combination of spa therapy, exercise, and self-management workshops for 6 days over usual care in the management of MSDs in terms of employee functional capacity in personal and professional daily life. Secondary aims are to assess the benefit of the intervention in terms of pain, quality of life, and accumulated duration of sick leave.

Discussion

This randomized controlled trial is the first that will aim to evaluate multidisciplinary management of UE-MSDs using nonpharmacological treatment combining exercise, self-management, and spa therapy. The originality of this intervention lies, in its short, intensive format, which is compatible with remaining in work; and in its multidisciplinary approach. This trial has the potential to demonstrate, with a good level of evidence, the benefits of a short course of spa therapy combined with a personalized self-management program on the functional capacity, pain, and quality of life of employees in their daily life.

Trial registration

Clinical trial.gov NCT02702466 retrospectively registered.

Protocol: Version 4 of 9/10/2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-1353-8) contains supplementary material, which is available to authorized users.

Optimizing literature search in systematic reviews - are MEDLINE, EMBASE and CENTRAL enough for identifying effect studies within the area of musculoskeletal disorders?

BACKGROUND

When conducting systematic reviews, it is essential to perform a comprehensive literature search to identify all published studies relevant to the specific research question. The Cochrane Collaborations Methodological Expectations of Cochrane Intervention Reviews (MECIR) guidelines state that searching MEDLINE, EMBASE and CENTRAL should be considered mandatory. The aim of this study was to evaluate the MECIR recommendations to use MEDLINE, EMBASE and CENTRAL combined, and examine the yield of using these to find randomized controlled trials (RCTs) within the area of musculoskeletal disorders.

METHODS

Data sources were systematic reviews published by the Cochrane Musculoskeletal Review Group, including at least five RCTs, reporting a search history, searching MEDLINE, EMBASE, CENTRAL, and adding reference- and hand-searching. Additional databases were deemed eligible if they indexed RCTs, were in English and used in more than three of the systematic reviews. Relative recall was calculated as the number of studies identified by the literature search divided by the number of eligible studies i.e. included studies in the individual systematic reviews. Finally, cumulative median recall was calculated for MEDLINE, EMBASE and CENTRAL combined followed by the databases yielding additional studies.

RESULTS

Deemed eligible was twenty-three systematic reviews and the databases included other than MEDLINE, EMBASE and CENTRAL was AMED, CINAHL, HealthSTAR, MANTIS, OT-Seeker, PEDro, PsychINFO, SCOPUS, SportDISCUS and Web of Science. Cumulative median recall for combined searching in MEDLINE, EMBASE and CENTRAL was 88.9% and increased to 90.9% when adding 10 additional databases.

CONCLUSION

Searching MEDLINE, EMBASE and CENTRAL was not sufficient for identifying all effect studies on musculoskeletal disorders, but additional ten databases did only increase the median recall by 2%. It is possible that searching databases is not sufficient to identify all relevant references, and that reviewers must rely upon additional sources in their literature search. However further research is needed.

Health-related quality of life and musculoskeletal function in patients with musculoskeletal disorders: after compared to before short-term group-based aqua-exercises

This study assessed health-related quality of life (HRQoL) and musculoskeletal function in patients with musculoskeletal disorders after participation in group-based aqua-exercising, compared to before participation. Physiotherapists instructed group-based aqua-exercising for 30 min twice a week for 8 weeks in 39 patients (81% women, mean age 55 ± 12 years), with musculoskeletal disorders located in the back (28%), neck (17%), general myalgia (21%), lower extremities (9%), shoulder (7%) and multiple/other regions (18%). Before and after the aqua-exercising, physiotherapists assessed patients’ musculoskeletal function categorized using Goal Attainment Scaling, and HRQoL was measured using EuroQol 5 Dimensions (EQ-5D). The median EQ-5D score was 0.36 (25th–75th percentiles 0.09–0.69) at the start, and after the intervention improved to 0.62 (0.09–0.73) (p = 0.038). The EQ-5D score and musculoskeletal function improved in 49% (EQ-5D) and 34% (physiotherapist assessment), were stable in 33% and 63%, and worsened in 18% and 7% of patients, respectively. In conclusion, comparable with improvements previously seen after more time-consuming exercise periods, patients with musculoskeletal disorders had improved HRQoL after 8 weeks of aqua-exercising compared to before exercising. This uncontrolled feasibility study does not reveal whether this was the result of aqua-exercising. The effects and costs need to be evaluated in randomized controlled studies.

A Water Rehabilitation Program in Patients with Hip Osteoarthritis Before and After Total Hip Replacement

BACKGROUND Pain associated with coxarthrosis, typically occurring in middle-aged and elderly patients, very commonly causes considerable limitation of motor fitness and dependence on pharmacotherapy. This article provides an assessment of a rehabilitation program with tailored water exercises in patients with osteoarthritis before and after total hip replacement. MATERIAL AND METHODS A total of 192 patients (the mean age 61.03±10.89) suffering from hip osteoarthritis (OA) were evaluated before and after total hip replacement (THR). The clinical study covered measurements of hip active ranges of motion (HAROM) and the forces generated by pelvis stabilizer muscles. Pain intensity was assessed according to analogue-visual scale of pain (VAS) and according to the Modified Laitinen Questionnaire. The patients were divided into 6 groups (4 treatment and 2 control). We compared 2 rehabilitation programs using kinesitherapy and low-frequency magnetic field. One of them also had specially designed exercises in the water. Statistical analysis was carried out at the significance level α=0.05. This was a cross-sectional study. RESULTS A positive effect of water exercises on a number of parameters was found in patients with OA both before and after total hip replacement surgery. We noted a significant reduction of pain (p<0.001), increased ranges of motion and muscle strength, and reduced use of medicines (NASAIDs) (p<0.001). A correlation was found between the degree of degenerative deforming lesions and the effects of the treatment process (p<0.01). CONCLUSIONS 1. The rehabilitation program including water exercises most significantly reduced pain in patients with OA before and after total hip replacement surgery. 2. Inclusion of water exercises in a rehabilitation program can reduce the use of medicines in patient with OA and after THR.

The PLE(2)NO self-management and exercise program for knee osteoarthritis: Study Protocol for a Randomized Controlled Trial

Background

International recommendations suggest exercise and self-management programs, including non-pharmacological treatments, for knee osteoarthritis (KOA) because they can benefit pain relief and improve function and exercise adherence. The implementation of a combined self-management and exercise program termed PLE²NO may be a good method for controlling KOA symptoms because it encourages the development of self-efficacy to manage the pathology. This study will assess the effects of a self-management and exercise program in comparison to an educational intervention (control program) on symptoms, physical fitness, health-related quality of life, self-management behaviors, self-efficacy, physical activity level and coping strategies.

Methods/Design

This PLE²NO study is a single-blinded, randomized controlled trial of elderly (aged above 60 yrs old) patients with clinical and radiographic KOA. The patients will be allocated into either an educational group (control) or a self-management and exercise group (experimental). All participants will receive a supplement of chondroitin and glucosamine sulfates. This paper describes the protocol that will be used in the PLE²NO program.

Discussion

This program has several strengths. First, it involves a combination of self-management and exercise approaches, is available in close proximity to the patients and occurs over a short period of time. The latter two characteristics are crucial for maintaining participant adherence. Exercise components will be implemented using low-cost resources that permit their widespread application. Moreover, the program will provide guidance regarding the effectiveness of using a self-management and exercise program to control KOA symptoms and improve self-efficacy and health-related quality of life.

Trial registration

NCT02562833 (09/23/2015)

Aquatic exercise for the treatment of knee and hip osteoarthritis

BACKGROUND

Osteoarthritis is a chronic disease characterized by joint pain, tenderness, and limitation of movement. At present, no cure is available. Thus only treatment of the person's symptoms and treatment to prevent further development of the disease are possible. Clinical trials indicate that aquatic exercise may have advantages for people with osteoarthritis. This is an update of a published Cochrane review.

OBJECTIVES

To evaluate the effects of aquatic exercise for people with knee or hip osteoarthritis, or both, compared to no intervention.

SEARCH METHODS

We searched the following databases up to 28 April 2015: the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library Issue 1, 2014), MEDLINE (from 1949), EMBASE (from 1980), CINAHL (from 1982), PEDro (Physiotherapy Evidence Database), and Web of Science (from 1945). There was no language restriction.

SELECTION CRITERIA

Randomized controlled clinical trials of aquatic exercise compared to a control group (e.g. usual care, education, social attention, telephone call, waiting list for surgery) of participants with knee or hip osteoarthritis.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data and assessed risk of bias of the included trials. We analysed the pooled results using standardized mean difference (SMD) values.

MAIN RESULTS

Nine new trials met the inclusion criteria and we excluded two earlier included trials. Thus the number of participants increased from 800 to 1190 and the number of included trials increased from six to 13. Most participants were female (75%), with an average age of 68 years and a body mass index (BMI) of 29.4. Osteoarthritis duration was 6.7 years, with a great variation of the included participants. The mean aquatic exercise duration was 12 weeks. We found 12 trials at low to unclear risk of bias for all domains except blinding of participants and personnel. They showed that aquatic exercise caused a small short term improvement compared to control in pain (SMD -0.31, 95% CI -0.47 to -0.15; 12 trials, 1076 participants) and disability (SMD -0.32, 95% CI -0.47 to -0.17; 12 trials, 1059 participants). Ten trials showed a small effect on quality of life (QoL) (SMD -0.25, 95% CI -0.49 to -0.01; 10 trials, 971 participants). These effects on pain and disability correspond to a five point lower (95% CI three to eight points lower) score on mean pain and mean disability compared to the control group (scale 0 to 100), and a seven point higher (95% CI 0 to 13 points higher) score on mean QoL compared with control group (scale 0 to 100). No included trials performed a radiographic evaluation. No serious adverse events were reported in the included trials with relation to aquatic exercise.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that aquatic exercise may have small, short-term, and clinically relevant effects on patient-reported pain, disability, and QoL in people with knee and hip OA. The conclusions of this review update does not change those of the previous published version of this Cochrane review.

Hyaluronic acid and other conservative treatment options for osteoarthritis of the ankle

BACKGROUND

The cause of ankle osteoarthritis (OA) is usually trauma. Patients are relatively young, since ankle trauma occurs at a relatively young age. Several conservative treatment options are available, evidence of the benefits and harms of these options are lacking.

OBJECTIVES

To assess the benefits and harms of any conservative treatment for ankle OA in adults in order to provide a synthesis of the evidence as a base for future treatment guidelines.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, issue 9), MEDLINE (Ovid) (1946 up to 11 September 2014), EMBASE (1947 to September 2014), PsycINFO (1806 to September 2014), CINAHL (1985 to September 2014), PEDro (all years till September 2014), AMED until September 2014, ClinicalTrials.gov, Current Controlled Trials, The Dutch Register. To identify potentially relevant studies we screened reference lists in retrieved review articles and trials.

SELECTION CRITERIA

We considered randomised or controlled clinical trials investigating any non-surgical intervention for ankle OA for inclusion.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

No other RCT concerning any other conservative treatment besides the use of hyaluronic acid (HA) for ankle OA was identified. Six randomised controlled trials (RCTs) were included.A total of 240 participants diagnosed with ankle OA were included in this review. The primary analysis included three RCTs (109 participants) which compared HA to placebo. One study compared HA to exercise therapy, one compared HA combined with exercise therapy to an intra-articular injection of botulinum toxin and one compared four different dosages of HA.Primary analysis: a pooled analysis of two trials (45 participants) found that the Ankle Osteoarthritis Scale (AOS) total score (measuring pain and physical function) was reduced by 12% (95% CI -24% to -1%) at six months (mean difference (MD) -12.53 (95% CI -23.84 to -1.22) on a scale of 0 to 100; number needed to treat for an additional beneficial outcome (NNTB) = 4 (95% CI 2 to 205); this evidence was graded as low quality, due to limitations in study design (unclear risk of selection bias for two studies and unclear risk for attrition bias for one study) and imprecision of results: a small population size (45 participants). It is not known if a mean difference of 12.53 points on a 100 point scale is clinically relevant. No minimal important clinical difference is known for this score. Pain and function outcomes were not reported separately. Radiographic joint structure changes were not investigated. For the mean quality of life at six months (two trials; 45 participants) no meta-analysis could be performed due to missing data. No serious adverse events (SAEs) were noted and no participants withdrew because of an adverse event. There were a few adverse events (AEs) 5/63 (8%) in the HA group and 2/46 (4%) in the placebo group. The Peto odds ratio (Peto OR) to have an adverse event was 2.34 higher compared to the control group (95% CI 0.45 to 12.11). This evidence is inconclusive because of a wide CI and a small number of events.For comparing HA to exercise therapy (30 participants) the results for pain on a Visual Analogue Scale (VAS 0 to 10) at 12 months are inconclusive (MD 0.70, 95% CI -2.54 to 1.14). The American Orthopedic Foot and Ankle Society score (AOFAS score) was 13.10 points (MD) higher in favour of HA (95% CI 2.97 to 23.23) on a scale of 0 to 100. The evidence was graded as low. No adverse events were found. Radiographic structure changes were not measured; no participants withdrew due to AEs; no SAEs were found.For the comparison of HA injection combined with exercise therapy to an intra-articular injection of botulinum toxin A (BoNT-A) (75 participants), the outcome of the AOS pain score of the affected joint at six months is inconclusive (MD 0.10, 95% CI -0.42 to 0.62). The physical function (the AOS disability score) at six months is inconclusive (MD 0.20, 95% CI -0.34 to 0.74). The same number of AEs were found in both groups; HA 2/37 (5.9%), BoNT-A 2/38 (5.8%) (risk ratio (RR) 1.03, 95% CI 0.15 to 6.91). Radiographic changes were not examined, no SAEs were found and no participants withdrew because of an AE. The evidence was graded as low.The RCT comparing four different dosing schedules for HA (26 participants) showed the best median decrease in pain on walking VAS (on a scale of 0 to 100) for 3 x 1 ml at 27 weeks with a median decrease of 30. Physical function, radiographic changes and quality of life were not measured.Twenty-seven percent of all participants had AEs, most of them in the 2ml group (57% in this group). No participants withdrew due to an AE and no SAEs were noted.Overall the quality of the evidence showed some serious limitations. The evidence was graded low for the primary analysis comparing HA to placebo. This was based on a limitation in design and implementation: sample sizes were small (45 to 92 participants) and and imprecision in results: there was an unclear risk of bias for several items concerning the three studies used in the meta analysis.

AUTHORS' CONCLUSIONS

Currently, there is insufficient data to create a synthesis of the evidence as a base for future guidelines for ankle OA. Since the aetiology of ankle OA is different, guidelines that are currently used for hip and knee OA may not be applicable for ankle OA. Simple analgesics as recommended for hip and knee OA seem however a reasonable first step to treat ankle OA. It is unclear if there is a benefit or harm for HA as treatment for ankle OA compared to placebo at six months based on a low quality of evidence. Inconclusive results were found comparing HA to other treatments. HA can be conditionally recommended if patients have an inadequate response to simple analgesics. It remains unclear which patients (age, grade of ankle OA) benefit the most from HA injections and which dosage schedule should be used.

Target intensity and interval walking training in water to enhance physical fitness in middle-aged and older women: a randomised controlled study

PURPOSE

To determine the target intensity for fast walking during interval walking training (IWT) in water for middle-aged and older people to enhance physical fitness.

METHODS

Thirty-one women [59 ± 5 (SD) years old] were randomly divided into two groups: IWT on land (LG, N = 15) and in water (WG, N = 16). All subjects were instructed to perform ≥ 6 sets of fast and slow walking for 3 min each in a day, ≥ 4 days week(-1), for 8 weeks, at an intensity 35% higher than the oxygen consumption rate at the gas exchange threshold (VO2GET), with a subjective feeling of 16-18 points of the Borg scale during fast walking in each condition. Before and after IWT, we measured VO2GET, peak aerobic capacity (VO2peak) by graded walking and cycling tests on land and isometric knee extension (F EXT) and flexion (F FLX) forces.

RESULTS

Before IWT, the VO2GET for walking in water was 14% higher and the heart rate (HR) at a given VO2 was ~10 beats min(-1) lower (P=0.001) than on land. During IWT, subjects in both groups performed IWT for ~4 days week(-1)(P > 0.9) with a 14% higher fast walking intensity in WG than in LG (P < 0.05). After IWT, the VO2peak and VO2GET for cycling, F EXT and F FLX increased more in WG than in LG (all, P < 0.05).

CONCLUSION

Walking in water elevated VO2GET and decreased HR at a given exercise intensity in middle-aged and older women, which enabled them to perform exercise at a higher metabolic rate than on land due to improved subjective feelings, which, for these subjects, resulted in greater gains in physical fitness.

Effects of Aquatic Therapy and Land-Based Therapy versus Land-Based Therapy Alone on Range of Motion, Edema, and Function after Hip or Knee Replacement: A Systematic Review and Meta-analysis

PURPOSE

To determine whether aquatic therapy in combination with land-based therapy improves patient outcomes after hip or knee arthroplasty compared with land-based therapy alone.

METHODS

For this systematic review, six online databases (MEDLINE, CINAHL, AMED, EMBASE, Cochrane, and PEDro) were searched from the earliest date available until September 2013. Controlled trials published in English in a peer-reviewed journal that compared aquatic therapy in combination with land-based therapy with land-based therapy alone were included; trial quality was assessed using the PEDro scale. Data were presented as standardized mean differences (SMDs), their associated 95% CIs, and meta-analyses.

RESULTS

Three small trials of moderate quality were included in the qualitative analysis. Meta-analysis of two of these studies found moderate-quality evidence that aquatic therapy in combination with land-based therapy improves functional outcomes (SMD=0.53; 95% CI, 0.03-1.03), knee range of motion (measured in knee or hip arthroplasty; SMD=0.78; 95% CI, 0.27-1.29), and edema (SMD=-0.66; 95% CI, -1.16 to -0.15) compared with land-based therapy alone. The results for improved functional outcomes were not considered clinically significant.

CONCLUSIONS

It is not possible to draw confident conclusions from this review because of the small number of studies of limited quality and the modest differences found. Further studies of sound methodological quality are required to confirm the results. Economic analysis alongside randomized controlled trials is needed to examine the cost-effectiveness of these clinical outcomes.

Efficacy of rehabilitation programs for improving muscle strength in people with hip or knee osteoarthritis: a systematic review with meta-analysis

To analyse the effect of exercise-based rehabilitation programs for improving lower limb muscle strength in individuals with hip or knee osteoarthritis (OA). A systematic search utilizing seven databases identified randomized controlled trials (RCTs) evaluating lower limb strength outcomes of exercise-based interventions for participants with hip or knee OA. All studies were screened for eligibility and methodological quality. Quality of evidence was assessed using Grading of Recommendation, Assessment, Development and Evaluation (GRADE) approach. Data were pooled and meta-analyses performed where appropriate. Forty RCTs were included and the majority (77%) involved resistance based exercise programs. For knee OA populations, there was high quality evidence for improved knee extension (standardized mean difference (SMD) = 0.47, 95% confidence intervals (CI) 0.29, 0.66) and flexion strength (SMD = 0.74, 95% CI 0.56, 0.92) with low-intensity resistance program when compared to a control at short term (ST) follow-up. There was moderate quality evidence for a large effect favouring high-intensity resistance programs (SMD = 0.76, 95% CI 0.47, 1.06) when compared to a control. This effect was sustained at intermediate term (IT) follow-up (SMD = 0.80, 95% CI 0.44, 1.17). Few studies reported on outcomes at long term (LT) follow-up. Only one study reported on a population with hip OA. When compared to a control group, high-intensity resistance exercise demonstrated moderate quality of evidence for large and sustained improvements for knee muscle strength in knee OA patients. Further work is needed to compare different modes of exercise at a LT follow-up for knee OA patients and to address the dearth of literature evaluating exercise interventions in people with hip OA.

Aquatic exercise training for fibromyalgia

BACKGROUND

Exercise training is commonly recommended for individuals with fibromyalgia. This review examined the effects of supervised group aquatic training programs (led by an instructor). We defined aquatic training as exercising in a pool while standing at waist, chest, or shoulder depth. This review is part of the update of the 'Exercise for treating fibromyalgia syndrome' review first published in 2002, and previously updated in 2007.

OBJECTIVES

The objective of this systematic review was to evaluate the benefits and harms of aquatic exercise training in adults with fibromyalgia.

SEARCH METHODS

We searched The Cochrane Library 2013, Issue 2 (Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, Health Technology Assessment Database, NHS Economic Evaluation Database), MEDLINE, EMBASE, CINAHL, PEDro, Dissertation Abstracts, WHO international Clinical Trials Registry Platform, and AMED, as well as other sources (i.e., reference lists from key journals, identified articles, meta-analyses, and reviews of all types of treatment for fibromyalgia) from inception to October 2013. Using Cochrane methods, we screened citations, abstracts, and full-text articles. Subsequently, we identified aquatic exercise training studies.

SELECTION CRITERIA

Selection criteria were: a) full-text publication of a randomized controlled trial (RCT) in adults diagnosed with fibromyalgia based on published criteria, and b) between-group data for an aquatic intervention and a control or other intervention. We excluded studies if exercise in water was less than 50% of the full intervention.

DATA COLLECTION AND ANALYSIS

We independently assessed risk of bias and extracted data (24 outcomes), of which we designated seven as major outcomes: multidimensional function, self reported physical function, pain, stiffness, muscle strength, submaximal cardiorespiratory function, withdrawal rates and adverse effects. We resolved discordance through discussion. We evaluated interventions using mean differences (MD) or standardized mean differences (SMD) and 95% confidence intervals (95% CI). Where two or more studies provided data for an outcome, we carried out meta-analysis. In addition, we set and used a 15% threshold for calculation of clinically relevant differences.

MAIN RESULTS

We included 16 aquatic exercise training studies (N = 881; 866 women and 15 men). Nine studies compared aquatic exercise to control, five studies compared aquatic to land-based exercise, and two compared aquatic exercise to a different aquatic exercise program.We rated the risk of bias related to random sequence generation (selection bias), incomplete outcome data (attrition bias), selective reporting (reporting bias), blinding of outcome assessors (detection bias), and other bias as low. We rated blinding of participants and personnel (selection and performance bias) and allocation concealment (selection bias) as low risk and unclear. The assessment of the evidence showed limitations related to imprecision, high statistical heterogeneity, and wide confidence intervals. Aquatic versus controlWe found statistically significant improvements (P value < 0.05) in all of the major outcomes. Based on a 100-point scale, multidimensional function improved by six units (MD -5.97, 95% CI -9.06 to -2.88; number needed to treat (NNT) 5, 95% CI 3 to 9), self reported physical function by four units (MD -4.35, 95% CI -7.77 to -0.94; NNT 6, 95% CI 3 to 22), pain by seven units (MD -6.59, 95% CI -10.71 to -2.48; NNT 5, 95% CI 3 to 8), and stiffness by 18 units (MD -18.34, 95% CI -35.75 to -0.93; NNT 3, 95% CI 2 to 24) more in the aquatic than the control groups. The SMD for muscle strength as measured by knee extension and hand grip was 0.63 standard deviations higher compared to the control group (SMD 0.63, 95% CI 0.20 to 1.05; NNT 4, 95% CI 3 to 12) and cardiovascular submaximal function improved by 37 meters on six-minute walk test (95% CI 4.14 to 69.92). Only two major outcomes, stiffness and muscle strength, met the 15% threshold for clinical relevance (improved by 27% and 37% respectively). Withdrawals were similar in the aquatic and control groups and adverse effects were poorly reported, with no serious adverse effects reported. Aquatic versus land-basedThere were no statistically significant differences between interventions for multidimensional function, self reported physical function, pain or stiffness: 0.91 units (95% CI -4.01 to 5.83), -5.85 units (95% CI -12.33 to 0.63), -0.75 units (95% CI -10.72 to 9.23), and two units (95% CI -8.88 to 1.28) respectively (all based on a 100-point scale), or in submaximal cardiorespiratory function (three seconds on a 100-meter walk test, 95% CI -1.77 to 7.77). We found a statistically significant difference between interventions for strength, favoring land-based training (2.40 kilo pascals grip strength, 95% CI 4.52 to 0.28). None of the outcomes in the aquatic versus land comparison reached clinically relevant differences of 15%. Withdrawals were similar in the aquatic and land groups and adverse effects were poorly reported, with no serious adverse effects in either group. Aquatic versus aquatic (Ai Chi versus stretching in the water, exercise in pool water versus exercise in sea water)Among the major outcomes the only statistically significant difference between interventions was for stiffness, favoring Ai Chi (1.00 on a 100-point scale, 95% CI 0.31 to 1.69).

AUTHORS' CONCLUSIONS

Low to moderate quality evidence relative to control suggests that aquatic training is beneficial for improving wellness, symptoms, and fitness in adults with fibromyalgia. Very low to low quality evidence suggests that there are benefits of aquatic and land-based exercise, except in muscle strength (very low quality evidence favoring land). No serious adverse effects were reported.

Exercise in osteoarthritis: moving from prescription to adherence

Exercise is recommended for the management of osteoarthritis (OA) in all clinical guidelines irrespective of disease severity, pain levels, and functional status. For knee OA, evidence supports the benefits of various types of exercise for improving pain and function in the short term. However, there is much less research investigating the effects of exercise in patients with OA at other joints such as the hip and hand. It is important to note that while the magnitude of exercise benefits may be considered small to moderate, these effects are comparable to reported estimates for simple analgesics and oral nonsteroidal anti-inflammatory drugs for OA pain but exercise has much fewer side effects. Exercise prescription should be individualized based on assessment findings and be patient centered involving shared decision making between the patient and clinician. Given that patient adherence to exercise declines over time, appropriate attention should be pain as reduced adherence attenuates the benefits of exercise. Given this, barriers and facilitators to exercise should be identified and strategies to maximize long-term adherence to exercise implemented.