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 electrophysical agents in subjects with frozen shoulder: a systematic review and meta-analysis

PURPOSE

This systematic review with meta-analysis aimed to assess the effectiveness of electrophysical agents in improving pain, function, disability, range of motion, quality of life, perceived stiffness, and time to recovery in subjects with frozen shoulder (FS).

METHODS

A thorough search of MEDLINE, Cochrane Library, PEDro, and EMBASE yielded 1143 articles, of which 23 randomized controlled trials were included. Risk of bias (RoB) was assessed through Cochrane Risk of Bias 2 tool. The certainty of evidence was evaluated through the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE).

RESULTS

The analysis included a total of 1073 subjects. None of the studies were judged as low RoB. Potentially clinically significant differences were observed in pain at 6 weeks and 5 months after extracorporeal shockwave therapy (ESWT), and in disability up to 3 months with laser therapy, albeit with uncertain results due to the high RoB and to the study heterogeneity. Ultrasound (US) therapy did not yield significant differences in any outcomes. The certainty of evidence was very low.

CONCLUSIONS

Based on the high heterogeneity and low quality and certainty of evidence, ESWT, laser, and US cannot be recommended for FS treatment. Caution should be exercised in interpreting the findings.

Comparison of the effectiveness of high-intensity laser and ultrasound therapies in adhesive capsulitis: A randomized controlled study

BACKGROUND

Adhesive capsulitis (AC) is a common musculoskeletal disease characterized with shoulder pain, limitation of range of motion (ROM) and disability. Although physical therapy is used in the treatment of AC, studies on its effectiveness are continuing.

OBJECTIVE

This study aimed to assess the effectiveness of ultrasound (US) and high-intensity laser therapy (HILT) in the treatment of AC.

METHODS

Sixty patients were randomized into two groups. Group I received US (15 sessions) and Group II received HILT (9 sessions) for 3 weeks. In addition, all patients received physical therapy program (hot pack, TENS and exercises). Assessments were made using VAS-pain, Shoulder Pain and Disability Index (SPADI), range of motion (ROM) at baseline and in post-treatment 3rd, 8th and 24th weeks.

RESULTS

There was no statistically significant difference between the groups in terms of all pre-treatment values. In intragroup assessment, statistically significant difference was identified in all the values of Groups 1 and 2 in all assessment periods compared with the pre-treatment values (p< 0.05). There was no significant difference between groups in all assessment periods.

CONCLUSION

According to results, US therapy and HILT were effective on the improvement of pain, ROM and functional conditions of patients in the treatment of AC.

Ultrasound improves motor distal latency on patients with carpal tunnel syndrome: systematic review and meta-analysis

INTRODUCTION

Is the application of ultrasound effective on pain, the severity of the symptoms, physical function, strength, and neurophysiological parameters of the median nerve conduction in patients with carpal tunnel syndrome?

EVIDENCE ACQUISITION

A systematic review and meta-analysis of randomized controlled trials was performed by using a structured search strategy in Scopus, CINAHL, Web of Science and PEDro databases. All the primary studies included samples with carpal tunnel syndrome treated by: ultrasound versus no treatment, therapeutic ultrasound versus sham ultrasound, ultrasound and usual care versus usual care, or ultrasound and other intervention versus the same intervention. The outcomes measures registered were pain, severity of symptoms, function, strength, and neurophysiological parameters (motor distal latency and sensory distal latency) of the median nerve. Methodological quality was evaluated by PEdro Scale.

EVIDENCE SYNTHESIS

Ten clinical trials met the inclusion criteria for the systematic review. Eight trials were meta-analyzed, which included a total of 2069 patients with carpal tunnel syndrome. The methodological quality of the included studies ranged among limited (5 trials), moderate (3 trials), and high (2 trials). In one of the electrophysiological parameters (motor distal latency), a significant difference between groups after the use of ultrasound was observed (MD=-0.10; fixed 95% CI=-0.20, -0.01; P=0.04). No significant differences between groups were observed at post-treatment for pain (P=0.29), severity of symptoms (P=0.99), function (P=0.54), strength (P=0.27) and for the rest of the electrophysiological parameters evaluated (P>0.05).

CONCLUSIONS

The use of ultrasound on patients with carpal tunnel syndrome seems to improve motor distal latency. This finding implies a partial improvement at the neurophysiological level, representing a reduction in the grade of clinical severity. Additional clinical trials with a high methodological quality are needed to investigate the doses at which ultrasound are most effective.

Carpal Tunnel Syndrome: Effectiveness of Physical Therapy and Electrophysical Modalities. An Updated Systematic Review of Randomized Controlled Trials

OBJECTIVE

To review scientific literature studying the effectiveness of physical therapy and electrophysical modalities for carpal tunnel syndrome (CTS).

DATA SOURCES

The Cochrane Library, PubMed, Embase, CINAHL, and Physiotherapy Evidence Database.

STUDY SELECTION

Two reviewers independently applied the inclusion criteria to select potential eligible studies.

DATA EXTRACTION

Two reviewers independently extracted the data and assessed the methodologic quality using the Cochrane Risk of Bias Tool.

DATA SYNTHESIS

A best-evidence synthesis was performed to summarize the results of the included studies (2 reviews and 22 randomized controlled trials [RCTs]). For physical therapy, moderate evidence was found for myofascial massage therapy versus ischemic compression on latent, or active, trigger points or low-level laser therapy in the short term. For several electrophysical modalities, moderate evidence was found in the short term (ultrasound vs placebo, ultrasound as single intervention vs other nonsurgical interventions, ultrasound vs corticosteroid injection plus a neutral wrist splint, local microwave hyperthermia vs placebo, iontophoresis vs phonophoresis, pulsed radiofrequency added to wrist splint, continuous vs pulsed vs placebo shortwave diathermy, and interferential current vs transcutaneous electrical nerve stimulation vs a night-only wrist splint). In the midterm, moderate evidence was found in favor of radial extracorporeal shockwave therapy (ESWT) added to a neutral wrist splint, in favor of ESWT versus ultrasound, or cryo-ultrasound, and in favor of ultrasound versus placebo. For all other interventions studied, only limited, conflicting, or no evidence was found. No RCTs investigating the long-term effects of physical therapy and electrophysical modalities were found. Because of heterogeneity in the treatment parameters used in the included RCTs, optimal treatment parameters could not be identified.

CONCLUSIONS

Moderate evidence was found for several physical therapy and electrophysical modalities for CTS in the short term and midterm. Future studies should concentrate on long-term effects and which treatment parameters of physical therapy and electrophysical modalities are most effective for CTS.

Electrotherapy modalities for rotator cuff disease

BACKGROUND

Management of rotator cuff disease may include use of electrotherapy modalities (also known as electrophysical agents), which aim to reduce pain and improve function via an increase in energy (electrical, sound, light, or thermal) into the body. Examples include therapeutic ultrasound, low-level laser therapy (LLLT), transcutaneous electrical nerve stimulation (TENS), and pulsed electromagnetic field therapy (PEMF). These modalities are usually delivered as components of a physical therapy intervention. This review is one of a series of reviews that form an update of the Cochrane review, 'Physiotherapy interventions for shoulder pain'.

OBJECTIVES

To synthesise available evidence regarding the benefits and harms of electrotherapy modalities for the treatment of people with rotator cuff disease.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), Ovid MEDLINE (January 1966 to March 2015), Ovid EMBASE (January 1980 to March 2015), CINAHL Plus (EBSCOhost, January 1937 to March 2015), ClinicalTrials.gov and the WHO ICTRP clinical trials registries up to March 2015, unrestricted by language, and reviewed the reference lists of review articles and retrieved trials, to identify potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-randomised trials, including adults with rotator cuff disease (e.g. subacromial impingement syndrome, rotator cuff tendinitis, calcific tendinitis), and comparing any electrotherapy modality with placebo, no intervention, a different electrotherapy modality or any other intervention (e.g. glucocorticoid injection). Trials investigating whether electrotherapy modalities were more effective than placebo or no treatment, or were an effective addition to another physical therapy intervention (e.g. manual therapy or exercise) were the main comparisons of interest. Main outcomes of interest were overall pain, function, pain on motion, patient-reported global assessment of treatment success, quality of life and the number of participants experiencing adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted the data, performed a risk of bias assessment and assessed the quality of the body of evidence for the main outcomes using the GRADE approach.

MAIN RESULTS

We included 47 trials (2388 participants). Most trials (n = 43) included participants with rotator cuff disease without calcification (four trials included people with calcific tendinitis). Sixteen (34%) trials investigated the effect of an electrotherapy modality delivered in isolation. Only 23% were rated at low risk of allocation bias, and 49% were rated at low risk of both performance and detection bias (for self-reported outcomes). The trials were heterogeneous in terms of population, intervention and comparator, so none of the data could be combined in a meta-analysis.In one trial (61 participants; low quality evidence), pulsed therapeutic ultrasound (three to five times a week for six weeks) was compared with placebo (inactive ultrasound therapy) for calcific tendinitis. At six weeks, the mean reduction in overall pain with placebo was -6.3 points on a 52-point scale, and -14.9 points with ultrasound (MD -8.60 points, 95% CI -13.48 to -3.72 points; absolute risk difference 17%, 7% to 26% more). Mean improvement in function with placebo was 3.7 points on a 100-point scale, and 17.8 points with ultrasound (mean difference (MD) 14.10 points, 95% confidence interval (CI) 5.39 to 22.81 points; absolute risk difference 14%, 5% to 23% more). Ninety-one per cent (29/32) of participants reported treatment success with ultrasound compared with 52% (15/29) of participants receiving placebo (risk ratio (RR) 1.75, 95% CI 1.21 to 2.53; absolute risk difference 39%, 18% to 60% more). Mean improvement in quality of life with placebo was 0.40 points on a 10-point scale, and 2.60 points with ultrasound (MD 2.20 points, 95% CI 0.91 points to 3.49 points; absolute risk difference 22%, 9% to 35% more). Between-group differences were not important at nine months. No participant reported adverse events.Therapeutic ultrasound produced no clinically important additional benefits when combined with other physical therapy interventions (eight clinically heterogeneous trials, low quality evidence). We are uncertain whether there are differences in patient-important outcomes between ultrasound and other active interventions (manual therapy, acupuncture, glucocorticoid injection, glucocorticoid injection plus oral tolmetin sodium, or exercise) because the quality of evidence is very low. Two placebo-controlled trials reported results favouring LLLT up to three weeks (low quality evidence), however combining LLLT with other physical therapy interventions produced few additional benefits (10 clinically heterogeneous trials, low quality evidence). We are uncertain whether transcutaneous electrical nerve stimulation (TENS) is more or less effective than glucocorticoid injection with respect to pain, function, global treatment success and active range of motion because of the very low quality evidence from a single trial. In other single, small trials, no clinically important benefits of pulsed electromagnetic field therapy (PEMF), microcurrent electrical stimulation (MENS), acetic acid iontophoresis and microwave diathermy were observed (low or very low quality evidence).No adverse events of therapeutic ultrasound, LLLT, TENS or microwave diathermy were reported by any participants. Adverse events were not measured in any trials investigating the effects of PEMF, MENS or acetic acid iontophoresis.

AUTHORS' CONCLUSIONS

Based on low quality evidence, therapeutic ultrasound may have short-term benefits over placebo in people with calcific tendinitis, and LLLT may have short-term benefits over placebo in people with rotator cuff disease. Further high quality placebo-controlled trials are needed to confirm these results. In contrast, based on low quality evidence, PEMF may not provide clinically relevant benefits over placebo, and therapeutic ultrasound, LLLT and PEMF may not provide additional benefits when combined with other physical therapy interventions. We are uncertain whether TENS is superior to placebo, and whether any electrotherapy modality provides benefits over other active interventions (e.g. glucocorticoid injection) because of the very low quality of the evidence. Practitioners should communicate the uncertainty of these effects and consider other approaches or combinations of treatment. Further trials of electrotherapy modalities for rotator cuff disease should be based upon a strong rationale and consideration of whether or not they would alter the conclusions of this review.

Phase 2 Study of Acupuncture-Like Transcutaneous Nerve Stimulation for Chemotherapy-Induced Peripheral Neuropathy

A prospective phase 2 study was conducted to evaluate the clinical utility of acupuncture-like transcutaneous nerve stimulation (ALTENS) for the treatment of chemotherapy-induced peripheral neuropathy (CIPN). Eligible cancer patients had a < 2 ECOG performance score, received neurotoxic chemotherapy, and developed CIPN symptoms for > two months. Randomization was used to eliminate bias in patient selection for ALTENS and was not to compare the effectiveness between the two treatments.ALTENS treatments were delivered using Codetron units. Bilateral acupuncture points included LI4 and LIV3, plus LI11 or ST36 were stimulated. Acupuncture treatments were administered to CV6, SP6, ST6, LI11, Bafeng, Baxie and selective Jing points bilaterally. Twelve treatments were delivered twice weekly over 6 to 8 weeks. The Modified Total Neuropathy Score (mTNS), Numbness Score, and Edmonton Symptom Assessment Score (ESAS) were assessed at baseline, treatment completion, plus at 3 and 6 months follow-up. The primary study endpoint was mTNS score at 6 months. We planned to recruit 23 patients into each group. After 30 patients were recruited, 2 were lost to follow-up at 3 months in the ALTENS group and 3 in the acupuncture group. The research team decided to recruit all remaining consecutive patients only to the ALTENS group to ensure an adequate evaluation of ALTENS, the primary object of evaluation. There were 27 patients in the ALTENS group, with an average symptom duration of 10 months after chemotherapy. Twenty four and 23 patients completed the 3 and 6 month follow-up respectively. The median mTNS scores were 7.1, 4.0, 3.6 and 3.1 at baseline, treatment completion, 3 and 6 months follow-up, respectively. One-way ANOVA analysis showed a significant improvement in mTNS scores (p<0.001) at 6 months. Numbness scores were also significantly improved at 6 months. ESAS pain scores and perception of well-being scores analyses were inconclusive. There were no significant reported side effects of ALTENS. There were only 13 patients in the acupuncture group and the number was insufficient for either an independent or a comparative analysis. The results of this study suggests that ALTENS significantly reduces the mTNS scores and numbness in patients suffering from CIPN symptoms.

Electrotherapy modalities for adhesive capsulitis (frozen shoulder)

BACKGROUND

Adhesive capsulitis (also termed frozen shoulder) is a common condition characterised by spontaneous onset of pain, progressive restriction of movement of the shoulder and disability that restricts activities of daily living, work and leisure. Electrotherapy modalities, which aim to reduce pain and improve function via an increase in energy (electrical, sound, light, thermal) into the body, are often delivered as components of a physical therapy intervention. This review is one in a series of reviews which form an update of the Cochrane review 'Physiotherapy interventions for shoulder pain'.

OBJECTIVES

To synthesise the available evidence regarding the benefits and harms of electrotherapy modalities, delivered alone or in combination with other interventions, for the treatment of adhesive capsulitis.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE, CINAHL Plus and the ClinicalTrials.gov and World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) clinical trials registries up to May 2014, unrestricted by language, and reviewed the reference lists of review articles and retrieved trials to identify any other potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and controlled clinical trials using a quasi-randomised method of allocation that included adults with adhesive capsulitis and compared any electrotherapy modality to placebo, no treatment, a different electrotherapy modality, or any other intervention. The two main questions of the review focused on whether electrotherapy modalities are effective compared to placebo or no treatment, or if they are an effective adjunct to manual therapy or exercise (or both). The main outcomes of interest were participant-reported pain relief of 30% or greater, overall pain, function, global assessment of treatment success, active shoulder abduction, quality of life, and the number of participants experiencing any adverse event.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted the data, performed a risk of bias assessment, and assessed the quality of the body of evidence for the main outcomes using the GRADE approach.

MAIN RESULTS

Nineteen trials (1249 participants) were included in the review. Four trials reported using an adequate method of allocation concealment and six trials blinded participants and personnel. Only two electrotherapy modalities (low-level laser therapy (LLLT) and pulsed electromagnetic field therapy (PEMF)) have been compared to placebo. No trial has compared an electrotherapy modality plus manual therapy and exercise to manual therapy and exercise alone. The two main questions of the review were investigated in nine trials.Low quality evidence from one trial (40 participants) indicated that LLLT for six days may result in improvement at six days. Eighty per cent (16/20) of participants reported treatment success with LLLT compared with 10% (2/20) of participants receiving placebo (risk ratio (RR) 8.00, 95% confidence interval (CI) 2.11 to 30.34; absolute risk difference 70%, 95% CI 48% to 92%). No participants in either group reported adverse events.We were uncertain whether PEMF for two weeks improved pain or function more than placebo at two weeks because of the very low quality evidence from one trial (32 participants). Seventy-five per cent (15/20) of participants reported pain relief of 30% or more with PEMF compared with 0% (0/12) of participants receiving placebo (RR 19.19, 95% CI 1.25 to 294.21; absolute risk difference 75%, 95% CI 53% to 97%). Fifty-five per cent (11/20) of participants reported total recovery of joint function with PEMF compared with 0% (0/12) of participants receiving placebo (RR 14.24, 95% CI 0.91 to 221.75; absolute risk difference 55%, 95% CI 31 to 79).Moderate quality evidence from one trial (63 participants) indicated that LLLT plus exercise for eight weeks probably results in greater improvement when measured at the fourth week of treatment, but a similar number of adverse events, compared with placebo plus exercise. The mean pain score at four weeks was 51 points with placebo plus exercise, while with LLLT plus exercise the mean pain score was 32 points on a 100 point scale (mean difference (MD) 19 points, 95% CI 15 to 23; absolute risk difference 19%, 95% CI 15% to 23%). The mean function impairment score was 48 points with placebo plus exercise, while with LLLT plus exercise the mean function impairment score was 36 points on a 100 point scale (MD 12 points, 95% CI 6 to 18; absolute risk difference 12%, 95% CI 6 to 18). Mean active abduction was 70 degrees with placebo plus exercise, while with LLLT plus exercise mean active abduction was 79 degrees (MD 9 degrees, 95% CI 2 to 16; absolute risk difference 5%, 95% CI 1% to 9%). No participants in either group reported adverse events. LLLT's benefits on function were maintained at four months.Based on very low quality evidence from six trials, we were uncertain whether therapeutic ultrasound, PEMF, continuous short wave diathermy, Iodex phonophoresis, a combination of Iodex iontophoresis with continuous short wave diathermy, or a combination of therapeutic ultrasound with transcutaneous electrical nerve stimulation (TENS) were effective adjuncts to exercise. Based on low or very low quality evidence from 12 trials, we were uncertain whether a diverse range of electrotherapy modalities (delivered alone or in combination with manual therapy, exercise, or other active interventions) were more or less effective than other active interventions (for example glucocorticoid injection).

AUTHORS' CONCLUSIONS

Based upon low quality evidence from one trial, LLLT for six days may be more effective than placebo in terms of global treatment success at six days. Based upon moderate quality evidence from one trial, LLLT plus exercise for eight weeks may be more effective than exercise alone in terms of pain up to four weeks, and function up to four months. It is unclear whether PEMF is more or less effective than placebo, or whether other electrotherapy modalities are an effective adjunct to exercise. Further high quality randomised controlled trials are needed to establish the benefits and harms of physical therapy interventions (that comprise electrotherapy modalities, manual therapy and exercise, and are reflective of clinical practice) compared to interventions with evidence of benefit (for example glucocorticoid injection or arthrographic joint distension).