Low-frequency electric muscle stimulation combined with physical therapy after total hip arthroplasty for hip osteoarthritis in elderly patients: a randomized controlled trial

Adherence to Neuromuscular Electrical Stimulation Interventions for Muscle Impairment in Hip and Knee Osteoarthritis: A Systematic Review

BACKGROUND

Neuromuscular electrical stimulation (NMES) provides a promising approach to counteract muscle impairment in hip and knee osteoarthritis, and to expedite recovery from joint replacement surgery. Nonetheless, application into clinical orthopaedic practice remains limited, partly due to concerns regarding patient tolerance.

OBJECTIVES

This systematic review aimed to quantify levels of adherence to NMES interventions for muscle impairment in hip and knee osteoarthritis and identify strategies to increase compliance.

DATA SOURCES

Randomised controlled trials (RCTs) were identified in a web-based literature review, completed in December 2020. The databases sourced included the Cochrane Library, CINAHL Complete, Medline Complete and PubMed.

ELIGIBILITY CRITERIA

Studies were included if they were: (i) conducted in cohorts of adults with hip or knee osteoarthritis; (ii) a protocol of electrical muscle stimulation prescribed to treat muscle impairment; and (iii) reported intervention adherence or attrition rate. Data were extracted on adherence rate, reasons for non-adherence and potential strategies to increase adherence. Risk of bias was assessed using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

The search yielded 120 articles, of which 15 studies were considered eligible and included in the analysis (n = 922). All NMES treatment was applied to the quadriceps, with 1 study targeting the quadriceps and calves. The mean PEDRO score of the included studies was 6.80 out of a possible 10 (range 6-8). Mean adherence did not differ between groups receiving treatment with NMES (85% ± 12%) and control groups receiving voluntary exercise or education (84% ± 9%) (P = .97). Reasons for non-adherence or attrition included a dislike of the device, dizziness, pain and discomfort. Strategies to increase adherence included NMES education, a familiarisation period, supervision, setting thresholds based upon patient tolerance, monitoring pain levels during stimulation and using built-in adherence trackers.

CONCLUSIONS

This systematic review indicates that adherence to NMES interventions for muscle impairment in hip and knee osteoarthritis in clinical trials does not differ to control groups receiving education or voluntary exercise, and hence should not be a barrier to application in clinical practice.

Influência da reabilitação física sobre aspectos funcionais em indivíduos submetidos à artroplastia total de quadril: uma revisão sistemática

Resumo Objetivo: Avaliar, por meio de revisão sistemática, a influência do tratamento fisioterapêutico sobre a funcionalidade, amplitude de movimento articular e força muscular em pacientes submetidos à artroplastia total de quadril devido à osteoartrite. Métodos: A busca sistemática de ensaios clínicos randomizados e não randomizados foi conduzida utilizando os bancos de dados eletrônicos PubMed, Web of Science, PEDro, Cochrane, Clinical Trials e SciELO, com base nas estratégias de pesquisa recomendadas pelos itens de relatórios preferenciais para análises sistemáticas e metanálises (PRISMA). Resultados: Em geral, protocolos supervisionados por fisioterapeutas associados à realização de exercícios ativos da musculatura periarticular do quadril e de extensores de joelho têm propiciado importante prognóstico físico e funcional. Exercícios resistidos (dinâmicos e isométricos) de alta intensidade são mais eficazes para a funcionalidade. Para a força muscular e Amplitude de movimento (ADM), exercícios dinâmicos com 3 a 5 séries de 8 a 12 repetições com baixa e alta intensidade promoveram ganhos mais expressivos em relação a outras modalidades terapêuticas. Conclusões: As técnicas e os protocolos utilizados pela fisioterapia para o tratamento da ATQ são variados e possuem importante eficácia clínica comprovada na literatura.

The Effect of Simultaneous Antigravity Treadmill Training and Electrical Muscle Stimulation After Total Hip Arthroplasty: Short Follow-Up Time

Objective

To assess the effectiveness of our devised hybrid physiotherapy regime using an anti-gravity treadmill and a low-frequency electrical stimulation device, as measured in patients with hip osteoarthritis after total hip arthroplasty (THA).

Methods

The outcomes of the postoperative rehabilitation in 44 patients who underwent THA for hip osteoarthritis were retrospectively examined. The conventional group (n=22) underwent the postoperative rehabilitation according to our protocol, while the hybrid group (n=22) underwent the same training, along with training on an anti-gravity treadmill and training using a low-frequency therapeutic device. The outcome measures were recorded and reviewed with the Numerical Rating Scale for pain, which rates pain on an 11-point scale from 0 to 10, surgical side knee joint extension force, 10-m walking test, Timed Up and Go test, and the 6-minute walking distance (6MD). The outcome measurement was taken 2 weeks after conducting pre-operation and antigravity treadmill training and electrical muscle stimulation, and compared the respective results.

Results

At the timeframe of 2 weeks from the surgery after conducting a devised hybrid physiotherapy, the values of knee extension muscle strength and 6MD were not worse in the hybrid group than conventional group. In the evaluation at 2 weeks after surgery, the knee extension muscle strength and 6MD values significantly decreased compared with the preoperative values only in the conventional group.

Conclusion

Lower limb muscular strength and endurance were maintained in the hybrid group, which suggested that hybrid physiotherapy could maintain physical functions early after THA operation.

Neuromuscular Electrical Stimulation for Treatment of Muscle Impairment: Critical Review and Recommendations for Clinical Practice

Purpose: In response to requests from physiotherapists for guidance on optimal stimulation of muscle using neuromuscular electrical stimulation (NMES), a review, synthesis, and extraction of key data from the literature was undertaken by six Canadian physical therapy (PT) educators, clinicians, and researchers in the field of electrophysical agents. The objective was to identify commonly treated conditions for which there was a substantial body of literature from which to draw conclusions regarding the effectiveness of NMES. Included studies had to apply NMES with visible and tetanic muscle contractions. Method: Four electronic databases (CINAHL, Embase, PUBMED, and SCOPUS) were searched for relevant literature published between database inceptions until May 2015. Additional articles were identified from bibliographies of the systematic reviews and from personal collections. Results: The extracted data were synthesized using a consensus process among the authors to provide recommendations for optimal stimulation parameters and application techniques to address muscle impairments associated with the following conditions: stroke (upper or lower extremity; both acute and chronic), anterior cruciate ligament reconstruction, patellofemoral pain syndrome, knee osteoarthritis, and total knee arthroplasty as well as critical illness and advanced disease states. Summaries of key details from each study incorporated into the review were also developed. The final sections of the article outline the recommended terminology for describing practice using electrical currents and provide tips for safe and effective clinical practice using NMES. Conclusion: This article provides physiotherapists with a resource to enable evidence-informed, effective use of NMES for PT practice.

Neuromuscular electrical stimulation for muscle weakness in adults with advanced disease

BACKGROUND

This review is an update of a previously published review in the Cochrane Database of Systematic Reviews Issue 1, 2013 on Neuromuscular electrical stimulation for muscle weakness in adults with advanced disease.Patients with advanced progressive disease often experience muscle weakness, which can impact adversely on their ability to be independent and their quality of life. In those patients who are unable or unwilling to undertake whole-body exercise, neuromuscular electrical stimulation (NMES) may be an alternative treatment to enhance lower limb muscle strength. Programmes of NMES appear to be acceptable to patients and have led to improvements in muscle function, exercise capacity, and quality of life. However, estimates regarding the effectiveness of NMES based on individual studies lack power and precision.

OBJECTIVES

Primary objective: to evaluate the effectiveness of NMES on quadriceps muscle strength in adults with advanced disease. Secondary objectives: to examine the safety and acceptability of NMES, and its effect on peripheral muscle function (strength or endurance), muscle mass, exercise capacity, breathlessness, and health-related quality of life.

SEARCH METHODS

We identified studies from searches of the Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews (CDSR), and Database of Abstracts of Reviews of Effects (DARE) (the Cochrane Library), MEDLINE (OVID), Embase (OVID), CINAHL (EBSCO), and PsycINFO (OVID) databases to January 2016; citation searches, conference proceedings, and previous systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials in adults with advanced chronic respiratory disease, chronic heart failure, cancer, or HIV/AIDS comparing a programme of NMES as a sole or adjunct intervention to no treatment, placebo NMES, or an active control. We imposed no language restriction.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data on study design, participants, interventions, and outcomes. We assessed risk of bias using the Cochrane 'Risk of bias' tool. We calculated mean differences (MD) or standardised mean differences (SMD) between intervention and control groups for outcomes with sufficient data; for other outcomes we described findings from individual studies. We assessed the evidence using GRADE and created a 'Summary of findings' table.

MAIN RESULTS

Eighteen studies (20 reports) involving a total of 933 participants with COPD, chronic respiratory disease, chronic heart failure, and/or thoracic cancer met the inclusion criteria for this update, an additional seven studies since the previous version of this review. All but one study that compared NMES to resistance training compared a programme of NMES to no treatment or placebo NMES. Most studies were conducted in a single centre and had a risk of bias arising from a lack of participant or assessor blinding and small study size. The quality of the evidence using GRADE comparing NMES to control was low for quadriceps muscle strength, moderate for occurrence of adverse events, and very low to low for all other secondary outcomes. We downgraded the quality of evidence ratings predominantly due to inconsistency among study findings and imprecision regarding estimates of effect. The included studies reported no serious adverse events and a low incidence of muscle soreness following NMES.NMES led to a statistically significant improvement in quadriceps muscle strength as compared to the control (12 studies; 781 participants; SMD 0.53, 95% confidence interval (CI) 0.19 to 0.87), equating to a difference of approximately 1.1 kg. An increase in muscle mass was also observed following NMES, though the observable effect appeared dependent on the assessment modality used (eight studies, 314 participants). Across tests of exercise performance, mean differences compared to control were statistically significant for the 6-minute walk test (seven studies; 317 participants; 35 m, 95% CI 14 to 56), but not for the incremental shuttle walk test (three studies; 434 participants; 9 m, 95% CI -35 to 52), endurance shuttle walk test (four studies; 452 participants; 64 m, 95% CI -18 to 146), or for cardiopulmonary exercise testing with cycle ergometry (six studies; 141 participants; 45 mL/minute, 95% CI -7 to 97). Limited data were available for other secondary outcomes, and we could not determine the most beneficial type of NMES programme.

AUTHORS' CONCLUSIONS

The overall conclusions have not changed from the last publication of this review, although we have included more data, new analyses, and an assessment of the quality of the evidence using the GRADE approach. NMES may be an effective treatment for muscle weakness in adults with advanced progressive disease, and could be considered as an exercise treatment for use within rehabilitation programmes. Further research is very likely to have an important impact on our confidence in the estimate of effect and may change the estimate. We recommend further research to understand the role of NMES as a component of, and in relation to, existing rehabilitation approaches. For example, studies may consider examining NMES as an adjuvant treatment to enhance the strengthening effect of programmes, or support patients with muscle weakness who have difficulty engaging with existing services.

Therapeutic modalities and postural balance of patients with knee osteoarthritis: systematic review

AbstractObjective The objective of this review was to evaluate the evidence of the influence of therapeutic modalities on postural balance in patients with knee osteoarthritis (OA).Methods A search for published papers on therapeutic modalities was conducted using the Pubmed, Medline, Lilacs and SciELO databases. The keywords “knee” and “balance” in combination with “osteoarthritis” were used as the search strategy. Randomized controlled clinical trials published in the last 10 years in either English or Portuguese were selected. The PEDro scale was applied to assess the quality of the selected clinical trials.Results A total of 46 studies of patients with knee OA were found, of which seven were analyzed in full and 39 were excluded because they did not meet the inclusion criteria. Of the seven studies reviewed, six were considered to have a high methodological quality on the PEDro scale. Several therapeutic modalities were found (physical exercise, hydrotherapy, electrotherapy and manual therapy), and postural balance improved in only three studies.Conclusion The studies included in this systematic review had a high methodological quality, so it can be concluded that the therapeutic modalities used in those studies improved postural balance in patients with knee OA.

Effect of cycle ergometer and conventional exercises on rehabilitation of older patients with total hip arthroplasty: study protocol for randomized controlled trial

Background

Total hip arthroplasty (THA) is an increasingly common treatment for older patients with hip osteoarthritis. The best strategy for a physiotherapy intervention for older people after THA is not clear in the literature. The purpose of this protocol study is to test the feasibility of undertaking a full trial clinical to evaluate the effect of ergometer cycling-associated conventional exercises on functional results and health-related quality of life (HRQOL) of older patients with THA.

Methods/Design

This study protocol is a prospective, single center, randomized controlled pilot clinical trial. Older patients (≥60 years) in the postoperative phase after primary unilateral THA for hip osteoarthritis will be consecutively recruited for this study and randomly allocated to 2 treatment groups. Group I will perform cycle ergometer and conventional exercises, and group II will perform only conventional exercises. The sessions will be conducted twice a week for 8 weeks. Assessments will be made at baseline (2 weeks postoperatively: the moment that the patients receive a referral for physical therapy, which will start after suture removal), after intervention (10 weeks postoperatively), and at 6 months of follow-up (24 weeks postoperatively). The primary outcomes are the function, evaluated using the Harris Hip Score (HHS) and the Short Physical Performance Battery (SPPB). The secondary outcome is HRQOL, measured using 2 evaluation instruments: the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Data collectors will be blinded and will not have contact with participants during the interventions.

Discussion

This randomized controlled trial will provide evidence regarding the effect of this exercise therapy on physical function and quality of life in older patients after THA. If our hypothesis is correct, both interventions will be effective, but the exercises on the cycle ergometer conferring better results in function, physical performance and quality of life. The study follows Consolidated Standards of Reporting Trials (CONSORT) guidelines, and the approval of the local ethics committee has been obtained.

Trial registration

ClinicalTrials.gov: NCT01622465 (14 June 2012)

Effectiveness of land-based physiotherapy exercise following hospital discharge following hip arthroplasty for osteoarthritis: an updated systematic review

BACKGROUND

Existing review required updating.

OBJECTIVE

To evaluate the effectiveness of physiotherapy exercise after discharge from hospital on function, walking, range of motion, quality of life and muscle strength, for patients following elective primary total hip arthroplasty for osteoarthritis.

DESIGN

Systematic review from January 2007 to November 2013.

DATA SOURCES

AMED, CINAHL, EMBASE, MEDLINE, Kingsfund Database, and PEDro. Cochrane CENTRAL, BioMed Central (BMC), The Department of Health National Research Register and Clinical Trials.gov register. Searches were overseen by a librarian. Authors were contacted for missing information. No language restrictions were applied.

ELIGIBILITY CRITERIA

Trials comparing physiotherapy exercise vs usual/standard care, or comparing two types of relevant exercise physiotherapy, following discharge from hospital after elective primary total hip replacement for osteoarthritis were reviewed.

OUTCOMES

Functional activities of daily living, walking, quality of life, muscle strength and joint range of motion.

STUDY APPRAISAL

Quality and risk of bias for studies were evaluated. Data were extracted and meta-analyses considered.

RESULTS

11 trials are included in the review. Trial quality was mixed. Newly included studies were assessed as having lower risk of bias than previous studies. Narrative review indicates that physiotherapy exercise after discharge following total hip replacement may potentially benefit patients in terms of function, walking and muscle strengthening.

LIMITATIONS

The overall quality and quantity of trials, and their diversity, prevented meta-analyses.

CONCLUSIONS

Disappointingly, insufficient evidence still prevents the effectiveness of physiotherapy exercise following discharge to be determined for this patient group. High quality, adequately powered, trials with long term follow up are required.

Peri-operative interventions producing better functional outcomes and enhanced recovery following total hip and knee arthroplasty: an evidence-based review

The increasing numbers of patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA), combined with the rapidly growing repertoire of surgical techniques and interventions available have put considerable pressure on surgeons and other healthcare professionals to produce excellent results with early functional recovery and short hospital stays. The current economic climate and the restricted healthcare budgets further necessitate brief hospitalization while minimizing costs.Clinical pathways and protocols introduced to achieve these goals include a variety of peri-operative interventions to fulfill patient expectations and achieve the desired outcomes.In this review, we present an evidence-based summary of common interventions available to achieve enhanced recovery, reduce hospital stay, and improve functional outcomes following THA and TKA. It covers pre-operative patient education and nutrition, pre-emptive analgesia, neuromuscular electrical stimulation, pulsed electromagnetic fields, peri-operative rehabilitation, modern wound dressings, standard surgical techniques, minimally invasive surgery, and fast-track arthroplasty units.

An appraisal of rehabilitation regimes used for improving functional outcome after total hip replacement surgery

This study aimed to systematically review the literature with regards to studies of rehabilitation programmes that have tried to improve function after total hip replacement (THR) surgery. 15 randomised controlled trials were identified of which 11 were centre-based, 2 were home based and 2 were trials comparing home and centre based interventions. The use of a progressive resistance training (PRT) programme led to significant improvement in muscle strength and function if the intervention was carried out early (< 1 month following surgery) in a centre (6/11 centre-based studies used PRT), or late (> 1 month following surgery) in a home based setting (2/2 home based studies used PRT). In direct comparison, there was no difference in functional measures between home and centre based programmes (2 studies), with PRT not included in the regimes prescribed. A limitation of the majority of these intervention studies was the short period of follow up. Centre based program delivery is expensive as high costs are associated with supervision, facility provision, and transport of patients. Early interventions are important to counteract the deficit in muscle strength in the affected limb, as well as persistent atrophy that exists around the affected hip at 2 years post-operatively. Studies of early home-based regimes featuring PRT with long term follow up are needed to address the problems currently associated with rehabilitation following THR.

Thigh and knee circumference, knee-extension strength, and functional performance after fast-track total hip arthroplasty

OBJECTIVE

To (1) quantify changes in knee-extension strength and functional-performance at discharge after fast-track total hip arthroplasty (THA) and (2) investigate whether these changes correlate to changes in thigh and knee circumference (ie, swelling) or pain.

DESIGN

A prospective, descriptive, hypothesis-generating study.

SETTING

A special unit for fast-track hip and knee arthroplasty operations at a university hospital.

PARTICIPANTS

Twenty-four patients (20 women and 4 men; ages 69 ± 6.1 years) scheduled for primary unilateral THA.

METHODS

All patients were evaluated before surgery and on the day of hospital discharge.

MAIN OUTCOME MEASURES

Knee-extension strength, thigh and knee joint circumference, hip pain, and functional performance (Timed Up & Go, 30-Second Chair Stand, and 10-Meter Walk tests).

RESULTS

All investigated variables changed significantly from before to after surgery, except for hip pain. The average loss in knee-extension strength after surgery (32%, P = .01) did not correlate with increased thigh circumference (6%, P < .01) or knee circumference (3%, P < .01) or with reductions in functional performance: Timed Up & Go test (114%, P = .01), 30-Second Chair Stand test (36%, P = .01), and 10-Meter Walk test (50%, P < .01). Only the increase in knee circumference correlated significantly with reduced performance in the 10-Meter Walk test time (R = -0.59, P < .01), explaining 34% of the variance in the 10-Meter Walk test. No correlations between changes in hip pain and functional performance or knee-extension strength were found. Mean postoperative hospital stay was 2.1 days.

CONCLUSIONS

Knee-extension strength is considerably reduced at discharge after THA, but the early strength reduction does not correlate with changes in thigh or knee circumferences. Because functional performance is also considerably reduced at discharge (unrelated to reduced knee-extension strength), other mechanisms such as fear, avoidance of movement, or decreased hip-muscle strength also may be involved.

Sample size calculation in physical medicine and rehabilitation: a systematic review of reporting, characteristics, and results in randomized controlled trials

OBJECTIVE

To assess systematically the reporting of sample size calculation in randomized controlled trials (RCTs) in 5 leading journals in the field of physical medicine and rehabilitation (PM&R).

DATA SOURCES

The data source was full reports of RCTs in 5 leading PM&R journals (Journal of Rehabilitation Medicine, Archives of Physical Medicine and Rehabilitation, American Journal of Physical Medicine and Rehabilitation, Clinical Rehabilitation, and Disability and Rehabilitation) between January and December of 1998 and 2008. Articles were identified in Medline.

STUDY SELECTION

A total of 111 articles met our inclusion criteria, which include RCTs of human studies in the 5 selected journals.

DATA EXTRACTION

Sample size calculation reporting and trial characteristics were collected for each trial by independent investigators.

DATA SYNTHESIS

In 2008, 57.3% of articles reported sample size calculation as compared with only 3.4% in 1998. The parameters that were commonly used were a power of 80% and alpha of 5%. Articles often failed to report effect size or effect estimates for sample size calculation. Studies reporting sample size calculation were more likely to describe the main outcome and to have a sample size greater than 50 subjects. The study outcome (positive vs negative) was not associated with the likelihood of sample size reporting. Trial characteristics of the 2 periods (1998 vs 2008) were similar except that in 1998 there were more negative studies compared with 2008.

CONCLUSIONS

Although sample size calculation reporting has improved dramatically in 10 years and is comparable with other fields in medicine, it is still not adequate given current publication guidelines.