Adjunctive electrophysical therapies used in addition to land-based exercise therapy for osteoarthritis of the hip or knee: A systematic review and meta-analysis

Objectives

To review evidence for effectiveness of electrophysical therapies (EPTs), used adjunctively with land-based exercise therapy, for hip or knee osteoarthritis (OA), compared with 1) placebo EPTs delivered with land-based exercise therapy or 2) land-based exercise therapy only.

Methods

Six databases were searched up to October 2023 for randomised controlled trials (RCTs)/quasi-RCTs comparing adjunctive EPTs alongside land-based exercise therapy versus 1) placebo EPTs alongside land-based exercise, or 2) land-based exercise in hip or knee OA. Outcomes included pain, function, quality of life, global assessment and adverse events. Risk of bias and overall certainty of evidence were assessed. We back-translated significant Standardised Mean Differences (SMDs) to common scales: 2 points/15% on a 0-10 Numerical Pain Rating Scale and 6 points/15% on the WOMAC physical function subscale.

Results

Forty studies (2831 patients) evaluated nine different EPTs for knee OA. Medium-term effects (up to 6 months) were evaluated in seven trials, and one evaluated long-term effects (>6 months). Adverse events were reported in one trial. Adjunctive laser therapy may confer short-term effects on pain (SMD -0.68, 95%CI -1.03 to -0.34; mean difference (MD) 1.18 points (95% CI -1.78 to -0.59) and physical function (SMD -0.60, 95%CI -0.88 to -0.34; MD 12.95 (95%CI -20.05 to -5.86)) compared to placebo EPTs, based on very low-certainty evidence. No other EPTs (TENS, interferential, heat, shockwave, shortwave, ultrasound, EMG biofeedback, NMES) showed clinically significant effects compared to placebo/exercise, or exercise only.

Conclusions

Very low-certainty evidence supports laser therapy used adjunctively with exercise for short-term improvement in pain and function. No other EPTs demonstrated clinically meaningful effects.

Effectiveness of neuromuscular electrical stimulation training combined with exercise on patient-reported outcomes measures in people with knee osteoarthritis: A systematic review and meta-analysis

OBJECTIVE

This study examined the effectiveness of neuromuscular electrical stimulation (NMES) added to the exercise or superimposed on voluntary contractions on patient-reported outcomes measures (PROMs) in people with knee osteoarthritis (OA).

METHODS

This systematic review was described according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials (RCTs) were obtained from a systematic literature search in five electronic databases (PubMed, PEDro, LILACS, EMBASE, and SPORTDiscus) in April 2022. We described the effects of intervention according to each PROMs (scores for Pain; Self-reported functional ability; Symptoms (hear clicking, swelling, catching, restricted range of motion, and stiffness); Daily living function; Sports function; and Quality of life) and used a random-effect model to examine the impact of NMES plus exercise on pain compared with exercise in people with knee OA.

RESULTS

Six RCTs (n = 367) were included. In the qualitative synthesis, the systematic literature analysis showed improvement in pain after NMES plus exercise compared with exercise alone in three studies. The other three studies revealed no difference between groups in pain, although similar improvement after treatments. In the meta-analysis, NMES at a specific joint angle combined with exercise was not superior to exercise alone in pain management (standardized mean difference = -0.33, 95% CI = -1.05 to 0.39, p = 0.37). There was no additional effect of NMES on exercise on self-reported functional ability, stiffness, and physical function compared with exercise alone. In only one study, symptoms, activities of daily living, sports function, and quality of life improved after whole-body electrostimulation combined with exercise.

CONCLUSION

This review found insufficient evidence for the effectiveness of NMES combined with exercise in treating knee OA considering PROMs. While pain relief was observed in some studies, more high-quality clinical trials are needed to support the use of NMES added to the exercise in clinical practice. Electrical stimulation in a whole-body configuration combined with exercise shows promise as an alternative treatment option.

Adjunctive therapies in addition to land-based exercise therapy for osteoarthritis of the hip or knee

BACKGROUND

Land-based exercise therapy is recommended in clinical guidelines for hip or knee osteoarthritis. Adjunctive non-pharmacological therapies are commonly used alongside exercise in hip or knee osteoarthritis management, but cumulative evidence for adjuncts to land-based exercise therapy is lacking.

OBJECTIVES

To evaluate the benefits and harms of adjunctive therapies used in addition to land-based exercise therapy compared with placebo adjunctive therapy added to land-based exercise therapy, or land-based exercise therapy only for people with hip or knee osteoarthritis.

SEARCH METHODS

We searched CENTRAL, MEDLINE, PsycINFO, EMBASE, CINAHL, Physiotherapy Evidence Database (PEDro) and clinical trials registries up to 10 June 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-RCTs of people with hip or knee osteoarthritis comparing adjunctive therapies alongside land-based exercise therapy (experimental group) versus placebo adjunctive therapies alongside land-based exercise therapy, or land-based exercise therapy (control groups). Exercise had to be identical in both groups. Major outcomes were pain, physical function, participant-reported global assessment, quality of life (QOL), radiographic joint structural changes, adverse events and withdrawals due to adverse events. We evaluated short-term (6 months), medium-term (6 to 12 months) and long-term (12 months onwards) effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias and certainty of evidence for major outcomes using GRADE.

MAIN RESULTS

We included 62 trials (60 RCTs and 2 quasi-RCTs) totalling 6508 participants. One trial included people with hip osteoarthritis, one hip or knee osteoarthritis and 59 included people with knee osteoarthritis only. Thirty-six trials evaluated electrophysical agents, seven manual therapies, four acupuncture or dry needling, or taping, three psychological therapies, dietary interventions or whole body vibration, two spa or peloid therapy and one foot insoles. Twenty-one trials included a placebo adjunctive therapy. We presented the effects stratified by different adjunctive therapies along with the overall results. We judged most trials to be at risk of bias, including 55% at risk of selection bias, 74% at risk of performance bias and 79% at risk of detection bias. Adverse events were reported in eight (13%) trials. Comparing adjunctive therapies plus land-based exercise therapy against placebo therapies plus exercise up to six months (short-term), we found low-certainty evidence for reduced pain and function, which did not meet our prespecified threshold for a clinically important difference. Mean pain intensity was 5.4 in the placebo group on a 0 to 10 numerical pain rating scale (NPRS) (lower scores represent less pain), and 0.77 points lower (0.48 points better to 1.16 points better) in the adjunctive therapy and exercise therapy group; relative improvement 10% (6% to 15% better) (22 studies; 1428 participants). Mean physical function on the Western Ontario and McMaster (WOMAC) 0 to 68 physical function (lower scores represent better function) subscale was 32.5 points in the placebo group and reduced by 5.03 points (2.57 points better to 7.61 points better) in the adjunctive therapy and exercise therapy group; relative improvement 12% (6% better to 18% better) (20 studies; 1361 participants). Moderate-certainty evidence indicates that adjunctive therapies did not improve QOL (SF-36 0 to 100 scale, higher scores represent better QOL). Placebo group mean QOL was 81.8 points, and 0.75 points worse (4.80 points worse to 3.39 points better) in the placebo adjunctive therapy group; relative improvement 1% (7% worse to 5% better) (two trials; 82 participants). Low-certainty evidence (two trials; 340 participants) indicates adjunctive therapies plus exercise may not increase adverse events compared to placebo therapies plus exercise (31% versus 13%; risk ratio (RR) 2.41, 95% confidence interval (CI) 0.27 to 21.90). Participant-reported global assessment was not measured in any studies. Compared with land-based exercise therapy, low-certainty evidence indicates that adjunctive electrophysical agents alongside exercise produced short-term (0 to 6 months) pain reduction of 0.41 points (0.17 points better to 0.63 points better); mean pain in the exercise-only group was 3.8 points and 0.41 points better in the adjunctive therapy plus exercise group (0 to 10 NPRS); relative improvement 7% (3% better to 11% better) (45 studies; 3322 participants). Mean physical function (0 to 68 WOMAC subscale) was 18.2 points in the exercise group and 2.83 points better (1.62 points better to 4.04 points better) in the adjunctive therapy plus exercise group; relative improvement 9% (5% better to 13% better) (45 studies; 3323 participants). These results are not clinically important. Mean QOL in the exercise group was 56.1 points and 1.04 points worse in the adjunctive therapies plus exercise therapy group (1.04 points worse to 3.12 points better); relative improvement 2% (2% worse to 5% better) (11 studies; 1483 participants), indicating no benefit (low-certainty evidence). Moderate-certainty evidence indicates that adjunctive therapies plus exercise probably result in a slight increase in participant-reported global assessment (short-term), with success reported by 45% in the exercise therapy group and 17% more individuals receiving adjunctive therapies and exercise (RR 1.37, 95% CI 1.15 to 1.62) (5 studies; 840 participants). One study (156 participants) showed little difference in radiographic joint structural changes (0.25 mm less, 95% CI -0.32 to -0.18 mm); 12% relative improvement (6% better to 18% better). Low-certainty evidence (8 trials; 1542 participants) indicates that adjunctive therapies plus exercise may not increase adverse events compared with exercise only (8.6% versus 6.5%; RR 1.33, 95% CI 0.78 to 2.27).

AUTHORS' CONCLUSIONS

Moderate- to low-certainty evidence showed no difference in pain, physical function or QOL between adjunctive therapies and placebo adjunctive therapies, or in pain, physical function, QOL or joint structural changes, compared to exercise only. Participant-reported global assessment was not reported for placebo comparisons, but there is probably a slight clinical benefit for adjunctive therapies plus exercise compared with exercise, based on a small number of studies. This may be explained by additional constructs captured in global measures compared with specific measures. Although results indicate no increased adverse events for adjunctive therapies used with exercise, these were poorly reported. Most studies evaluated short-term effects, with limited medium- or long-term evaluation. Due to a preponderance of knee osteoarthritis trials, we urge caution in extrapolating the findings to populations with hip osteoarthritis.

The effects of preoperative neuromuscular electrical stimulation on the postoperative quadriceps muscle strength and functional status in patients with fast-track total knee arthroplasty

This study aimed to investigate the effect of pre- operative neuromuscular electrical stimulation (NMES) on postoperative quadriceps muscle strength, functional status, and quality of life in patients with fast-track total knee arthroplasty (TKA). This prospective study was carried out at Orthopedics department from September 2017 to October 2018. A total of 40 patients were randomly divided into NMES (n=20) and control group (n=20). Patients in NMES group were asked to use home NMES device daily for 20 minutes, 5 times a day, for 6 weeks before surgery. The control group was placed on the 6-week waiting list for surgery without any preoperative intervention. Standard home exercise program was applied to both groups after discharge. The patients were evaluated baseline, preoperatively (6-weeks after baseline) and at the 4th and 12th weeks after surgery. Knee range of motion, quadriceps muscle strength, patient-reported (WOMAC and KOOS) and performance-based activity limitation (30-second chair-stand test, 40-meter fast-paced walk test, and stair-climb test) were evaluated at each visit. Preoperative NMES resulted in significant improvement in KOOS-function in daily living and WOMAC total score (p≤0.05) but had a non-significant trend toward to improve quadriceps muscle strength, KOOS-pain and -other symptoms, performance- based activity limitation, and quality of life scores (p>0.05). However, there was no significant difference between groups in the postoperative period (p>0.05). NMES has beneficial effects in terms of patient- reported and performance-based physical functions and quality of life in preoperative period ; however, it does not provide any additional benefit for post- operative outcomes in patients with fast-track TKA.

The effects of neuromuscular electrical stimulation on strength, pain, and function in individuals with knee osteoarthritis: a systematic review with meta-analysis

ABSTRACT We aimed to investigate the effects of neuromuscular electrical stimulation on muscle strength, pain relief, and improvement in function in patients with knee osteoarthritis. Databases were searched from December 2017 to July 2020 and included PubMed, Embase, LILACS, and the Cochrane Central Register of Controlled Trials. A manual search was also performed by checking the reference lists of eligible articles. The PRISMA guidelines were followed. The studies selected compared NMES with an exercise program on isometric muscle strength as a primary outcome. The secondary outcomes were pain and function. The quality of the studies was assessed using the Risk of Bias assessment and PEDro scale, and the overall quality of the evidence was assessed using the GRADE approach. Eight studies were included in this systematic review. A total of 571 patients were analyzed. Neuromuscular electrical stimulation associated with exercise promoted an increase in isometric strength of the quadriceps muscle compared to the active control group, demonstrating heterogeneity and statistical difference (95% CI=1.16 to 5.10, I2=97%, p=0.002; very low-certainty evidence). NMES associated with exercise did not improve physical function (95% CI=−0.37 to 0.59, I2=0%, p=0.67; low-certainty evidence) and showed controversial results for pain compared to an active control group (qualitative assessment). In conclusion, NMES induces an increase in muscle strength in patients with osteoarthritis compared to an active control group. No differences were found for physical function and pain outcomes. Further research is needed due to the uncertain level of evidence.

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

Background

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

Objectives

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

Data Sources

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

Eligibility Criteria

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

Results

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

Conclusions

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

A Meta-Analysis of Group-Based Pain Management Programs: Overall Effect on Quality of Life and Other Chronic Pain Outcome Measures, with an Exploration into Moderator Variables that Influence the Efficacy of Such Interventions

OBJECTIVES

Group-based pain management programs (GPMPs) have been found to significantly improve quality of life and other pain outcome measures in patients with chronic musculoskeletal pain. The aims of this meta-analysis were to reevaluate the overall effect of GPMPs on various pain outcomes for individuals experiencing chronic musculoskeletal conditions and to explore moderator variables that potentially contribute to the overall efficacy of GPMPs.

METHODS

Using the R package called metaphor and RevMan, we estimated the overall effectiveness of GPMPs on various pain outcome measures. The differential effectiveness of GPMPs was examined by conducting a mixed-effects meta-analytic model using various study-level characteristics. Moderator analyses included three content moderator variables and seven format moderator variables. Receiver operating characteristic curves investigated optimal points in some of the moderator variable analysis results.

RESULTS

Significant overall main effects of GPMPs were found on all the explored outcome measures in this study (P < 0.05). In moderator analyses, it was found that the structure of GPMPs, rather than the content, significantly improved outcomes (P < 0.05). Receiver operating characteristic curve analyses identified the optimal number of GPMP sessions and number of participants per group.

DISCUSSION AND CLINICAL RELEVANCE

GPMPs have a statistically significant overall effect on all explored pain outcome measures. The investigation into content and structural moderators suggests that certain GPMP design factors have a greater effect on pain outcomes than do content factors. Therefore, GPMP structural designs appear to be important in reducing pain and improving quality of life for patients with chronic pain and warrant further investigation.

Reliability of Tibialis Anterior Muscle Voluntary Activation Using the Interpolated Twitch Technique and the Central Activation Ratio in People with Stroke

Voluntary activation (VA) is measured by applying supramaximal electrical stimulation to a muscle during a maximal voluntary contraction (MVC). The amplitude of the evoked muscle twitch is used to determine any VA deficit, and indicates incomplete central neural drive to the motor units. People with stroke experience VA deficits and greater levels of central fatigue, which is the decrease in VA that occurs following exercise. This study investigated the between-session reliability of VA and central fatigue of the tibialis anterior muscle (TA) in people with chronic stroke (n = 12), using the interpolated twitch technique (ITT), adjusted-ITT, and central activation ratio (CAR) methods. On two separate sessions, supramaximal electrical stimulation was applied to the TA when it was at rest and maximally activated, at the start and end of a 30-s isometric dorsiflexor MVC. The most reliable measures of VA were obtained using the CAR calculation on transformed data, which produced an ICC of 0.92, and a lower bound confidence interval in the good range (95% CI 0.77 to 0.98). Reliability was lower for the CAR calculation on non-transformed data (ICC 0.82, 95% CI 0.63 to 0.91) and the ITT and adjusted-ITT calculations on transformed data (ICCs 0.82, 95% CIs 0.51 to 0.94), which had lower bound confidence intervals in the moderate range. The two ITT calculations on non-transformed data demonstrated the poorest reliability (ICCs 0.62, 95% CI 0.25 to 0.74). Central fatigue measures demonstrated very poor reliability. Thus, the reliability for VA in people with chronic stroke ranged from good to poor, depending on the calculation method and statistical analysis method, whereas the reliability for central fatigue was very poor.

Analgesic Tolerance Development during Repetitive Electric Stimulations Is Associated with Changes in the Expression of Activated Microglia in Rats with Osteoarthritis

Electric stimulation is used for managing osteoarthritic (OA) pain; however, little is known about the development of analgesic tolerance during repeated stimulations and the relation of spinal microglia with OA pain. We investigated the changes in the analgesic effects of repeated electric stimulations and the relation between the development of analgesic tolerance and spinal microglial expression in rats with OA. To induce OA, monosodium iodoacetate was injected into the synovial space of the right knee joint of the rats (n = 185). Repeated high frequency, low frequency, or sham transcutaneous electric nerve stimulation (TENS) was performed to the ipsilateral knee joint for 20 min in rats with OA (n = 45). Minocycline or minocycline plus TENS (HF, LF, or sham) was treated in OA rats with repeated TENS-induced tolerance (n = 135). Immunohistochemistry of the microglia in the L3–L5 spinal segments was performed. Knee joint pain during passive movement of the knee joint were quantified using the knee-bend score and the proportion of activated microglia was calculated as primary variables. Paw withdrawal threshold (hypersensitivity to mechanical stimuli) was assessed and the resting and activated microglia were counted as secondary variables. Repeated applications decreased the analgesic effect of TENS on OA pain and failed to reduce the expression of activated microglia in the spinal cord. However, spinal microglial inhibition by minocycline restored the analgesic effect of TENS on OA pain in TENS-tolerant OA rats. TENS combined with minocycline treatment improved knee joint pain and mechanical hypersensitivity in TENS-tolerant OA rats, and inhibited the expression of activated microglia in the spinal cord. These results suggest a possible relationship between repetitive electric stimulation-induced analgesic tolerance for OA pain control and changes in microglia activation.

Effect of exercise on pain processing and motor output in people with knee osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

Guidelines recommend exercise as a core treatment for knee osteoarthritis. However, it is unclear how exercise affects measures of pain processing and motor function. The aim was to evaluate the effect of exercise on measures of pain processing and motor function in people with knee osteoarthritis.

METHODS

We searched five electronic databases (MEDLINE, EMBASE, CINAHL, SCOPUS and Cochrane Central Register of Controlled Trials) for studies on knee osteoarthritis, of any design, evaluating pain processing and motor function before and after exercise. Data were pooled with random-effects meta-analysis. Study quality was assessed using the Downs and Black and quality of evidence was assessed using the GRADE.

RESULTS

Eighteen studies were eligible and 16 were included. Following acute exercise, pressure pain threshold increased local to the study limb (standardised mean difference [95% confidence interval (CI)] 0.26, [0.02, 0.51], n = 159 from 5 studies), but there was no statistically significant change remote from the study limb (0.09, [-0.11, 0.29], n = 90 from 4 studies). Following an exercise program (range 5-12 weeks) there were no statistically significant changes in pressure pain threshold (local 0.23, [-0.01, 0.47], n = 218 from 8 studies; remote 0.33 [-0.13, 0.79], n = 76 from 4 studies), temporal pain summation (0.38 [-0.08, 0.85], n = 122 from 3 studies) or voluntary quadriceps muscle activation (4.23% [-1.84 to 10.30], n = 139 from 4 studies).

CONCLUSION

Very-low quality evidence suggests that pressure pain threshold increases following acute exercise. Very-low quality evidence suggests that pressure pain threshold, temporal pain summation or voluntary quadriceps activation do not change statistically significantly following exercise programs.

New Guidelines for Electrical Stimulation Parameters in Adult Patients With Knee Osteoarthritis Based on a Systematic Review of the Current Literature

OBJECTIVE

The goal of this systematic review was to provide guidelines for treatment parameters regarding electrical stimulation by investigating its efficacy in improving muscle strength and decreasing pain in patients with knee osteoarthritis.

DESIGN

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standard, three electronic databases (CINAHL, PubMed, and PEDro) and gray literature were used. Randomized control trials comparing electrical stimulation and conservative physical therapy were critically appraised using the 2005 University of Oxford standard.

RESULTS

Nine randomized control trials were included in our review. First, our review confirmed that neuromuscular electrical stimulation is the most effective electrical stimulation treatment in the management of knee OA, and its efficiency is higher when combined with a strengthening program. Second, frequency of at least 50 Hz and no more than 75 Hz with a pulse duration between 200 and 400 μs and a treatment duration of 20 mins is necessary for successful treatment.

CONCLUSIONS

For the first time, our review provides standardized clinical treatment parameters for neuromuscular electrical stimulation to be included in a strengthening program for the adult patient with knee OA.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Recall the impact of quadriceps femoris weakness on joint stability; (2) Summarize the mechanism of action of neuromuscular electrical stimulation (NMES) on reducing pain and increasing muscle strength; and (3) Plan the clinical treatment parameters of NMES to be included in a strengthening program for an adult patient with knee osteoarthritis.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Additive effect of tDCS combined with Peripheral Electrical Stimulation to an exercise program in pain control in knee osteoarthritis: study protocol for a randomized controlled trial

BACKGROUND

Knee osteoarthritis (OA) has been linked to maladaptive plasticity in the brain, which may contribute to chronic pain. Neuromodulatory approaches, such as Transcranial Direct Current Stimulation (tDCS) and Peripheral Electrical Stimulation (PES), have been used therapeutically to counteract brain maladaptive plasticity. However, it is currently unclear whether these neuromodulatory techniques enhance the benefits of exercise when administered together. Therefore, this protocol aims to investigate whether the addition of tDCS combined or not with PES enhances the effects of a land-based strengthening exercise program in patients with knee OA.

METHODS

Patients with knee OA (n = 80) will undertake a structured exercise program for five consecutive days. In addition, they will be randomized into four subgroups receiving either active anodal tDCS and sham PES (group 1; n = 20), sham tDCS and active PES (group 2, n = 20), sham tDCS and PES (group 3, n = 20), or active tDCS and PES (group 4, n = 20) for 20 min/day for five consecutive days just prior to commencement of the exercise program. The primary outcomes will be subjective pain intensity (VAS) and related function (WOMAC). Secondary outcomes will include quality of life (SF-36), anxiety and depression symptoms (HAD), self-perception of improvement, pressure pain thresholds over the knee, quadriceps strength, and quadriceps electromyographic activity during maximum knee extension voluntary contraction. We will also investigate cortical excitability using transcranial magnetic stimulation. Outcome measures will be assessed at baseline, 1 month after, before any intervention, after 5 days of intervention, and at 1 month post exercise intervention.

DISCUSSION

The motor cortex becomes less responsive in knee OA because of poorly adapted plastic changes, which can impede exercise therapy benefits. Adding tDCS and/or PES may help to counteract those maladaptive plastic changes and improve the benefits of exercises, and the combination of both neuromodulatory techniques must have a higher magnitude of effect.

TRIAL REGISTRATION

Brazilian Registry on Clinical Trials (ReBEC) - Effects of electrical stimulation over the skull and tight together with exercises for knee OA; protocol number RBR-9D7C7B.

TRIAL REGISTRATION

ID: RBR-9D7C7B . Registered on 29 February 2016.

Interventional strategies to combat muscle disuse atrophy in humans: focus on neuromuscular electrical stimulation and dietary protein

Numerous situations, such as the recovery from illness or rehabilitation after injury, necessitate a period of muscle disuse in otherwise healthy individuals. Even a few days of immobilization or bed rest can lead to substantial loss of skeletal muscle tissue and compromise metabolic health. The decline in muscle mass is attributed largely to a decline in postabsorptive and postprandial muscle protein synthesis rates. Reintroduction of some level of muscle contraction by the application of neuromuscular electrical stimulation (NMES) can augment both postabsorptive and postprandial muscle protein synthesis rates and, as such, prevent or attenuate muscle loss during short-term disuse in various clinical populations. Whereas maintenance of habitual dietary protein consumption is a prerequisite for muscle mass maintenance, supplementing dietary protein above habitual intake levels does not prevent muscle loss during disuse in otherwise healthy humans. Combining the anabolic properties of physical activity (or surrogates) with appropriate nutritional support likely further increases the capacity to preserve skeletal muscle mass during a period of disuse. Therefore, effective interventional strategies to prevent or alleviate muscle disuse atrophy should include both exercise (mimetics) and appropriate nutritional support.

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

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

The effects of various physical non-operative modalities on the pain in osteoarthritis of the knee

The purpose of this study was to evaluate the effect of various non-operative modalities of treatment (transcutaneous electrical nerve stimulation (TENS); neuromuscular electrical stimulation (NMES); insoles and bracing) on the pain of osteoarthritis (OA) of the knee. We conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify the therapeutic options which are commonly adopted for the management of osteoarthritis (OA) of the knee. The outcome measurement tools used in the different studies were the visual analogue scale and The Western Ontario and McMaster Universities Arthritis Index pain index: all pain scores were converted to a 100-point scale. A total of 30 studies met our inclusion criteria: 13 on insoles, seven on TENS, six on NMES, and four on bracing. The standardised mean difference (SMD) in pain after treatment with TENS was 1.796, which represented a significant reduction in pain. The significant overall effect estimate for NMES on pain was similar to that of TENS, with a SMD of 1.924. The overall effect estimate of insoles on pain was a SMD of 0.992. The overall effect of bracing showed a significant reduction in pain of 1.34. Overall, all four non-operative modalities of treatment were found to have a significant effect on the reduction of pain in OA of the knee. This study shows that non-operative physical modalities of treatment are of benefit when treating OA of the knee. However, much of the literature reviewed evaluates studies with follow-up of less than six months: future work should aim to evaluate patients with longer follow-up.

Identifying potential working mechanisms behind the positive effects of exercise therapy on pain and function in osteoarthritis; a systematic review

OBJECTIVE

Although physical exercise is the commonly recommended for osteoarthritis (OA) patients, the working mechanism behind the positive effects of physical exercise on pain and function is a black box phenomenon. In the present study we aimed to identify possible mediators in the relation between physical exercise and improvements of pain and function in OA patients.

DESIGN

A systematic search for all studies evaluating the effects of physical exercise in OA patients and select those that additionally reported the change in any physiological factor from pre-to post-exercise.

RESULTS

In total, 94 studies evaluating 112 intervention groups were included. Most included studies evaluated subjects with solely knee OA (96 out of 112 groups). Based on the measured physiological factors within the included studies, 12 categories of possible mediators were formed. Muscle strength and ROM/flexibility were the most measured categories of possible mediators with 61 and 21 intervention groups measuring one or more physiological factors within these categories, respectively. 60% (31 out of 52) of the studies showed a significant increase in knee extensor muscle strength and 71% (22 out of 31) in knee flexor muscle strength over the intervention period. All 5 studies evaluating extension impairments and 10 out of 12 studies (83%) measuring proprioception found a significant change from pre-to post-intervention.

CONCLUSION

An increase of upper leg strength, a decrease of extension impairments and improvement in proprioception were identified as possible mediators in the positive association between physical exercise and OA symptoms.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

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

Osteoarthritis year in review 2014: rehabilitation and outcomes

OBJECTIVE

To highlight research studies examining rehabilitation for hip and knee osteoarthritis (OA), as well as the outcome measures used to assess treatment efficacy, published in 2013.

DESIGN

A systematic search was performed in Medline, CIHAHL and Embase databases from January to December 2013. The search was limited to 2013, human studies, and English. Rehabilitation intervention studies included were prospective controlled designs. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to evaluate the quality of evidence. First, individual articles were rated for quality. Second, articles were grouped based on outcome: OA disease markers, pain, physical function (self-reported, performance), and health.

RESULTS

Of 503 titles reviewed, 36 studies were included. The outcome measures related to OA disease markers were organized into subthemes of anthropometrics, biomechanics and physiology. The quality of evidence was of moderate, high, and low quality for anthropometric, biomechanical and physiological measures respectively. These studies supported the use of diet for weight loss combined with exercise. Bodies of evidence that showed the efficacy of exercise and passive strategies (thermal/electrical modalities, traction, manual therapy) for reducing pain were of low and moderate quality respectively. The evidence supporting diet and exercise, physiotherapy, and passive strategies to improve physical function was of moderate quality. Evidence supporting exercise to improve psychological factors was of moderate quality.

CONCLUSIONS

Exercise combined with diet for weight loss should be the mainstays of rehabilitation for people with knee and hip OA to provide benefit to OA disease markers, pain, physical function, and health.

The effectiveness of physiotherapist-delivered group education and exercise interventions to promote self-management for people with osteoarthritis and chronic low back pain: a rapid review part I

BACKGROUND

Osteoarthritis (OA) and chronic low back pain (CLBP) are two of the most common and costly musculoskeletal conditions globally. Healthcare service demands mean that multiple condition group-based interventions are of increasing clinical interest, but no reviews have evaluated the effectiveness of group-based physiotherapy-led self-management interventions (GPSMI) for both conditions.

OBJECTIVES

This rapid review aimed to evaluate the effectiveness of GPSMI for OA and CLBP.

DESIGN

Rapid reviews are an increasingly valid means of expediting knowledge dissemination and are particularly useful for addressing focused research questions.

METHOD

The electronic databases MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews and Cochrane Register of Controlled Trials were searched. Structured group-based interventions that aimed to promote self-management delivered by health-care professionals (including at least one physiotherapist) involving adults' with OA and/or CLBP were included. The screening and selection of studies, data extraction and risk of bias assessment were conducted independently by two reviewers.

RESULTS

22 Studies were found (10 OA, 12 CLBP). No significant difference was found between the effectiveness of GPSMI and individual physiotherapy or usual medical management for any outcome.

CONCLUSIONS

GPSMI is as clinically effective as individual physiotherapy or usual medical management, but the best methods of measuring clinical effectiveness warrant further investigation. Further research is also needed to determine the cost-effectiveness of GPSMI and its implications.

Implementation fidelity of physiotherapist-delivered group education and exercise interventions to promote self-management in people with osteoarthritis and chronic low back pain: a rapid review part II

BACKGROUND

Implementation fidelity is the extent to which an intervention is delivered as intended by intervention developers, and is extremely important as it increases confidence that changes in study outcomes are due to the effect of the intervention itself and not due to variability in implementation. A paucity of literature exists concerning implementation fidelity in physiotherapy research.

DESIGN AND OBJECTIVES

This rapid review aimed to evaluate the implementation fidelity of group-based self-management interventions for people with osteoarthritis (OA) and/or chronic low back pain (CLBP).

METHOD

Group-based self-management interventions delivered by health-care professionals (including at least one physiotherapist) involving adults with OA and/or CLBP were eligible for inclusion. The National Institutes of Health Behaviour Change Consortium Treatment Fidelity checklist was used to assess fidelity and applied independently by two reviewers.

RESULTS

In total, 22 studies were found. Fidelity was found to be very low (mean score 36%) within the included studies with only one study achieving >80% on the framework. The domain of Training of Providers achieved the lowest fidelity rating (10%) across all studies.

CONCLUSIONS

Overall levels of implementation fidelity are low in self-management interventions for CLBP and/or OA; however it is unclear whether fidelity is poor within the trials included in this review, or just poorly reported. There is a need for the development of fidelity reporting guidelines and for the refinement of fidelity frameworks upon which to base these guidelines.

The effects of exercise and neuromuscular electrical stimulation in subjects with knee osteoarthritis: a 3-month follow-up study

Background

Strengthening exercises of the quadriceps femoris muscle (QFM) are beneficial for patients with knee osteoarthritis (OA). Studies reporting short-term effects of neuromuscular electrical stimulation (NMES) of the QFM in this population support the use of this modality as an adjunct treatment. The objectives of this follow-up study are to compare the effects of an exercise program with and without NMES of the QFM on pain, functional performance, and muscle strength immediately posttreatment and 12 weeks after completion of the intervention.

Methods

Sixty-three participants with knee OA were randomly assigned into two groups receiving 12 biweekly treatments: An exercise-only program or an exercise program combined with NMES.

Results

A significantly greater reduction in knee pain was observed immediately after treatment in the NMES group, which was maintained 12 weeks postintervention in both groups. Although at this stage NMES had no additive effect, both groups demonstrated an immediate increase in muscle strength and in functional abilities, with no differences between groups. Although the improvements in gait velocity and in self-report functional ability were maintained at the follow-up session, the noted improvements in muscle strength, time to up and go, and stair negotiation were not maintained.

Conclusion

Supplementing an exercise program with NMES to the QFM increased pain modulation immediately after treatment in patients with knee OA. Maintenance of the positive posttreatment effects during a 12-week period was observed only for pain, self-reported functional ability, and walk velocity, with no difference between groups.

Clinical rehabilitation effect

The effects of a comprehensive group exercise program with or without NMES are partially maintained 12 weeks after completion of the intervention. The addition of NMES is recommended primarily for its immediate effect on pain. Further studies are necessary to determine the effects of repeated bouts of exercise with and without NMES in this population.

Quadriceps femoris muscle fatigue in patients with knee osteoarthritis

The purpose of this study was to characterize quadriceps femoris muscle fatigue of both lower extremities in patients with knee osteoarthritis (OA). Sixty-two subjects (mean age 68.2 years, standard deviation [SD] ± 7.9 years) with knee OA participated in the study. Significantly higher knee pain was reported in the involved knee than in the contralateral knee, as determined by a visual analog scale. Significant differences were demonstrated between the lower extremities in terms of maximal voluntary isometric contraction, in favor of the less involved leg (P = 0.0001). In contrast, the degree of fatigue of the quadriceps femoris muscle, as measured by the decrement in force production following ten repeated contractions, was significantly higher in the contralateral leg (P = 0.0002). Furthermore, normalization of the fatigue results to the first contraction yielded a similar result (P < 0.0001). Similar results were noted when analysis was performed separately for subjects whose involvement was unilateral or bilateral. The results indicate that, irrespective of the initial strength of contraction, the rate of muscle fatigue in the contralateral leg is significantly higher than in the involved leg. Hypotheses for these unexpected results are suggested. Rehabilitation of patients with knee OA should focus on increasing quadriceps muscle strength and endurance for both lower extremities.