Supervised Exercise plus Acupuncture for Moderate to Severe Knee Osteoarthritis: A Small Randomised Controlled Trial

Prehabilitation for Patients Undergoing Orthopedic Surgery: A Systematic Review and Meta-analysis

Importance

Prehabilitation programs for patients undergoing orthopedic surgery have been gaining popularity in recent years. However, the current literature has produced varying results.

Objective

To evaluate whether prehabilitation is associated with improved preoperative and postoperative outcomes compared with usual care for patients undergoing orthopedic surgery.

Data Sources

Bibliographic databases (MEDLINE, CINAHL [Cumulative Index to Nursing and Allied Health Literature], AMED [Allied and Complementary Medicine], Embase, PEDRO [Physiotherapy Evidence Database], and Cochrane Central Register of Controlled Trials) were searched for published trials, and the Institute for Scientific Information Web of Science, System for Information on Grey Literature in Europe, and European clinical trials registry were searched for unpublished trials from January 1, 2000, to June 30, 2022.

Study Selection

Randomized clinical trials (RCTs) comparing prehabilitation with standard care for any orthopedic surgical procedure were included.

Data Extraction and Synthesis

Two independent reviewers screened trials. Data were pooled using a random-effects model. Recommendations were determined using the Grading of Recommendations Assessment, Development and Evaluation system and the study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline.

Main Outcomes and Measures

Pain, function, muscle strength, and health-related quality of life (HRQOL).

Results

Forty-eight unique trials involving 3570 unique participants (2196 women [61.5%]; mean [SD] age, 64.1 [9.1] years) were analyzed. Preoperatively, moderate-certainty evidence favoring prehabilitation was reported for patients undergoing total knee replacement (TKR) for function (standardized mean difference [SMD], -0.70 [95% CI, -1.08 to -0.32]) and muscle strength and flexion (SMD, 1.00 [95% CI, 0.23-1.77]) and for patients undergoing total hip replacement (THR) for HRQOL on the 36-item Short Form Health Survey (weighted mean difference [WMD], 7.35 [95% CI, 3.15-11.54]) and muscle strength and abduction (SMD, 1.03 [95% CI, 0.03-2.02]). High-certainty evidence was reported for patients undergoing lumbar surgery for back pain (WMD, -8.20 [95% CI, -8.85 to -7.55]) and moderate-certainty evidence for HRQOL (SMD, 0.46 [95% CI, 0.13-0.78]). Postoperatively, moderate-certainty evidence favoring prehabilitation was reported for function at 6 weeks in patients undergoing TKR (SMD, -0.51 [95% CI, -0.85 to -0.17]) and at 6 months in those undergoing lumbar surgery (SMD, -2.35 [95% CI, -3.92 to -0.79]). Other differences in outcomes favoring prehabilitation were of low to very low quality of evidence.

Conclusions and Relevance

In this systematic review and meta-analysis of RCTs, moderate-certainty evidence supported prehabilitation over usual care in improving preoperative function and strength in TKR and HRQOL and muscle strength in THR, high-certainty evidence in reducing back pain, and moderate-certainty evidence in improving HRQOL in lumbar surgery. Postoperatively, moderate-certainty evidence supported prehabilitation for function following TKR at 6 weeks and lumbar surgery at 6 months. Prehabilitation showed promising results for other outcomes, although high risk of bias and heterogeneity affected overall quality of evidence. Additional RCTs with a low risk of bias investigating preoperative and postoperative outcomes for all orthopedic surgical procedures are required.

Prehabilitation for Total Knee or Total Hip Arthroplasty: A Systematic Review

ABSTRACT

We sought to systematically review the evidence on the benefits and harms of prehabilitation interventions for patients who are scheduled to undergo elective, unilateral total knee arthroplasty or total hip arthroplasty surgery for the treatment of primary osteoarthritis. We searched PubMed, Embase, The Cochrane Central Register of Controlled Trials, CINAHL, PsycINFO, Scopus, and ClinicalTrials.gov from January 1, 2005, through May 3, 2021. We selected for inclusion randomized controlled trials and adequately adjusted nonrandomized comparative studies of prehabilitation programs reporting performance-based, patient-reported, or healthcare utilization outcomes. Three researchers extracted study data and assessed risk of bias, verified by an independent researcher. Experts in rehabilitation content and complex interventions independently coded rehabilitation interventions. The team assessed strength of evidence. While large heterogeneity across evaluated prehabilitation programs limited strong conclusions, evidence from 13 total knee arthroplasty randomized controlled trials suggest that prehabilitation may result in increased strength and reduced length of stay and may not lead to increased harms but may be comparable in terms of pain, range of motion, and activities of daily living (all low strength of evidence). There was no evidence or insufficient evidence for all other outcomes after total knee arthroplasty. Although there were six total hip arthroplasty randomized controlled trials, there was no evidence or insufficient evidence for all total hip arthroplasty outcomes.

The impact of waiting time for orthopaedic consultation on pain levels in individuals with osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

Time spent waiting for access to orthopaedic specialist health services has been suggested to result in increased pain in individuals with osteoarthritis (OA). We assessed whether time spent on an orthopaedic waiting list resulted in a detrimental effect on pain levels in patients with knee or hip OA.

METHODS

We searched Ovid MEDLINE, EMBASE and EBSCOhost databases from inception until September 2021. Eligible articles included individuals with OA on an orthopaedic waitlist and not receiving active treatment, and reported pain measures at two or more time points. Random-effects meta-analysis was used to estimate the pooled effect of waiting time on pain levels. Meta-regression was used to determine predictors of effect size.

RESULTS

Thirty-three articles were included (n = 2,490 participants, 67 ± 3 years and 62% female). The range of waiting time was 2 weeks to 2 years (20.8 ± 18.8 weeks). There was no significant change in pain over time (effect size = 0.082, 95% CI = -0.009, 0.172), nor was the length of time associated with longitudinal changes in pain over time (β = 0.004, 95% CI = -0.005, 0.012). Body mass index was a significant predictor of pain (β = -0.043, 95% CI = -0.079, 0.006), whereas age and sex were not.

CONCLUSIONS

Pain remained stable for up to 1 year in patients with OA on an orthopaedic waitlist. Future research is required to understand whether pain increases in patients waiting longer than 1 year.

Content and delivery of pre-operative interventions for patients undergoing total knee replacement: a rapid review

BACKGROUND

Total knee replacement (TKR) is a common operation typically performed for end-stage knee osteoarthritis. Patients awaiting TKR often have poor health-related quality of life. Approximately 20% of patients experience persistent pain post-TKR. Pre-operative TKR interventions could improve pre- and post-operative outcomes, but future research is required to inform their design. This review aimed to identify and synthesize recent literature on the content and delivery of pre-operative TKR interventions to help guide future research and clinical practice.

METHODS

This rapid review included randomized trials of pre-operative TKR interventions ("outcomes studies") and primary studies exploring patients' and/or health professionals' views of pre-operative TKR interventions ("views studies"). Medline, Embase, PsycINFO, CINAHL and the Cochrane Central Register of Controlled Trials were searched for English language studies published between January 2009 and December 2020. Eligible studies' reference lists were screened. Studies were appraised using the Mixed Methods Appraisal Tool. The findings were narratively synthesized using a convergent segregated approach.

RESULTS

From 3263 records identified, 52 studies were included (29 outcomes studies, 21 views studies, two outcomes/views studies). The studies' methodological quality varied but was generally highest in qualitative studies. The outcomes studies investigated education (n=5), exercise (n=20), psychological (n=2), lifestyle (n=1), and/or other interventions (n=5). The views studies addressed education (n=20), exercise (n=3), psychological (n=1), lifestyle (n=4), and/or other interventions (n=1). Only three outcomes studies (two randomized controlled trials (RCTs) and a pilot study) compared the effectiveness of intervention components/delivery approaches. The two RCTs' results suggest that pre-operative TKR exercise interventions are equally effective regardless of whether they include strength or strength plus balance training and whether they are hospital- or home-based. Personal tailoring and using more than one delivery format were associated with improved outcomes and/or perceived as beneficial for multiple intervention types.

CONCLUSIONS

Definitive evidence on the optimal design of pre-operative TKR interventions is lacking. Personal tailoring and employing multiple delivery formats appear to be valuable design elements. Preliminary evidence suggests that including balance training and hospital versus home delivery may not be critical design elements for pre-operative TKR exercise interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019143248 FUNDER: National Institute for Health and Care Research (ICA-CDRF-2018-04-ST2-006).

Effectiveness and safety of fire needle for knee osteoarthritis: A protocol of systematic review and meta-analysis

BACKGROUND

There is a lack of curative medical treatment for patients with knee osteoarthritis (KOA). Acupuncture represents an important alternative therapy. In various forms of acupuncture and moxibustion, the fire needle is an indispensable part. Knee osteoarthritis (KOA) is a series of symptoms and signs of knee joint caused by local injury and inflammation and chronic strain of the knee joint resulting in cartilage degeneration of the articular surface and reactive bone loss of the subchondral bone plate. The results of clinical trial indicated that the fire needle therapy has obvious curative effect in treating KOA. This protocol is intended to describe how to collate and accumulate evidence for the current efficient and safe treatment of KOA with fire needle.

METHODS

Seven electronic databases were used to retrieve the literature for the KOA randomized controlled trials, including 3 English databases (PubMed, EMBASE, the Cochrane Central Register of Controlled Trials [Cochrane Library]), and 4 Chinese databases (Chinese National Knowledge Infrastructure, Chinese VIP Information, Wanfang Database, and Chinese Biomedical Literature Database). This systematic review will include all randomized controlled clinical trials using fire needle therapy for KOA. The observation Index is the Change of Western Ontario and McMaster Universities Osteoarthritis Index Total, first proposed by Bellamy in 1988. The selection of the study will be completed independently by 2 reviewers, extract the data, and evaluate the quality of the study before selecting the title, abstract, and full text. Revman 5.4 software will be used to perform meta-analyses of randomized controlled trials, where risk ratios for dichotomous data and standardized or weighted mean differences for continuous data are the results.

RESULT

The results will be published in a peer-reviewed journal.

CONCLUSION

This systematic review will provide the latest evidence to evaluate the safety and efficacy of fire needle therapy in patients with KOA.

TRIAL REGISTRATION NUMBER

INPLASY202080030.

Acupuncture for knee osteoarthritis with sensitized acupoints: results from a pilot, feasibility randomized controlled trial

Background

Although previous clinical studies suggest possible benefits of acupuncture for knee osteoarthritis (KOA), the value of acupuncture at sensitized points is uncertain. We aimed to preliminarily assess the feasibility of performing a definitive randomized controlled trial to explore the effectiveness of acupuncture for KOA with highly sensitized acupoints.

Methods

In this randomized, single-blind, parallel, pilot trial, 36 participants with KOA were randomly assigned to receive acupuncture at highly sensitized acupoints (high-sensitization group) or at low/non-sensitized points (low/non-sensitization group) by a computer-generated random sequence. Both groups received three treatment sessions per week for four consecutive weeks (12 sessions in total). Assessments were performed at screening and at 4, 8, 12, and 16 weeks after randomization. Primary feasibility outcomes were patient recruitment, retention rate, and adherence to group treatment. Secondary outcomes included the change of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score from baseline to 16 weeks, the change of Short Form (SF)-12 health survey score, and safety outcomes.

Results

Patient recruitment of 36 patients took 2 months, achieving the recruitment target. Retention rates were similar between the treatment groups, 14 (77.8%) patients in the high-sensitization group completed the 16-week follow-up and compared to 14 (77.8%) patients in low/non-sensitization group, but the result was lower than expected. All patients received at least ten treatment sessions in total. The WOMAC total score and the pain, stiffness, and physical function score in the high-sensitization group were lower or very close to those in the control group at each assessment point. Similar results were observed on quality of life. No adverse events occurred.

Conclusion

This trial has presented preliminary data on the feasibility of conducting a large trial to test the effectiveness of acupuncture at sensitized points in KOA patients.

Trial registration

ClinicalTrials.gov, NCT03008668. Registered on 26 December 2016—retrospectively registered.

Interaction of energetic points, tendinomuscular meridian and 5 elements in the treatment of osteoarthritis of the knee in patients over 45 years old: a randomized controlled trial

INTRODUCTION

Acupuncture had a different approaches since its beginnings. Using traditional energetic points with an interaction of 5 elements and meridian theories with manual diagnosis of tender points has been proposed. This procedure can be an effective treatment in musculoskeletal disease but its development is short.

OBJECTIVES

To evaluate the efficacy of energetic points of tendinomuscular meridian in the treatment of pain, quality of life and function of the knee.

DESIGN

Randomized controlled trial, non standardized and double blind. Inclusions criteria were: being over 45 years, having had pain for more than 3 months, level II o greater in Kellgren-Lawrence and suffering morning stiffness. Exclusion criteria were artoplasty, corticosteroids and rehabilitation, arthropaties, autoinmune diseases and neuropathic pain.

RESULTS

Intervention group had significant improvement in average pain in the last 15 days at end of treatment (p<0.04) and quality of life at the end of follow-up (p<0.015). Other measurements no show significant differences between groups.

CONCLUSIONS

Energetic points of tendinomuscular meridian and the 5 elements related are equal or better than local acupuncture in the treatment of pain, quality of life and function in osteoarthritis of the knee. However, it is necessary to have more research with more tracing and poblation to improve the quality of the results.

Acupuncture treatment for knee osteoarthritis with sensitive points: protocol for a multicentre randomised controlled trial

INTRODUCTION

There is a lack of curative medical treatment for patients with knee osteoarthritis (KOA). Acupuncture represents an important alternative therapy. According to the theory of traditional Chinese medicine and preliminary clinical evidence, the patients' acupoints and tender points may become sensitised when the body suffers from a disease state; stimulation of such sensitive points could lead to a disease improvement. It is thus hypothesised that acupuncture at highly sensitised points on patients with KOA would achieve better treatment outcomes than acupuncture at low/non-sensitised points. Previously, we conducted a pilot trial to prove the feasibility of further investigation.

METHODS AND ANALYSIS

A three-arm, parallel, multicentre randomised controlled trial of 666 patients will be conducted at four hospitals of China. Eligible patients with KOA who consent to participate will be randomly assigned to a high-sensitisation group (patients receive acupuncture treatment at high-sensitive points), a low/non-sensitisation group (patients receive acupuncture treatment at low/non-sensitive points) or a waiting-list group (patients receive standard acupuncture treatment after the study is concluded) via a central randomisation system using 1:1:1 ratio. The primary outcome is the change of Western Ontario and McMaster Universities Osteoarthritis Index total score from baseline to 16 weeks. Outcome assessors and data analysts will be blinded and participants will be asked not to reveal their allocation to assessors. The outcome analyses will be performed both on the intention-to-treat and per-protocol population. The primary analyses will test if acupuncture at highly sensitised points would achieve statistically better treatment outcomes than acupuncture at low/non-sensitised points and no acupuncture (ie, waiting list), respectively. A small number of prespecified subgroup analyses will be conducted.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Bioethics Subcommittee of West China Hospital, Sichuan University: 2017 (Number 228). Results will be expected to be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03299439.

Risk of bias and methodological issues in randomised controlled trials of acupuncture for knee osteoarthritis: a cross-sectional study

OBJECTIVE

To assess risk of bias and to investigate methodological issues concerning the design, conduct and analysis of randomised controlled trials (RCTs) testing acupuncture for knee osteoarthritis (KOA).

METHODS

PubMed, EMBASE, Cochrane Central Register of Controlled Trials and four major Chinese databases were searched for RCTs that investigated the effect of acupuncture for KOA. The Cochrane tool was used to examine the risk of bias of eligible RCTs. Their methodological details were examined using a standardised and pilot-tested questionnaire of 48 items, together with the association between four predefined factors and important methodological quality indicators.

RESULTS

A total of 248 RCTs were eligible, of which 39 (15.7%) used computer-generated randomisation sequence. Of the 31 (12.5%) trials that stated the allocation concealment, only one used central randomisation. Twenty-five (10.1%) trials mentioned that their acupuncture procedures were standardised, but only 18 (7.3%) specified how the standardisation was achieved. The great majority of trials (n=233, 94%) stated that blinding was in place, but 204 (87.6%) did not clarify who was blinded. Only 27 (10.9%) trials specified the primary outcome, for which 7 used intention-to-treat analysis. Only 17 (6.9%) trials included details on sample size calculation; none preplanned an interim analysis and associated stopping rule. In total, 46 (18.5%) trials explicitly stated that loss to follow-up occurred, but only 6 (2.4%) provided some information to deal with the issue. No trials prespecified, conducted or reported any subgroup or adjusted analysis for the primary outcome.

CONCLUSION

The overall risk of bias was high among published RCTs testing acupuncture for KOA. Methodological limitations were present in many important aspects of design, conduct and analyses. These findings inform the development of evidence-based methodological guidance for future trials assessing the effect of acupuncture for KOA.

Effective exercise intervention period for improving body function or activity in patients with knee osteoarthritis undergoing total knee arthroplasty: a systematic review and meta-analysis

BACKGROUND

Various systematic reviews and/or meta-analyses examining the effects of pre- or postoperative exercise on body function or activity in patients undergoing total knee arthroplasty (TKA) have been published. However, the interventional period needed to at least improve outcomes is unknown.

OBJECTIVE

The aim of this systematic review and meta-analysis was to investigate the exercise intervention period needed to effectively improve body function or activity before and after TKA in patients with knee osteoarthritis (OA).

METHODS

Studies published until July 2017 were included in the review. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was applied to each meta-analysis to determine the quality of the evidence.

RESULTS

Twenty-seven randomized controlled trials were identified. A meta-analysis indicated that exercises performed for 8 weeks after discharge in addition to standard postoperative intervention effectively improved body function as assessed using pain level; physical function, and stiffness on the Western Ontario and McMaster Universities Arthritis Index; extension strength; active knee flexion range of motion; timed up and go test; and gait speed.

CONCLUSION

Overall, we found low- to moderate-quality evidence that an 8-week exercise period was needed after discharge to improve body function and activity in patients with knee OA undergoing TKA.

Does preoperative physiotherapy improve postoperative, patient-based outcomes in older adults who have undergone total knee arthroplasty? A systematic review

BACKGROUND

Knee osteoarthritis (OA) is a leading cause of disability in older adults (≥60) in the UK. If nonsurgical management fails and if OA severity becomes too great, knee arthroplasty is a preferred treatment choice. Preoperative physiotherapy is often offered as part of rehabilitation to improve postoperative patient-based outcomes.

OBJECTIVES

Systematically review whether preoperative physiotherapy improves postoperative, patient-based outcomes in older adults who have undergone total knee arthroplasty (TKA) and compare study interventions to best-practice guidelines.

METHOD

A literature search of Randomized Controlled Trials (RCTs), published April 2004-April 2014, was performed across six databases. Individual studies were evaluated for quality using the PEDro Scale.

RESULTS

Ten RCTs met the full inclusion/exclusion criteria. RCTs compared control groups versus: preoperative exercise (n = 5); combined exercise and education (n = 2); combined exercise and acupuncture (n = 1); neuromuscular electrical stimulation (NMES; n = 1); and acupuncture versus exercise (n = 1). RCTs recorded many patient-based outcomes including knee strength, ambulation, and pain. Minimal evidence is presented that preoperative physiotherapy is more effective than no physiotherapy or usual care. PEDro Scale and critical appraisal highlighted substantial methodological quality issues within the RCTs.

CONCLUSION

There is insufficient quality evidence to support the efficacy of preoperative physiotherapy in older adults who undergo total knee arthroplasty.

Traditional Chinese medicine in patients with osteoarthritis of the knee

To evaluate whether the use of traditional Chinese medicine (TCM; 中醫 zhōng yī) influences symptoms or functional outcomes in patients with osteoarthritis (OA) of the knee (膝關節炎 xī guān jié yán).

A systematic review of randomized control trials was conducted. Searches for studies in PubMed that were performed between 1965 and August 2013, and retrieved studies were subjected to reference screening. The types of studies included in our review were 1) placebo-based or comparative studies; 2) open label, single-blinded or double-blinded studies; 3) studies evaluating the efficacy of TCM for treating OA of the knee; and 4) studies evaluating only TCM or combination preparations. Trials were conducted with participants over 18 years of age with knee pain and at least three of the following characteristics: 1) an age greater than 50 years; 2) morning stiffness lasting for fewer than 30 min; 3) a crackling or grating sensation; 4) bony tenderness of the knee; 5) bony enlargement of the knee; or 6) no detectable warmth of the joint to the touch. Studies were rated for risk of bias and graded for quality.

After screening, 104 studies that satisfied the eligibility requirements were identified, and only 18 randomized control trials were included in the quantitative and qualitative synthesis. Upon review, we found “moderate-quality” evidence of effects from acupuncture (針灸 zhēn jiǔ) on pain, which was measured using a visual analogue scale, and physical function, which was measured using qigong (氣功 qì gōng) with motion. “Low-quality” evidence was found regarding the effects of acupuncture on physical function, and no evidence was found regarding the effects of herbal medicine on pain or physical function. Herbal patches (藥布 yào bù) appeared to affect pain and physical and function, but these effects were not found to be significant.

The initial findings included in this review suggest that acupuncture is a promising intervention according to the primary outcome measure, pain, and qigong with motion is an effective method for treating physical function. However, according to the Grades of Recommendation, Assessment, Development, and Evaluation criteria, only moderate-quality evidence was found in these studies. Further rigorous studies are warranted to investigate the application of TCM in treating OA of knee.

Exercise for osteoarthritis of the knee

BACKGROUND

Knee osteoarthritis (OA) is a major public health issue because it causes chronic pain, reduces physical function and diminishes quality of life. Ageing of the population and increased global prevalence of obesity are anticipated to dramatically increase the prevalence of knee OA and its associated impairments. No cure for knee OA is known, but exercise therapy is among the dominant non-pharmacological interventions recommended by international guidelines.

OBJECTIVES

To determine whether land-based therapeutic exercise is beneficial for people with knee OA in terms of reduced joint pain or improved physical function and quality of life.

SEARCH METHODS

Five electronic databases were searched, up until May 2013.

SELECTION CRITERIA

All randomised controlled trials (RCTs) randomly assigning individuals and comparing groups treated with some form of land-based therapeutic exercise (as opposed to exercise conducted in the water) with a non-exercise group or a non-treatment control group.

DATA COLLECTION AND ANALYSIS

Three teams of two review authors independently extracted data, assessed risk of bias for each study and assessed the quality of the body of evidence for each outcome using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach. We conducted analyses on continuous outcomes (pain, physical function and quality of life) immediately after treatment and on dichotomous outcomes (proportion of study withdrawals) at the end of the study; we also conducted analyses on the sustained effects of exercise on pain and function (two to six months, and longer than six months).

MAIN RESULTS

In total, we extracted data from 54 studies. Overall, 19 (20%) studies reported adequate random sequence generation and allocation concealment and adequately accounted for incomplete outcome data; we considered these studies to have an overall low risk of bias. Studies were largely free from selection bias, but research results may be vulnerable to performance and detection bias, as only four of the RCTs reported blinding of participants to treatment allocation, and, although most RCTs reported blinded outcome assessment, pain, physical function and quality of life were participant self-reported.High-quality evidence from 44 trials (3537 participants) indicates that exercise reduced pain (standardised mean difference (SMD) -0.49, 95% confidence interval (CI) -0.39 to -0.59) immediately after treatment. Pain was estimated at 44 points on a 0 to 100-point scale (0 indicated no pain) in the control group; exercise reduced pain by an equivalent of 12 points (95% CI 10 to 15 points). Moderate-quality evidence from 44 trials (3913 participants) showed that exercise improved physical function (SMD -0.52, 95% CI -0.39 to -0.64) immediately after treatment. Physical function was estimated at 38 points on a 0 to 100-point scale (0 indicated no loss of physical function) in the control group; exercise improved physical function by an equivalent of 10 points (95% CI 8 to 13 points). High-quality evidence from 13 studies (1073 participants) revealed that exercise improved quality of life (SMD 0.28, 95% CI 0.15 to 0.40) immediately after treatment. Quality of life was estimated at 43 points on a 0 to 100-point scale (100 indicated best quality of life) in the control group; exercise improved quality of life by an equivalent of 4 points (95% CI 2 to 5 points).High-quality evidence from 45 studies (4607 participants) showed a comparable likelihood of withdrawal from exercise allocation (event rate 14%) compared with the control group (event rate 15%), and this difference was not significant: odds ratio (OR) 0.93 (95% CI 0.75 to 1.15). Eight studies reported adverse events, all of which were related to increased knee or low back pain attributed to the exercise intervention provided. No study reported a serious adverse event.In addition, 12 included studies provided two to six-month post-treatment sustainability data on 1468 participants for knee pain and on 1279 (10 studies) participants for physical function. These studies indicated sustainability of treatment effect for pain (SMD -0.24, 95% CI -0.35 to -0.14), with an equivalent reduction of 6 (3 to 9) points on 0 to 100-point scale, and of physical function (SMD -0.15 95% CI -0.26 to -0.04), with an equivalent improvement of 3 (1 to 5) points on 0 to 100-point scale.Marked variability was noted across included studies among participants recruited, symptom duration, exercise interventions assessed and important aspects of study methodology. Individually delivered programmes tended to result in greater reductions in pain and improvements in physical function, compared to class-based exercise programmes or home-based programmes; however between-study heterogeneity was marked within the individually provided treatment delivery subgroup.

AUTHORS' CONCLUSIONS

High-quality evidence indicates that land-based therapeutic exercise provides short-term benefit that is sustained for at least two to six months after cessation of formal treatment in terms of reduced knee pain, and moderate-quality evidence shows improvement in physical function among people with knee OA. The magnitude of the treatment effect would be considered moderate (immediate) to small (two to six months) but comparable with estimates reported for non-steroidal anti-inflammatory drugs. Confidence intervals around demonstrated pooled results for pain reduction and improvement in physical function do not exclude a minimal clinically important treatment effect. Since the participants in most trials were aware of their treatment, this may have contributed to their improvement. Despite the lack of blinding we did not downgrade the quality of evidence for risk of performance or detection bias. This reflects our belief that further research in this area is unlikely to change the findings of our review.

Pain management with acupuncture in osteoarthritis: a systematic review and meta-analysis

BACKGROUND

The utility of acupuncture in managing osteoarthritis symptoms is uncertain. Trial results are conflicting and previous systematic reviews may have overestimated the benefits of acupuncture.

METHODS

Two reviewers independently identified randomized controlled trials (up to May 2014) from multiple electronic sources (including PubMed/Medline, EMBASE, and CENTRAL) and reference lists of relevant articles, extracted data and assessed risk of bias (Cochrane's Risk of Bias tool). Pooled data are expressed as mean differences (MD), with 95% confidence intervals (CI) (random-effects model).

RESULTS

We included 12 trials (1763 participants) comparing acupuncture to sham acupuncture, no treatment or usual care. We adjudicated most trials to be unclear (64%) or high (9%) risk of bias. Acupuncture use was associated with significant reductions in pain intensity (MD -0.29, 95% CI -0.55 to -0.02, I2 0%, 10 trials, 1699 participants), functional mobility (standardized MD -0.34, 95% CI -0.55 to -0.14, I2 70%, 9 trials, 1543 participants), health-related quality of life (standardized MD -0.36, 95% CI -0.58 to -0.14, I2 50%, 3 trials, 958 participants). Subgroup analysis of pain intensity by intervention duration suggested greater pain intensity reduction with intervention periods greater than 4 weeks (MD -0.38, 95% CI -0.69 to -0.06, I2 0%, 6 trials, 1239 participants).

CONCLUSIONS

The use of acupuncture is associated with significant reductions in pain intensity, improvement in functional mobility and quality of life. While the differences are not as great as shown by other reviews, current evidence supports the use of acupuncture as an alternative for traditional analgesics in patients with osteoarthritis.

SYSTEMATIC REVIEW REGISTRATION

CRD42013005405.

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.

Group acupuncture for knee pain: evaluation of a cost-saving initiative in the health service

BACKGROUND

Acupuncture has been provided in nurse-led group clinics in St Albans since 2008. It is funded by a commissioning group within the National Health Service, on a trial basis, for patients with knee osteoarthritis who would otherwise be referred to an orthopaedic surgeon.

AIM

To evaluate the patients seen in the service's first year of operation and their outcome up to the end of 2010.

METHODS

Service evaluation was made of patient data from the referral centre and the acupuncture clinics, including baseline characteristics, attendance data and Measure Yourself Medical Outcome Profile (MYMOP) symptom, function and well-being scores over at least 2 years.

RESULTS

114 patients were offered acupuncture, of whom 90 patients were assessed in the acupuncture clinics. 41 of these were still attending after 1 year and 31 (34%) after 2 years. MYMOP scores showed clinically significant improvements at 1 month for pain (4.2 (SD 1.2) to 2.9 (SD 1.4)), stiffness (4.1 (SD 1.3) to 2.9 (SD 1.3)) and function (4.5 (SD 1.1) to 3.3 (SD 1.2)) which continued up to 2 years. Well-being scores did not change.

CONCLUSIONS

This is the first evaluation of nurse-led group (multibed) acupuncture clinics for patients with knee osteoarthritis to include a 2 year follow-up. It shows the practicability of offering a low-cost acupuncture service as an alternative to knee surgery and the service's success in providing long-term symptom relief in about a third of patients. Using realistic assumptions, the cost consequences for the local commissioning group are an estimated saving of £100 000 a year. Sensitivity analyses are presented using different assumptions.