Home based exercise programme for knee pain and knee osteoarthritis: randomised controlled trial

Does Higher Compliance With American College of Sports Medicine Exercise Prescription Guidelines Influence Exercise Outcomes in Knee Osteoarthritis? A Systematic Review With Meta-Analysis

OBJECTIVE

We wanted to determine if higher compliance with American College of Sports Medicine (ACSM) exercise prescription guidelines influences exercise outcomes in knee osteoarthritis (OA).

METHODS

We conducted a systematic review. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase up to January 4, 2024, for randomized controlled trials evaluating resistance and/or aerobic exercise for knee OA. Interventions were classified as higher compliance (meeting ≥60% of ACSM guideline recommendations for frequency, intensity, and duration) or lower compliance (meeting <60% of recommendations). Effects on pain and function were evaluated via meta-analysis, stratified by compliance.

RESULTS

Twenty-five trials (3,290 participants) evaluated combined resistance and aerobic programs, with no differences in outcomes between those with higher and lower compliance (standardized mean difference [SMD] pain: -0.38 [95% confidence interval (CI) -0.59 to -0.17] vs -0.31 [95% CI -0.45 to -0.16], respectively; SMD function: -0.43 [95% CI -0.64 to -0.21] vs -0.36 [95% CI -0.58 to -0.14]). Sixty-six trials (5,231 participants) evaluated resistance exercise, with no differences between interventions with higher and lower compliance (SMD pain: -0.60 [95% CI -0.81 to -0.39] vs -0.93 [95% CI -1.27 to -0.59]; SMD function: -0.64 [95% CI -0.83 to -0.44] vs -0.85 [95% CI -1.20 to -0.49]). Twelve trials (958 participants) evaluated aerobic exercise, with no differences between interventions with higher and lower compliance (SMD pain: -0.79 [95% CI -1.20 to -0.38] vs -1.00 [95% CI -2.52 to 0.53]; SMD function: -0.83 [95% CI -1.27 to -0.38] vs -0.76 [95% CI -2.02 to 0.50]).

CONCLUSION

Higher or lower compliance with ACSM exercise prescription guidelines did not influence exercise outcomes. Given there was substantial heterogeneity and many publications were at risk of bias, our results should be interpreted with caution.

Effect of Clinic-Based and Asynchronous Video-Based Exercise on Clinic and Psychosocial Outcomes in Patients With Knee Osteoarthritis: Quasi-Experimental Study

BACKGROUND

Telerehabilitation is promising for improving knee osteoarthritis, but the effect of different telerehabilitation strategies on knee osteoarthritis is unclear.

OBJECTIVE

This study aimed to examine the effect of a clinic-based strengthening exercise (CbSE) and asynchronous video-based strengthening exercise (AVbSE) on pain, range of motion, muscle strength, quality of life, and physical function among patients with knee osteoarthritis.

METHODS

A total of 52 consenting patients participated in this 8-week experimental study; they were assigned to the CbSE or AVbSE group at 2 different study sites. CbSE is a circuit exercise module comprising knee flexion and extension warm-up in sitting, quadriceps isometric setting, quadriceps strengthening exercise, hamstring clenches, wall squat, and a cooldown of knee flexion and extension. The AVbSE is an asynchronous video-based version of the CbSE.

RESULTS

This study spanned from March 31, 2021, to November 26, 2021. Eight out of 62 participants discontinued participation. Data collection and analysis have been completed. Significant differences were only observed in the mental health (t50=-3, P=.004), pain (t39.4=-3.6, P<.001), social support (t50=-2.7, P=.009), and social activities (t50=2.2, P=.03) domains of the Osteoarthritis Knee and Hip Quality of Life (OAKHQoL) questionnaire with higher scores in the AVbSE group at the end of week 4. At the end of week 8, significant differences were observed in mental health (t50=-2.1, P=.04) and pain (t37.3=-2.8, P=.008) measures with higher scores in AVbSE; however, a significantly higher score was observed in the CbSE group for the Quadruple Visual Analog Scale. No significant main effect of time was observed in this study, except in the muscle strength (F2100=1.5, P=.24), social support (F2100=2.5, P=.09), and social activity (F2100=0.7, P=.48) domains of the OAKHQoL questionnaire and activity limitation (F2100=0.1, P=.90), and performance restriction (F2100=1.3, P=.27) domains of the Ibadan Knee and Hip Osteoarthritis Outcome Measure (IKHOAM) questionnaire. There was no significant difference between groups in all OAKHQoL domains except social activities (mean 17.6, SD 1.2 vs 22.8, SD 1.2; P=.003) and average pain (2.8, SD 1.6 vs 2.3, SD 1.6; P=.03) with higher AVbSE mean scores. However, a higher score was observed for the CbSE group in the Quadruple Visual Analog Scale's least pain domain (1.2, SD 0.2 vs 0.7, SD 0.2; P=.04). Also, interaction effects showed that AVbSE scores were significantly higher for the OAKHQoL questionnaire's physical activity and mental health domains at all time points. However, the CbSE score was higher for the physical performance domain of the IKHOAM questionnaire in the eighth week.

CONCLUSIONS

CbSE circuit training and its AVbSE variant effectively improve treatment outcomes and increase the quality of life of patients. While AVbSE was associated with higher improvement in most health-related quality of life domains, CbSE led to higher improvement in average pain.

TRIAL REGISTRATION

Pan African Clinical Trial Registry PACTR202208515182119, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=23943.

Effectiveness of the ARTHE-e app for exercise adherence in people with knee osteoarthritis: protocol for a randomised controlled trial

INTRODUCTION

Osteoarthritis, the most prevalent joint disease, poses a significant challenge due to its progressive nature and impact on the whole joint and periarticular structures. Although exercise is crucial for symptom improvement and progression slowdown, adherence to exercise programmes remains a concern. In response, we have developed a novel smartphone-based m-health application, ARTH-e, specifically designed to enhance adherence to adapted physical activity in individuals with knee osteoarthritis. We aim to perform a prospective,multicenter, randomized (1:1) controlled trial to compare the effectiveness of m-health application ARTH-e (intervention group) with standard care (control group) on exercise adherence in people with knee osteoarthritis. We hypothesise that adherence will be stronger among users of the ARTH-e application.

METHODS AND ANALYSIS

We will recruit 120 participants from 5 hospitals in France. The participants will undergo a comprehensive assessment, including the Exercise Adherence Rating Scale (EARS) at 2, 4 and 6 months, Knee Injury and Osteoarthritis Outcome Score, Evaluation of the Perception of Physical Activity, Tampa Scale of Kinesiophobia, European Quality of Life 5 Dimensions and 3 Lines and a Visual Analogue Scale rating of pain at baseline and 6 months. Adherence will be monitored using a connected bracelet. The intervention group will use the ARTH-e application for 6 months, while the control group will follow stay-active advice from their physician. The primary outcome will be the difference between groups in the evolution of the EARS score at 6 months.

ETHICS AND DISSEMINATION

The study has been approved by the medical ethics committee (Comité de Protection des Personnes) XI of Saint Germain en Laye (27 March 2024) (ID for ethics approval: 24.00330.000201). Eligible individuals will sign the informed consent form before enrolment. Study results will be reported in peer-reviewed publications and at scientific meetings.

TRIAL REGISTRATION NUMBER

NCT06359171.

Adherence Support Strategies for Physical Activity Interventions in People With Chronic Musculoskeletal Pain-A Systematic Review and Meta-Analysis

BACKGROUND

Chronic musculoskeletal (MSK) pain significantly impacts individuals' quality of life. Regular physical activity is an important key to therapy. However, adherence to exercise is often below the intended levels. This systematic review aims to assess the effectiveness of adherence support strategies in physical activity randomized controlled trials (RCTs) for patients with chronic MSK pain, to address the challenge of motivation and adherence in this population.

METHODS

Ovid and CINAHL databases were searched for MSK "chronic pain," "adherence" and "physical activity" (in various synonyms) for RCTs with a follow-up of at least 6 months. After a screening process that included several team members, a narrative synthesis and a meta-analysis on adherence and effect sizes of different outcomes were performed.

RESULTS

An initial database output of 5816 articles resulted in 76 RCTs that remained for analysis. These RCTs showed high heterogeneity of intervention design and outcome data. Adherence to exercise varied widely, with 21 RCTs achieving rates of 80% or higher using strategies like education, goal setting, self-monitoring, and personal feedback. The meta-analysis, based on 29 out of 76 RCTs, indicated a nonsignificant correlation between adherence levels and an improved outcome (eg, pain or quality of life). No individual strategy emerged as superior, emphasizing the complexity and diversity of intervention designs.

CONCLUSIONS

This review offers strategies, such as information/education and individual goal setting/feedback that may be beneficial for enhancing physical activity in patients with chronic MSK pain. Future research should focus on including promising adherence support strategies and providing data for adherence calculations.

The effect of an educational intervention based on the theory of planned behavior on the prevention of knee osteoarthritis in women

Knee osteoarthritis offers significant opportunities for prevention and the mitigation of its severity and associated symptoms through lifestyle modifications. This study aimed to investigate the efficacy of an educational intervention based on the Theory of Planned Behavior (TPB) in promoting preventive behaviors against knee osteoarthritis among women aged over 40 years residing in Fars, Iran. This research utilized a quasi-experimental design. The study population comprised 100 women over the age of 40 who were registered at health centers in Fasa, Iran. Data were collected using a questionnaire based on the Theory of Planned Behavior (TPB). The intervention was implemented through eight educational sessions specifically designed to promote TPB-informed preventive behaviors against knee osteoarthritis. The findings revealed statistically significant differences between the experimental and control groups regarding their scores on attitude, subjective norms, perceived behavioral control, intention, and behavior, both before and after the intervention. At 3 months post-intervention, the experimental group demonstrated significant improvements in all measured constructs, while the control group showed no substantial changes. This study demonstrates that implementing structured educational interventions grounded in behavioral theory, specifically the Theory of Planned Behavior (TPB), can effectively promote preventive behaviors against knee osteoarthritis, thereby potentially reducing its associated morbidity.

Exercise for osteoarthritis of the knee

BACKGROUND

Knee osteoarthritis (OA) is a major public health issue causing chronic pain, impaired physical function, and reduced quality of life. As there is no cure, self-management of symptoms via exercise is recommended by all current international clinical guidelines. This review updates one published in 2015.

OBJECTIVES

We aimed to assess the effects of land-based exercise for people with knee osteoarthritis (OA) by comparing: 1) exercise versus attention control or placebo; 2) exercise versus no treatment, usual care, or limited education; 3) exercise added to another co-intervention versus the co-intervention alone.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and two trial registries (ClinicalTrials.gov and World Health Organisation International Clinical Trials Registry Platform), together with reference lists, from the date of the last search (1st May 2013) until 4 January 2024, unrestricted by language.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated exercise for knee OA versus a comparator listed above. Our outcomes of interest were pain severity, physical function, quality of life, participant-reported treatment success, adverse events, and study withdrawals.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane for systematic reviews of interventions.

MAIN RESULTS

We included 139 trials (12,468 participants): 30 (3065 participants) compared exercise to attention control or placebo; 60 (4834 participants) compared exercise with usual care, no intervention or limited education; and 49 (4569 participants) evaluated exercise added to another intervention (e.g. weight loss diet, physical therapy, detailed education) versus that intervention alone. Interventions varied substantially in duration, ranging from 2 to 104 weeks. Most of the trials were at unclear or high risk of bias, in particular, performance bias (94% of trials), detection bias (94%), selective reporting bias (68%), selection bias (57%), and attrition bias (48%). Exercise versus attention control/placebo Compared with attention control/placebo, low-certainty evidence indicates exercise may result in a slight improvement in pain immediately post-intervention (mean 8.70 points better (on a scale of 0 to 100), 95% confidence interval (CI) 5.70 to 11.70; 28 studies, 2873 participants). Moderate-certainty evidence indicates exercise likely results in an improvement in physical function (mean 11.27 points better (on a scale of 0 to 100), 95% CI 7.64 to 15.09; 24 studies, 2536 participants), but little to no improvement in quality of life (mean 6.06 points better (on a scale of 0 to 100), 95% CI -0.13 to 12.26; 6 studies, 454 participants). There was moderate-certainty evidence that exercise likely increases participant-reported treatment success (risk ratio (RR) 1.46, 95% CI 1.11 to 1.92; 2 studies 364 participants), and likely does not increase study withdrawals (RR 1.08, 95% CI 0.92 to 1.26; 29 studies, 2907 participants). There was low-certainty evidence that exercise may not increase adverse events (RR 2.02, 95% CI 0.62 to 6.58; 11 studies, 1684 participants). Exercise versus no treatment/usual care/limited education Compared with no treatment/usual care/limited education, low-certainty evidence indicates exercise may result in an improvement in pain immediately post-intervention (mean 13.14 points better (on a scale of 0 to 100), 95% CI 10.36 to 15.91; 56 studies, 4184 participants). Moderate-certainty evidence indicates exercise likely results in an improvement in physical function (mean 12.53 points better (on a scale of 0 to 100), 95% CI 9.74 to 15.31; 54 studies, 4352 participants) and a slight improvement in quality of life (mean 5.37 points better (on a scale of to 100), 95% CI 3.19 to 7.54; 28 studies, 2328 participants). There was low-certainty evidence that exercise may result in no difference in participant-reported treatment success (RR 1.33, 95% CI 0.71 to 2.49; 3 studies, 405 participants). There was moderate-certainty evidence that exercise likely results in no difference in study withdrawals (RR 1.03, 95% CI 0.88 to 1.20; 53 studies, 4408 participants). There was low-certainty evidence that exercise may increase adverse events (RR 3.17, 95% CI 1.17 to 8.57; 18 studies, 1557 participants). Exercise added to another co-intervention versus the co-intervention alone Moderate-certainty evidence indicates that exercise when added to a co-intervention likely results in improvements in pain immediately post-intervention compared to the co-intervention alone (mean 10.43 points better (on a scale of 0 to 100), 95% CI 8.06 to 12.79; 47 studies, 4441 participants). It also likely results in a slight improvement in physical function (mean 9.66 points better, 95% CI 7.48 to 11.97 (on a 0 to 100 scale); 44 studies, 4381 participants) and quality of life (mean 4.22 points better (on a 0 to 100 scale), 95% CI 1.36 to 7.07; 12 studies, 1660 participants) immediately post-intervention. There was moderate-certainty evidence that exercise likely increases participant-reported treatment success (RR 1.63, 95% CI 1.18 to 2.24; 6 studies, 1139 participants), slightly reduces study withdrawals (RR 0.82, 95% CI 0.70 to 0.97; 41 studies, 3502 participants), and slightly increases adverse events (RR 1.72, 95% CI 1.07 to 2.76; 19 studies, 2187 participants). Subgroup analysis and meta-regression We did not find any differences in effects between different types of exercise, and we found no relationship between changes in pain or physical function and the total number of exercise sessions prescribed or the ratio (between exercise group and comparator) of real-time consultations with a healthcare provider. Clinical significance of the findings To determine whether the results found would make a clinically meaningful difference to someone with knee OA, we compared our results to established 'minimal important difference' (MID) scores for pain (12 points on a 0 to 100 scale), physical function (13 points), and quality of life (15 points). We found that the confidence intervals of mean differences either did not reach these thresholds or included both a clinically important and clinically unimportant improvement.

AUTHORS' CONCLUSIONS

We found low- to moderate-certainty evidence that exercise probably results in an improvement in pain, physical function, and quality of life in the short-term. However, based on the thresholds for minimal important differences that we used, these benefits were of uncertain clinical importance. Participants in most trials were not blinded and were therefore aware of their treatment, and this may have contributed to reported improvements.

Effectiveness of strategies to improve adherence to physical therapy in patients with knee and hip osteoarthritis: a systematic review and meta-analysis

PURPOSE

To determine the effectiveness of current strategies oriented to increase adherence to physical therapy in subjects with knee and hip osteoarthritis (OA).

MATERIAL AND METHODS

A systematic review of electronic databases was conducted from inception until March 2023. Studies with experimental interventions using strategies to increase adherence to physical therapy programs in subjects with knee or hip OA were included. A meta-analysis compared the effects of such interventions with usual care for adherence-related measures (primary outcome), and functional and pain outcomes, using standardized mean differences (SMD) with a 95% confidence interval (CI). GRADE was used to determine the strength of the resultant evidence and the external validity of the findings.

RESULTS

Fifteen articles, assessing 1,818 participants, were included. The interventions included cognitive-behavior strategies, telephone calls, internet-based interventions, communication technologies, and booster sessions. A meta-analysis revealed that the experimental interventions increased adherence over usual care with a moderate effect size of SMD = 0.39 (95%CI = 0.08-0.71) and moderate certainty in this evidence.

CONCLUSION

Overall, this review supports that the strategies to promote adherence to physical therapy in individuals with knee and hip OA are effective. However, the positive impact on adherence rates does not always translate into improved clinical outcomes.

Just-in-Time Adaptive Interventions for Behavior Change in Physiological Health Outcomes and the Use Case for Knee Osteoarthritis: Systematic Review

BACKGROUND

The prevalence of knee osteoarthritis (KOA) in the adult population is high and patients profit from individualized therapy approaches. Just-in-time adaptive interventions (JITAIs) are upcoming digital interventions for behavior change.

OBJECTIVE

This systematic review summarizes the features and effectiveness of existing JITAIs regarding important physiological health outcomes and derives the most promising features for the use case of KOA.

METHODS

The electronic databases PubMed, Web of Science, Scopus, and EBSCO were searched using keywords related to JITAIs, physical activity (PA), sedentary behavior (SB), physical function, quality of life, pain, and stiffness. JITAIs for adults that focused on the effectiveness of at least 1 of the selected outcomes were included and synthesized qualitatively. Study quality was assessed with the Quality Assessment Tool Effective Public Health Practice Project.

RESULTS

A total of 45 studies with mainly weak overall quality were included in this review. The studies were mostly focused on PA and SB and no study examined stiffness. The design of JITAIs varied, with a frequency of decision points from a minute to a day, device-based measured and self-reported tailoring variables, intervention options including audible or vibration prompts and tailored feedback, and decision rules from simple if-then conditions based on 1 variable to more complex algorithms including contextual variables.

CONCLUSIONS

The use of frequent decision points, device-based measured tailoring variables accompanied by user input, intervention options tailored to user preferences, and simple decision rules showed the most promising results in previous studies. This can be transferred to a JITAI for the use case of KOA by using target variables that include breaks in SB and an optimum of PA considering individual knee load for the health benefits of patients.

Mitigating Persistent Symptoms Following Rehabilitation in Musculoskeletal Disorders: A Scoping Review on After-discharge Strategies

BACKGROUND

The majority of patients with musculoskeletal pain (62% to 64%) achieve their treatment goals upon completing rehabilitation. However, a high re-consultation rate after discharge is frequently reported. Numerous authors have recognized the necessity of secondary prevention programs (after-discharge strategy) to ensure that the gains are maintained or further pursued after the completion of a rehabilitation program. Little is known about the different strategies currently in use, and a detailed review of the existing strategies is needed for future integration into the healthcare systems.

OBJECTIVE

This review systematically scopes and synthesizes the after-discharge strategies reported in the literature following rehabilitation for individuals experiencing musculoskeletal pain.

METHODS

Four databases (OVID MEDLINE, EMBASE, Web of Sciences, and OVID PsycInfo) were screened from their inception until May 4, 2023. Literature search, screening, and extraction were performed according to the PRISMA extension for scoping review guidelines.

RESULTS

Different after-discharge strategies were identified and grouped into 2 main categories: (1) in-person and (2) remote strategies. In-person strategies included (1.1) in-person booster sessions and (1.2) the use of existing community programs after discharge. Remote strategies included remote strategies that (2.1) involve a health care professional service or (2.2) strategies that do not involve any health care professional service.

DISCUSSION

We identified various after-discharge strategies designed to sustain gains and improve patients' self-management skills following the completion of a rehabilitation program. The existence of numerous promising strategies suggests their potential suitability for various contexts.

Electroacupuncture versus exercise in patients with knee osteoarthritis: Study protocol for a randomized controlled trial

PURPOSE

Knee osteoarthritis (KOA) is a common disorder among middle and older individuals. Electroacupuncture and exercise are present as two popular physical therapies for the management of KOA, and both were demonstrated to produce considerable results. However, the clinical decision-making process between these therapeutic interventions remains challenging due to the limited evidence of distinctions in their respective effects. This study aims to evaluate the clinical effect and cost effectiveness of electroacupuncture versus exercise in patients with KOA.

STUDY DESIGN AND METHODS

This is a randomized controlled trial in which 196 symptomatic KOA patients will be randomly assigned 1:1 either to the electroacupuncture group (n = 98) and the exercise group (n = 98). Patients in the electroacupuncture group will receive acupuncture with electric stimulation 3 times a week for 8 weeks, whereas patients in the exercise group will receive neuromuscular training twice a week for 8 weeks. Education concerning KOA management will be provided in both therapies. Co-primary outcomes include changes in numerical rating scale (NRS) and Knee injury and Osteoarthritis Outcome Score (KOOS) Activities of Daily Living (ADL) subscale from baseline at week 8. Secondary outcomes include KOOS Pain subscale, KOOS knee-related Quality of Life (QOL) subscale, Short Form 6 Dimensions (SF-6D), five-level EuroQol five-dimensional questionnaire (EQ-5D-5L), Credibility/ Expectancy Questionnaire, Patient's global assessment (PGA), 30-second Chair Stand Test (30s-CST), 40m (4*10m) Fast Paced Walk Test (40m FPWT), and Daily Physical Activity level (DPA).

DISCUSSION

The results of this study will provide evidence regarding differences between these 2 physical therapies in multiple aspects and will provide specific guidance for the development of treatments based on the needs of individual patients.

TRIAL REGISTRATION

ChiCTR2300070376.

Effectiveness of Mulligan Mobilization Technique and Core Stabilization Exercises in Female Patients With Knee Osteoarthritis: A Randomized Controlled Single-Blind Study

OBJECTIVES

The aim of this study was to compare the effectiveness of the Mulligan mobilization (MM) technique and Core stabilization (CS) exercises added to the conventional physiotherapy (CP) program in female patients with knee osteoarthritis (KOA).

METHODS

The study included 42 female patients diagnosed with bilateral KOA. Participants were randomly divided into 3 groups as CP group (mean age: 57.79 ± 7.43 years), MM group (mean age: 56.14 ± 6.95 years), and CS group (mean age: 54.36 ± 6.56 years). They were divided into 3 groups and treated 3 sessions per week for 4 weeks. Pain intensity, range of motion (ROM), and muscle strength were evaluated with visual analog scale, universal goniometer, and handheld dynamometer, respectively. Balance, aerobic capacity, and functional level were assessed with 30-second sit-to-stand test, 6-minute walk test, and Western Ontario and McMaster Universities Osteoarthritis Index. The quality of life of the participants was evaluated with the Nottingham Health Profile.

RESULTS

After treatment, significant improvement was achieved in the all parameters evaluated in the groups (P < .05). CS was found to be more effective in reducing resting pain intensity than the other two treatment approaches (P = .001). It was observed that MM technique increased knee flexion ROM more (P = .001). There was no superiority of MM group and CS group over each other in balance, functional level, aerobic capacity, and quality of life assessments (P > .05).

CONCLUSION

Our study showed that CP, MM technique, and CS exercises were effective treatment approaches in the management of KOA in female patients. Results revealed that the MM technique was more effective in increasing knee flexion ROM, and the CS exercise was more effective in reducing resting pain intensity in female patients with KOA.

Knee Osteoarthritis: Clinical and MRI Outcomes After Multiple Intra-Articular Injections With Expanded Autologous Adipose-Derived Stromal Cells or Platelet-Rich Plasma

OBJECTIVE

To directly compare clinical and MRI outcomes of multiple intra-articular injections of adipose-derived stromal cells (ASCs) or platelet-rich plasma (PRP) in patients with knee osteoarthritis (OA).

DESIGN

We retrospectively compared 24-month outcomes in (1) 27 patients receiving 3-monthly intra-articular injections with a total of 43.8 million ASCs and (2) 23 patients receiving 3-monthly injections of 3-ml preparation of PRP. All patients had Kellgren-Lawrence grade 1, 2, or 3 knee OA with failed conservative medical therapy. The Numeric Pain Rating Scale (NPRS) scores; Knee injury and Osteoarthritis Outcome Score (KOOS) at baseline, 6, 12, and 24 months after the first injection; and the MRI Osteoarthritis Knee Score (MOAKS) at 12 and 24 months were considered as outcomes.

RESULTS

No major complications occurred in any patient. Both groups significantly improved in pain NPRS score and KOOS at 6 months. At 12- and 24-month evaluations, the ASC group significantly decreased scores to a greater degree (P < 0.001) than the PRP group. MOAKS scores indicated a decrease in disease progression in the ASC group.

CONCLUSION

Both ASCs and PRP were safe and resulted in clinical improvement in patients with knee OA at 6 months; however, at 12 and 24 months, ASCs outperformed leukocyte-poor PRP in clinical and radiological outcomes.

Dose-Response Relationships of Resistance Training in Adults With Knee Osteoarthritis: A Systematic Review and Meta-analysis

BACKGROUND AND PURPOSE

To determine the effects of resistance training (RT) on symptoms, function, and lower limb muscle strength in patients with knee osteoarthritis (KOA), and to determine the optimal dose-response relationships.

DATA SOURCES

We searched the PubMed, MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and ClinicalTrials.gov databases from inception to January 23, 2022.

ELIGIBILITY CRITERIA

Randomized controlled trials that examined the effects of RT in KOA patients (mean age ≥50 years) were included.

DATA SYNTHESIS

We applied Hedges' g of the random-effects model to calculate the between-subject standardized mean difference (SMDbs). A random-effects metaregression was calculated to explain the influence of key training variables on the effectiveness of RT. We used the Grading of Recommendations Assessments, Development and Evaluation (GRADE) method to appraise the certainty of evidence.

RESULTS

A total of 46 studies with 4289 participants were included. The analysis revealed moderate effects of RT on symptoms and function (SMDbs =-0.52; 95% CI: -0.64 to -0.40), and lower limb muscle strength (SMDbs = 0.53; 95% CI: 0.42 to 0.64) in the intervention group compared with the control group. The results of the metaregression revealed that only the variable "training period" (P< .001) had significant effects on symptoms, function, and lower limb muscle strength, and the 4 to 8 weeks of training subgroup showed greater effects than other subgroups (SMDbs =-0.70, -0.91 to -0.48; SMDbs = 0.76, 0.56 to 0.96).

CONCLUSIONS

Compared with inactive treatments, RT is strongly recommended to improve symptoms, function, and muscle strength in individuals with KOA. Dose-response relationship analysis showed that 4 to 8 weeks of RT had more benefits.

The effectiveness of exercise with behavior change techniques in people with knee osteoarthritis: A systematic review with meta-analysis

OBJECTIVE

The purpose of this systematic review with meta-analysis was to examine the effectiveness of exercise with behavior change techniques (BCTs) on core outcome sets in people with knee osteoarthritis.

LITERATURE SURVEY

We searched randomized controlled trials (RCTs) in eight databases (MEDLINE, Embase, CENTRAL, CINAHL, PsycINFO, PEDro, ICTRP, and ClinicalTrials.gov) up to November 4, 2021.

METHODOLOGY

Eligible participants were people with knee osteoarthritis. The intervention was exercise with BCTs. Primary outcomes included physical function, quality of life (QOL) 6 to 12 months after intervention, and adverse events. Secondary outcomes were knee pain, exercise adherence, mobility, and self-efficacy 3 months or more after intervention. The bias risk was assessed using the Risk of Bias 2 tool. The random-effects model was used for the meta-analysis.

SYNTHESIS

We found 16 individual BCTs, and 37.7% of trials used a single BCT. For meta-analysis, we included 21 RCTs (n = 1623). Most outcomes had a very low certainty of evidence, and the risk of bias was the consistent reason for downgrading evidence levels. The standardized mean difference (SMD) with 95% confidence interval (95% CI) was 0.00 (-0.24, 0.24) in physical function, 0.33 (-0.51, 1.17) in exercise adherence, and 0.04 (-0.39, 0.47) in self-efficacy. The risk ratio (95% CI) of adverse events was 3.6 (0.79, 16.45). QOL was not pooled due to insufficient data (very low certainty of evidence). In contrast, the SMD (95% CI) for knee pain reduction and mobility improvement was -0.33 (-0.53, -0.13) and 0.21 (-0.05, 0.47) with moderate and low certainty of evidence, respectively.

CONCLUSION

The evidence is inconclusive regarding the effectiveness of BCTs with exercises on core outcome sets. Further research should explore the effectiveness of BCTs with valid design.

PROTOCOL REGISTRATION

PROSPERO (CRD42020212904).

Effectiveness of home-based exercise interventions on pain, physical function and quality of life in individuals with knee osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

The objective of the study was to evaluate the effectiveness of home-based exercise interventions on pain, physical function and quality of life in individuals with knee osteoarthritis (KOA).

METHODS

Five databases (PubMed, Embase, Cochrane Library, CINAHL, Web of Science Core Collection) were searched for relevant randomized controlled trials (RCTs) published from database inception to 2 August 2022. The Cochrane Collaboration's standards were followed for study selection, eligibility criteria, data extraction and statistics, using the Cochrane Collaboration Risk of Bias Tool and PEDro for quality assessment. A meta-analysis and subgroup analyses, stratified by control condition and intervention duration, were conducted using RevMan 5.4. The study was reported in compliance with the PRISMA statement.

RESULTS

A total of 12 independent RCTs with 1442 participants were included. The meta-analysis showed that the home-based exercise interventions significantly reduced pain in individuals with KOA (SMD =  - 0.32, 95% CI [- 0.41, - 0.22], p < .01) and improved physical function (SMD =  - 0.25, 95% CI [- 0.47, - 0.02], p = .03) and quality of life (SMD = 0.63, 95% CI [0.41, 0.85], p < .001). Subgroup analysis revealed that home-based exercise interventions were superior to health education and no treatment, in terms of pain and physical function, and similar to clinic-based exercise and pharmacologic treatment.

CONCLUSIONS

The effect of home-based exercise intervention is significantly better than health education and no treatment for reducing knee pain and improving physical function, and was able to achieve the effects of clinic-based exercise treatment and pharmacologic treatment. With regard to quality of life, the unsupervised home strength exercise intervention showed a significant effect compared with the health education control and combined with cognitive behavioural therapies may produce better results. Although home-based intervention provides effective treatment options for individuals with clinical treatment limitations, individual disease complications and the dosimetry of exercise need to be considered in practice. Furthermore, growing evidence supports the effectiveness of Tai Chi in the rehabilitation of KOA.

Moderators of the effect of therapeutic exercise for knee and hip osteoarthritis: a systematic review and individual participant data meta-analysis

BACKGROUND

Many international clinical guidelines recommend therapeutic exercise as a core treatment for knee and hip osteoarthritis. We aimed to identify individual patient-level moderators of the effect of therapeutic exercise for reducing pain and improving physical function in people with knee osteoarthritis, hip osteoarthritis, or both.

METHODS

We did a systematic review and individual participant data (IPD) meta-analysis of randomised controlled trials comparing therapeutic exercise with non-exercise controls in people with knee osteoathritis, hip osteoarthritis, or both. We searched ten databases from March 1, 2012, to Feb 25, 2019, for randomised controlled trials comparing the effects of exercise with non-exercise or other exercise controls on pain and physical function outcomes among people with knee osteoarthritis, hip osteoarthritis, or both. IPD were requested from leads of all eligible randomised controlled trials. 12 potential moderators of interest were explored to ascertain whether they were associated with short-term (12 weeks), medium-term (6 months), and long-term (12 months) effects of exercise on self-reported pain and physical function, in comparison with non-exercise controls. Overall intervention effects were also summarised. This study is prospectively registered on PROSPERO (CRD42017054049).

FINDINGS

Of 91 eligible randomised controlled trials that compared exercise with non-exercise controls, IPD from 31 randomised controlled trials (n=4241 participants) were included in the meta-analysis. Randomised controlled trials included participants with knee osteoarthritis (18 [58%] of 31 trials), hip osteoarthritis (six [19%]), or both (seven [23%]) and tested heterogeneous exercise interventions versus heterogeneous non-exercise controls, with variable risk of bias. Summary meta-analysis results showed that, on average, compared with non-exercise controls, therapeutic exercise reduced pain on a standardised 0-100 scale (with 100 corresponding to worst pain), with a difference of -6·36 points (95% CI -8·45 to -4·27, borrowing of strength [BoS] 10·3%, between-study variance [τ2] 21·6) in the short term, -3·77 points (-5·97 to -1·57, BoS 30·0%, τ2 14·4) in the medium term, and -3·43 points (-5·18 to -1·69, BoS 31·7%, τ2 4·5) in the long term. Therapeutic exercise also improved physical function on a standardised 0-100 scale (with 100 corresponding to worst physical function), with a difference of -4·46 points in the short term (95% CI -5·95 to -2·98, BoS 10·5%, τ2 10·1), -2·71 points in the medium term (-4·63 to -0·78, BoS 33·6%, τ2 11·9), and -3·39 points in the long term (-4·97 to -1·81, BoS 34·1%, τ2 6·4). Baseline pain and physical function moderated the effect of exercise on pain and physical function outcomes. Those with higher self-reported pain and physical function scores at baseline (ie, poorer physical function) generally benefited more than those with lower self-reported pain and physical function scores at baseline, with the evidence most certain in the short term (12 weeks).

INTERPRETATION

There was evidence of a small, positive overall effect of therapeutic exercise on pain and physical function compared with non-exercise controls. However, this effect is of questionable clinical importance, particularly in the medium and long term. As individuals with higher pain severity and poorer physical function at baseline benefited more than those with lower pain severity and better physical function at baseline, targeting individuals with higher levels of osteoarthritis-related pain and disability for therapeutic exercise might be of merit.

FUNDING

Chartered Society of Physiotherapy Charitable Trust and the National Institute for Health and Care Research.

What are the unsupervised exercise adherence rates in clinical trials for knee osteoarthritis? A systematic review

BACKGROUND

Exercise is an effective intervention for knee osteoarthritis (OA), and unsupervised exercise programs should be a common adjunct to most treatments. However, it is unknown if current clinical trials are capturing information regarding adherence.

OBJECTIVE

To summarize the extent and quality of reporting of unsupervised exercise adherence in clinical trials for knee OA.

METHODS

Reviewers searched five databases (PubMed, CINAHL, Medline (OVID), EMBASE and Cochrane). Randomized controlled trials where participants with knee OA engaged in an unsupervised exercise program were included. The extent to which exercise adherence was monitored and reported was assessed and findings were subgrouped according to method for tracking adherence. The types of adherence measurement categories were synthesized. A quality assessment was completed using the Physiotherapy Evidence Database (PEDro) scores.

RESULTS

Of 3622 abstracts screened, 176 studies met criteria for inclusion. PEDro scores for study quality ranged from two to ten (mean=6.3). Exercise adherence data was reported in 72 (40.9%) studies. Twenty-six (14.8%) studies only mentioned collection of adherence. Adherence rates ranged from 3.7 to 100% in trials that reported adherence. For 18 studies (10.2%) that tracked acceptable adherence, there was no clear superiority in treatment effect based on adherence rates.

CONCLUSIONS

Clinical trials for knee OA do not consistently collect or report adherence with unsupervised exercise programs. Slightly more than half of the studies reported collecting adherence data while only 40.9% reported findings with substantial heterogeneity in tracking methodology. The clinical relevance of these programs cannot be properly contextualized without this information.

Bibliometric Analysis of Publications in Clinical Trials on Knee Osteoarthritis Between 2001 and 2022

Purpose

Clinical treatment of knee osteoarthritis has gained great interest, and numerous clinical studies have been reported. Few studies have described the detailed characterizations of clinical trials on knee osteoarthritis. This study is to identify, visualize, and characterize the clinical trials in knee osteoarthritis research.

Design and Methods

Articles published in recent two decades were extracted from the Web of Science core collection database using a query based on MeSH terms and topics of knee osteoarthritis and clinical trial. Basic characteristics of publications were analyzed based on the publication year, authors, institutions, counties, and keywords covered in the article. CiteSpace and VOS viewer were used for data visualization. The data were retrieved on May 28, 2022.

Results

A total of 1972 trials on knee osteoarthritis were identified. The number of publications has experienced rapid growth in the past two decades. America, England, and China had strong contributions in publication. Osteoarthritis and Cartilage, Annals of the Rheumatic Diseases and American Journal of Sports Medicine were highly cited and bellwether journals. Clustering mapping of the collaborative network, co-citation, and co-occurrence analyses showed that the research hotspots are mainly focused on disease-modifying medications, intra-articular injections, physical therapy for symptom control, lifestyle intervention, Chinese medicine treatment, and knee replacement.

Conclusion

Clinical treatments of knee OA are evolving. Pharmacologic therapy, intra-articular therapy, nonpharmacologic therapy including exercise or diet, self-management programs, Chinese medicine treatment, and knee replacement were highly represented in clinical trials of knee OA. Adjustment of combination therapy may be the next study focus in the future.

The quality of physiotherapy and rehabilitation program and the effect of telerehabilitation on patients with knee osteoarthritis

OBJECTIVE

To compare the effects of telerehabilitation vs home-based exercise programs for knee osteoarthritis (KOA).

METHOD

Patients diagnosed with moderate/mild KOA were enrolled in the study and randomized into two groups. The patients in the telerehabilitation group did their exercises via video conference simultaneously, accompanied by a physiotherapist, while the patients in the control group were given a brochure showing how to do the exercises and explaining how to do each exercise. Patients completed 30-s chair stand test (30 CST), Knee Injury and Osteoarthritis Outcome Score (KOOS), Numeric Rating Scale (NRS), International Physical Activity Questionnaire Short Form (IPAQ-SF), Hospital Anxiety and Depression Scale (HADS), TAMPA Kinesiophobia Scale (TKS), Fatigue Severity Scale (FSS) twice before and after 8-week treatment, and Quality Indicators Questionnaire for Physiotherapy Management of Hip and Knee Osteoarthritis (QUIPA) and Exercise Adherence Rating Scale (EARS) after treatment only. Moreover, the number of painkillers that patients used in the last 15 days was recorded before and after treatment, and patient satisfaction with treatment was questioned after treatment.

RESULTS

Forty-eight patients were included in the study. The mean age of patients was 55.83 ± 6.93 years, and 43 (89.6%) patients were women. No significant differences were determined between groups in terms of baseline characteristics. After the 8-week follow-up, telerehabilitation group demonstrated better 30 CST, IPAQ-SF, KOOS, QUIPA, treatment satisfaction, and total and C subscale of EARS scores increment and greater NRS, HADS, TKS, and FSS score reduction than the control group. It was determined that there was a statistically significant difference between the telerehabilitation and control groups for all of the specified parameters; however, no statistically significant difference was found for the B subscale of EARS.

CONCLUSION

This study indicated that telerehabilitation is superior to self-management. Moreover, through this innovative and population specific web-based approach for KOA, a vast number of patients who have internet access could be reached. Thus, patients with KOA received effective treatment.

Resistance Training Modulates Reticulum Endoplasmic Stress, Independent of Oxidative and Inflammatory Responses, in Elderly People

Aging is related to changes in the redox status, low-grade inflammation, and decreased endoplasmic reticulum unfolded protein response (UPR). Exercise has been shown to regulate the inflammatory response, balance redox homeostasis, and ameliorate the UPR. This work aimed to investigate the effects of resistance training on changes in the UPR, oxidative status, and inflammatory responses in peripheral blood mononuclear cells of elderly subjects. Thirty elderly subjects volunteered to participate in an 8-week resistance training program, and 11 youth subjects were included for basal assessments. Klotho, heat shock protein 60 (HSP60), oxidative marker expression (catalase, glutathione, lipid peroxidation, nuclear factor erythroid 2-related factor 2, protein carbonyls, reactive oxygen species, and superoxide dismutase 1 and 2), the IRE1 arm of UPR, and TLR4/TRAF6/pIRAK1 pathway activation were evaluated before and following training. No changes in the HSP60 and Klotho protein content, oxidative status markers, and TLR4/TRAF6/pIRAK1 pathway activation were found with exercise. However, an attenuation of the reduced pIRE1/IRE1 ratio was observed following training. Systems biology analysis showed that a low number of proteins (RPS27A, SYVN1, HSPA5, and XBP1) are associated with IRE1, where XBP1 and RPS27A are essential nodes according to the centrality analysis. Additionally, a gene ontology analysis confirms that endoplasmic reticulum stress is a key mechanism modulated by IRE1. These findings might partially support the modulatory effect of resistance training on the endoplasmic reticulum in the elderly.

Self-care behaviors in older adults suffering from knee osteoarthritis: Application of theory of planned behavior

BACKGROUND

Osteoarthritis is one of the main reasons causing disablement. Educational intervention for self-care behaviors of patients suffering from knee osteoarthritis is important because its effect on quality of patient life decreases the economic burden of disorder on society and family. This study aimed to investigate the effect of educational intervention based on the theory of planned behavior (TPB) on promoting self-care behaviors in elderly patients suffering from knee osteoarthritis.

METHODS

This quasi-experimental study was performed on 200 elderlies suffering from knee osteoarthritis in the rheumatology clinics of Shiraz, Iran, in 2019. The subjects were divided into two groups (100 experimental and 100 control). Before and after 4 months, both experimental and control groups filled a questionnaire. After administering a pre-test to both groups, only the experimental group was trained based on the TPB constructs on self-care behaviors in elderly people suffering from knee osteoarthritis in eight sessions by presenting educational films and images, power points, and group discussions for solving problems.

RESULTS

The mean age of the experimental group was 67.25 ± 3.64, and the mean age of the control group was 66.12 ± 3.50. The average scores of attitudes, subjective norms, perceived behavioral control, intention, and behavior before the educational intervention did not have significant differences in experimental and control groups, however, 4 months after the educational intervention, the paired t-test indicated significant enhancement in every construct in the experimental group, but no significant changes in the control group.

CONCLUSION

According to the results, the educational intervention increased the self-care behaviors of patients suffering from knee osteoarthritis based on the theory of planned behavior. Therefore, the results of this study can be used in theory-based intervention strategies for self-care behaviors of patients suffering from knee osteoarthritis.

High baseline pain is associated with treatment adherence in persons diagnosed with thumb base osteoarthritis: An observational study

BACKGROUND

Thumb osteoarthritis (OA) is a common and disabling condition. Adherence to prescribed conservative interventions may affect outcomes of thumb OA trials.

PURPOSE

The aim of the study was to determine whether baseline pain and hand function is associated with treatment adherence over 12 weeks in participants with thumb base OA.

STUDY DESIGN

Observational cohort study nested within a randomized-controlled trial.

METHODS

Ninety-four participants from the intervention group were included in the analysis. Baseline pain and function were assessed using a 100 mm Visual Analogue Scale and the Functional Index for Hand Osteoarthritis questionnaire (0-30), respectively. Participants received a combination of treatments including education, orthosis, hand exercises, and topical anti-inflammatory gel. Adherence was measured using a daily self-reported diary. Participants were classified as non-adherent, partially adherent or fully adherent if they completed none, 1 and/or 2 or all 3 of the interventions as prescribed. Ordinal logistic regression modelling was performed.

RESULTS

At 12-week follow-up, half of the participants were fully adherent to the treatments (n = 46, 48.9%), 30.9% of participants were partially adherent (n = 29) and 20.2% were non-adherent (n = 19, 20.2%). High baseline pain was a significantly associated with better adherence in the unadjusted model [OR = 3.15, 95% CI (1.18, 8.42)] and adjusted model [OR = 3.20, 95% CI (1.13, 8.20)]. Baseline function was not associated with adherence [OR = 1.03, 95% CI (0.47, 2.23)].

CONCLUSION

High baseline pain was associated with better adherence in participants with thumb base OA. Higher baseline functional impairment was not associated with better adherence.

Safety and Efficacy of Injecting Mesenchymal Stem Cells Into a Human Knee Joint To Treat Osteoarthritis: A Systematic Review

Intraarticular stem cell therapy has become increasingly used to treat knee osteoarthritis (KOA) with minimal high-quality evidence to support its use. This study aims to see how well intra-articular injections of mesenchymal stem cells (MSCs) worked and how safe they were for individuals with KOA. A total of 10 studies were extracted using PubMed, Cochrane Library, and PMC from 2017 to 2021 in the English language. An assessment of the risk of bias was applied via the Cochrane Collaborative Bias Risk Tool and Newcastle-Ottawa Quality. Changes in pain and functional outcomes in patients with KOA were measured by a Knee injury and Osteoarthritis Outcome Score (KOOS) scores, Visual Analogue Scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores at baseline, and follow-up evaluation criteria. The magnetic resonance imaging (MRI) was evaluated using the whole-organ magnetic resonance imaging score (WORMS) and cartilage volume changes. A total of six randomized controlled trials (RCTs), three prospective retrospective clinical trials, and one retrospective clinical trial included 723 patients. They were diagnosed with unilateral or bilateral KOA with Kellgren-Lawrence (KL) grade 1-4 KOA and followed up for six, 12, and 24 months. The experimental groups received multipotent MSCs, mesenchymal progenitor cells (MPCs), adipose tissue progenitor stem cells (AD-MPCs), adipose tissue mesenchymal stem cells (AD-MSCs), bone marrow mesenchymal stem cells (BM-MSCs), bone marrow aspiration (BMA), bone marrow aspiration concentration (BMAC), or micro fragmented adipose tissue (MFAT) while the controlled groups received normal saline (NS), hyaluronic acid (HA), placebo, or went through conservative management. In conclusion, significant improvements were noticed in the MSCs groups via different outcome measuring tools like KOOS, VAS, WOMAC, and MRI. Furthermore, no significant adverse events (AEs) have been observed. Therefore, intra-articular injections of MSCs are effective and safe in relieving pain and improving motor function in individuals with KOA in the short term, contrary to earlier research findings.

Comparing an e-Health program vs home rehabilitation program in patients with non-specific low back pain: A study protocol randomized feasibility trial

BACKGROUND

There is little evidence on the reliability of the web application-based rehabilitation systems to treat chronic low back pain (CLBP).

METHODS

This protocol describes a double-blind, randomized controlled feasibility trial of an e-Health intervention developed to support the self-management of people with CLBP in primary care physiotherapy. Three Hospitals with primary care for outpatients will be the units of randomisation, in each Hospital the participants will be randomized to one of two groups, a pragmatic control group receiving either the usual home program based on electrostimulation and McKenzie Therapy and e-Health intervention. Patients are followed up at 2 and 6 months. The primary outcomes are (1) acceptability and demand of the intervention by GPs, physiotherapists and patients and (2) feasibility and optimal study design/methods for a definitive trial. Secondary outcomes will include analysis in the clinical outcomes of pain, disability, fear of movement, quality of life, isometric resistance of the trunk flexors, lumbar anteflexion and lumbar segmental range of motion.

DISCUSSION

The specific e-Health programs to home could increase adherence to treatment, prevent stages of greater pain and disability, and improve the painful symptomatology.

CONCLUSIONS

The e-Health programs could be an effective healthcare tool that can reach a large number of people living in rural or remote areas.

Is Telerehabilitation a Viable Option for People With Low Back Pain? Associations Between Telerehabilitation and Outcomes During the COVID-19 Pandemic

OBJECTIVE

The aims of this study were to examine associations between frequency of telerehabilitation (TR) and outcomes of functional status (FS), number of visits, and patient satisfaction during COVID-19 and to compare FS outcomes by TR delivery mode for individuals with low back pain.

METHODS

Propensity score matching was used to match episodes of care with or without TR exposure by the probability of receiving TR. FS, visits, and satisfaction were compared for individuals without TR and those who received care by TR for "any," "few," "most," or "all" frequencies (4 matched samples), and FS was compared for individuals receiving synchronous, asynchronous, and mixed TR modes (3 matched samples). Standardized differences were used to compare samples before and after matching. Outcomes between matched samples were compared using z tests with 95% CI.

RESULTS

The sample consisted of 91,117 episodes of care from 1398 clinics located in 46 states (58% women; mean age = 55 [SD = 18]). Of those, only 5013 episodes (5.5%) involved any amount of TR. All standardized differences between matched samples were <0.1. There was no significant difference in FS points (range = 0-100, with higher representing better FS) between matched samples, except for episodes that had ``few'' (-1.7) and ``all'' (+2.0) TR frequencies or that involved the asynchronous (-2.6) TR mode. These point differences suggest limited clinical importance. Episodes with any TR frequency involved significantly fewer visits (0.7-1.3) than episodes with no TR, except that those with the "most" TR frequency had non-significantly fewer visits (0.6). A smaller proportion of individuals with TR (-4.0% to -5.0%) than of individuals with no telerehabilitation reported being very satisfied with treatment results, except for those with the "all" TR frequency.

CONCLUSIONS

A positive association between TR and rehabilitation outcomes was observed, with a trend for better FS outcomes and fewer visits when all care was delivered through TR. Satisfaction tended to be lower with TR use. Overall, this observational study showed that for people with low back pain, physical therapy delivered through TR was equally effective as and more efficient than in-person care, with a trend of higher effectiveness when used for all visits during the episode of care. No differences in FS outcomes were observed between care delivered with synchronous and mixed TR delivery modes and care delivered with no TR. However, the asynchronous mode of TR was associated with worse functional outcomes than no TR. Although the majority of people were very satisfied with their treatment results with and without TR, very high satisfaction rates were reported by a slightly smaller proportion of individuals with TR versus those without TR. Our results suggest that TR is a viable option for rehabilitation care for individuals with low back pain and should also be considered in the post-COVID-19 era.

Effective interventions to improve long-term physiotherapy exercise adherence among patients with lower limb osteoarthritis. A systematic review

Introduction

Osteoarthritis (OA) is a chronic condition. Physiotherapy is known to be beneficial for people with OA. Patient adherence to physiotherapy exercise is essential for the effective management of OA.

Objectives

To determine different methods used to enhance physiotherapy exercise adherence for a period of more than 12 months among patients with OA and to report the most effective methods to enhance exercise adherence among people with lower limb OA.

Design

Systematic review.

Methods

PubMed, Pedro, Web of Science, and EMBASE databases were searched for randomized controlled trials, cohort studies, case-control studies, and cross-sectional studies published in the English language from 2000 to 2020. The literature search was done on 27 August 2020. Two researchers independently conducted the screening, eligibility assessment, data extraction, methodology quality assessment using the PEDro scale, and risk of bias assessment using RoB2. A narrative synthesis of key outcomes is presented, percentage of adherence rate; Preferred Reporting Items for Systematic Review was used to report the review. Meta-analysis was not performed due to heterogeneity of studies. The study protocol was registered in Prospero (Prospero ID: CRD42020205653).

Results

The primary search strategy identified 5839 potentially relevant articles, of which 5157 remained after discarding duplicates. After screening based on title and abstract, 40 papers were potentially eligible for inclusion. Five of these papers met all predefined eligibility criteria. Introducing methods to enhance exercise adherence has caused a significant increase in exercise adherence for less than 6 or 12 months. There were no significant differences in adherence for more than 12 months with different methods. The results indicate that booster-sessions (89.69%) and telephone-linked communication (86%) had higher percentages for exercise adherence. Secondary outcomes such as pain, stiffness and function show positive outcomes with increasing exercise adherence. However, there were no significant differences on these secondary outcomes.

Conclusion

The booster sessions and telephone-linked communication appear to enhance exercise adherence for more than 12 months among patients with OA. However, the number of high-quality studies is inadequate to confirm our findings. Therefore, more studies with higher methodological quality are needed to determine the best strategies to enhance long-term exercise adherence among people with OA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05050-0.

Effects of booster sessions on self-management interventions for chronic musculoskeletal pain: a systematic review and meta-analysis of randomised controlled trials

ABSTRACT

Our objective was to investigate the effectiveness of booster sessions after self-management interventions as a means of maintaining self-management behaviours in the treatment of chronic musculoskeletal pain. We searched MEDLINE, EMBASE, Science Citation Index, Cochrane Central Register of Controlled Trials, and PsychINFO. Two authors independently identified eligible trials and collected data. We calculated the odds ratio for the analyses of dichotomous data and standardised mean differences (SMDs) with 95% confidence interval (CI) for continuous variables. Our search identified 14 studies with a total of 1695 patients. All studies were at high risk of bias and provided very low quality evidence. For the primary outcomes, booster sessions had no evidence of an effect on improving patient-reported outcomes on physical function (SMD -0.13, 95% CI -0.32 to -0.06; P = 0.18), pain-related disability (SMD -0.16, 95% CI -0.36 to 0.03; P = 0.11), and pain self-efficacy (SMD 0.15, 95% CI -0.07 to 0.36; P = 0.18). For the secondary outcomes, booster sessions caused a significant reduction in patient-reported pain catastrophising (SMD -0.42, 95% CI -0.64 to -0.19; P = 0.0004) and no evidence of an effect on patient-reported pain intensity, depression, coping, or treatment adherence. There is currently little evidence that booster sessions are an effective way to prolong positive treatment effects or improve symptoms of long-term musculoskeletal conditions after self-management interventions. However, the studies were few with high heterogeneity, high risk of bias, and overall low quality of evidence. Our review argues against including booster sessions routinely to self-management interventions for the purpose of behaviour maintenance.

Virtual reality exergame for supplementing multimodal pain therapy in older adults with chronic back pain: a randomized controlled pilot study

Immersive Virtual Reality (VR) with head-mounted displays (HMD) can be a promising tool for increasing adherence to exercise in older adults. However, there is little known about the effectiveness of an interactive multimodal therapy in VR for older chronic back pain (CBP) patients. The aim of the exploratory randomized controlled trial was to examine the preliminary effectiveness of a VR multimodal therapy for older adults with CBP in a laboratory setting over a period of four weeks. The intervention group (IG; n = 11) received a multimodal pain therapy in VR (movement therapy and psychoeducation) and the control group (CG; n = 11) received a conventional multimodal pain therapy (chair-based group exercises and psychoeducation in a group setting). Although the VR therapy (IG) did not reach the pain intensity reduction of the CG (IG: MD = 0.64, p = .535; CG: MD = 1.64, p = .07), both groups showed a reduction in pain intensity on the Numeric Rating Scale. The functional capacity in the IG improved from Visit 1, x ¯ = 73.11% to Visit 2, x ¯ = 81.82% (MD = 8.71%; p = .026). In the changes of fear avoidance beliefs and general physical and mental health, no significance was achieved in either group. Although the IG did not reach a significant pain intensity reduction compared to the CG, the results of the present study showed that a pain intensity reduction can be achieved with the current VR application.

Alterations in the Functional Knee Alignment Are Not an Effective Strategy to Modify the Mediolateral Distribution of Knee Forces During Closed Kinetic Chain Exercises

Pain felt while performing rehabilitation exercises could be a reason for the low adherence of knee osteoarthritis patients to physical rehabilitation. Reducing compressive forces on the most affected knee regions may help to mitigate the pain. Knee frontal plane positioning with respect to pelvis and foot (functional knee alignment) has been shown to modify the mediolateral distribution of the tibiofemoral joint contact force in walking. Hence, different functional knee alignments could be potentially used to modify joint loading during rehabilitation exercises. The aim was to understand whether utilizing different alignments is an effective strategy to unload specific knee areas while performing rehabilitation exercises. Eight healthy volunteers performed 5 exercises with neutral, medial, and lateral knee alignment. A musculoskeletal model was modified for improved prediction of tibiofemoral contact forces and used to evaluate knee joint kinematics, moments, and contact forces. Functional knee alignment had only a small and inconsistent effect on the mediolateral distribution joint contact force. Moreover, the magnitude of tibiofemoral and patellofemoral contact forces, knee moments, and measured muscle activities was not significantly affected by the alignment. Our results suggest that altering the functional knee alignment is not an effective strategy to unload specific knee regions in physical rehabilitation.

Single versus multi-dose intra-articular injection of platelet rich plasma in early stages of osteoarthritis of the knee: A single-blind, randomized, superiority trial

Objectives

This study aims to compare the effectiveness of single, double, and triple doses of intra-articular (IA) platelet rich plasma (PRP) in early stages of osteoarthritis (OA) of the knee.

Patients and methods

This single-blind, randomized, superiority trial included a total of 180 knees of 90 patients (22 males, 68 females; mean age: 47.9 years; range, 36 to 60 years) with bilateral OA knee of Kellgren-Lawrence Grade 1-2 between May 2017 and December 2018. The patients were randomized (30 in each group) to receive single, double, or triple doses of IA PRP (two weeks apart in repeat injections). The outcome measures were Visual Analog Scale, International Knee Documentation Committee Score, Knee Injury and Osteoarthritis Outcome Score, and Tegner Lysholm Knee Score. The assessor of outcome was blinded. The scores were collected before intervention and at six weeks, three months, six months, and one year after the intervention.

Results

All patients completed the study. All three groups were comparable with respect to demographic and disease characteristics. All four scores were comparable among the three groups before intervention and at six weeks, three months, and six months. However, at one-year follow-up, the three-dose group showed superiority to others in terms of all four scores. All three groups showed improvement until six months and deterioration thereafter, which was only marginal in the three-dose group. All groups showed a statistically significant improvement of scores compared to baseline scores at one year. There were no major complications.

Conclusion

The IA administration of three doses of PRP yields superior outcome to single and double doses at the end of one year. Repeat doses are probably needed to sustain the benefit achieved at one year.

A Biomechanical Analysis of the Effect of Pilates Exercise on Female College Students with Knee Joint Deformity

BACKGROUND Current research on genu varum shows the favorable influence of exercise on the biomechanics of the knee joint by reducing the static malalignment and mechanical imbalances, however the transference to a more optimum gait has not been investigated.OBJECTIVES To investigate the effects of Pilates exercise on the changes of gait and lower limb malalignment in female students with genu varum.METHODS A total of 23 female college students with verified genu varum participated in this study. The participants were randomly assigned to two groups a Pilates exercise group (n=15) and a control group (n=8). The Pilates exercise group participated in 1 hour Pilates exercise 3 times per week for a total of 10 weeks. Each of the participants had an X-ray and performed gait 5 times before and after the exercise treatment. The participants kinetic and kinematic data were gathered using an eight Vicon Motion camera system and two force platforms.RESULTS For the Pilates group gait their maximum extension and internal rotation knee moment, and maximum adduction and internal rotation hip moment significantly increased, while the maximum knee moment flexion decreased. For the control group gait their maximum hip extension and hip adduction moment significantly decreased. For the Pilates group there was a significant reduction in the distance from the anatomical axis to the weight bearing line in the left leg, but there was no significant change for the control group.CONCLUSIONS The results suggest that Pilates exercise may be beneficial for females with genu varum by helping to improve both their static alignment and helping their gait to become more balanced.

Placebo response and effect in randomized clinical trials: meta-research with focus on contextual effects

BACKGROUND

Contextual effects (i.e., placebo response) refer to all health changes resulting from administering an apparently inactive treatment. In a randomized clinical trial (RCT), the overall treatment effect (i.e., the post-treatment effect in the intervention group) can be regarded as the true effect of the intervention plus the impact of contextual effects. This meta-research was conducted to examine the average proportion of the overall treatment effect attributable to contextual effects in RCTs across clinical conditions and treatments and explore whether it varies with trial contextual factors.

METHODS

Data was extracted from trials included in the main meta-analysis from the latest update of the Cochrane review on "Placebo interventions for all clinical conditions" (searched from 1966 to March 2008). Only RCTs reported in English having an experimental intervention group, a placebo comparator group, and a no-treatment control group were eligible.

RESULTS

In total, 186 trials (16,655 patients) were included. On average, 54% (0.54, 95%CI 0.46 to 0.64) of the overall treatment effect was attributable to contextual effects. The contextual effects were higher for trials with blinded outcome assessor and concealed allocation. The contextual effects appeared to increase proportional to the placebo effect, lower mean age, and proportion of females.

CONCLUSION

Approximately half of the overall treatment effect in RCTs seems attributable to contextual effects rather than to the specific effect of treatments. As the study did not include all important contextual factors (e.g., patient-provider interaction), the true proportion of contextual effects could differ from the study's results. However, contextual effects should be considered when assessing treatment effects in clinical practice.

TRIAL REGISTRATION

PROSPERO CRD42019130257 . Registered on April 19, 2019.

Impact of home exercise program on self-efficacy and quality of life among primary knee osteoarthritis patients: a randomized controlled clinical study

Background

Knee osteoarthritis (KOA) is a common joint disorder in elderly individuals, causing pain, loss of physical functioning, disability, and reduction of life quality. Home exercise programs (HEP) serve as a crucial complement to outpatient rehabilitation therapy, as they save the cost of supervised physical therapy sessions, while also offering a high level of treatment. The aim of this study was to evaluate the effectiveness of the 6-month HEP on pain, quality of life, and self-efficacy in patients with primary KOA and to identify the adherence level to exercises and associations with patients’ characteristics and clinical outcomes.

Results

After 6 months of HEP, there were statistically significant differences between groups for self-efficacy (p ≤ 0.001, from 58.29 to 71.5) (p = 0.23, from 55.98 to 57.72), quality of life (p ≤0.001, from 60.1 to 72.2) (p = 0.074, from 60.35 to 60.92), and pain severity (P ≤0.001, from 58.29 to 41.4) (P = 0.88, from 61.2 to 60.9) in favor of exercise group.

Conclusions

Home-based exercise program improves pain score, self-efficacy, and quality of life in patients with knee osteoarthritis. Adherence level to the exercise program may have a positive impact on patient improvement.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43166-021-00073-2.

Analysis of Movement-Based Mind-Body Interventions to Guide the Implementation of Osteoarthritis Exercise Programs: A Descriptive Review of Randomized Controlled Trials

Background: Clear and complete reporting of the components of complex interventions is required in clinical trials to ensure that research can be reliably replicated and successfully translated into clinical practice. Movement-based mind-body exercises, such as Tai Chi, qigong, and Yoga (TQY), are considered complex interventions and recommended for individuals with osteoarthritis in the latest guidelines of the American College of Rheumatology. This review analyzes the intervention reporting of randomized controlled trials of TQY to guide the implementation in osteoarthritis exercise programs. Methods: We searched PubMed, Cochrane Central Register of Controlled Trials, and EMBASE for TQY exercise trials in osteoarthritis between 2000 and 2020. Pairs of researchers independently screened the records, extracted study characteristics, and assessed 19 items on the Consensus on Exercise Reporting Template (CERT) checklist. For each of these items, the numbers of studies that clearly reported the item were calculated. We then identified the items in the studies that are key to delivering home-based exercises for further analysis. Results: We included 27 publications reporting 22 TQY interventions in the analysis. None of the studies reported sufficient details on all the 19 CERT items. The median completeness of reporting score was 11 and ranged from 6 to 15 of 19. The most frequently incompletely reported items (number reporting and percentage of studies) were "starting level rule" (n = 1, 5%) and "progression rule" (n = 1, 5%). Other incompletely reported items included "fidelity or adherence (planned)" (n = 9, 41%), "motivations" (n = 9, 41%), and "progression description" (n = 5, 23%). Conclusions: The content analysis highlights motivational strategies for long-term adherence to home-based exercises, which may help clinicians develop interventions for their patients. Details of TQY exercises interventions for osteoarthritis are incompletely reported in the included studies. The study suggests that improvements in content reporting are especially needed on items related to exercise intensity and program progression decisions, and motivational strategies in future implementation.

[Possibilities and limits of conservative treatment for osteoarthritis : Sport advice, training therapy, orthotics and cartilage therapeutics]

Hintergrund

Arthrose – die Degeneration von Gelenken – ist ein weit verbreitetes Problem durch alle Bevölkerungsschichten, das im zunehmenden Alter vermehrt auftritt und die häufigste Ursache für mobilitätseinschränkende Schmerzen am Bewegungsapparat ist. Etwa 70–80 % der über 70-Jährigen zeigen Zeichen einer Gelenksdegeneration. Insgesamt sind bis zu 25 % der Gesamtbevölkerung davon betroffen, aufgrund der generellen Alterung der Bevölkerung mit steigender Tendenz. Die Inzidenz der Arthrose steigt aber schon ab dem 40 Lebensjahr, wobei besonders posttraumatische und sekundäre Arthroseformen zum Tragen kommen.

Anspruch

Der Wunsch nach hoher Mobilität und Sport zieht sich als Phänomen ebenfalls durch alle Altersgruppe. Dies ist mit hohen Gelenkbelastungen verbunden und stellt damit eine große Herausforderung an vor allem früh degenerativ veränderte Gelenksstrukturen dar. In diesem Zusammenhang ist der orthopädisch tätige Arzt gefordert, die Belastbarkeit von geschädigten Gelenken abzuschätzen und so früh wie möglich präventive Schritte sowie gegebenenfalls konservative Therapien einzuleiten, um die Progression der Arthrose zu verhindern und damit den eventuell notwendigen Gelenkersatz möglichst weit nach hinten zu schieben.

Physical Therapists' Opinion of E-Health Treatment of Chronic Low Back Pain

(1) Background: Using new technologies to manage home exercise programmes is an approach that allows more patients to benefit from therapy. The objective of this study is to explore physical therapists’ opinions of the efficacy and disadvantages of implementing a web-based telerehabilitation programme for treating chronic low back pain (CLBP). (2) Methods: Nineteen physical therapists from academic and healthcare fields in both the public and private sector participated in the qualitative study. Texts extracted from a transcript of semi-structured, individual, in-depth interviews with each consenting participant were analysed to obtain the participants’ prevailing opinions. The interviews lasted approximately 40 min each. The participants’ responses were recorded. (3) Results: The results suggest that telerehabilitation can only be successful if patients become actively involved in their own treatment. However, exercise programmes for LBP are not always adapted to patient preferences. New technologies allow physical therapists to provide their patients with the follow-up and remote contact they demand, but long-term adherence to treatment stems from knowledge of the exercises and the correct techniques employed by the patients themselves. (4) Conclusions: Physical therapists treating patients with chronic non-specific low back pain believe that new technologies can provide highly effective means of reaching a greater number of patients and achieving significant savings in healthcare costs, despite the limitations of a telerehabilitation approach in developing an appropriate and effective patient-based physiotherapy programme.

A systematic review exploring the evidence reported to underpin exercise dose in clinical trials of rheumatoid arthritis

We aimed to evaluate the evidence reported to underpin exercise dose in randomised controlled trials (RCTs) using strengthening exercise in RA. We searched six different databases between 1 January 2000 and 3 April 2019. We included RCTs, where a main component of the intervention and/or control used strengthening exercise. Evidence sources cited to underpin dose were judged for their quality, consistency and applicability. Thirty-two RCTs were reviewed. Four (12.5%) piloted the intervention without using dose-escalation designs to determine optimal dose-response. Twenty (62.5%) reported no evidence underpinning dose. Where reported, quality, consistency and applicability of the underpinning evidence was a cause for methodological concern. The majority of RCTs did not report the evidence underpinning dose. When reported, the evidence was often not applicable to the clinical population. Frequently, the dose used differed to the dose reported/recommended by the underpinning evidence. Our findings illustrate exercise dose may not be optimised for use with clinical populations prior to evaluation by RCT.

The effect of innovative smartphone application on adherence to a home-based exercise programs for female older adults with knee osteoarthritis in Saudi Arabia: a randomized controlled trial

PURPOSE

To examine the effects of an Arabic smartphone application on adherence to home exercise programs (HEPs) and the effectiveness of mobile-based HEPs on pain, physical function, and lower-limb muscle strength among older women with knee osteoarthritis (OA).

MATERIALS AND METHODS

This randomised control trial (ClinicalTrials.gov: (NCT04159883) enrolled 40 women aged ≥50 years with knee OA who were randomised into the app group (experimental; n = 20) receiving HEPs using an Arabic smartphone application called "My Dear Knee", whereas the paper group (control; n = 20) receiving HEPs as hand-outs. Both groups had the same exercise program. Outcome measures were self-reported adherence, changes in the Arabic Numeric Pain Rating Scale, the Arabic version of the reduced Western Ontario, McMaster Universities Osteoarthritis Index-Physical Function subscale, and Five-Times Sit-To-Stand Test scores. All participants were assessed at baseline, at week 3 and week 6. Using completer-only analyses, the repeated measures ANOVA was used to compare the means of the outcome measures between the two groups.

RESULTS

At the end of week 6, the app group reported greater adherence to HEPs (p = .002) and significant reduction in pain (p = .015).

CONCLUSIONS

A smartphone application with motivational and attractive features could enhance adherence to HEPs in this patient cohort.IMPLICATIONS FOR REHABILITATIONOlder adults with knee OA may face many obstacles that prevent or limit their adherence to the prescribed HEP.Smart device apps supported with attractive and motivational features could be an effective strategy to enhance adherence to HEPs among older adults with knee OA.Using such remote technology appears to overcome the barriers that may limit the ability of older women to receive supervised physical therapy in a clinical setting.

Virtual reality in pain therapy: a requirements analysis for older adults with chronic back pain

BACKGROUND

Today immersive environments such as Virtual Reality (VR) offer new opportunities for serious gaming in exercise therapy and psychoeducation. Chronic back pain (CBP) patients could benefit from exergames in VR. The requirements in older CBP patients for a VR pain therapy have not yet been determined in studies. The aim of the study was to perform a requirements analysis for the user group of geriatric patients with CBP for a VR exergame. The objective was to find out the expectations, desires, preferences and barriers in order to collect them as requirements for this vulnerable group and to determine frameworks of therapy by physiotherapists and psychotherapists.

METHODS

We conducted a requirements analysis through semi-structured interviews with 10 elderly participants with CBP. Furthermore, two focus groups were conducted with three physiotherapists and two psychotherapists to determine frameworks of therapy programs for the target group. The qualitative data were transcribed and examined through a structuring content analysis. Subsequently, the results of the analysis were prioritized by all participants of the study.

RESULTS

The results of the requirements analysis indicate mandatory requirements for the overall system, hardware, software and gamification elements. The key requirements were target-group-specific applications of the VR exergame through e.g. individual briefing, user-friendly handling, inclusion of movement limitations, presentation of everyday scenarios in combination with biofeedback, age-appropriate feedback through praise and awards and a maximum exercise duration of 30 min and 15 min of relaxation.

CONCLUSION

It should be possible to use the determined requirements productively to create user-friendly VR exergames that motivate elderly chronic back pain patients to perform exercises regularly.

TRIAL REGISTRATION

The study is registered in the German Clinical Trials Register (DRKS-ID: DRKS00015294 12.10.2018).

A machine learning-based diagnostic model associated with knee osteoarthritis severity

Knee osteoarthritis (KOA) is characterized by pain and decreased gait function. We aimed to find KOA-related gait features based on patient reported outcome measures (PROMs) and develop regression models using machine learning algorithms to estimate KOA severity. The study included 375 volunteers with variable KOA grades. The severity of KOA was determined using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). WOMAC scores were used to classify disease severity into three groups. A total of 1087 features were extracted from the gait data. An ANOVA and student's t-test were performed and only features that were significant were selected for inclusion in the machine learning algorithm. Three WOMAC subscales (physical function, pain and stiffness) were further divided into three classes. An ANOVA was performed to determine which selected features were significantly related to the subscales. Both linear regression models and a random forest regression was used to estimate patient the WOMAC scores. Forty-three features were selected based on ANOVA and student's t-test results. The following number of features were selected from each joint: 12 from hip, 1 feature from pelvic, 17 features from knee, 9 features from ankle, 1 feature from foot, and 3 features from spatiotemporal parameters. A significance level of < 0.0001 and < 0.00003 was set for the ANOVA and t-test, respectively. The physical function, pain, and stiffness subscales were related to 41, 10, and 16 features, respectively. Linear regression models showed a correlation of 0.723 and the machine learning algorithm showed a correlation of 0.741. The severity of KOA was predicted by gait analysis features, which were incorporated to develop an objective estimation model for KOA severity. The identified features may serve as a tool to guide rehabilitation and progress assessments. In addition, the estimation model presented here suggests an approach for clinical application of gait analysis data for KOA evaluation.

Digital Self-Management Interventions for People With Osteoarthritis: Systematic Review With Meta-Analysis

BACKGROUND

Osteoarthritis (OA) is not curable, but the symptoms can be managed through self-management programs (SMPs). Owing to the growing burden of OA on the health system and the need to ensure high-quality integrated services, delivering SMPs through digital technologies could be an economic and effective community-based approach.

OBJECTIVE

This study aims to analyze the effectiveness of digital-based structured SMPs on patient outcomes in people with OA.

METHODS

A total of 7 web-based and 3 gray literature databases were searched for randomized controlled trials assessing digital-based structured SMPs on self-reported outcomes including pain, physical function, disability, and health-related quality of life (QoL) in people with OA. Two reviewers independently screened the search results and reference lists of the identified papers and related reviews. Data on the intervention components and delivery and behavioral change techniques used were extracted. A meta-analysis, risk of bias sensitivity analysis, and subgroup analysis were performed where appropriate. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was used to assess the quality of evidence.

RESULTS

A total of 8 studies were included in this review involving 2687 patients with knee (n=2); knee, hip, or both (n=5); and unspecified joint (n=1) OA. SMPs were delivered via telephone plus audio and video, internet, or mobile apps. Studies reported that digital-based structured SMPs compared with the treatment as usual control group (n=7) resulted in a significant, homogeneous, medium reduction in pain and improvement in physical function (standardized mean difference [SMD] -0.28, 95% CI -0.38 to -0.18 and SMD -0.26, 95% CI -0.35 to -0.16, respectively) at posttreatment. The digital-based structured SMP effect on pain and function reduced slightly at the 12-month follow-up but remained to be medium and significant. The posttreatment effect of digital-based structured SMPs was small and significant for disability, but nonsignificant for QoL (SMD -0.10, 95% CI -0.17 to 0.03 and SMD -0.17, 95% CI -0.47 to 0.14, respectively; each reported in 1 study only). The 12-month follow-up effect of the intervention was very small for disability and QoL. The quality of evidence was rated as moderate for pain and physical function and low and very low for disability and QoL, respectively, using the GRADE approach.

CONCLUSIONS

Digital-based structured SMPs may result in improvement in pain and physical function that is largely sustained at the 12-month follow-up in people with knee and hip OA. The effects on disability and QoL are smaller and less clear. The quality of evidence is moderate to low, and further research is required to confirm the findings of the review and assess the effects of digital-based structured SMPs on other health-related outcomes.

How Do Physical Therapists Approach Management of People With Early Knee Osteoarthritis? A Qualitative Study

BACKGROUND

Knee osteoarthritis (OA) is a leading cause of disability. There is increasing emphasis on initiating treatment earlier in the disease. Physical therapists are central to the management of OA through the delivery of exercise programs. There is a paucity of research on physical therapists' perceptions and clinical behaviors related to early knee OA management.

OBJECTIVE

The study aimed to explore how physical therapists approached management of early knee OA, with a focus on evidence-based strategies. This is an important first step to begin to optimize care by physical therapists for this population.

DESIGN

We used a qualitative, descriptive research design.

METHODS

Semistructured interviews were conducted with 33 physical therapists working with people with knee symptoms and/or diagnosed knee OA in community or outpatient settings in Canada. Data were analyzed using thematic analysis.

RESULTS

Five main themes were constructed: (1) Physical therapists' experience and training: clinical experiences and continuing professional development informed clinical decision-making. (2) Tailoring treatment from the physical therapist "toolbox:" participants described their toolbox of therapeutic interventions, highlighting the importance of tailoring treatments to people. (3) The central role of exercise and physical activity in management: exercise was consistently recommended by participants. (4) Variability in support for weight management: there was variation related to how participants addressed weight management. (5) Facilitating "buy-in" to management: physical therapists used a range of strategies to gain "buy-in."

LIMITATIONS

Participants were recruited through a professional association specializing in orthopedic physical therapy and worked an average of 21 years.

CONCLUSIONS

Participants' accounts emphasized tailoring of interventions, particularly exercises, which is an evidence-based strategy for OA. Findings illuminated variations in management that warrant further exploration to optimize early intervention (eg, weight management, behavior change techniques).

Baseline self-report 'central mechanisms' trait predicts persistent knee pain in the Knee Pain in the Community (KPIC) cohort

OBJECTIVES

We investigated whether baseline scores for a self-report trait linked to central mechanisms predict 1 year pain outcomes in the Knee Pain in the Community cohort.

METHOD

1471 participants reported knee pain at baseline and responded to a 1-year follow-up questionnaire, of whom 204 underwent pressure pain detection thresholds (PPTs) and radiographic assessment at baseline. Logistic and linear regression models estimated the relative risks (RRs) and associations (β) between self-report traits, PPTs and pain outcomes. Discriminative performance for each predictor was compared using receiver-operator characteristics (ROC) curves.

RESULTS

Baseline Central Mechanisms trait scores predicted pain persistence (Relative Risk, RR = 2.10, P = 0.001) and persistent pain severity (β = 0.47, P < 0.001), even after adjustment for age, sex, BMI, radiographic scores and symptom duration. Baseline joint-line PPTs also associated with pain persistence (RR range = 0.65 to 0.68, P < 0.02), but only in univariate models. Lower baseline medial joint-line PPT was associated with persistent pain severity (β = -0.29, P = 0.013) in a fully adjusted model. The Central Mechanisms trait model showed good discrimination of pain persistence cases from resolved pain cases (Area Under the Curve, AUC = 0.70). The discrimination power of other predictors (PPTs (AUC range = 0.51 to 0.59), radiographic OA (AUC = 0.62), age, sex and BMI (AUC range = 0.51 to 0.64), improved significantly (P < 0.05) when the central mechanisms trait was included in each logistic regression model (AUC range = 0.69 to 0.74).

CONCLUSION

A simple summary self-report Central Mechanisms trait score may indicate a contribution of central mechanisms to poor knee pain prognosis.

Evaluating the efficacy of Internet-Based Exercise programme Aimed at Treating knee Osteoarthritis (iBEAT-OA) in the community: a study protocol for a randomised controlled trial

INTRODUCTION

Knee osteoarthritis (OA) is the most common joint disease worldwide. As of today, there are no disease-modifying drugs, but there is evidence that muscle strengthening exercises can substantially reduce pain and improve function in this disorder, and one very well tested physiotherapy protocol is the 'Better Management of Patients with Osteoarthritis' developed in Sweden. Given the high prevalence of knee OA, a potentially cost-effective, digitally delivered approach to treat knee OA should be trialled. This study aims to explore the benefits of iBEAT-OA (Internet-Based Exercise programme Aimed at Treating knee Osteoarthritis) in modulating pain, function and other health-related outcomes in individuals with knee OA.

METHODS AND ANALYSIS

A randomised controlled trial was designed to evaluate the efficacy of a web-based exercise programme in a population with knee OA compared with standard community care provided by general practitioners (GPs) in the UK. We anticipate recruiting participants into equal groups. The intervention group (n=67) will exercise for 20-30 min daily for six consecutive weeks, whereas the control group (n=67) will follow GP-recommended routine care. The participants will be assessed using a Numerical Rating Scale, the Western Ontario and McMaster Universities Osteoarthritis Index, the Arthritis Research UK Musculoskeletal Health Questionnaire, the Pittsburgh Sleep Quality Index, 30 s sit to stand test, timed up and go test, quantitative sensory testing, musculoskeletal ultrasound scan, muscle thickness assessment of the vastus lateralis, and quadriceps muscles force generation during an isokinetic maximum voluntary contraction (MVC). Samples of urine, blood, faeces and synovial fluid will be collected to establish biomarkers associated with changes in pain and sleep patterns in individuals affected with knee OA. Standard parametric regression methods will be used for statistical analysis.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Research Ethics Committee (ref: 18/EM/0154) and the Health Research Authority (protocol no: 18021). The study was registered in June 2018. The results of the trial will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03545048.

A systematic review of economic evaluations of conservative treatments for chronic lower extremity musculoskeletal complaints

Objective

The aim was to appraise and synthesize studies evaluating the clinical and cost effectiveness of conservative interventions for chronic lower extremity musculoskeletal (MSK) conditions and describe their characteristics, including the type of economic evaluation, primary outcomes and which conditions.

Methods

The search strategy related to economic evaluations of lower limb MSK conditions that used conservative therapies. Eight electronic databases were searched (CENTRAL, MEDLINE, PubMed, EMBASE, CINAHL, PEDro, NHSEED and Proquest), as were the reference lists from included articles. The quality of articles was appraised using a modified version of the economic evaluations’ reporting checklist (economic) and The Cochrane Collaboration’s tool for assessing risk of bias (clinical).

Results

Twenty-six studies were eligible and included in the review. Economic evaluations of conservative interventions for OA or pain affecting the knee/hip (n = 25; 93%) were most common. The main approaches adopted were cost–utility analysis (n = 17; 68%) or cost–effectiveness analysis (n = 5; 19%). Two studies involved interventions including footwear/foot orthoses; for heel pain (n = 1; 4%) and overuse injuries (n = 1; 4%). Fifty per cent of economic evaluations adopted the EQ-5D-3L as the primary outcome measure for quality of life and quality-adjusted life year calculations.

Conclusion

Economic evaluations have been conducted largely for exercise-based interventions for MSK conditions of the hip and knee. Few economic evaluations have been conducted for other clinically important lower limb MSK conditions. A matrix presentation of costs mapped with outcomes indicated increasing costs with either no difference or improvements in clinical effectiveness. The majority of economic evaluations were of good reporting quality, as were the accompanying clinical studies.

Concurrent Change in Quadriceps Strength and Physical Function Over Five Years in the Multicenter Osteoarthritis Study

OBJECTIVE

Quadriceps weakness, associated with functional limitations, is a target of treatment of knee osteoarthritis (OA). Limited data exist on the relationship between modest strength increases and improvements in function. The aim of this study was to evaluate concurrent change in strength and physical function over 5 years.

METHODS

Among subjects from the Multicenter Osteoarthritis (MOST) study, we excluded those with knee replacement after baseline. A 3-category variable defined whether, at 5 years, knee extensor strength increased, decreased, or remained within 15% of baseline, a clinically important cut-off. The outcomes were the 5-times sit-to-stand test, 20-meter walk test, Western Ontario and McMaster Universities Osteoarthritis (WOMAC) physical function score, and 3 individual physical functions from WOMAC: arising from a chair, going up stairs, and getting on/off toilet. Linear and logistic models, stratified by sex, evaluated associations between change in strength and change in physical function over 5 years. To compare weaker versus stronger women, we stratified analyses at 56 Nm baseline strength.

RESULTS

Among 1,534 participants (60.6% women), 22% of men and 30% of women increased strength by at least 15% at 5 years. Compared with women whose strength did not change, women whose strength increased had improved chair stand performance (odds ratio 2.27 [95% confidence interval 1.56, 3.30]) but no improvement in other functions. In men, an increase in strength was not associated with significant improvement in physical function. Similar results were observed for a 20% or 30% increase.

CONCLUSION

Modest improvement in quadriceps strength was associated with improved chair stand performance in women but not in men. Most functions did not improve with an increase in strength, and targeted interventions may be required to improve functional status.

The effects of a home-based exercise intervention on elderly patients with knee osteoarthritis: a quasi-experimental study

Background

Knee osteoarthritis (KOA) is common in elderly people, causes pain, loss of physical functioning, and disability. This was a two-arm, superiority, quasi-experimental trial. The aim of this study was to evaluate the effectiveness of a home-based exercise intervention (HBEI) to reduce KOA symptoms and improve the physical functioning of elderly patients.

Methods

A total of 171 elderly patients (60 years of age or older) with KOA were recruited from four community centers. Patients from two community centers were randomly assigned to the intervention group (IG) and the other two centers were randomly assigned to the control group (CG). Participants in the IG received a 12-week HBEI (including four 2-h sessions supervised by a physiotherapist and fortnightly telephone support) combined with health education, while patients in the CG only received health education. The participants and physiotherapists were aware of the group assignment and alternative treatment components, but the study’s hypotheses were not disclosed to the participants. Pain intensity, joint stiffness, lower-limb muscle strength, balance, mobility, and quality of life were measured before and after the intervention by the same blinded assessor.

Results

A total of 171 patients (IG: n = 84, CG: n = 87) were enrolled. Data were obtained from 141 patients with an average age of 68 (range, 60–86 years) who completed the 12-week study (IG: n = 71, CG: n = 70). No significant group differences were found in any outcome measures at baseline. At week 12, the pretest/posttest changes 3significant between-group differences in decreases in pain intensity (− 1.60 (CI, − 2.75 to − 0.58)) and stiffness (− 0.79 (CI, − 1.37 to − 0.21)), with the IG exhibiting significantly larger improvements on both measures than the CG. The IG also showed significantly greater improvements on all the secondary outcomes than the CG did.

Conclusions

HBEI may be effective for relieving KOA symptoms, increasing the physical functioning, and improving quality of life in community-dwelling KOA elderly patients. A large randomized controlled trial with long-term follow-up is needed to confirm these findings.

Trial registration

Chinese Clinical Trails Registry number ChiCTR1800017026 (retrospectively registered). Registered 9 July 2018.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2521-4) contains supplementary material, which is available to authorized users.