Comparison of the therapeutic efficacy of TENS versus intra-articular hyaluronic acid injection in patients with knee osteoarthritis: a prospective randomized study

Comparative Efficacy of Intra-Articular Injection, Physical Therapy, and Combined Treatments on Pain, Function, and Sarcopenia Indices in Knee Osteoarthritis: A Network Meta-Analysis of Randomized Controlled Trials

Knee osteoarthritis (KOA) is associated with a high risk of sarcopenia. Both intra-articular injections (IAIs) and physical therapy (PT) exert benefits in KOA. This network meta-analysis (NMA) study aimed to identify comparative efficacy among the combined treatments (IAI+PT) in patients with KOA. Seven electronic databases were systematically searched from inception until January 2023 for randomized controlled trials (RCTs) reporting the effects of IAI+PT vs. IAI or PT alone in patients with KOA. All RCTs which had treatment arms of IAI agents (autologous conditioned serum, botulinum neurotoxin type A, corticosteroids, dextrose prolotherapy (DxTP), hyaluronic acid, mesenchymal stem cells (MSC), ozone, platelet-rich plasma, plasma rich in growth factor, and stromal vascular fraction of adipose tissue) in combination with PT (exercise therapy, physical agent modalities (electrotherapy, shockwave therapy, thermal therapy), and physical activity training) were included in this NMA. A control arm receiving placebo IAI or usual care, without any other IAI or PT, was used as the reference group. The selected RCTs were analyzed through a frequentist method of NMA. The main outcomes included pain, global function (GF), and walking capability (WC). Meta-regression analyses were performed to explore potential moderators of the treatment efficacy. We included 80 RCTs (6934 patients) for analyses. Among the ten identified IAI+PT regimens, DxTP plus PT was the most optimal treatment for pain reduction (standard mean difference (SMD) = -2.54) and global function restoration (SMD = 2.28), whereas MSC plus PT was the most effective for enhancing WC recovery (SMD = 2.54). More severe KOA was associated with greater changes in pain (β = -2.52) and WC (β = 2.16) scores. Combined IAI+PT treatments afford more benefits than do their corresponding monotherapies in patients with KOA; however, treatment efficacy is moderated by disease severity.

Characterising the Features of 381 Clinical Studies Evaluating Transcutaneous Electrical Nerve Stimulation (TENS) for Pain Relief: A Secondary Analysis of the Meta-TENS Study to Improve Future Research

Background and Objectives: Characterising the features of methodologies, clinical attributes and intervention protocols, of studies is valuable to advise directions for research and practice. This article reports the findings of a secondary analysis of the features from studies screened as part of a large systematic review of TENS (the meta-TENS study). Materials and Methods: A descriptive analysis was performed on information associated with methodology, sample populations and intervention protocols from 381 randomised controlled trials (24,532 participants) evaluating TENS delivered at a strong comfortable intensity at the painful site in adults with pain, irrespective of diagnosis. Results: Studies were conducted in 43 countries commonly using parallel group design (n = 334) and one comparator group (n = 231). Mean ± standard deviation (SD) study sample size (64.05 ± 58.29 participants) and TENS group size (27.67 ± 21.90 participants) were small, with only 13 of 381 studies having 100 participants or more in the TENS group. Most TENS interventions were ‘high frequency’ (>10 pps, n = 276) and using 100 Hz (109/353 reports that stated a pulse frequency value). Of 476 comparator groups, 54.2% were active treatments (i.e., analgesic medication(s), exercise, manual therapies and electrophysical agents). Of 202 placebo comparator groups, 155 used a TENS device that did not deliver currents. At least 216 of 383 study groups were able to access other treatments whilst receiving TENS. Only 136 out of 381 reports included a statement about adverse events. Conclusions: Clinical studies on TENS are dominated by small parallel group evaluations of high frequency TENS that are often contaminated by concurrent treatment(s). Study reports tended focus on physiological and clinical implications rather than the veracity of methodology and findings. Previously published criteria for designing and reporting TENS studies were neglected and this should be corrected in future research using insights gleaned from this analysis.

Effects of transcutaneous electrical nerve stimulation (TENS) in people with knee osteoarthritis: A systematic review and meta-analysis

OBJECTIVE

To evaluate the effects of Transcutaneous Electric Nerve Stimulation (TENS) on pain, function, walking ability and stiffness in people with Knee osteoarthritis (KOA).

DESIGN

Systematic review and meta-analysis of randomized controlled trials.

METHODS

We searched MEDLINE, EMBASE, PubMed, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database (PEDro), clinicaltrials.gov and Web of Science (last search November 2021) for randomized controlled trials. The Cochrane Risk of Bias Tool was used for the included studies, and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) was used to interpret the certainty of results. Standardized Mean Differences (SMDs) and 95% confidence interval (CI) were calculated for meta-analysis.

RESULTS

Twenty-nine studies were found (1398 people, age range 54-85, 74% are female) and fourteen were included in this review. Intervention duration was divided as short term (immediately after intervention), medium term (<four weeks) and long term (≥ four weeks). Active TENS showed greater improvement in Visual Analogue Scale (VAS) than sham TENS.Combining TENS with other interventions produced superior outcomes compared with other interventions for VAS in all the terms. In the meanwhile, TENS combined with other interventions was superior to other interventions for the pain subgroup of Western Ontario and McMaster Universities Arthritis Index in the medium term and long term. TENS combined with other interventions was superior to other interventions for function in the medium term and long term.

CONCLUSION

TENS could significantly relieve pain, decrease dysfunction and improve walking ability in people with KOA, but it is not effective for stiffness.

Phisical modalities on the functional performance in knee osteoarthritis: a sytematic review

Abstract Introduction: Despite recent advances in the treatment of osteoarthritis (OA), few studies have evaluated the longitudinal effect of physical modalities in functional capacity in patients with knee OA. Thereby, since the physical components and pain can affect the functional performance of daily activities, the effect of these treatment’s form is still to be established. Objective: Evaluate the effectiveness of therapeutic ultrasound, electrical stimulation and phototherapy in the functional performance, in patients with knee osteoarthritis. Methods: Articles present in the PubMed, Lilacs, SciELO and PEDro’s databases were evaluated. The used keywords were “pulsed ultrasound therapy”, “ultrasound therapy”, “electric stimulation” and “low level laser therapy” in combination with “knee osteoarthritis”. Were included in this presented review, randomized clinical studies using ultrasound, electrical and laser stimulation in subjects with knee osteoarthritis. To evaluate the methodological quality of the selected studies, was used the PEDro’s scale. The dependent variables of the study were: pain, physical function, joint stiffness, life quality and functional performance. Results: 268 studies were found, of these, 41 studies met eligibility criteria and were classified for analysis in full. The used methodology in the studies varied widely, however, in most cases there was improvement in functional performance of individuals with knee OA, with the use of physical modalities, for the pulsed ultrasound, continuous ultrasound, electrical stimulation and laser resourses. Conclusion: The physical modalities used in the studies demonstrated improvement in functional performance of individuals with knee OA.

SF-36 total score as a single measure of health-related quality of life: Scoping review

According to the 36-Item Short Form Health Survey questionnaire developers, a global measure of health-related quality of life such as the “SF-36 Total/Global/Overall Score” cannot be generated from the questionnaire. However, studies keep on reporting such measure. This study aimed to evaluate the frequency and to describe some characteristics of articles reporting the SF-36 Total/Global/Overall Score in the scientific literature. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses method was adapted to a scoping review. We performed searches in PubMed, Web of Science, SCOPUS, BVS, and Cochrane Library databases for articles using such scores. We found 172 articles published between 1997 and 2015; 110 (64.0%) of them were published from 2010 onwards; 30.0% appeared in journals with Impact Factor 3.00 or greater. Overall, 129 (75.0%) out of the 172 studies did not specify the method for calculating the “SF-36 Total Score”; 13 studies did not specify their methods but referred to the SF-36 developers’ studies or others; and 30 articles used different strategies for calculating such score, the most frequent being arithmetic averaging of the eight SF-36 domains scores. We concluded that the “SF-36 Total/Global/Overall Score” has been increasingly reported in the scientific literature. Researchers should be aware of this procedure and of its possible impacts upon human health.

Knee Osteoarthritis: Does Transcutaneous Electrical Nerve Stimulation Work?

Transcutaneous electrical nerve stimulation has been proposed as a nonoperative treatment for osteoarthritis. The purpose of this study was to evaluate the outcomes of a novel transcutaneous electrical nerve stimulation device compared with those of other standard nonoperative modalities for the treatment of osteoarthritis of the knee.

Product Differences in Intra-articular Hyaluronic Acids for Osteoarthritis of the Knee

BACKGROUND

Knee osteoarthritis (OA) is a common and often disabling joint disorder among adults that may result in impaired activity and daily function. A variety of treatment options are currently available and prescribed for knee OA depending on the severity of the disorder and physician preference. Intra-articular hyaluronic acid (IA-HA) injection is a treatment for knee OA that reportedly provides numerous biochemical and biological benefits, including shock absorption, chondroprotection, and anti-inflammatory effects within the knee. Clarity is needed as to whether the available IA-HA products should be considered for therapy as a group or whether there are significant differences in the products that need to be considered in treatment of OA of the knee.

PURPOSE

To determine whether there are differences in efficacy and safety with respect to intrinsic properties of available IA-HA injections for knee OA.

STUDY DESIGN

Meta-analysis.

METHODS

A comprehensive literature search of the Medline, EMBASE, and PubMed databases was conducted for all existing randomized trials of IA-HA. The primary outcome measure analyzed was the mean pain score at the reported follow-up nearest to 26 weeks after injection. Pooled efficacy and safety results were recorded for subgroupings of HA product characteristics.

RESULTS

A total of 68 studies were included for analysis. Products with an average molecular weight ≥3000 kDa provided favorable efficacy results when compared with products of an average molecular weight <3000 kDa. Products with a molecular weight ≥3000 kDa demonstrated significantly fewer discontinuations due to treatment-related adverse events than did ≤1500 kDa counterparts, while trial discontinuation rates were similar between biological fermentation-derived HA products and avian-derived HA. The results did not demonstrate a significant difference in the occurrence of effusion across molecular weight subgroups. Additionally, biological fermentation-derived HA had a significantly smaller incidence of effusion than did avian-derived HA. Biological fermentation-derived HA demonstrated fewer acute flare-ups at the injection site than did avian-derived HA products, while high-molecular-weight products demonstrated the highest rate of injection site flare-up.

CONCLUSION

Despite similarities, IA-HA products should not be treated as a group, as there are differences in IA-HA products that influence both efficacy and safety. In the available literature, IA-HA products with a molecular weight ≥3000 kDa and those derived from biological fermentation relate to superior efficacy and safety-factors that may influence selection an IA-HA product for OA of the knee.

Complementary and alternative medicine in osteoarthritis

The intent of this focused clinical review is to assess the current literature on a variety of complementary and alternative medicine treatments for osteoarthritis. This review assesses acupuncture techniques, moxibustion, transcutaneous electrical nerve stimulation, low-level laser therapy, and massage. These treatment methods are growing in popularity among the general public. It is important that providers become aware of the existing literature regarding the efficacy of these alternative methods for the treatment of osteoarthritis to adequately respond to the inquiries of our patients.

Non-surgical management of early knee osteoarthritis

Conservative approach is usually the first choice for the management of the knee degeneration processes, especially in the phase of the disease recognized as early osteoarthritis (OA) with no clear lesions or associated abnormalities requiring to be addressed surgically. A wide spectrum of treatments is available, from non-pharmacological modalities to dietary supplements and pharmacological therapies, as well as minimally invasive procedures involving injections of various substances aiming to restore joint homeostasis and provide clinical improvement and possibly a disease-modifying effect. Numerous pharmaceuticals have been proposed, but since no therapy has shown all the characteristic of an ideal treatment, and side effects have been reported at both systemic and local level, the use of pharmacological agents should be considered with caution by assessing the risk/benefit ratio of the drugs prescribed. Both patients and physicians should have realistic outcome goals in pharmacological treatment, which should be considered together with other conservative measures. A combination of these therapeutic options is a more preferable scenario, in particular considering the evidence available for non-pharmacological management. In fact, exercise is an effective conservative approach, even if long-term effectiveness and optimal dose and administration modalities still need to be clarified. Finally, physical therapies are emerging as viable treatment options, and novel biological approaches are under study. Further studies to increase the limited medical evidence on conservative treatments, optimizing results, application modalities, indications, and focusing on early OA will be necessary in the future. Level of evidence IV.

Hylan g-f 20: review of its safety and efficacy in the management of joint pain in osteoarthritis

BACKGROUND

Osteoarthritis (OA) is a chronic degenerative joint disease that is a clinically and economically important disease. The increased prevalence of OA with aging, coupled to the demographics of aging populations, make OA a high priority health care problem. Viscosupplementation (VS) is a well-established treatment option in knee OA that is included in the professional guidelines for treatment of this joint disease, and could potentially provide a useful alternative in treating such patients with painful OA. Theoretically VS is an approach that should apply to all synovial joints.

OBJECTIVES

The aim of this review is to assess the efficacy and safety of viscosupplementation with Hylan GF-20 (Synvisc(®)) in the management of joint pain in osteoarthritis.

METHODS

THE FOLLOWING DATABASES WERE SEARCHED: Medline, Database of Abstract on Reviews and Effectiveness, Cochrane Database of Systematic Reviews. Furthermore, the lists of references of retrieved publications were manually checked for additional references. The search terms Review, Viscosupplementation, Osteoarthritis, Hyaluronic acid, Hyaluronan, Sodium Hyaluronate, Hylan GF-20, Synvisc, intra-articular injection were used to identify all studies relating to the use of Synvisc(®) viscosupplementation therapy in OA.

RESULTS

Hylan GF-20 is a safe and effective treatment for decreasing pain and improving function in patients suffering from knee and hip OA but new evidences are emerging for its use in other joints.

Functional polymers as therapeutic agents: concept to market place

Biologically active synthetic polymers have received considerable scientific interest and attention in recent years for their potential as promising novel therapeutic agents to treat human diseases. Although a significant amount of research has been carried out involving polymer-linked drugs as targeted and sustained release drug delivery systems and prodrugs, examples on bioactive polymers that exhibit intrinsic therapeutic properties are relatively less. Several appealing characteristics of synthetic polymers including high molecular weight, molecular architecture, and controlled polydispersity can all be utilized to discover a new generation of therapies. For example, high molecular weight bioactive polymers can be restricted to gastrointestinal tract, where they can selectively recognize, bind, and remove target disease causing substances from the body. The appealing features of GI tract restriction and stability in biological environment render these polymeric drugs to be devoid of systemic toxicity that are generally associated with small molecule systemic drugs. The present article highlights recent developments in the rational design and synthesis of appropriate functional polymers that have resulted in a number of promising polymer based therapies and biomaterials, including some marketed products.

Medial knee joint loading increases in those who respond to hyaluronan injection for medial knee osteoarthritis

Knee osteoarthritis (OA) is a cause of decline in function and the medial compartment is often affected. Intraarticular injection of hyaluronic acid (HA) is indicated as a symptom modifying treatment with at least 6 months passing between consecutive injection series. The effects of HA injection on gait variables have not been extensively examined. Therefore, our objective was to investigate the effects of HA injection on gait in people with medial knee OA. Twenty-seven subjects were included; each was tested prior to treatment (baseline), no later than 3 weeks following the last injection (post-HA), and again 5 months after treatment ended (follow-up). Responder criteria were defined to identify responders and non-responders. Subjects underwent 3D gait analysis, muscle activity was sampled, and co-contraction indices were calculated. Responders experienced increased peak knee adduction moments post-HA, whereas non-responders did not. Improved self-report scores were associated with increased knee adduction moments and increased medial co-contraction. Pain relief may result in higher loading onto the already vulnerable medial compartment due to changes in lower limb mechanics and muscle activation patterns. Eventually this may result in a more rapid progression of joint deterioration.

Functional and perceived response to intra-articular hyaluronan injection in patients with knee osteoarthritis: persistence of treatment effects over 5 months

Intra-articular injections of hyaluronic acid are currently indicated as a symptom-modifying treatment for knee osteoarthritis to palliate symptoms and improve function. A series of three to five weekly injections are typically delivered once per week and a period of at least 6 months must pass between consecutive injection series. Little is known about why some patients do not respond to this treatment or about its effects on outcome measures recorded during functional activities. In addition to investigating short-term self-report and measured functional changes, the purpose of this study was to evaluate the persistence of treatment effects over the typical time interval between consecutive treatment series. According to the a priori definition for response to treatment, over two-thirds of patients experienced improved knee function during the typical period between series of intra-articular injection of hyaluronic acid while a one-third did not demonstrate a change in self-report scores. Differences in response were similarly seen between groups in functional tests. Many had immediate benefits and although some did not retain their gains, others experienced a delayed response in the following months. Knee flexion range of motion was related to self-report and tested function, and improvements in range of motion were associated with concurrent improvements in other functional measures across the testing period. A short functional test and knee-specific questionnaire may provide an index that provides an indication as to whether or not a particular patient is likely to respond to hyaluronan injections. Such information may provide valuable input when decisions are made regarding which treatment option is recommended to individuals with knee osteoarthritis.

Clinical outcomes from a physiotherapist-led intra-articular hyaluronic acid injection clinic

OBJECTIVES

To describe the clinical course of knee osteoarthritis following a single course of intra-articular hyaluronic acid (HA) injection clinic, and specifically to explore treatment withdrawal.

DESIGN

Prospective consecutive case series with follow-up, set in an innovative physiotherapist-led clinic, based in a hospital orthopaedic surgery department.

PARTICIPANTS

A total of 100 patients with knee osteoarthritis referred to the clinic received a single course of five injections of Hyalgan. Patients were followed up in clinic at five, 13, 26 and 52 weeks. The primary outcome measures were Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) Likert 3.0 pain (0-20) and physical function (0-68) scores. In addition, at 13 and 26 weeks, patients were reviewed independently by an orthopaedic surgeon, with the option of withdrawing for alternative management those patients who had not responded.

RESULTS

Ninety (90%) patients were successfully followed to study endpoint. Improvements were seen at five weeks and, to a lesser extent, at 13 weeks (mean reduction in WOMAC pain at 13 weeks = 1.3; 95% confidence interval [CI] 0.5, 2.0; mean reduction in WOMAC Physical Function at 13 weeks = 5.6; 95% CI 3.0, 8.1). Of 34 treatment withdrawals, most had returned to baseline levels by 13 weeks. The remaining 56 patients maintained improvements up to 52 weeks, although the pattern of outcome was highly variable between individuals. Withdrawals and non-responders had higher initial pain severity.

CONCLUSIONS

Physiotherapist-led intra-articular HA clinics are feasible. Clinical outcomes for individual patients are highly heterogeneous up to one year after injections. Patients with initially high levels of pain may be less likely to benefit.

Transcutaneous electrical nerve stimulation (TENS) for chronic pain

BACKGROUND

Transcutaneous electrical nerve stimulation (TENS) is a popular pain treatment modality but its effectiveness in chronic pain management is unknown. This review is an update of the original Cochrane review published in Issue 3, 2001.

OBJECTIVES

To evaluate the effectiveness of TENS in chronic pain.

SEARCH STRATEGY

The Cochrane Library, EMBASE, MEDLINE and CINAHL were searched. Reference lists from retrieved reports and reviews were examined. Date of the most recent search: April 2008.

SELECTION CRITERIA

RCTs were eligible if they compared active TENS versus sham TENS controls; active TENS versus 'no treatment' controls; or active TENS versus active TENS controls (e.g. High Frequency TENS (HFTENS) versus Low Frequency TENS (LFTENS)). Studies of chronic pain for three months or more which included subjective outcome measures for pain intensity or relief were eligible for evaluation. No restrictions were made to language or sample size. Abstracts, letters, or unpublished studies, and studies of TENS in angina, headache, migraine, dysmenorrhoea and cancer-related pain were excluded.

DATA COLLECTION AND ANALYSIS

Data were extracted and summarised on the following items: patients and details of pain condition, treatments, study duration, design, methods, subjective pain outcome measures, methodological quality, results for pain outcome measures and adverse effects, and conclusions by authors of the studies. Extracted data and methodological quality of studies were confirmed by the review authors.

MAIN RESULTS

Of 124 studies identified from the searches, 99 did not fulfil pre-defined entry criteria. Twenty-five RCTs involving 1281 participants were evaluated. Included studies varied in design, analgesic outcomes, chronic pain conditions, TENS treatments and methodological quality. The reporting of methods and results for analgesic outcomes were inconsistent across studies and generally poor. Meta-analysis was not possible. Overall in 13 of 22 inactive control studies, there was a positive analgesic outcome in favour of active TENS treatments. For multiple dose treatment comparison studies, eight of fifteen were considered to be in favour of the active TENS treatments. Seven of the nine active controlled studies found no difference in analgesic efficacy between High Frequency (HF) TENS and Low Frequency (LF) TENS.

AUTHORS' CONCLUSIONS

Since the last version of this review, new relevant studies have not provided additional information to change the conclusions. Published literature on the subject lacks the methodological rigour or robust reporting needed to make confident assessments of the role of TENS in chronic pain management. Large multi-centre RCTs of TENS in chronic pain are still needed.

Hylan versus corticosteroid versus placebo for treatment of basal joint arthritis: a prospective, randomized, double-blinded clinical trial

PURPOSE

Conservative, nonsurgical therapies for basal joint osteoarthritis, such as thumb spica splinting and intra-articular corticosteroid injections, remain the mainstays for symptomatic treatment. This study compares intra-articular hylan, corticosteroid, and placebo injections with regard to pain relief, strength, symptom improvement, and metrics of manual function in a randomized, controlled, double-blinded study.

METHODS

Sixty patients with basal joint arthritis were randomized to receive 2 intra-articular hylan injections 1 week apart, 1 placebo injection followed by 1 corticosteroid injection 1 week later, or 2 placebo injections 1 week apart. Patients were evaluated at 2, 4, 12, and 26 weeks and assessed with Visual Analog Scale pain scores, strength measures, difference scores, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and range of motion measurements.

RESULTS

All groups reported pain relief at 2 weeks. The steroid and placebo groups had significantly less pain at week 4 compared with baseline, but this effect disappeared by week 12. Only hylan injections continued to provide pain relief at 12 and 26 weeks compared with baseline. There were no significant differences in pain between groups at any time. At 12 and 26 weeks, the hylan group had improved grip strength compared with baseline, whereas the steroid and placebo groups were weaker. At 4 weeks, the steroid group reported in the difference score a greater improvement in symptoms (68%) compared with the hylan (44%) and placebo (50%) groups. Whereas at 26 weeks the hylan group reported the largest improvement in symptoms (68%), this was not statistically different from the placebo (47%) and steroid (58%) groups. There were no significant differences in Disabilities of the Arm, Shoulder, and Hand scores or range of motion among the groups. There were no complications from any injection.

CONCLUSIONS

There were no statistically significant differences among hylan, steroid, and placebo injections for most of the outcome measures at any of the follow-up time points. However, based on the durable relief of pain, improved grip strength, and the long-term improvement in symptoms compared with preinjection values, hylan injections should be considered in the management of basal joint arthritis of the thumb.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

Pain relief in osteoarthritis and rheumatoid arthritis: TENS

Pain is a common symptom experienced by people with osteoarthritis and rheumatoid arthritis and impacts upon mobility and quality of life. This article reviews the limited evidence relating to TENS for pain relief which suggests that it is beneficial for some patients and does no harm. More research is needed to clarify optimal treatments regimes and its cost-effectiveness compared to conventional analgesia.