Therapeutic ultrasound versus sham ultrasound for the management of patients with knee osteoarthritis: a randomized double-blind controlled clinical study

Ultrasound therapy for pain reduction in musculoskeletal disorders: a systematic review and meta-analysis

Background

Ultrasound therapy is a non-invasive technique used to address a variety of health issues.

Objectives

This systematic review and meta-analysis aim to assess the effectiveness of ultrasound therapy in alleviating pain associated with musculoskeletal diseases.

Design

This study was conducted following PRISMA guidelines, with relevant articles identified through comprehensive searches in electronic databases.

Data sources and methods

We conducted searches across multiple databases, including Scopus, PubMed, MEDLINE, ProQuest, Science Direct, CINAHL, AIM, and ELDIS. Two independent reviewers screened the titles and abstracts of the retrieved articles. We included randomized controlled trials (RCTs) and observational cohort studies published between 2010 and 2023 that evaluated ultrasound therapy for knee and shoulder skeletal disorders. The selected data were analyzed qualitatively and synthesized, with the risk of bias assessed using the RoB2 tool.

Results

Initially, 117 articles were reviewed using the search strategy, and 10 trials that met the inclusion criteria were identified. In seven of these studies, the primary musculoskeletal disorder was osteoarthritis, while three studies focused on shoulder pain and impingement. Most studies indicated that ultrasound therapy significantly reduced pain. The meta-analysis showed that ultrasound therapy was significantly more effective than other interventions for knee disorders (I 2 = 51%, Z = 2.65, p = 0.008). However, for shoulder disorders, both ultrasound and other intervention methods were found to be ineffective (I 2 = 93%, Z = 0.73, p = 0.46).

Conclusion

The current evidence supports the effectiveness of ultrasound therapy in reducing pain and aiding rehabilitation for knee conditions. However, there are mixed results regarding its efficacy for shoulder conditions, highlighting the need for further research in this area.

Effects of therapeutic ultrasound in patients with knee osteoarthritis: A systematic review and meta-analysis

Background

Therapeutic ultrasound (US) is a treatment for knee osteoarthritis (KOA), but its efficacy and safety are unclear. The objective of this study is to quantify the effect of US on pain relief and function recovery in KOA, and to analyze the US treatment duration and parameters on treatment outcome.

Methods

We searched PubMed, MEDLINE, EMBASE, Google Scholar, Cochrane databases and ClinicalTrials.gov databases up to April 7, 2023. RCTs that compared the efficacy of therapeutic US with the control in KOA were included in the study, and the methodological quality of the trials was assessed using the Cochrane Risk of Bias tool.

Results

Twenty-one RCTs (1315 patients) were included. US had a positive effect on visual analog scale (VAS) (SMD = -0.64, 95 % CI [-0.88, -0.40], I2 = 71 %) and Western Ontario and McMaster Universities (WOMAC) total scale (SMD = -0.45, 95 % CI [-0.69, -0.20]; I2 = 67 %). Pulsed US with an intensity ≤2.5 W/cm2 reduced visual analog scale (VAS), and differed in sessions (24 sessions (SMD = -0.80, 95 % CI [-1.07, -0.53], I2 = 0 %) vs 10 sessions (SMD = -0.71, 95 % CI [-1.09, -0.33], I2 = 68 %)). For pulsed US, a duration of treatment of 4-8 weeks (SMD = -0.69, 95 % CI [-1.13, -0.25], I2 = 73 %) appeared to be superior to ≤4 weeks (SMD = -0.77, 95 % CI [-1.04, -0.49], I2 = 0 %) for reducing visual analog scale (VAS). No US treatment-related adverse events were reported.

Conclusion

Therapeutic US may be a safe and effective treatment for patients with KOA. The mode, intensity, frequency, and duration of US may affect the effectiveness of pain relief. Pulsed US with an intensity ≤2.5 W/cm2, 24 sessions, and a treatment duration of ≤4 weeks appears to have better pain relief.

3D Bioprinting of Hyaline Articular Cartilage: Biopolymers, Hydrogels, and Bioinks

The musculoskeletal system, consisting of bones and cartilage of various types, muscles, ligaments, and tendons, is the basis of the human body. However, many pathological conditions caused by aging, lifestyle, disease, or trauma can damage its elements and lead to severe disfunction and significant worsening in the quality of life. Due to its structure and function, articular (hyaline) cartilage is the most susceptible to damage. Articular cartilage is a non-vascular tissue with constrained self-regeneration capabilities. Additionally, treatment methods, which have proven efficacy in stopping its degradation and promoting regeneration, still do not exist. Conservative treatment and physical therapy only relieve the symptoms associated with cartilage destruction, and traditional surgical interventions to repair defects or endoprosthetics are not without serious drawbacks. Thus, articular cartilage damage remains an urgent and actual problem requiring the development of new treatment approaches. The emergence of biofabrication technologies, including three-dimensional (3D) bioprinting, at the end of the 20th century, allowed reconstructive interventions to get a second wind. Three-dimensional bioprinting creates volume constraints that mimic the structure and function of natural tissue due to the combinations of biomaterials, living cells, and signal molecules to create. In our case-hyaline cartilage. Several approaches to articular cartilage biofabrication have been developed to date, including the promising technology of 3D bioprinting. This review represents the main achievements of such research direction and describes the technological processes and the necessary biomaterials, cell cultures, and signal molecules. Special attention is given to the basic materials for 3D bioprinting-hydrogels and bioinks, as well as the biopolymers underlying the indicated products.

The therapeutic effects of low-intensity pulsed ultrasound in musculoskeletal soft tissue injuries: Focusing on the molecular mechanism

Musculoskeletal soft tissue injuries are very common and usually occur during both sporting and everyday activities. The intervention of adjuvant therapies to promote tissue regeneration is of great importance to improving people's quality of life and extending their productive lives. Though many studies have focused on the positive results and effectiveness of the LIPUS on soft tissue, the molecular mechanisms standing behind LIPUS effects are much less explored and reported, especially the intracellular signaling pathways. We incorporated all research on LIPUS in soft tissue diseases since 2005 and summarized studies that uncovered the intracellular molecular mechanism. This review will also provide the latest evidence-based research progress in this field and suggest research directions for future experiments.

The efficacy of low-intensity pulsed ultrasound on articular cartilage and clinical evaluations in patients with knee osteoarthritis

BACKGROUND

While a number of preclinical studies have examined the effectiveness of low-intensity pulsed ultrasound (LIPUS) as a potential treatment for knee osteoarthritis (OA), there have been few clinical studies which have indirectly confirmed cartilage regeneration by magnetic resonance imaging (MRI).

OBJECTIVE

The aim of this clinical trial was to investigate whether LIPUS effectively increased knee cartilage thickness and improved pain and function in knee OA patients.

METHODS

This study was a prospective, single-group, home-based self-therapy trial. We included patients (n= 20) with OA pain. Each patient used an ultrasonic stimulation device (BODITREK JOINT™) for more than 20 sessions. Outcomes were assessed by MRI, Visual Analogue Scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the 36-Item Short Form Survey (SF-36) for assessing quality of life.

RESULTS

Nineteen subjects completed this study. There was no significant increase in the cartilage thickness measured by MRI after LIPUS treatment. LIPUS therapy significantly decreased VAS score and WOMAC score, and significantly increased SF-36 score. The subgroup analysis in patients with knee OA showed that LIPUS treatment showed better for older patients with lower Kellgren-Lawrence grades.

CONCLUSION

Pain, function, and quality of life improved after LIPUS, but there was no significant increase in cartilage thickness through MRI.

Mechanical-based therapies may reduce pain and disability in some patients with knee osteoarthritis: A systematic review with meta-analysis

BACKGROUND

Mechanical-based therapies are not yet recommended to manage osteoarthritis (OA). This systematic review and meta-analysis aim to assess the effects of passive mechanical-based therapies (isolated or combined with other therapies) on patients with knee OA compared to placebo, other isolated or combined interventions.

METHODS

Pubmed, Cochrane, Web of Science and EMBASE were searched up to December 2020. We included randomized and non-randomized trials using therapeutic ultrasound, phonophoresis, extracorporeal shockwave therapy (ESWT) and vibration (single or combined with other therapies) compared to placebo, and/or other physical therapies groups. Biochemical, patient-reported, physical and imaging outcome measures were retrieved. We judged risk of bias using the RoB2 tool for randomized studies, the ROBINS-I tool for non-randomized studies, and the GRADE to interpret certainty of results.

RESULTS

We included 77 clinical studies. Ultrasound and ESWT statistically improved pain and disability comparing to placebo (combined or not with other therapies), and when added to other therapies versus other therapies alone. Ultrasound was statistically inferior to phonophoresis (combined or not with other therapies) in reducing pain and disability for specific therapeutic gels and/or combined therapies. Vibration plus exercise statistically improved pain relief and function versus exercise alone. All meta-analyses showed very-low certainty of evidence, with 15 of 42 (38%) pooled comparisons being statistically significant (weak to large effect).

CONCLUSIONS

Despite the inconsistent evidence with very-low certainty, the potential benefits of passive mechanical-based therapies should not be disregard and cautiously recommended that clinicians might use them in some patients with knee OA.

A Meta-Analysis of Analgesic Effect of Ultrasound Therapy for Patients With Knee Osteoarthritis

To compare the efficacy of therapeutic ultrasound in pain relief and functional recovery in knee osteoarthritis. A comprehensive search of five databases including EMBASE, PubMed, CBM, the Cochrane Library, and Google scholar was conducted to identify relevant studies published between January 1, 2005 and December 31, 2020. Eligible randomized trials were screened for inclusion in this study. Data about the mean change of visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and range of motion (ROM) were collected. Fourteen randomized trials covering 1080 patients with treatment durations of 2 to 24 weeks were included. Both pulsed (SMD [CI] = 1.11 [0.86, 1.36], P for heterogeneity < .00001, I²  = 18%) and continuous ultrasound (SMD [CI] = 1.18 [0.78, 1.57], P for heterogeneity < .00001, I²  = 72%) therapy had obvious pain relief effects, and high-intensity (>1.5 W/cm² ) ultrasound seemed more effective (SMD [CI] = 1.34 [0.94, 1.73], P for heterogeneity < .00001, I²  = 35%). In addition, therapeutic ultrasound was also effective in increasing joint function by WOMAC (SMD [CI] = 8.18 [5.88, 10.48], P for heterogeneity < .00001, I²  = 59%). There was a certain degree of heterogeneity due to the differences between the subjects in the study and the ultrasound parameter settings. Our analysis confirmed that both pulsed and continuous ultrasound are effective and safe for pain relief and functional recovery of knee osteoarthritis, especially in high intensity (> 1.5 W/cm² ). However, more high-quality randomized controlled trials will be necessary.

Efficacy and safety of focused low-intensity pulsed ultrasound versus pulsed shortwave diathermy on knee osteoarthritis: a randomized comparative trial

The aim of this study was to compare the efficacy and safety of focused low-intensity pulsed ultrasound (FLIPUS) with pulsed shortwave diathermy (PSWD) in subjects with painful knee osteoarthritis (OA). In a prospective randomized trial, 114 knee OA patients were randomly allocated to receive FLIPUS or PSWD therapy. The primary outcome was the change from baseline in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total scores. Secondary outcomes included the numerical rating scale (NRS) for pain assessment, time up and go (TUG) test, active joint range of motion (ROM) test, and Global Rating of Change (GRC) scale. Data were collected at baseline, 12 days, 12 weeks and 24 weeks. Patients receiving FLIPUS therapy experienced significantly greater improvements in the WOMAC total scores than patients receiving PSWD therapy at 12 days (mean difference, - 10.50; 95% CI - 13.54 to - 7.45; P = 0.000). The results of the NRS, TUG test, ROM test and GRC scale showed that participants treated with FLIPUS reported less pain and better physical function and health status than those treated with PSWD at 12 days (P = 0.011, P = 0.005, P = 0.025, P = 0.011, respectively). Furthermore, patients in the FLIPUS group showed significant improvements in the WOMAC total scores and NRS scores at 12 weeks (mean difference, - 7.57; 95% CI - 10.87 to - 4.26; P = 0.000 and - 1.79; 95% CI - 2.11 to - 1.47, respectively) and 24 weeks (mean difference, - 6.96; 95% CI - 10.22 to - 3.71; P = 0.000 and - 1.37; 95% CI - 1.64 to - 0.96; P = 0.000, respectively) of follow-up. There were no adverse events during or after the interventions in either group. This study concluded that both FLIPUS and pulsed SWD are safe modalities, and FLIPUS was more effective than PSWD in alleviating pain and in improving dysfunction and health status among subjects with knee OA in the short term.Trial registration: Chinese Clinical Trial Registry, ChiCTR2000032735. Registered 08/05/2020, http://www.chictr.org.cn/showproj.aspx?proj=53413 .

A Review of Laser Therapy and Low-Intensity Ultrasound for Chronic Pain States

PURPOSE OF REVIEW

Chronic pain management therapies have expanded quickly over the past decade. In particular, the use of laser therapy and ultrasound in the management of chronic pain has risen in recent years. Understanding the uses of these types of therapies can better equip chronic pain specialists for managing complicated chronic pain syndromes. The purpose of this review was to summarize the current literature regarding laser radiation and ultrasound therapy used for managing chronic pain syndromes.

RECENT FINDINGS

In summary, there is stronger evidence supporting the usage of laser therapy for managing chronic pain states compared to low-intensity ultrasound therapies. As a monotherapy, laser therapy has proven to be beneficial in managing chronic pain in patients with a variety of pain syndromes. On the other hand, LIUS has less clear benefits as a monotherapy with an uncertain, optimal delivery method established. Both laser therapy and low-intensity ultrasound have proven beneficial in managing various pain syndromes and can be effective interventions, in particular, when utilized in combination therapy.

Correlation between pain severity and levels of anxiety and depression in osteoarthritis patients: a systematic review and meta-analysis

OBJECTIVES

Osteoarthritis (OA) is a chronic degenerative musculoskeletal disease that causes articular damage and chronic pain, with a prevalence of up to 50% in individuals >60 years of age. Patients suffering from chronic painful conditions, including OA, also frequently report anxiety or depression. A systematic review and meta-analysis were performed to assess the correlation between pain severity and depressive and anxious symptomatology in OA patients.

METHODS

A systematic search was conducted using four databases (PubMed, Medline, Scopus, and Web of Science) from inception up to 14th January of 2020. We included original articles evaluating pain severity and anxiety and/or depression severity in OA-diagnosed patients. Detailed data were extracted from each study, including patients' characteristics and pain, anxiety, and depression severity. When available, the Pearson correlation coefficient between pain and depression severity and pain and anxiety severity was collected and a meta-analysis of random effects was applied.

RESULTS

This systematic review included 121 studies, with a total of 38085 participants. The mean age was 64.3 years old and subjects were predominantly female (63%). The most used scale to evaluate pain severity was the Western Ontario and the McMaster Universities Osteoarthritis Index, while for anxiety and depression, the Hospital Anxiety and Depression Scale was the most used. The meta-analysis showed a moderate positive correlation between pain severity and both anxious (r = 0.31, p < 0.001) and depressive symptomatology (r = 0.36, p < 0.001).

CONCLUSIONS

Our results demonstrate a significant correlation between pain and depression/anxiety severity in OA patients, highlighting the need for its routine evaluation by clinicians.

Therapeutic Ultrasound for Chronic Pain Management in Joints: A Systematic Review

BACKGROUND

Treatments for joint pain and dysfunction focus on restoration of joint motion, improvement in pain and a return to the previous level of the patient's daily activity. Therapeutic ultrasound is a noninvasive modality widely utilized in the management of musculoskeletal disorders. The objective of this systematic review was to evaluate the effectiveness of therapeutic ultrasound in the management of patients with knee, shoulder and hip pain.

METHODS

Using PRISMA guidelines, a search of the PubMed, CENTRAL (The Cochrane Library), Web of Science and Scopus databases was performed to retrieve randomized controlled trials (RCTs) that evaluated therapeutic ultrasound (continuous and pulsed) in patients with chronic knee, shoulder and hip pain.

RESULTS

The search strategy identified 8 trials for knee, 7 trials for shoulder and 0 trials for hip that met the criteria for inclusion. All 8 trials showed improvement in knee pain, and of these studies 3 showed statistical significance improvement for therapeutic ultrasound versus the comparator. For shoulder pain, all 7 trials showed reduction in pain, but should be noted that 4 of studies demonstrated that therapeutic ultrasound is inferior to the comparator modality.

CONCLUSION

Therapeutic ultrasound is frequently used in the treatment of knee, shoulder and hip pain and is often combined with other physiotherapeutic modalities. The literature on knee arthritis is most robust, with some evidence supporting therapeutic ultrasound, though the delivery method of ultrasound (pulsed vs continuous) is controversial. As a monotherapy, ultrasound treatment may not have a significant impact on functional improvement but can be a reasonable adjunct to consider with other common modalities. In all three pain syndromes, especially for hip pain, further trials are needed to define the true effect of low-intensity ultrasound therapy knee, shoulder and hip pain. No conclusive recommendations may be made for optimal settings or session duration.

The effectiveness of pulsed ultrasound treatment on pain, function, synovial sac thickness and femoral cartilage thickness in patients with knee osteoarthritis: a randomized, double-blind clinical, controlled study

OBJECTIVE

This study aims to investigate the efficacy of therapeutic pulsed ultrasound on pain, function, synovial sac and femoral cartilage in knee osteoarthritis.

DESIGN

Randomized, double-blind, controlled study.

SETTING

Dokuz Eylul University, Department of Physical Medicine and Rehabilitation.

SUBJECTS

A total of 96 patients with knee osteoarthritis.

INTERVENTIONS

Participants were randomized into two groups; Group I (n = 48, pulsed ultrasound) and Group II (n = 48, sham ultrasound). The sessions were held three times a week for 8 weeks. The study continued for 12 weeks (with 4 weeks follow-up). All participants performed exercises at home for 12 weeks.

MAIN MEASURES

Knee pain (at rest and ADLs) was assessed using the visual analog scale (VAS). Functionality was assessed using the Timed Up and Go test and Western Ontario and McMaster Universities Osteoarthritis (WOMAC) questionnaire. Femoral cartilage and synovial sac thickness was measured using ultrasonography. All evaluations were performed at the baseline, at the 8 and 12 weeks after baseline.

RESULTS

The study was completed with a total of 75 patients (n = 39 in group I and n = 36 in group II). The mean (SD) pain at ADLs score at baseline and week 12 was 7.2 (2.1), with 3.6 (2.9) in the group I, and 6.7 (2.0) and 4.3 (2.2) in the group II, respectively. Both groups presented significant improvements in terms of pain and function (P < 0.001). There was no difference between groups for any parameters.

CONCLUSION

Treatment of pulsed ultrasound has no positive effect on knee pain, function, femoral cartilage and synovial sac thickness in knee osteoarthritis.

A clinical practice guideline for physical therapy in patients with hip or knee osteoarthritis

OBJECTIVE

The purpose of this paper is to revise the 2010 Dutch guideline for physical therapy (PT) in patients with hip or knee osteoarthritis (OA), issued by the Royal Dutch Society for Physical Therapy (KNGF).

METHOD

This revised guideline was developed according to the Appraisal of Guidelines for Research and Evaluation (AGREE) and Guidelines International Network (G-I-N) standards. A multidisciplinary guideline panel formulated clinical questions based on perceived barriers to current care. A narrative or systematic literature review was undertaken in response to each clinical question. The panel formulated recommendations based on evidence and additional considerations, as described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Evidence-to-Decision framework.

RESULTS

A comprehensive assessment should be based on the International Classification of Functioning Disability and Health (ICF) core set for OA, including the identification of OA-related red flags. Based on the assessment, four treatment profiles were distinguished: (1) education and instructions for unsupervised exercises, (2) education and short-term supervised exercise therapy, (3) education and longer term supervised exercise therapy, and (4) education and exercise therapy before and/or after total hip or knee surgery. Education included individualized information, advice, instructions, and self-management support. Exercise programs were tailored to individual OA-related issues, were adequately dosed, and were in line with public health recommendations for physical activity. Recommended measurement instruments included the Patient-Specific Complaints Instrument, the Numeric Pain Rating Scale, the Hip Disability and Osteoarthritis Outcome Score/the Knee Injury Osteoarthritis Outcome Score, and the Six Minute Walk Test.

CONCLUSION

An evidence-based PT guideline for the management of patients with hip or knee OA was developed. To improve quality of care for these patients, an extensive implementation strategy is necessary.

Importance of Rehabilitation in Primary Knee Osteoarthritis

In our observational study, we aim to highlight the role of rehabilitation program in the control and maintaining of the clinical and functional status of people with primary knee osteoarthritis and co-morbidities. We established that the complete rehabilitation program (diet, symptomatic medication and herbal products, electrotherapy measures and kinetic exercises) will give the optimal healthcare for this type of patients.

Effects of therapeutic ultrasound for knee osteoarthritis: a systematic review and meta-analysis

Objective:

To assess the effectiveness and safety of therapeutic ultrasound with sham ultrasound on pain relief and functional improvement in knee osteoarthritis patients. As phonophoresis is a unique therapeutic ultrasound, we also compared the effects of phonophoresis with conventional non-drug ultrasound.

Data sources:

PubMed, EMBASE, and the Cochrane Library were systematically searched for randomized controlled trials from inception up to June 2019.

Review methods:

Randomized controlled trials comparing therapeutic ultrasound with sham ultrasound in knee osteoarthritis patients were included. Phonophoresis in the experimental and control groups were compared through conventional ultrasound, and corresponding trials were also included. Two reviewers independently identified eligible studies and extracted data. Risk of bias assessments and therapeutic ultrasound safety assessments were also performed.

Results:

Fifteen studies including three phonophoresis-related studies with 1074 patients were included. Meta-analyses demonstrated that therapeutic ultrasound significantly relieved pain ( P < 0.00001) and reduced the Western Ontario and McMaster Universities (WOMAC) physical function score ( P = 0.03). In addition, therapeutic ultrasound increased the active range of motion ( P < 0.00001) and reduced the Lequesne index ( P < 0.00001). Subgroup analysis of phonophoresis ultrasound illustrated significant differences on the visual analogue scale ( P = 0.009), but no significant differences on WOMAC pain subscales ( P = 0.10), and total WOMAC scores were observed ( P = 0.30). There was no evidence to suggest that ultrasound was unsafe treatment.

Conclusions:

Therapeutic ultrasound is a safe treatment to relieve pain and improve physical function in patients with knee osteoarthritis. However, phonophoresis does not produce additional benefits to functional improvement, but may relieve pain compared to conventional non-drug ultrasound.

Effects of combination therapy and infrared radiation on pain, physical function, and quality of life in subjects with knee osteoarthritis: A randomized controlled study

Background:

Knee osteoarthritis (KOA) is a common degenerative articular disease that causes disability and poor quality of life (QoL) of the individuals. Electrotherapeutic agents such as therapeutic ultrasound (US), interferential current (IFC), and infrared radiation are used in the treatment. It is not clear which of these agents is the best in improving these variables.

Objective:

The study aimed to compare the effects of the combined application of US and IFC therapies and infrared radiation on pain, functional activities, and QoL in people with KOA.

Methods:

In a randomized controlled study, 60 participants were randomized into two groups, the combination therapy group (CTG) and the infrared radiation group (IRG). Each group received 15-min treatment three times per week for 12 weeks. The visual analog scale (VAS) was used to assess the pain, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) for functional activities and the Short Form Health Survey questionnaire for QoL.

Results:

Participants in the CTG had a significant (p<0.05) reduction in pain and significant (p<0.05) improvement in functional activities and QoL compared to the IRG.

Conclusion:

The results of this study support the use of the combination of IFC and US therapies to reduce pain and improve function and QoL for KOA patients.

The TeMPO trial (treatment of meniscal tears in osteoarthritis): rationale and design features for a four arm randomized controlled clinical trial

BACKGROUND

Meniscal tears often accompany knee osteoarthritis, a disabling condition affecting 14 million individuals in the United States. While several randomized controlled trials have compared physical therapy to surgery for individuals with knee pain, meniscal tear, and osteoarthritic changes (determined via radiographs or magnetic resonance imaging), no trial has evaluated the efficacy of physical therapy alone in these subjects.

METHODS

The Treatment of Meniscal Tear in Osteoarthritis (TeMPO) Trial is a four-arm multi-center randomized controlled clinical trial designed to establish the comparative efficacy of two in-clinic physical therapy interventions (one focused on strengthening and one containing placebo) and two protocolized home exercise programs.

DISCUSSION

The goal of this paper is to present the rationale behind TeMPO and describe the study design and implementation strategies, focusing on methodologic and clinical challenges.

TRIAL REGISTRATION

The TeMPO Trial was first registered at clinicaltrials.gov with registration No. NCT03059004 . on February 14, 2017.

Effects of Low-Intensity Pulsed Ultrasound on Knee Osteoarthritis: A Meta-Analysis of Randomized Clinical Trials

Background

Osteoarthritis (OA) is a common degeneration disease characterized with joint pain. The aim of the present study was to systemically review the effects of LIPUS on pain relief and functional recovery in patients with knee osteoarthritis (OA).

Methods

PubMed, Embase, and Cochrane Library were searched manually for researches on LIPUS treatment in patients with knee OA from 1945 to July 2017. Two investigators independently selected the studies according to the inclusion and exclusion criteria, extracted the concerned data, and assessed the included studies. Meta-analysis was performed to evaluate VAS, WOMAC, and ambulation speed between control and LIPUS groups.

Results

Five studies were selected in this study. Compared with control group, LIPUS group received a decrease of pain intensity with moderate heterogeneity (-0.79, 95% CI, -1.57 to 0.00; I² = 65%, P = 0.04) by VAS and improvement in knee function by WOMAC (-5.30, 95% CI, -2.88 to -7.71; I² = 44%, P = 0.17). No significant improvement was found in ambulation speed (0.08 m/s, 95% CI, -0.02 to 0.18 m/s; I² = 68%, P = 0.03).

Conclusion

The present study includes 5 high quality randomized controlled trials. The result indicated that LIPUS, used to treat knee OA without any adverse effect, had a beneficial effect on pain relief and knee functional recovery. More evidence is needed to prove whether LIPUS is effective in improving walking ability.

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.

Low-level laser therapy and interferential current in patients with knee osteoarthritis: a randomized controlled trial protocol

The aim of this study is to investigate the effects of low-level laser therapy and interferential current (IFC) on pain intensity, central sensitization, muscle strength and functional capacity in patients with knee osteoarthritis. Participants will be patients aged between 50 and 80 years, with knee osteoarthritis, pain intensity ranging from 3 to 8 points (0–10 scale), Lequesne Algofunctional Index ranging from 5 to 15 points, and Kellgren & Lawrence grade ≥2. A total of 168 patients will be randomly allocated into four groups as follows: active IFC + laser sham (G1), IFC sham + active laser (G2), active IFC + laser (G3) and IFC + laser sham (G4). Evaluators will be blinded to group allocation. Primary outcomes will be pain at rest and during movement measured with the visual analog pain scale. Clinical Trials Registry (NCT02898025. Registered on 20 April 2016).

Ultrasound plus low-level laser therapy for knee osteoarthritis rehabilitation: a randomized, placebo-controlled trial

This study evaluated the synergistic effects of ultrasound (US) and low-level laser therapy (LLLT) with or without therapeutic exercises (TE) in women with knee osteoarthritis. Forty-two Caucasian women with knee osteoarthritis were allocated into three groups: (1) the placebo group who did not perform TE, but the prototype without emitting light or ultrasonic waves was applied, (2) the US + LLLT group in which only the prototype was applied and (3) the TE + US + LLLT group that performed TE before the prototype was applied. However, 35 women completed the full clinical trial. Pressure pain thresholds (PPT) using an algometer and functional performance during the sit-to-stand test were carried out. The average PPT levels increased for US + LLLT (41 ± 9 to 54 ± 15 N, p < 0.01) and TE + US + LLLT (32 ± 8 to 45 ± 9 N, p < 0.01) groups. The number of sit-to-stands was significantly higher for all groups. However, the change between pre-treatment and post-treatment (delta value) was greater for the US + LLLT (4 ± 1) and TE + US + LLLT groups (5 ± 1) than for the placebo group (2 ± 1) with a significant intergroup difference (p < 0.05). This study showed reduced pain and increased physical functionality after 3 months of US + LLLT with and without TE.

Effects of pulsed therapeutic ultrasound on the treatment of people with knee osteoarthritis

[Purpose] The aim was to evaluate the effect of therapeutic ultrasound on the pain, joint mobility, muscle strength, physical function, and quality of life of people with knee OA. [Subjects and Methods] One-site, one-arm, before-after study that included people with Grade II or III tibiofemoral osteoarthritis. Ten therapeutic ultrasound sessions (duty cycle=20%, ERA=10 cm², BNR=6:1, SATP=2.2 W/cm², SATA=0.44 W/cm², frequency=1 MHz, time=4 minutes) were applied. Assessments of primary outcome variables: pain intensity and function, and secondary variables: joint mobility, muscle strength and quality of life, were performed at onset and end of therapy; an additional intermediate evaluation was included for the primary variables. [Results] Means of repeated measurements of pain intensity (pain at rest, pain on palpation and pain after functional activities) and function showed significant differences. There was a significant reduction in pain intensity at the end of functional activities as well as a significant increase in function and in quadriceps muscle strength. [Conclusion] Therapeutic ultrasound applied in accordance with the parameters used, could be recommended during the treatment of individuals with knee osteoarthritis, because it significantly decreased the intensity of pain after the 5th session, and this reduction was maintained until the end of the intervention.

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.

Therapeutic ultrasound associated with copaiba oil reduces pain and improves range of motion in patients with knee osteoarthritis

Abstract Introduction: Osteoarthritis is a disease that affects millions of Brazilians.Therapeutic ultrasound has been used in its treatment, either alone or associated with drugs. Objective: The aim of this study was to evaluate the effects of ultrasound (US) associated with Copaiba oil (CO) on knee osteoarthritis. Methods: Patients were divided into three different groups: US, US+CO, CO.Ten treatment sessions were held twice a week, 30 minutes each.Pain intensity was assessed through the Visual Analog Scale (VAS) and Range of Motion (ROM) by goniometry, and muscle strength was assessed by means of the Medical Research Council Scale. Statistical analysis was performed by Cohen’s d test, student’s t test and ANOVA, considering p<0.05 as significant. Results: Pain reduced in all groups.The US+CO group (d = -3.50) presented larger effect size when compared to the other groups. Regarding ROM, the largest effect size was observed in the US+CO group for flexion (d = 0.86) and extension (d = 0.97) in comparison with the remainder groups. Muscle strength increased in the US (d = 1.54) and US+CO (d = 1.60) groups for flexion.Regarding extension, the US group presented the largest effect size (d = 1.80). Conclusion: Therapeutic ultrasound associated with copaiba oil is a practical and effective therapy for the treatment of inflammatory diseases such as osteoarthritis.

The effectiveness of braces and orthoses for patients with knee osteoarthritis: A systematic review of Japanese-language randomised controlled trials

BACKGROUND

Knee osteoarthritis is common. The evidence regarding the effectiveness of braces and orthoses for patients with knee osteoarthritis is inconclusive according to English-language literature. English-language reviews to date have not included Japanese-language studies.

OBJECTIVES

This study aimed to collect and synthesise Japanese-language randomised controlled trials investigating the effectiveness of braces and orthoses for patients with knee osteoarthritis.

STUDY DESIGN

Systematic review.

METHODS

Eight databases were systematically searched from inception to 29 July 2015. Only Japanese-language randomised controlled trials were included. Risk of bias was assessed using Physiotherapy Evidence Database scale. A meta-analysis was not appropriate due to the heterogeneity in the included studies.

RESULTS

Seven randomised controlled trials with low to high risks of bias were included. Six of seven included studies were conducted by the same author group. Limited evidence supported the positive effects of short-lever elastic knee braces to improve pain and functional disability in specific outcomes. No evidence was found to support the use of foot orthoses, such as laterally wedged insoles, medial arch support and metatarsal arch pad.

CONCLUSION

Our systematic review found no conclusive evidence about the effectiveness of any braces and orthoses for patients with medial knee osteoarthritis. Future Japanese-language studies should address methodological flaws exposed in this review and strengthen the international evidence base. Clinical relevance This is the first systematic review of Japanese-language randomised controlled trials investigating orthoses for patients with knee osteoarthritis. Clinicians can consider the use of short-lever elastic knee braces to improve specifically pain on squat or walking. Evidence found in this review does not support the use of foot orthoses.

The Effect of Therapeutic Ultrasound on Pain and Physical Function in Patients with Knee Osteoarthritis

Osteoartritis (OA) is one of the most frequent causes of pain, loss of function and disability in adults. The prevalence of OA is expected to increase substantially in the future. Knee OA is the most common subset of OA. Therapeutic ultrasound (US) is one of several physical therapy modalities suggested for the management of pain and loss of function due to OA. The purpose of our study was to investigate the efficacy of US therapy in reducing pain and functional loss and improving the quality of life in patients with knee OA in comparison to sham US therapy. The study involved 62 patients. The patients were randomly divided into two groups. The patients in group 1 (n = 30) were administered 1 W/cm², 1 MHz continuous US, and the patients in group 2 (n = 32) were administered sham US. The US treatment was applied for 8 min to each knee, 16 min in total, 5 d a wk, for a total of 10 sessions during 2 wk. The patients were evaluated immediately after treatment and 1 mo after therapy according to the visual analog scale (VAS), night pain, range of motion, morning stiffness, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lequesne and Short Form-36 (SF-36) scales and 6 min walking distance. Improvement in pain and joint functions was observed in both groups according to the evaluation immediately after treatment and at 1 mo after the therapy. According to the evaluation results immediately after treatment, there was significant improvement in all pain scales (VAS, WOMAC, Lequesne, SF-36), morning stiffness and 6 min walking distance in patients receiving real US treatment (p < 0.05), but only in some pain scales (VAS, WOMAC) and functions in the group receiving sham US (p < 0.05). Significantly better improvement was observed in some pain scales (SF-36), functions (WOMAC, SF-36) and 6 min walking distance in the real US group. At 1 mo after therapy, no significant difference was observed between groups except for improvement in night pain in the real US group. In conclusion, US therapy has been found to be effective in reducing pain and improving physical function in the short term, but this positive effect was not persistent in the long term. However, we believe that the results of our study may contribute to ongoing research for the treatment of patients with knee OA, and further systematic investigation on larger patient populations may delineate the role of US in knee OA treatment.

Ultrasound with mineral water or aqua gel to reduce pain and improve the WOMAC of knee osteoarthritis

AIMS

Osteoarthritis is the most degenerative joint disease. The aim was to investigate the effects of ultrasound using mineral water or aqua sonic gel on severity of knee pain, measured by the visual analog scale and the Western Ontario and McMaster Universities Arthritis Index (WOMAC).

MATERIALS AND METHODS

Thirty women with bilateral osteoarthritis of the knee were assigned to two groups: ultrasound with mineral water (group 1, n = 15) or with aqua sonic gel (group 2, n = 15). Both groups underwent 4 weeks intervention, three per week. The participants were assessed using the visual analog scale and the WOMAC. Tests were performed before and after interventions.

RESULTS

Both groups had significantly reduced pain and improved WOMAC compared with preintervention values.

DISCUSSION

The ultrasound with mineral water group had more pronounced improvement at p-value < 0.001.

CONCLUSION

Ultrasound with mineral water is preferable in treatment of knee OA.

Efficacy of focused low-intensity pulsed ultrasound therapy for the management of knee osteoarthritis: a randomized, double blind, placebo-controlled trial

The aim of this study was to investigate the effects of focused low-intensity pulsed ultrasound (FLIPUS) therapy on the functional and health status of patients with knee osteoarthritis (KOA). A total of 106 subjects with bilateral KOA were randomized sequentially into two groups. Group I received FLIPUS + diclofenac sodium, and group II received sham FLIPUS + diclofenac sodium. The therapeutic effects of the interventions were evaluated by measuring changes in VAS pain, the WOMAC scores, and the LI scores after 10 days of treatment as well as changes in LI and VAS at follow-up, 4 and 12 weeks later. In addition, changes in the range of motion, ambulation speed, and the SF-36 in each group were recorded after 10 days of treatment. Compared with those in group II, patients in group Ishowed significant improvements in VAS, WOMAC, LI, ambulation speed, and most items in the SF-36 after 10 days of treatment. In addition, patients in group I showed significant improvements in LI and VAS at follow-up. There were no FLIPUS-related adverse events during and after the interventions. In conclusion, FLIPUS is a safe and effective treatment modality for relieving pain and improving the functions and quality of life of patients with KOA.

A study to evaluate the effect of ultrasound treatment on nodules in multiple sclerosis patients

Purpose/aim: Ultrasound has demonstrated anti-inflammatory and pain-relief benefits in several conditions such as cellulite or trauma events. We assessed the efficacy of ultrasound therapy on nodules associated with first-line treatments in multiple sclerosis patients.

MATERIALS AND METHODS

Twenty-two multiple sclerosis patients were enrolled during 2013 and randomized to two groups: in the control group patients were treated only with a conventional gel prescribed for cellulite and nodules, while in the experimental group the gel was combined with ultrasound therapy. Patients were treated during 10 weeks and followed up for 10 additional weeks. Three nodules were assessed for each patient, measuring size, pain and redness at 0, 10 and 20 weeks.

RESULTS

We found a significant decrease in both groups in size, pain and redness across the three visits (p < 0.0001 for size, p = 0.01 and p < 0.0001 for pain, and p = 0.0002 and p < 0.0001 for redness, respectively for the difference at visit 2 and 3 with respect to visit 1). More interestingly, we observed a greater reduction in pain and redness in the ultrasound-treated group, but the difference was only statistically significant at 10 weeks (p = 0.01 for both pain and redness). On the third visit, no differences between control and experimental groups were detected, both achieving the same levels in measured variables.

CONCLUSIONS

Both treatments are useful to improve skin reaction after first-line treatments, but ultrasound in combination with gel achieves a faster reduction in pain and redness, suggesting that ultrasound treatment might be a good analgesic for nodule management in multiple sclerosis patients.

Prevalence of depressive symptoms and anxiety in osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

osteoarthritis is a leading cause of disability. This systematic review aimed to establish the prevalence of depressive symptoms and anxiety among people with osteoarthritis in comparison to those without osteoarthritis.

METHOD

we systematically reviewed databases including AMED, EMBASE, MEDLINE, PsycINFO, BNI, CINAHL and the Cochrane database library from their inception to January 2015. Studies presenting data on depressive symptoms and anxiety in people with osteoarthritis were included. A random- and fixed-effect meta-analysis was conducted on all eligible data.

RESULTS

a total of 49 studies were included, representing 15,855 individuals (59% women; mean age 65.2 years). The evidence base was moderate in quality. The pooled prevalence of depressive symptoms in osteoarthritis was 19.9% (95% confidence intervals (CI): 15.9-24.5%, n = 10,811). The corresponding pooled prevalence was 21.3% (95% CI: 15.5-28.5%; n = 1,226) for anxiety symptoms. The relative risk of depression among people with osteoarthritis was 1.17 (95% CI 0.69-2.00, three studies, n = 941) compared with people without osteoarthritis. The relative risk of anxiety was 1.35 (95% CI: 0.51-3.59; three studies, n = 733) compared with those without osteoarthritis.

CONCLUSION

one-fifth of people with osteoarthritis experience symptoms of depression and anxiety. However, it is uncertain whether this is increased compared with those without osteoarthritis, with no direct evidence to support an increase in anxiety and depression in osteoarthritis.

PROSPERO REGISTRATION NUMBER

CRD42013006733.

Comparison of therapeutic duration of therapeutic ultrasound in patients with knee osteoarthritis

[Purpose] The aim of study was to compare different durations of ultrasound in patients with knee osteoarthritis. [Subjects and Methods] One hundred patients diagnosed with bilateral knee osteoarthritis (OA) were enrolled in this study. Patients were divided into two groups. The first group (G1) received 4 minutes of ultrasound. The second group (G2) received the exact same treatment, but the duration of ultrasound was longer at 8 minutes. Patients in both groups underwent a total of 10 ultrasound over 2 weeks. Following treatment, all patients provided self-evaluations of pain via the Visual Analog Scale (VAS), overall physical function with WOMAC, disability via the Lequesne index (Leq), and depressive symptoms with the Beck Depression Index (BDI). [Results] There were no significant differences in VAS, WOMAC Leq, and BDI values between groups 1 and 2. After treatment, VAS, WOMAC, Leq, and BDI values improved for both treatment groups. However, following treatment, G2 had significantly greater values for WOMAC functional and total scores than G1. No statistically significant differences were observed for VAS scores while inactive, WOMAC pain and stiffness scores, and BDI values after treatment between both groups. VAS pain scores while active and Leq index values were significantly lower in G1 than G2. [Conclusion] Patients in both groups demonstrated improved functionality, pain and psychological status following a consistent, 2-week regimen of 4-minute or 8-minute treatments with ultrasound. Yet, patients that experienced longer treatment durations of 8 minutes demonstrated better outcomes in pain and the ability to carry out activities of daily living.

Effects of therapeutic ultrasound on pain, physical functions and safety outcomes in patients with knee osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

To explore the effects of therapeutic ultrasound with sham or no intervention on pain, physical function and safety outcomes in patients with knee osteoarthritis.

DATA SOURCES

This systematic review was searched on CENTRAL, EMBASE, MEDLINE, CINAHL, Physiotherapy Evidence Database, Open Gray on 4 September 2015. Trials included randomized controlled trials that compared therapeutic ultrasound with a sham or no intervention in patients with osteoarthritis of the knee.

REVIEW METHODS

Eligible trials and extracted data were identified by two independent investigators. Standardized mean differences (SMDs) and 95% confidence interval (CI) were calculated for pain and physical function outcomes. Heterogeneity was assessed by the I² test and inverse-variance random-effects analysis was applied to all trials.

RESULTS

Ten randomized controlled trials (645 patients) met the inclusion criteria. Therapeutic ultrasound showed a positive effect on pain (SMD = -0.93, 95%, CI = -1.22 to -0.64, p < 0.01, p for heterogeneity = 0.12, I² = 42%). For physical function, therapeutic ultrasound was advantageous for reducingWestern Ontario and McMaster Universities physical function score (SMD = -0.37, 95% CI = -0.73 to -0.01, p = 0.04, p for heterogeneity = 0.94, I² = 0%). In terms of safety, no occurrence of adverse events caused by therapeutic ultrasound was reported in any trial.

CONCLUSION

The authors suggested that therapeutic ultrasound is beneficial for reducing knee pain and improving physical functions in patients with knee osteoarthritis and could be a safe treatment.

Electrical stimulation for pain relief in knee osteoarthritis: systematic review and network meta-analysis

OBJECTIVE

To investigate the efficacy of different electrical stimulation (ES) therapies in pain relief of patients with knee osteoarthritis (OA).

METHOD

Electronic databases including MEDLINE, Embase and Cochrane Library were searched through for randomized controlled trials (RCTs) comparing any ES therapies with control interventions (sham or blank) or with each other. Bayesian network meta-analysis was used to combine both the direct and indirect evidence on treatment effectiveness.

RESULTS

27 trials and six kinds of ES therapies, including high-frequency transcutaneous electrical nerve stimulation (h-TENS), low-frequency transcutaneous electrical nerve stimulation (l-TENS), neuromuscular electrical stimulation (NMES), interferential current (IFC), pulsed electrical stimulation (PES), and noninvasive interactive neurostimulation (NIN), were included. IFC is the only significantly effective treatment in terms of both pain intensity and change pain score at last follow-up time point when compared with the control group. Meanwhile, IFC showed the greatest probability of being the best option among the six treatment methods in pain relief. These estimates barely changed in sensitivity analysis. However, the evidence of heterogeneity and the limitation in sample size of some studies could be a potential threat to the validity of results.

CONCLUSION

IFC seems to be the most promising pain relief treatment for the management of knee OA. However, evidence was limited due to the heterogeneity and small number of included trials. Although the recommendation level of the other ES therapies is either uncertain (h-TENS) or not appropriate (l-TENS, NMES, PES and NIN) for pain relief, it is likely that none of the interventions is dangerous.

LEVEL OF EVIDENCE

LevelⅡ, systematic review and network meta-analysis of RCTs.

Efficacy of therapeutic ultrasound vs sham ultrasound on pain and physical function in people with knee osteoarthritis: A meta-analysis of randomized controlled trials

AIM: To determine the efficacy of therapeutic ultrasound vs sham for improving pain and physical function immediately post-intervention in people with knee osteoarthritis (OA).

METHODS: We hand searched meta-analyses on the topic published in 2010 and updated the search in three electronic databases (MEDLINE, EMBASE, CINAHL) January 1, 2009 to September 5, 2013 to identify relevant studies. The inclusion criteria were human randomized controlled trials published in the English language in which active therapeutic ultrasound was compared to sham ultrasound, data for people with knee OA were reported separately, participants were blinded to treatment allocation and outcomes assessed before and after treatment included pain, self-reported physical function and performance-based physical function. Two reviewers independently screened titles and abstracts retrieved in the search to identify trials suitable for full text review. Data extraction and risk of bias assessment of the identified trials were completed independently by two reviewers. Pooled analyses were conducted using inverse-variance random effects models.

RESULTS: We screened 1013 titles and abstracts. Meta-analysis of pain outcomes from 5 small trials (281 participants/OA knees) showed that, compared to sham ultrasound, therapeutic ultrasound improves pain [standardized mean difference (SMD) (95%CI) = -0.39 (-0.70, -0.08); P = 0.01] but not physical function [self-reported in 3 trials (130 participants/OA knees): SMD (95%CI) = -0.21 (-0.55, 0.14), P = 0.24; walking performance in 4 trials (130 participants/OA knees): SMD (95%CI) = -0.11 (-0.59, 0.37), P = 0.65). For the walking performance outcome, the dispersion of the estimated effects exceeded that expected due to sampling error (χ² = 8.37, P = 0.04, I² = 64%). Subgroup analyses of three trials that administered high dose ultrasound improved the consistency (I² = 28%) but the treatment effect remained insignificant.

CONCLUSION: Meta-analyzed double-blind placebo-controlled randomized trials provide low-strength evidence that therapeutic ultrasound decreases knee OA pain and very low-strength evidence that it does not improve physical function.

Effectiveness of continuous and pulsed ultrasound for the management of knee osteoarthritis: a systematic review and network meta-analysis

BACKGROUND

To investigate the efficacy of continuous and pulsed ultrasound (US) in the management of knee osteoarthritis (OA).

DESIGN

This systematic review and network meta-analysis covered 12 trials in total. Electronic databases including MEDLINE, Embase and Cochrane Library were searched through to identify randomized controlled trials comparing the two modes of US with control interventions (sham or blank) or with each other. Bayesian network meta-analysis was used to integrate both the direct and indirect evidences on treatment effectiveness.

RESULTS

Pulsed US (PUS) is more effective in both pain relief and function improvement when compared with the control group; but for continuous US (CUS), there is only a significant difference in pain relief in comparison with the control group. In addition, no matter in terms of pain intensity or function at the last follow-up time point, PUS always exhibited a greater probability of being the preferred mode. However, the evidence of heterogeneity and the limitation in sample size of some studies could be a potential threat to the validity of results.

CONCLUSIONS

Our findings indicated that PUS, with a greater probability of being the preferred mode, is more effective in both pain relief and function improvement when compared with the control group. However, CUS could only be considered as a pain relief treatment in the management of knee OA. The findings also confirmed that none of these modes is dangerous.

LEVEL OF EVIDENCE

Level II, systematic review and network meta-analysis of randomized controlled trials.

OARSI guidelines for the non-surgical management of knee osteoarthritis

OBJECTIVE

To develop concise, up-to-date, patient-focused, evidence-based, expert consensus guidelines for the management of knee osteoarthritis (OA), intended to inform patients, physicians, and allied healthcare professionals worldwide.

METHOD

Thirteen experts from relevant medical disciplines (primary care, rheumatology, orthopedics, physical therapy, physical medicine and rehabilitation, and evidence-based medicine), three continents and ten countries (USA, UK, France, Netherlands, Belgium, Sweden, Denmark, Australia, Japan, and Canada) and a patient representative comprised the Osteoarthritis Guidelines Development Group (OAGDG). Based on previous OA guidelines and a systematic review of the OA literature, 29 treatment modalities were considered for recommendation. Evidence published subsequent to the 2010 OARSI guidelines was based on a systematic review conducted by the OA Research Society International (OARSI) evidence team at Tufts Medical Center, Boston, USA. Medline, EMBASE, Google Scholar, Web of Science, and the Cochrane Central Register of Controlled Trials were initially searched in first quarter 2012 and last searched in March 2013. Included evidence was assessed for quality using Assessment of Multiple Systematic Reviews (AMSTAR) criteria, and published criticism of included evidence was also considered. To provide recommendations for individuals with a range of health profiles and OA burden, treatment recommendations were stratified into four clinical sub-phenotypes. Consensus recommendations were produced using the RAND/UCLA Appropriateness Method and Delphi voting process. Treatments were recommended as Appropriate, Uncertain, or Not Appropriate, for each of four clinical sub-phenotypes and accompanied by 1-10 risk and benefit scores.

RESULTS

Appropriate treatment modalities for all individuals with knee OA included biomechanical interventions, intra-articular corticosteroids, exercise (land-based and water-based), self-management and education, strength training, and weight management. Treatments appropriate for specific clinical sub-phenotypes included acetaminophen (paracetamol), balneotherapy, capsaicin, cane (walking stick), duloxetine, oral non-steroidal anti-inflammatory drugs (NSAIDs; COX-2 selective and non-selective), and topical NSAIDs. Treatments of uncertain appropriateness for specific clinical sub-phenotypes included acupuncture, avocado soybean unsaponfiables, chondroitin, crutches, diacerein, glucosamine, intra-articular hyaluronic acid, opioids (oral and transdermal), rosehip, transcutaneous electrical nerve stimulation, and ultrasound. Treatments voted not appropriate included risedronate and electrotherapy (neuromuscular electrical stimulation).

CONCLUSION

These evidence-based consensus recommendations provide guidance to patients and practitioners on treatments applicable to all individuals with knee OA, as well as therapies that can be considered according to individualized patient needs and preferences.

Osteoarthritis year in review: outcome of rehabilitation

PURPOSE

This review highlights seminal publications of rehabilitation interventions for osteoarthritis (OA) since April 2012.

METHODS

Medline in process, Embase, CINAHL and Cochrane databases were searched from April 2012 through February 2013 for English language publications using key words osteoarthritis, rehabilitation, physiotherapy, physical therapy, and exercise. Rehabilitation intervention studies included randomized trials or systematic reviews/meta-analyses or pre-post studies. Pilot randomized trials, feasibility studies and studies of surgical interventions unless they included evaluation of a rehabilitation intervention were excluded.

RESULTS

Twenty-five studies were identified for inclusion and grouped thematically. The short-term benefits (i.e., to 3 months) of variable types and dosages of exercise were demonstrated for a number of outcomes including pain, stiffness, function, balance, biomarkers, and executive function and dual task performance (related to falling) in people with knee OA. Modalities such as 890-nm radiation, interferential current, short wave diathermy, ultrasound and neuromuscular functional electrical stimulation did not demonstrate benefit over sham controls in those with knee OA. Spa therapy improved pain over the period of treatment in those with knee and hand OA. Supervised self-management based on cognitive therapy principles resulted in improved outcomes for people with knee OA. Shock absorbing insoles compared to normal footwear minimally improved knee pain and but not function and did not decrease knee load. Neuromuscular and motor training improved function in those with total hip replacement. Accelerated weight-bearing and rehabilitation (8 versus 11 weeks) was demonstrated to be safe and effective at 5 years following matrix autologous chondrocyte implantation for cartilage defects in the knee.

CONCLUSIONS

Exercise remains a mainstay of conservative management although most studies report only short-term outcomes. Self-management strategies also are beneficial in knee OA. There seems to be a placebo effect with most trials of physical modalities although spa therapy demonstrated very short-term effects.

Effectiveness of acupressure versus isometric exercise on pain, stiffness, and physical function in knee osteoarthritis female patients

Osteoarthritis (OA) is the most common form of arthritis and a leading cause of disability in older adults. Conservative non-pharmacological strategies, particularly exercise, are recommended by clinical guidelines for its management. The aim of this study was to assess the effectiveness of acupressure versus isometric exercise on pain, stiffness, and physical function in knee OA female patients. This quasi experimental study was conducted at the inpatient and outpatient sections at Al-kasr Al-Aini hospital, Cairo University. It involved three groups of 30 patients each: isometric exercise, acupressure, and control. Data were collected by an interview form and the Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) scale. The study revealed high initial scores of pain, stiffness, and impaired physical functioning. After the intervention, pain decreased in the two intervention groups compared to the control group (p < 0.001), while the scores of stiffness and impaired physical function were significantly lower in the isometric group (p < 0.001) compared to the other two groups. The decrease in the total WOMAC score was sharper in the two study groups compared to the control group. In multiple linear regression, the duration of illness was a positive predictor of WOMAC score, whereas the intervention is associated with a reduction in the score. In conclusion, isometric exercise and acupressure provide an improvement of pain, stiffness, and physical function in patients with knee OA. Since isometric exercise leads to more improvement of stiffness and physical function, while acupressure acts better on pain, a combination of both is recommended. The findings need further confirmation through a randomized clinical trial.