1
|
Shi Y, Wu W. Multimodal non-invasive non-pharmacological therapies for chronic pain: mechanisms and progress. BMC Med 2023; 21:372. [PMID: 37775758 PMCID: PMC10542257 DOI: 10.1186/s12916-023-03076-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 09/11/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND Chronic pain conditions impose significant burdens worldwide. Pharmacological treatments like opioids have limitations. Non-invasive non-pharmacological therapies (NINPT) encompass diverse interventions including physical, psychological, complementary and alternative approaches, and other innovative techniques that provide analgesic options for chronic pain without medications. MAIN BODY This review elucidates the mechanisms of major NINPT modalities and synthesizes evidence for their clinical potential across chronic pain populations. NINPT leverages peripheral, spinal, and supraspinal mechanisms to restore normal pain processing and limit central sensitization. However, heterogeneity in treatment protocols and individual responses warrants optimization through precision medicine approaches. CONCLUSION Future adoption of NINPT requires addressing limitations in standardization and accessibility as well as synergistic combination with emerging therapies. Overall, this review highlights the promise of NINPT as a valuable complementary option ready for integration into contemporary pain medicine paradigms to improve patient care and outcomes.
Collapse
Affiliation(s)
- Yu Shi
- Department of Rehabilitation, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, China
| | - Wen Wu
- Department of Rehabilitation, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, China.
| |
Collapse
|
2
|
Hatefi F, Kazemi M, Manglian P, Shahi Moridi D, Heydari S, Hasani H. The effects of cold compress and transcutaneous electrical nerve stimulation on the pain associated with chest tube removal among patients with coronary bypass grafting. J Cardiothorac Surg 2023; 18:186. [PMID: 37231409 DOI: 10.1186/s13019-023-02182-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 03/12/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND AND AIM Chest tube removal (CTR) can cause severe acute pain which is usually described by patients as a painful experience. This study compared the effects of cold compress, transcutaneous electrical nerve stimulation (TENS), and combined cold compress-TENS on CTR-associated pain among patients with coronary artery bypass grafting (CABG). METHODS This randomized controlled trial was conducted in 2018-2019 using a double-blind four-group design. Participants were 120 patients with CABG selected from Shafa hospital, Kerman, Iran, and randomly allocated to a cold compress, a TENS, a combined cold compress-TENS, and a placebo group (compress with room temperature) and TENS with an off TENS device. Each participant received the intervention for 15 min immediately before CTR. CTR-associated pain was assessed before, during, immediately after, and 15 min after CTR. Data were analyzed using the SPSS program (v. 22.0) at a significance level of less than 0.05. RESULTS The data of 29 participants in the placebo group, 26 in the TENS group, 30 in the cold compress group, and 26 in the combined cold compress-TENS group was gathered. Baseline demographic and clinical characteristics and pain intensity scores of participants had no statistically significant differences among all four groups (P > 0.05). The mean score of pain intensity in all groups was at its highest level during CTR and gradually decreased afterwards, but this pain intensity reduction in the compress-TENS group was significantly greater than other groups (P < 0.001). CONCLUSION Combined cold compress-TENS is more effective than separate cold compress and TENS in reducing CTR-associated pain among patients with CABG. Therefore, non-pharmacological methods such as combined cold compress-TENS are recommended for managing CTR-associated pain.
Collapse
Affiliation(s)
- Fatemeh Hatefi
- Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Majid Kazemi
- Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Non-Communicable Disease Research Center, Rafsanjan University of Medical Sciences, Nurse Street, Rafsanjan, Iran.
| | - Parvin Manglian
- Department of Critical Care Nursing, Faculty of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran
| | - Dadullah Shahi Moridi
- Department of Basic Science, Faculty of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Shahin Heydari
- Department of Fundamental Nursing, Geriatric Care Research Center, Faculty of Nursing and Midwifery, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Hadi Hasani
- Department of Medical Surgical Nursing, Jovein School of Nursing, Sabzevar University of Medical Sciences, Sabzevar, Iran
| |
Collapse
|
3
|
Paley CA, Wittkopf PG, Jones G, Johnson MI. Does TENS Reduce the Intensity of Acute and Chronic Pain? A Comprehensive Appraisal of the Characteristics and Outcomes of 169 Reviews and 49 Meta-Analyses. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:1060. [PMID: 34684097 PMCID: PMC8539683 DOI: 10.3390/medicina57101060] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/21/2021] [Accepted: 09/22/2021] [Indexed: 12/11/2022]
Abstract
Background and Objectives: Uncertainty about the clinical efficacy of transcutaneous electric nerve stimulation (TENS) to alleviate pain spans half a century. There has been no attempt to synthesise the entire body of systematic review evidence. The aim of this comprehensive review was to critically appraise the characteristics and outcomes of systematic reviews evaluating the clinical efficacy of TENS for any type of acute and chronic pain in adults. Materials and Methods: We searched electronic databases for full reports of systematic reviews of studies, overviews of systematic reviews, and hybrid reviews that evaluated the efficacy of TENS for any type of clinical pain in adults. We screened reports against eligibility criteria and extracted data related to the characteristics and outcomes of the review, including effect size estimates. We conducted a descriptive analysis of extracted data. Results: We included 169 reviews consisting of eight overviews, seven hybrid reviews and 154 systematic reviews with 49 meta-analyses. A tally of authors' conclusions found a tendency toward benefits from TENS in 69/169 reviews, no benefits in 13/169 reviews, and inconclusive evidence in 87/169 reviews. Only three meta-analyses pooled sufficient data to have confidence in the effect size estimate (i.e., pooled analysis of >500 events). Lower pain intensity was found during TENS compared with control for chronic musculoskeletal pain and labour pain, and lower analgesic consumption was found post-surgery during TENS. The appraisal revealed repeated shortcomings in RCTs that have hindered confident judgements about efficacy, resulting in stagnation of evidence. Conclusions: Our appraisal reveals examples of meta-analyses with 'sufficient data' demonstrating benefit. There were no examples of meta-analyses with 'sufficient data' demonstrating no benefit. Therefore, we recommend that TENS should be considered as a treatment option. The considerable quantity of reviews with 'insufficient data' and meaningless findings have clouded the issue of efficacy. We offer solutions to these issues going forward.
Collapse
Affiliation(s)
- Carole A. Paley
- Centre for Pain Research, Leeds Beckett University, Leeds LS1 3HE, UK; (C.A.P.); (P.G.W.); (G.J.)
- Research and Development Department, Airedale National Health Service (NHS) Foundation Trust, Skipton Road, Steeton, Keighley BD20 6TD, UK
| | - Priscilla G. Wittkopf
- Centre for Pain Research, Leeds Beckett University, Leeds LS1 3HE, UK; (C.A.P.); (P.G.W.); (G.J.)
| | - Gareth Jones
- Centre for Pain Research, Leeds Beckett University, Leeds LS1 3HE, UK; (C.A.P.); (P.G.W.); (G.J.)
| | - Mark I. Johnson
- Centre for Pain Research, Leeds Beckett University, Leeds LS1 3HE, UK; (C.A.P.); (P.G.W.); (G.J.)
| |
Collapse
|
4
|
Rahimi F, Nejati V, Nassadj G, Ziaei B, Mohammadi HK. The effect of transcranial direct stimulation as an add-on treatment to conventional physical therapy on pain intensity and functional ability in individuals with knee osteoarthritis: A randomized controlled trial. Neurophysiol Clin 2021; 51:507-516. [PMID: 34518098 DOI: 10.1016/j.neucli.2021.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 06/01/2021] [Accepted: 06/01/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To investigate the effect of adding transcranial direct current stimulation (tDCS) to conventional physiotherapy treatment (PT) on pain and performance of individuals with knee osteoarthritis (KOA). METHODS Eighty people suffering from chronic KOA participated in this study. They were randomly divided into four treatment groups, including PT combined with tDCS over the primary motor cortex (M1), PT combined with tDCS over the primary sensory cortex (S1), PT combined with tDCS over the dorsolateral prefrontal cortex (DLPFC), and PT combined with sham tDCS. A visual analog scale (VAS) for pain intensity, the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire for knee-related disability, and several performance tests (stepping 15 s, chair stand test in 30 s, and walking 4 × 10 m) were used for assessment following 10 sessions of tDCS (T1), and one month after the last session of tDCS (T2). RESULTS Differential effects on pain intensity, knee-related disability, and performance were found between groups. Compared to sham tDCS: (i) tDCS over M1 improved VAS pain score, KOOS disability score, and performance tests at T1 and T2; (ii) tDCS over S1 improved VAS pain score at T1 and T2 and KOOS disability score and performance tests at T2; (iii) tDCS over the DLPFC improved VAS pain score at T1 and performance tests at T1 and T2. CONCLUSION tDCS could be a beneficial add-on treatment to conventional PT for pain relief, disability reduction and functional improvement in patients with KOA.
Collapse
Affiliation(s)
- Fatemeh Rahimi
- Department of Physiotherapy, Musculoskeletal Rehabilitation Research Center, Rehabilitation School, Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Vahid Nejati
- Cognitive Neurosciences, Shahid Beheshti University, Tehran, Iran
| | - Gholamhossein Nassadj
- Department of Physiotherapy, Musculoskeletal Rehabilitation Research Center, Rehabilitation School, Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Bahare Ziaei
- Department of Physiotherapy, Musculoskeletal Rehabilitation Research Center, Rehabilitation School, Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Hossein Kouhzad Mohammadi
- Department of Physiotherapy, Musculoskeletal Rehabilitation Research Center, Rehabilitation School, Jundishapur University of Medical Sciences, Ahvaz, Iran
| |
Collapse
|
5
|
Maeda T, Yoshida H, Sasaki T, Oda A. Does transcutaneous electrical nerve stimulation (TENS) simultaneously combined with local heat and cold applications enhance pain relief compared with TENS alone in patients with knee osteoarthritis? J Phys Ther Sci 2017; 29:1860-1864. [PMID: 29184307 PMCID: PMC5684028 DOI: 10.1589/jpts.29.1860] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 07/22/2017] [Indexed: 01/12/2023] Open
Abstract
[Purpose] The purpose of this study was to investigate whether transcutaneous electrical
nerve stimulation simultaneously combined with local heat and cold applications enhances
pain relief compared with transcutaneous electrical nerve stimulation alone in patients
with knee osteoarthritis. [Subjects and Methods] Fourty-five patients with knee
osteoarthritis participated in this study. They were randomly assigned to the following
three interventions: transcutaneous electrical nerve stimulation simultaneously combined
with local heat using a hot pack; combined with local cold using a cold pack; and
transcutaneous electrical nerve stimulation alone. In each intervention, the knee pain
level during walking and standing up from a chair, as well as dynamic balance and gait
ability were evaluated immediately before and after a single intervention using the visual
analogue scale and the timed up & go test, respectively. [Results] A significant
improvement in dynamic balance and gait ability was only observed immediately after
transcutaneous electrical nerve stimulation simultaneously combined with local heat
application, although the degree of pain relief during standing and walking were
comparable among the three interventions. [Conclusion] These results suggest that
transcutaneous electrical nerve stimulation simultaneously combined with local heat
application can immediately improve not only knee pain during standing and walking but
also dynamic balance and gait ability in patients with knee osteoarthritis.
Collapse
Affiliation(s)
- Takaya Maeda
- Department of Rehabilitation, Hirosaki Memorial Hospital: 59-1 Sakaizeki Nishida, Hirosaki-city, Aomori 036-8067, Japan.,Department of Comprehensive Rehabilitation Science, Hirosaki University Graduate School of Health Sciences, Japan
| | - Hideki Yoshida
- Department of Comprehensive Rehabilitation Science, Hirosaki University Graduate School of Health Sciences, Japan
| | - Tomoyuki Sasaki
- Department of Rehabilitation, Hirosaki Memorial Hospital: 59-1 Sakaizeki Nishida, Hirosaki-city, Aomori 036-8067, Japan
| | - Atsushi Oda
- Department of Comprehensive Rehabilitation Science, Hirosaki University Graduate School of Health Sciences, Japan
| |
Collapse
|
6
|
Valenza MC, Torres-Sánchez I, Cabrera-Martos I, Valenza-Demet G, Cano-Cappellacci M. Acute Effects of Contract-Relax Stretching vs. TENS in Young Subjects With Anterior Knee Pain. J Strength Cond Res 2016. [DOI: 10.1519/jsc.0000000000000215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
7
|
Valenza MC, Torres-Sánchez I, Cabrera-Martos I, Valenza-Demet G, Cano-Cappellacci M. Acute Effects of Contract-Relax Stretching vs. TENS in Young Subjects With Anterior Knee Pain: A Randomized Controlled Trial. J Strength Cond Res 2016. [DOI: 10.1519/jsc.0b013e3182a953db] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
8
|
Zotz TGG, Paula JBD. Influence of transcutaneous electrical stimulation on heterotopic ossification: an experimental study in Wistar rats. ACTA ACUST UNITED AC 2015; 48:1055-62. [PMID: 26292223 PMCID: PMC4671533 DOI: 10.1590/1414-431x20153426] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 03/16/2015] [Indexed: 11/30/2022]
Abstract
Heterotopic ossification (HO) is a metaplastic biological process in which there is
newly formed bone in soft tissues, resulting in joint mobility deficit and pain.
Different treatment modalities have been tried to prevent HO development, but there
is no consensus on a therapeutic approach. Since electrical stimulation is a widely
used resource in physiotherapy practice to stimulate joint mobility, with analgesic
and anti-inflammatory effects, its usefulness for HO treatment was investigated. We
aimed to identify the influence of electrical stimulation on induced HO in Wistar
rats. Thirty-six male rats (350-390 g) were used, and all animals were anesthetized
for blood sampling before HO induction, to quantify the serum alkaline phosphatase.
HO induction was performed by bone marrow implantation in both quadriceps of the
animals, which were then divided into 3 groups: control (CG), transcutaneous
electrical nerve stimulation (TENS) group (TG), and functional electrical stimulation
(FES) group (FG) with 12 rats each. All animals were anesthetized and electrically
stimulated twice per week, for 35 days from induction day. After this period, another
blood sample was collected and quadriceps muscles were bilaterally removed for
histological and calcium analysis and the rats were killed. Calcium levels in muscles
showed significantly lower results when comparing TG and FG (P<0.001) and between
TG and CG (P<0.001). Qualitative histological analyses confirmed 100% HO in FG and
CG, while in TG the HO was detected in 54.5% of the animals. The effects of the
muscle contractions caused by FES increased HO, while anti-inflammatory effects of
TENS reduced HO.
Collapse
Affiliation(s)
- T G G Zotz
- Escola de Saùde e Biociências, Departamento de Fisioterapia, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brasil
| | - J B de Paula
- Universidade Estadual de Ponta Grossa, Departamento de Medicina, Universidade Estadual de Ponta Grossa, Ponta Grossa, PR, Brasil
| |
Collapse
|
9
|
Khadilkar A, Phillips K, Jean N, Lamothe C, Milne S, Sarnecka J. Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation. Top Stroke Rehabil 2015; 13:1-269. [PMID: 16939981 DOI: 10.1310/3tkx-7xec-2dtg-xqkh] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this project was to create guidelines for 13 types of physical rehabilitation interventions used in the management of adult patients (>18 years of age) presenting with hemiplegia or hemiparesis following a single clinically identifiable ischemic or hemorrhagic cerebrovascular accident (CVA). METHOD Using Cochrane Collaboration methods, the Ottawa Methods Group identified and synthesized evidence from comparative controlled trials. The group then formed an expert panel, which developed a set of criteria for grading the strength of the evidence and the recommendation. Patient-important outcomes were determined through consensus, provided that these outcomes were assessed with a validated and reliable scale. RESULTS The Ottawa Panel developed 147 positive recommendations of clinical benefit concerning the use of different types of physical rehabilitation interventions involved in post-stroke rehabilitation. DISCUSSION AND CONCLUSION The Ottawa Panel recommends the use of therapeutic exercise, task-oriented training, biofeedback, gait training, balance training, constraint-induced movement therapy, treatment of shoulder subluxation, electrical stimulation, transcutaneous electrical nerve stimulation, therapeutic ultrasound, acupuncture, and intensity and organization of rehabilitation in the management of post stroke.
Collapse
|
10
|
Zhang W, Nuki G, Moskowitz RW, Abramson S, Altman RD, Arden NK, Bierma-Zeinstra S, Brandt KD, Croft P, Doherty M, Dougados M, Hochberg M, Hunter DJ, Kwoh K, Lohmander LS, Tugwell P. OARSI recommendations for the management of hip and knee osteoarthritis: part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage 2010; 18:476-99. [PMID: 20170770 DOI: 10.1016/j.joca.2010.01.013] [Citation(s) in RCA: 1049] [Impact Index Per Article: 74.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2010] [Revised: 01/26/2010] [Accepted: 01/26/2010] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To update evidence for available therapies in the treatment of hip and knee osteoarthritis (OA) and to examine whether research evidence has changed from 31 January 2006 to 31 January 2009. METHODS A systematic literature search was undertaken using MEDLINE, EMBASE, CINAHL, AMED, Science Citation Index and the Cochrane Library. The quality of studies was assessed. Effect sizes (ESs) and numbers needed to treat were calculated for efficacy. Relative risks, hazard ratios (HRs) or odds ratios were estimated for side effects. Publication bias and heterogeneity were examined. Sensitivity analysis was undertaken to compare the evidence pooled in different years and different qualities. Cumulative meta-analysis was used to examine the stability of evidence. RESULTS Sixty-four systematic reviews, 266 randomised controlled trials (RCTs) and 21 new economic evaluations (EEs) were published between 2006 and 2009. Of 51 treatment modalities, new data on efficacy have been published for more than half (26/39, 67%) of those for which research evidence was available in 2006. Among non-pharmacological therapies, ES for pain relief was unchanged for self-management, education, exercise and acupuncture. However, with new evidence the ES for pain relief for weight reduction reached statistical significance, increasing from 0.13 [95% confidence interval (CI) -0.12, 0.36] in 2006 to 0.20 (95% CI 0.00, 0.39) in 2009. By contrast, the ES for electromagnetic therapy which was large in 2006 (ES=0.77, 95% CI 0.36, 1.17) was no longer significant (ES=0.16, 95% CI -0.08, 0.39). Among pharmacological therapies, the cumulative evidence for the benefits and harms of oral and topical non-steroidal anti-inflammatory drugs, diacerhein and intra-articular (IA) corticosteroid was not greatly changed. The ES for pain relief with acetaminophen diminished numerically, but not significantly, from 0.21 (0.02, 0.41) to 0.14 (0.05, 0.22) and was no longer significant when analysis was restricted to high quality trials (ES=0.10, 95% CI -0.0, 0.23). New evidence for increased risks of hospitalisation due to perforation, peptic ulceration and bleeding with acetaminophen >3g/day have been published (HR=1.20, 95% CI 1.03, 1.40). ES for pain relief from IA hyaluronic acid, glucosamine sulphate, chondroitin sulphate and avocado soybean unsponifiables also diminished and there was greater heterogeneity of outcomes and more evidence of publication bias. Among surgical treatments further negative RCTs of lavage/debridement were published and the pooled results demonstrated that benefits from this modality of therapy were no greater than those obtained from placebo. CONCLUSION Publication of a large amount of new research evidence has resulted in changes in the calculated risk-benefit ratio for some treatments for OA. Regular updating of research evidence can help to guide best clinical practice.
Collapse
Affiliation(s)
- W Zhang
- Nottingham City Hospital, University of Nottingham, Nottingham, UK.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Rutjes AWS, Nüesch E, Sterchi R, Kalichman L, Hendriks E, Osiri M, Brosseau L, Reichenbach S, Jüni P. Transcutaneous electrostimulation for osteoarthritis of the knee. Cochrane Database Syst Rev 2009; 2009:CD002823. [PMID: 19821296 PMCID: PMC7120411 DOI: 10.1002/14651858.cd002823.pub2] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Osteoarthritis is the most common form of joint disease and the leading cause of pain and physical disability in the elderly. Transcutaneous electrical nerve stimulation (TENS), interferential current stimulation and pulsed electrostimulation are used widely to control both acute and chronic pain arising from several conditions, but some policy makers regard efficacy evidence as insufficient. OBJECTIVES To compare transcutaneous electrostimulation with sham or no specific intervention in terms of effects on pain and withdrawals due to adverse events in patients with knee osteoarthritis. SEARCH STRATEGY We updated the search in CENTRAL, MEDLINE, EMBASE, CINAHL and PEDro up to 5 August 2008, checked conference proceedings and reference lists, and contacted authors. SELECTION CRITERIA Randomised or quasi-randomised controlled trials that compared transcutaneously applied electrostimulation with a sham intervention or no intervention in patients with osteoarthritis of the knee. DATA COLLECTION AND ANALYSIS We extracted data using standardised forms and contacted investigators to obtain missing outcome information. Main outcomes were pain and withdrawals or dropouts due to adverse events. We calculated standardised mean differences (SMDs) for pain and relative risks for safety outcomes and used inverse-variance random-effects meta-analysis. The analysis of pain was based on predicted estimates from meta-regression using the standard error as explanatory variable. MAIN RESULTS In this update we identified 14 additional trials resulting in the inclusion of 18 small trials in 813 patients. Eleven trials used TENS, four interferential current stimulation, one both TENS and interferential current stimulation, and two pulsed electrostimulation. The methodological quality and the quality of reporting was poor and a high degree of heterogeneity among the trials (I(2) = 80%) was revealed. The funnel plot for pain was asymmetrical (P < 0.001). The predicted SMD of pain intensity in trials as large as the largest trial was -0.07 (95% CI -0.46 to 0.32), corresponding to a difference in pain scores between electrostimulation and control of 0.2 cm on a 10 cm visual analogue scale. There was little evidence that SMDs differed on the type of electrostimulation (P = 0.94). The relative risk of being withdrawn or dropping out due to adverse events was 0.97 (95% CI 0.2 to 6.0). AUTHORS' CONCLUSIONS In this update, we could not confirm that transcutaneous electrostimulation is effective for pain relief. The current systematic review is inconclusive, hampered by the inclusion of only small trials of questionable quality. Appropriately designed trials of adequate power are warranted.
Collapse
Affiliation(s)
- Anne WS Rutjes
- University of BernDivision of Clinical Epidemiology and Biostatistics, Institute of Social and Preventive MedicineFinkenhubelweg 11BernSwitzerland3012
| | - Eveline Nüesch
- University of BernDivision of Clinical Epidemiology and Biostatistics, Institute of Social and Preventive MedicineFinkenhubelweg 11BernSwitzerland3012
| | - Rebekka Sterchi
- University of BernDivision of Clinical Epidemiology and Biostatistics, Institute of Social and Preventive MedicineFinkenhubelweg 11BernSwitzerland3012
| | - Leonid Kalichman
- Ben‐Gurion University of the NegevDepartment of Physical Therapy, Recanati School for Community Health Professions, Faculty of Health SciencesBeer ShevaIsrael84105
| | - Erik Hendriks
- Maastricht UniversityEpidemiology DepartmentP.O. Box 616MaastrichtNetherlandsNL‐6200 MD
| | - Manathip Osiri
- Faculty of MedicineDepartment of MedicineChulalongkorn University1873 Rama IV Road, PathumwanBangkokThailand10330
| | - Lucie Brosseau
- University of OttawaSchool of Rehabilitation Sciences, Faculty of Health Sciences451 Smyth RoadOttawaOntarioCanadaK1H 8M5
| | - Stephan Reichenbach
- University HospitalDepartment for Rheumatology, Clinical Immunology, and AllergologyInselspitalBernSwitzerland
| | - Peter Jüni
- University of BernDivision of Clinical Epidemiology and Biostatistics, Institute of Social and Preventive MedicineFinkenhubelweg 11BernSwitzerland3012
| | | |
Collapse
|
12
|
OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage 2008; 16:137-62. [PMID: 18279766 DOI: 10.1016/j.joca.2007.12.013] [Citation(s) in RCA: 1774] [Impact Index Per Article: 110.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Accepted: 12/20/2007] [Indexed: 02/02/2023]
Abstract
PURPOSE To develop concise, patient-focussed, up to date, evidence-based, expert consensus recommendations for the management of hip and knee osteoarthritis (OA), which are adaptable and designed to assist physicians and allied health care professionals in general and specialist practise throughout the world. METHODS Sixteen experts from four medical disciplines (primary care, rheumatology, orthopaedics and evidence-based medicine), two continents and six countries (USA, UK, France, Netherlands, Sweden and Canada) formed the guidelines development team. A systematic review of existing guidelines for the management of hip and knee OA published between 1945 and January 2006 was undertaken using the validated appraisal of guidelines research and evaluation (AGREE) instrument. A core set of management modalities was generated based on the agreement between guidelines. Evidence before 2002 was based on a systematic review conducted by European League Against Rheumatism and evidence after 2002 was updated using MEDLINE, EMBASE, CINAHL, AMED, the Cochrane Library and HTA reports. The quality of evidence was evaluated, and where possible, effect size (ES), number needed to treat, relative risk or odds ratio and cost per quality-adjusted life years gained were estimated. Consensus recommendations were produced following a Delphi exercise and the strength of recommendation (SOR) for propositions relating to each modality was determined using a visual analogue scale. RESULTS Twenty-three treatment guidelines for the management of hip and knee OA were identified from the literature search, including six opinion-based, five evidence-based and 12 based on both expert opinion and research evidence. Twenty out of 51 treatment modalities addressed by these guidelines were universally recommended. ES for pain relief varied from treatment to treatment. Overall there was no statistically significant difference between non-pharmacological therapies [0.25, 95% confidence interval (CI) 0.16, 0.34] and pharmacological therapies (ES=0.39, 95% CI 0.31, 0.47). Following feedback from Osteoarthritis Research International members on the draft guidelines and six Delphi rounds consensus was reached on 25 carefully worded recommendations. Optimal management of patients with OA hip or knee requires a combination of non-pharmacological and pharmacological modalities of therapy. Recommendations cover the use of 12 non-pharmacological modalities: education and self-management, regular telephone contact, referral to a physical therapist, aerobic, muscle strengthening and water-based exercises, weight reduction, walking aids, knee braces, footwear and insoles, thermal modalities, transcutaneous electrical nerve stimulation and acupuncture. Eight recommendations cover pharmacological modalities of treatment including acetaminophen, cyclooxygenase-2 (COX-2) non-selective and selective oral non-steroidal anti-inflammatory drugs (NSAIDs), topical NSAIDs and capsaicin, intra-articular injections of corticosteroids and hyaluronates, glucosamine and/or chondroitin sulphate for symptom relief; glucosamine sulphate, chondroitin sulphate and diacerein for possible structure-modifying effects and the use of opioid analgesics for the treatment of refractory pain. There are recommendations covering five surgical modalities: total joint replacements, unicompartmental knee replacement, osteotomy and joint preserving surgical procedures; joint lavage and arthroscopic debridement in knee OA, and joint fusion as a salvage procedure when joint replacement had failed. Strengths of recommendation and 95% CIs are provided. CONCLUSION Twenty-five carefully worded recommendations have been generated based on a critical appraisal of existing guidelines, a systematic review of research evidence and the consensus opinions of an international, multidisciplinary group of experts. The recommendations may be adapted for use in different countries or regions according to the availability of treatment modalities and SOR for each modality of therapy. These recommendations will be revised regularly following systematic review of new research evidence as this becomes available.
Collapse
|
13
|
Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, Bierma-Zeinstra S, Brandt KD, Croft P, Doherty M, Dougados M, Hochberg M, Hunter DJ, Kwoh K, Lohmander LS, Tugwell P. OARSI recommendations for the management of hip and knee osteoarthritis, part I: critical appraisal of existing treatment guidelines and systematic review of current research evidence. Osteoarthritis Cartilage 2007; 15:981-1000. [PMID: 17719803 DOI: 10.1016/j.joca.2007.06.014] [Citation(s) in RCA: 496] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2007] [Accepted: 06/16/2007] [Indexed: 02/02/2023]
Abstract
PURPOSE As a prelude to developing updated, evidence-based, international consensus recommendations for the management of hip and knee osteoarthritis (OA), the Osteoarthritis Research Society International (OARSI) Treatment Guidelines Committee undertook a critical appraisal of published guidelines and a systematic review (SR) of more recent evidence for relevant therapies. METHODS Sixteen experts from four medical disciplines (primary care two, rheumatology 11, orthopaedics one and evidence-based medicine two), two continents and six countries (USA, UK, France, Netherlands, Sweden and Canada) formed the guidelines development team. Three additional experts were invited to take part in the critical appraisal of existing guidelines in languages other than English. MEDLINE, EMBASE, Science Citation Index, CINAHL, AMED, Cochrane Library, seven Guidelines Websites and Google were searched systematically to identify guidelines for the management of hip and/or knee OA. Guidelines which met the inclusion/exclusion criteria were assigned to four groups of four appraisers. The quality of the guidelines was assessed using the AGREE (Appraisal of Guidelines for Research and Evaluation) instrument and standardised percent scores (0-100%) for scope, stakeholder involvement, rigour, clarity, applicability and editorial independence, as well as overall quality, were calculated. Treatment modalities addressed and recommended by the guidelines were summarised. Agreement (%) was estimated and the best level of evidence to support each recommendation was extracted. Evidence for each treatment modality was updated from the date of the last SR in January 2002 to January 2006. The quality of evidence was evaluated using the Oxman and Guyatt, and Jadad scales for SRs and randomised controlled trials (RCTs), respectively. Where possible, effect size (ES), number needed to treat, relative risk (RR) or odds ratio and cost per quality-adjusted life year gained (QALY) were estimated. RESULTS Twenty-three of 1462 guidelines or consensus statements retrieved from the literature search met the inclusion/exclusion criteria. Six were predominantly based on expert opinion, five were primarily evidence based and 12 were based on both. Overall quality scores were 28%, 41% and 51% for opinion-based, evidence-based and hybrid guidelines, respectively (P=0.001). Scores for aspects of quality varied from 18% for applicability to 67% for scope. Thirteen guidelines had been developed for specific care settings including five for primary care (e.g., Prodigy Guidance), three for rheumatology (e.g., European League against Rheumatism recommendations), three for physiotherapy (e.g., Dutch clinical practice guidelines for physical therapy) and two for orthopaedics (e.g., National Institutes of Health consensus guidelines), whereas 10 did not specify the target users (e.g., Ontario guidelines for optimal therapy). Whilst 14 guidelines did not separate hip and knee, eight were specific for knee but only one for hip. Fifty-one different treatment modalities were addressed by these guidelines, but only 20 were universally recommended. Evidence to support these modalities ranged from Ia (meta-analysis/SR of RCTs) to IV (expert opinion). The efficacy of some modalities of therapy was confirmed by the results of RCTs published between January 2002 and 2006. These included exercise (strengthening ES 0.32, 95% confidence interval (CI) 0.23, 0.42, aerobic ES 0.52, 95% CI 0.34, 0.70 and water-based ES 0.25, 95% CI 0.02, 0.47) and nonsteroidal anti-inflammatory drugs (NSAIDs) (ES 0.32, 95% CI 0.24, 0.39). Examples of other treatment modalities where recent trials failed to confirm efficacy included ultrasound (ES 0.06, 95% CI -0.39, 0.52), massage (ES 0.10, 95% CI -0.23, 0.43) and heat/ice therapy (ES 0.69, 95% CI -0.07, 1.45). The updated evidence on adverse effects also varied from treatment to treatment. For example, while the evidence for gastrointestinal (GI) toxicity of non-selective NSAIDs (RR=5.36, 95% CI 1.79, 16.10) and for increased risk of myocardial infarction associated with rofecoxib (RR=2.24, 95% CI 1.24, 4.02) were reinforced, evidence for other potential drug related adverse events such as GI toxicity with acetaminophen or myocardial infarction with celecoxib remained inconclusive. CONCLUSION Twenty-three guidelines have been developed for the treatment of hip and/or knee OA, based on opinion alone, research evidence or both. Twenty of 51 modalities of therapy are universally recommended by these guidelines. Although this suggests that a core set of recommendations for treatment exists, critical appraisal shows that the overall quality of existing guidelines is sub-optimal, and consensus recommendations are not always supported by the best available evidence. Guidelines of optimal quality are most likely to be achieved by combining research evidence with expert consensus and by paying due attention to issues such as editorial independence, stakeholder involvement and applicability. This review of existing guidelines provides support for the development of new guidelines cognisant of the limitations in existing guidelines. Recommendations should be revised regularly following SR of new research evidence as this becomes available.
Collapse
Affiliation(s)
- W Zhang
- University of Edinburgh, Osteoarticular Research Group, The Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh EH16 4TJ, United Kingdom
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|