Effects of kinesiotherapy, ultrasound and electrotherapy in management of bilateral knee osteoarthritis: prospective clinical trial

Mechanical-based therapies may reduce pain and disability in some patients with knee osteoarthritis: A systematic review with meta-analysis

BACKGROUND

Mechanical-based therapies are not yet recommended to manage osteoarthritis (OA). This systematic review and meta-analysis aim to assess the effects of passive mechanical-based therapies (isolated or combined with other therapies) on patients with knee OA compared to placebo, other isolated or combined interventions.

METHODS

Pubmed, Cochrane, Web of Science and EMBASE were searched up to December 2020. We included randomized and non-randomized trials using therapeutic ultrasound, phonophoresis, extracorporeal shockwave therapy (ESWT) and vibration (single or combined with other therapies) compared to placebo, and/or other physical therapies groups. Biochemical, patient-reported, physical and imaging outcome measures were retrieved. We judged risk of bias using the RoB2 tool for randomized studies, the ROBINS-I tool for non-randomized studies, and the GRADE to interpret certainty of results.

RESULTS

We included 77 clinical studies. Ultrasound and ESWT statistically improved pain and disability comparing to placebo (combined or not with other therapies), and when added to other therapies versus other therapies alone. Ultrasound was statistically inferior to phonophoresis (combined or not with other therapies) in reducing pain and disability for specific therapeutic gels and/or combined therapies. Vibration plus exercise statistically improved pain relief and function versus exercise alone. All meta-analyses showed very-low certainty of evidence, with 15 of 42 (38%) pooled comparisons being statistically significant (weak to large effect).

CONCLUSIONS

Despite the inconsistent evidence with very-low certainty, the potential benefits of passive mechanical-based therapies should not be disregard and cautiously recommended that clinicians might use them in some patients with knee OA.

Characterising the Features of 381 Clinical Studies Evaluating Transcutaneous Electrical Nerve Stimulation (TENS) for Pain Relief: A Secondary Analysis of the Meta-TENS Study to Improve Future Research

Background and Objectives: Characterising the features of methodologies, clinical attributes and intervention protocols, of studies is valuable to advise directions for research and practice. This article reports the findings of a secondary analysis of the features from studies screened as part of a large systematic review of TENS (the meta-TENS study). Materials and Methods: A descriptive analysis was performed on information associated with methodology, sample populations and intervention protocols from 381 randomised controlled trials (24,532 participants) evaluating TENS delivered at a strong comfortable intensity at the painful site in adults with pain, irrespective of diagnosis. Results: Studies were conducted in 43 countries commonly using parallel group design (n = 334) and one comparator group (n = 231). Mean ± standard deviation (SD) study sample size (64.05 ± 58.29 participants) and TENS group size (27.67 ± 21.90 participants) were small, with only 13 of 381 studies having 100 participants or more in the TENS group. Most TENS interventions were ‘high frequency’ (>10 pps, n = 276) and using 100 Hz (109/353 reports that stated a pulse frequency value). Of 476 comparator groups, 54.2% were active treatments (i.e., analgesic medication(s), exercise, manual therapies and electrophysical agents). Of 202 placebo comparator groups, 155 used a TENS device that did not deliver currents. At least 216 of 383 study groups were able to access other treatments whilst receiving TENS. Only 136 out of 381 reports included a statement about adverse events. Conclusions: Clinical studies on TENS are dominated by small parallel group evaluations of high frequency TENS that are often contaminated by concurrent treatment(s). Study reports tended focus on physiological and clinical implications rather than the veracity of methodology and findings. Previously published criteria for designing and reporting TENS studies were neglected and this should be corrected in future research using insights gleaned from this analysis.

Neuromuscular exercises on pain intensity, functional disability, proprioception, and balance of military personnel with chronic low back pain

BACKGROUND

Due to their occupational status, military personnel are a high-risk group for low back pain (LBP).

PURPOSE

The aim of this study was to investigate the effect of neuromuscular exercises on the severity of pain, functional disability, proprioception, and balance in military personnel with LBP.

METHODS

Military personnel with LBP were randomly assigned into two groups: intervention (n=15) and control (n=15). The intervention group performed 60 minutes of neuromuscular exercises three times per week for eight weeks while the control group continued their routine physical activities.

RESULTS

The mean post-intervention pain intensity, disability, and proprioception error significantly decreased in the intervention group. Whereas their mean post-interventions static and dynamic balance scores significantly increased.

CONCLUSIONS

The results indicate eight weeks of neuromuscular exercise decreased pain intensity and improved functional ability, static and dynamic balance, and proprioception among military staff suffering chronic low back pain.

Effects of various types of ultrasound therapy in hip osteoarthritis - a double-blind, randomized, controlled, follow-up study

Purpose: To compare the effects of various types of ultrasound therapy (UST) on pain, function, and quality of life in patients with hip osteoarthritis.Methods: Seventy-one patients receiving conventional physiotherapy (exercise, massage, and balneotherapy), were randomly allocated into four treatment groups: (1) continuous UST, (2) pulsed UST, (3) UST combined with transcutaneous electrical nerve stimulation (TENS), (4) placebo UST. We evaluated the hip pain (Visual Analog Scale), medication use, functional impairment (Western Ontario and McMaster Universities Arthritis Index; 6-minute walking test) and quality of life (SF-36) before, right after the treatments, and at 3 months follow-up.Results: Resting pain improved significantly in all treatment groups at the follow-up visit compared to baseline (p (group1-4) ≤0.002). The proportion of patients achieving Minimal Clinically Important Improvement (MCII) in function at month 3 was the highest in group 3 (73%). The 6-minute walking test significantly improved in each group during the follow-up period (p (group1-4) ≤ 0.025). Pain (p (group1-4) ≤ 0.014) and general health domains of the SF-36 showed the greatest improvement (p (group 2-4) ≤ 0.018).Conclusions: There was no difference among the effects of various types of UST on pain, function, and quality of life in the treatment of hip osteoarthritis. Additional ultrasound treatment is not likely to increase the effect of the conventional therapy on pain and function in hip osteoarthritis.

Effects of Nurse-Led Pain Management Interventions for Patients with Total Knee/Hip Replacement

BACKGROUND

A literature review was conducted to assess nurse-led nonpharmacologic pain management interventions intended for total knee/hip replacement patients.

DESIGN

This was a systematic review and meta-analysis.

DATA SOURCES

The PubMed, Embase, CINAHL, and Cochrane Library databases were searched to identify relevant studies.

REVIEW METHODS

The systematic review was conducted based on the Cochrane Handbook for Systematic Reviews of Interventions and all Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting guidelines. Two reviewers independently selected the studies and appraised their quality. Thereafter, the effects of all described nurse-led nonpharmacologic pain management interventions were estimated regarding pain, anxiety, and satisfaction through a meta-analysis.

RESULTS

In total, 219 relevant studies were found through a search. Finally, 23 studies were selected for review, with 17 included in the meta-analysis. Nurse-led nonpharmacologic pain management was effective for pain relief (effect size, -0.22; 95% confidence interval [CI], -0.42 to -0.02), and educational interventions were especially effective (effect size, -0.36; 95% CI, -0.69 to -0.03). Although interventions reduced anxiety and improved satisfaction, these results were not statistically significant based on the analysis.

CONCLUSION

Our findings support that nurse-led nonpharmacologic pain management interventions could help reduce pain in patients with total knee/hip replacement by supplementing pharmacologic pain management.

IMPLICATIONS FOR NURSING

Nurse-led nonpharmacologic pain interventions should be considered to reduce patient pain with total knee/hip replacement.

Efeito da fotobiomodulação associada a exercícios na dor e na funcionalidade de pacientes com osteoartrite de joelho: estudo-piloto

RESUMO O objetivo do estudo foi avaliar o efeito da fotobiomodulação associada a exercícios na dor e na funcionalidade de pacientes com osteoartrite de joelho. Para isso foram recrutados 20 pacientes com osteoartrite do joelho uni ou bilateral, que foram distribuídos em dois grupos: grupo-controle (GC), que realizou aplicação de fotobiomodulação (FBM) placebo e um protocolo de exercício; e grupo fotobiomodulação (GF), que realizou aplicação ativa da FBM e o protocolo de exercício, sendo esse realizado duas vezes por semana durante oito semanas e consistindo de alongamentos passivos dos músculos de membros inferiores, straight leg raise, treinamento proprioceptivo e exercícios para o controle da marcha. A FBM foi aplicada com o aparelho cluster contendo quatro diodos de 670 nm e cinco diodos de 850 nm, com uma potência de saída de 540 mW, sendo a dose utilizada de 4 J/cm2. Os grupos foram avaliados pré e pós-tratamento com os questionários SF-36, Lequesne, Tinetti, e por meio da Escala Visual Analógica de dor (EVA). Os dados foram analisados com o método Anova, seguido do Bonferroni. Os dados indicaram melhoras significativas para o GF ao fim do tratamento para as avaliações da EVA (2±1,25 vs. 0,7±0,82; p=0,009). Embora ambos os grupos tenham obtido melhoras significativas ao longo do tratamento, não foi possível observar diferenças significativas entre eles para o restante das avaliações ao final do tratamento. Portanto, conclui-se que o uso da FBM associada a exercícios apresentou melhora da dor nos pacientes com osteoartrite de joelho, embora não tenha sido possível observar diferenças significativas no que diz respeito à funcionalidade.

The effectiveness of foot orthoses in the treatment of medial knee osteoarthritis: A systematic review

BACKGROUND

Knee osteoarthritis is a disease of the joint causing decreased function and pain. Currently, treatments range from medication to surgery, with the use of different insoles and footwear recommended. These methods are effective by either correcting the position of the knee or providing shock absorption. However, there is little understanding of the effective characteristics of these devices.

RESEARCH QUESTION

This paper aims to investigate this question and provide future areas of research to help better define treatment guidelines. Foot orthoses are an example of non-pharmacological conservative treatments mentioned in National Institute for Health and Care Excellence (NICE) guidelines to treat knee osteoarthritis (OA). These include lateral wedge insoles (LWI), developed with the intention of load reduction of the knee. Different footwear has also been shown to affect pain, biomechanical and functional outcomes in knee OA patients.

METHODS

To address what features of LWIs and footwear make them effective in the treatment of knee OA, scientific databases were used to search for papers on this topic and then selected to be included based on pre-defined criteria. Data were extracted and analysed from these studies to provide a basis for possible areas for future development of these foot orthoses, and research required to improve clinical treatment guidelines. Databases used were PubMed, Scopus and Web of Science.

RESULTS AND SIGNIFICANCE

Thirty-four out of 226 papers were included after application of inclusion and exclusion criteria. Regarding LWIs, the characteristics showing the most beneficial effect on either biomechanical, functional or pain outcomes were customisation, full-length, 5° elevation, shock absorption and arch support. For footwear, barefoot mimicking soles produced the most favourable biomechanics. Results also showed that insoles work in correcting the position of the knee, but it may or may not affect patients' pain and function.

Phonophoresis of Phyllanthus amarus nanoparticle gel improves functional capacity in individuals with knee osteoarthritis: A randomized controlled trial

OBJECTIVE

This study examined the effects of treatment with Phyllanthus amarus nanoparticle gel applied by phonophoresis (PP) and ultrasound therapy (UT) in patients with symptomatic knee osteoarthritis (OA) using a randomized, double-blind, controlled trial.

METHODS

Patients with knee OA (n = 40; mean age ± SD, 64.30 ± 9.71 years), who had visual analogue scale (VAS) scores for knee pain intensity of 68.00 ± 9.58 (UT group) and 71.00 ± 8.74 (PP group, respectively) before treatment, were randomly allocated into two groups. Both groups were treated with an ultrasound program in continuous mode, 1.0 W/cm², 10 min per session, for 10 sessions. Nanoparticles of P. amarus were used in the PP group, whereas a nondrug coupling gel was used in the UT group. The 6-min walk test (6-MWT) was performed to evaluate functional capacity. The VAS and the 6-MWT were evaluated before and after 10 treatment sessions in both groups using a double-blind procedure.

RESULTS

VAS and 6-MWT showed significant improvement after treatment in both groups (p < 0.05). The PP group showed more significant effects than the UT group, in terms of both reducing the VAS pain score (p < 0.05) and improving 6-MWT (p < 0.05).

CONCLUSIONS

PP is suggested as an effective method for the treatment of symptomatic knee OA for reducing pain and improving functional capacity.

Lifestyle and Pain in Women With Knee Osteoarthritis

Osteoarthritis (OA) is the main cause of pain and disability in the elderly. The disease leads to chronic musculoskeletal pain, characterized by an abnormal excitability of pain conduction pathways, and lifestyle may interfere in this pathophysiological aspect. Thus, the aim of this study was to compare perceived pain, pressure pain threshold, and lifestyle of adult and elderly women with and without knee OA. A total of 143 women were recruited and divided into 2 groups: OA (n = 68) and control (n = 75). Volunteers were evaluated for pressure pain tolerance (algometry in vastus medialis and vastus lateralis muscles), perceived pain (visual analogue scale) and lifestyle (FANTASTIC questionnaire). Patients with OA of the present study presented higher weight (P = .001) and body mass index (P < .001) than controls. Results also revealed less tolerance to pressure pain (P < .001) and higher pain perception (P < .001) in patients with OA. OA group scored significantly lower in lifestyle questionnaire than controls (P = .03). Patients with OA in the present study who presented lifestyle scores below median presented significantly higher values of pain perception than the ones above it (P = .03). In conclusion, patients with OA present more sensitivity to pain, more perceived pain, and worse lifestyle than healthy individuals.

Drug-Free Interventions to Reduce Pain or Opioid Consumption After Total Knee Arthroplasty: A Systematic Review and Meta-analysis

Importance

There is increased interest in nonpharmacological treatments to reduce pain after total knee arthroplasty. Yet, little consensus supports the effectiveness of these interventions.

Objective

To systematically review and meta-analyze evidence of nonpharmacological interventions for postoperative pain management after total knee arthroplasty.

Data Sources

Database searches of MEDLINE (PubMed), EMBASE (OVID), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Web of Science (ISI database), Physiotherapy Evidence (PEDRO) database, and ClinicalTrials.gov for the period between January 1946 and April 2016.

Study Selection

Randomized clinical trials comparing nonpharmacological interventions with other interventions in combination with standard care were included.

Data Extraction and Synthesis

Two reviewers independently extracted the data from selected articles using a standardized form and assessed the risk of bias. A random-effects model was used for the analyses.

Main Outcomes and Measures

Postoperative pain and consumption of opioids and analgesics.

Results

Of 5509 studies, 39 randomized clinical trials were included in the meta-analysis (2391 patients). The most commonly performed interventions included continuous passive motion, preoperative exercise, cryotherapy, electrotherapy, and acupuncture. Moderate-certainty evidence showed that electrotherapy reduced the use of opioids (mean difference, -3.50; 95% CI, -5.90 to -1.10 morphine equivalents in milligrams per kilogram per 48 hours; P = .004; I2 = 17%) and that acupuncture delayed opioid use (mean difference, 46.17; 95% CI, 20.84 to 71.50 minutes to the first patient-controlled analgesia; P < .001; I2 = 19%). There was low-certainty evidence that acupuncture improved pain (mean difference, -1.14; 95% CI, -1.90 to -0.38 on a visual analog scale at 2 days; P = .003; I2 = 0%). Very low-certainty evidence showed that cryotherapy was associated with a reduction in opioid consumption (mean difference, -0.13; 95% CI, -0.26 to -0.01 morphine equivalents in milligrams per kilogram per 48 hours; P = .03; I2 = 86%) and in pain improvement (mean difference, -0.51; 95% CI, -1.00 to -0.02 on the visual analog scale; P < .05; I2 = 62%). Low-certainty or very low-certainty evidence showed that continuous passive motion and preoperative exercise had no pain improvement and reduction in opioid consumption: for continuous passive motion, the mean differences were -0.05 (95% CI, -0.35 to 0.25) on the visual analog scale (P = .74; I2 = 52%) and 6.58 (95% CI, -6.33 to 19.49) opioid consumption at 1 and 2 weeks (P = .32, I2 = 87%), and for preoperative exercise, the mean difference was -0.14 (95% CI, -1.11 to 0.84) on the Western Ontario and McMaster Universities Arthritis Index Scale (P = .78, I2 = 65%).

Conclusions and Relevance

In this meta-analysis, electrotherapy and acupuncture after total knee arthroplasty were associated with reduced and delayed opioid consumption.

Extracorporeal shockwave therapy vs. kinesiotherapy for osteoarthritis of the knee: A pilot randomized controlled trial

BACKGROUND

Osteoarthritis (OA) of the knee is a degenerative, painful pathology, needing conservative treatment for symptoms' relief.

OBJECTIVE

Comparing the effects of Extracorporeal shockwave therapy (ESWT) and Kinesiotherapy (KIN) on perceived health and range of motion (ROM) of the affected knee.

METHOD

A pilot randomized controlled trial with concealed allocation, assessor blinding, intention-to-treat analysis. Forty participants, aged 40-75 with OA of the knee were randomized to an ESWT and a KIN groups. The ESWT group completed 5 interventions for 5 weeks, the KIN group completed the same number of interventions. All evaluations were performed at baseline and after the treatment for: perceived health (Western Ontario and McMaster Universities questionnaire - WOMAC), range of motion (ROM).

RESULTS

After the intervention the statistical significant between groups differences favoring the ESWT were found in the WOMAC with regard to pain (p< 0.000), stiffness (p= 0.018), physical function (p< 0.000), total score (p< 0.000), extension and flexion of the affected knee (p= 0.015, p< 0.000) respectively.

CONCLUSIONS

ESWT improves WOMAC and ROM better then KIN on the affected knee in patients with OA of the knee.

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.

Ultrasound with mineral water or aqua gel to reduce pain and improve the WOMAC of knee osteoarthritis

AIMS

Osteoarthritis is the most degenerative joint disease. The aim was to investigate the effects of ultrasound using mineral water or aqua sonic gel on severity of knee pain, measured by the visual analog scale and the Western Ontario and McMaster Universities Arthritis Index (WOMAC).

MATERIALS AND METHODS

Thirty women with bilateral osteoarthritis of the knee were assigned to two groups: ultrasound with mineral water (group 1, n = 15) or with aqua sonic gel (group 2, n = 15). Both groups underwent 4 weeks intervention, three per week. The participants were assessed using the visual analog scale and the WOMAC. Tests were performed before and after interventions.

RESULTS

Both groups had significantly reduced pain and improved WOMAC compared with preintervention values.

DISCUSSION

The ultrasound with mineral water group had more pronounced improvement at p-value < 0.001.

CONCLUSION

Ultrasound with mineral water is preferable in treatment of knee OA.

The immediate effect of patellar tendon strap on weight-bearing asymmetry during squatting in patients with unilateral knee osteoarthritis: A pilot study

BACKGROUND

Knee osteoarthritis has commonly been associated with a symptom of pain resulting in an inter-limb weight-bearing asymmetry during functional tasks. Patellar tendon strap is one of the non-pharmacologic interventions to alleviate knee pain.

OBJECTIVES

To investigate the immediate effect of a patellar tendon strap on weight-bearing asymmetry during squatting in people with unilateral knee osteoarthritis.

STUDY DESIGN

Cross-sectional study.

METHODS

Ten patients with unilateral knee osteoarthritis and 10 healthy subjects were included in the study. Weight-bearing asymmetry of patients was assessed using a weight-bearing squat test during squatting at 30° and 60° both with and without patellar tendon strap. Pain intensity was assessed during squatting in unstrapped and strapped conditions with Visual Analog Scale.

RESULTS

The decrease in weight-bearing asymmetry values immediately after wearing patellar tendon strap during 30° (p = 0.006) and 60° (p = 0.011) of squatting tests was significantly higher in knee osteoarthritis patients than in healthy subjects. Reported pain intensity was similar in unstrapped and strapped conditions (p = 0.066).

CONCLUSION

The results of this study showed improved inter-limb weight-bearing symmetry during squatting. Further research with larger sample sizes investigating the effect of patellar tendon strap on weight-bearing asymmetry during functional activities in people with knee osteoarthritis is warranted.

CLINICAL RELEVANCE

Patellar tendon straps (easily fit and cheap unlike knee braces) had more improvements in inter-limb weight-bearing symmetry during squatting in people with knee osteoarthritis compared to healthy subjects. This study is a new insight for future studies to investigate clinical benefits of wearing patellar tendon straps in this population.

Transcutaneous Electrical Nerve Stimulation in Patients With Knee Osteoarthritis: Evidence From Randomized-controlled Trials

OBJECTIVES

Transcutaneous electrical nerve stimulation (TENS) has been reported to relieve pain and improve function in patients with knee osteoarthritis. The purpose of this systematic review and meta-analysis was to evaluate the efficacy of TENS for the management of knee osteoarthritis.

METHODS

We searched Embase, PubMed, CENTRAL, SIGLE, PEDro, and clinicaltrials.gov, up to June 2014 for literature related to TENS used for the treatment of knee osteoarthritis. Two authors independently screened the searched records based on the title and abstract. Information including the authors, study design, mean age, sex, study population, stimulation frequency (of TENS), outcome measures, and follow-up periods were extracted by the 2 authors.

RESULTS

Eighteen trials were included in the qualitative systematic review, and 14 were included in the meta-analysis. TENS significantly decreased pain (standard mean difference, -0.79; 95% confidence interval [CI], -1.31 to -0.27; P<0.00001) compared with control groups. There was no significant difference in the Western Ontario and McMaster Universities Osteoarthritis Index (standard mean differences, -0.13; 95% CI, -0.35 to 0.1; P=0.09) or the rate of all-cause discontinuation (risk ratio, 0.77; 95% CI, 0.48 to 1.22; P=0.94) between the TENS and control groups.

DISCUSSION

TENS might relieve pain due to knee osteoarthritis. Further randomized-controlled trials should focus on large-scale studies and a longer duration of follow-up.

Effects of therapeutic ultrasound on pain, physical functions and safety outcomes in patients with knee osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

To explore the effects of therapeutic ultrasound with sham or no intervention on pain, physical function and safety outcomes in patients with knee osteoarthritis.

DATA SOURCES

This systematic review was searched on CENTRAL, EMBASE, MEDLINE, CINAHL, Physiotherapy Evidence Database, Open Gray on 4 September 2015. Trials included randomized controlled trials that compared therapeutic ultrasound with a sham or no intervention in patients with osteoarthritis of the knee.

REVIEW METHODS

Eligible trials and extracted data were identified by two independent investigators. Standardized mean differences (SMDs) and 95% confidence interval (CI) were calculated for pain and physical function outcomes. Heterogeneity was assessed by the I² test and inverse-variance random-effects analysis was applied to all trials.

RESULTS

Ten randomized controlled trials (645 patients) met the inclusion criteria. Therapeutic ultrasound showed a positive effect on pain (SMD = -0.93, 95%, CI = -1.22 to -0.64, p < 0.01, p for heterogeneity = 0.12, I² = 42%). For physical function, therapeutic ultrasound was advantageous for reducingWestern Ontario and McMaster Universities physical function score (SMD = -0.37, 95% CI = -0.73 to -0.01, p = 0.04, p for heterogeneity = 0.94, I² = 0%). In terms of safety, no occurrence of adverse events caused by therapeutic ultrasound was reported in any trial.

CONCLUSION

The authors suggested that therapeutic ultrasound is beneficial for reducing knee pain and improving physical functions in patients with knee osteoarthritis and could be a safe treatment.

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.

Effects of isometric exercise using biofeedback on maximum voluntary isometric contraction, pain, and muscle thickness in patients with knee osteoarthritis

[Purpose] The purpose of our study was to investigate the effects of isometric exercises using electromyographic biofeedback (EMGBF) and ultrasound biofeedback (USBF) on maximum voluntary isometric contraction (MVIC), pain assessed by the Visual Analogue Scale (VAS), and vastus medialis oblique (VMO) thickness in patients with knee osteoarthritis (OA). [Subjects and Methods] Thirty females over 65 years of age who had been diagnosed with knee osteoarthritis were recruited and randomly assigned to three groups, each comprising of 10 subjects. The Subjects in the EMGBF training and USBF training groups were trained with the corresponding physical training exercise program targeting the vastus medialis oblique, whereas the subjects in the control group were treated with conventional physical therapies, such as a hot pack, ultrasound, and transcutaneous electrical nerve stimulation. Subjects in each group were trained or treated for 20 min, 3 times a week for 8 weeks. [Results] The MVIC in the EMGBF and USBF training groups was significantly increased compared with that in the control group, and the VAS score (for measurement of pain) in the EMGBF and USBF training groups was significantly decreased compared with that in the control group. Only the EMGBF training group showed a significantly increased VMO thickness compared with before training. [Conclusion] These results suggest that USBF training is similar to EMGBF training in terms of its effectiveness and is helpful for treating patients with knee OA.

Exercise for osteoarthritis of the knee

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

Five electronic databases were searched, up until May 2013.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

The effects of transcutaneous electrical nerve stimulation on joint position sense in patients with knee joint osteoarthritis

OBJECTIVE

To study the effects of transcutaneous electrical nerve stimulation (TENS) on joint position sense (JPS) in knee osteoarthritis (OA) subjects.

METHODS

Thirty subjects with knee OA (40-60 years old) using non-random sampling participated in this study. In order to evaluate the absolute error of repositioning of the knee joint, Qualysis Track Manager system was used and sensory electrical stimulation was applied through the TENS device.

RESULTS

The mean errors in repositioning of the joint, in two position of the knee joint with 20 and 60 degree angle, after applying the TENS was significantly decreased (p < 0.05).

CONCLUSION

Application of TENS in subjects with knee OA could improve JPS in these subjects.