Short-term efficacy of physical interventions in osteoarthritic knee pain. A systematic review and meta-analysis of randomised placebo-controlled trials

Low-Level Laser Therapy for Thumb Carpometacarpal Joint Osteoarthritis: A Randomized Controlled Trial

Background and aim Low-level laser therapy (LLLT) is considered a promising non-invasive treatment option for osteoarthritis (OA). The current study aimed to evaluate the effectiveness of LLLT on patients with OA of the first carpometacarpal joint (CMC1) of the thumb. Methods An open-level, prospective, randomized controlled trial was conducted in the Department of Physical Medicine and Rehabilitation, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, for one year. Initially, 120 patients were approached for the study. Among them, 112 eligible patients were randomly divided into two groups: the intervention group received LLLT in addition to conservative treatment, while the control group received conservative treatment alone for four weeks. Pain and functional capability (motor) improvement were assessed on a weekly follow-up basis by using various parameters such as the visual analogue scale (VAS), Ritchie articular index (tenderness scale), grip strength, key pinch strength, Dreiser functional index, and CMC1 palmer abduction. Eventually, 90 patients completed the follow-ups and were included in the analysis. Results The majority of patients diagnosed with CMC1 joint OA were in their fifties. At baseline, patients of both intervention and control groups were indifferent in terms of demography, pain intensity, motor responses, and duration of suffering. After four weeks of treatment, results indicated an overall improvement in both groups. However, the reduction of pain and increase in functional capability were not found statistically significant (p-value: ≥0.5). Conclusion LLLT with conventional treatment was not found significantly more effective enough than conventional treatment alone, but more well-designed clinical trials with larger sample sizes are needed to reach a definitive conclusion.

Relationship between Laser Intensity at the Peripheral Nerve and Inhibitory Effect of Percutaneous Photobiomodulation on Neuronal Firing in a Rat Spinal Dorsal Horn

Photobiomodulation is an effective treatment for pain. We previously reported that the direct laser irradiation of the exposed sciatic nerve inhibited firing in the rat spinal dorsal horn evoked by mechanical stimulation, corresponding to the noxious stimulus. However, percutaneous laser irradiation is used in clinical practice, and it is unclear whether it can inhibit the firing of the dorsal horn. In this study, we investigated whether the percutaneous laser irradiation of the sciatic nerve inhibits firing. Electrodes were inserted into the lamina II of the dorsal horn, and mechanical stimulation was applied using von Frey filaments (vFFs) with both pre and post laser irradiation. Our findings show that percutaneous laser irradiation inhibited 26.0 g vFF-evoked firing, which corresponded to the noxious stimulus, but did not inhibit 0.6 g and 8.0 g vFF-evoked firing. The post- (15 min after) and pre-irradiation firing ratios were almost the same as those for direct and percutaneous irradiation. A photodiode sensor implanted in the sciatic nerve showed that the power density reaching the sciatic nerve percutaneously was attenuated to approximately 10% of that on the skin. The relationship between the laser intensity reaching the nerve and its effect could be potentially useful for a more appropriate setting of laser conditions in clinical practice.

Effect of Transcutaneous Electrical Nerve Stimulation on Pain-related Quantitative Sensory Tests in Chronic Musculoskeletal Pain and Acute Experimental Pain: Systematic Review and Meta-analysis

This report provides a systematic review of the literature to analyze the effects of transcutaneous electrical nerve stimulation (TENS) on analgesia on sensitization measures, in studies with chronic musculoskeletal pain and in studies with acute experimental pain. The protocol was registered at PROSPERO (CRD42020213473). The authors searched Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Latin American and Caribbean Health Sciences Literature via Biblioteca Virtual de Saúde, Physiotherapy Evidence Database, PubMed, ScienceDirect, Web of Science, Google Scholar, and hand-searched reference lists were also conducted. Among 22,252 manuscripts found, 58 studies were included in the systematic review and 35 in the meta-analysis. Thirty-four studies assessed pain intensity; 24 studies investigated hyperalgesia; temporal summation was only evaluated in 2 studies; and conditioned pain modulation was not observed in the included studies. Meta-analyses favored TENS, despite its limitations and heterogeneity. Primary hyperalgesia in studies with musculoskeletal pain presented a high level of evidence, while other outcomes presented moderate evidence in the studies that were included. It is not possible to infer results about both temporal summation and conditioned pain modulation. Moderate evidence suggests that TENS promotes analgesia by reducing both central and peripheral sensitization, as shown by the reduction in primary and secondary hyperalgesia, pain intensity at rest, and during movement in experimental acute pain and chronic musculoskeletal pain. Overall, both types of studies analyzed in this review presented meta-analyses favorable to the use of TENS (compared to placebo TENS), showing reductions in both primary and secondary hyperalgesia, as well as decreases in pain intensity at rest and in motion. PERSPECTIVE: This article presents data from the literature on the effect of TENS through sensitization assessments in individuals with chronic musculoskeletal pain, or acute experimental pain. These data contribute to knowledge about pain neuroscience research, using TENS technology.

Physiotherapists' Understanding of Shortwave Diathermy Contraindications: A Questionnaire Survey

Purpose

It is known that electromagnetic fields and heat generated by shortwave diathermy (SWD) can have adverse effects on living tissue. The purpose of this research is to evaluate Jordanian physiotherapists' knowledge of pulsed and continuous SWD contraindications. And investigate the potential contraindications about which Jordanian physiotherapists may have limited knowledge.

Subjects and Methods

This cross-sectional study investigates Jordanian physiotherapists' knowledge of SWD contraindications. In 38 private and public hospitals, a self-administered questionnaire survey was carried out. Participants were asked to classify 32 conditions as "always, sometime, or never" contraindicated or "I do not know". Participants are physiotherapists with two or more years of postgraduate experience. Two forms comprised the survey. The first consisted of assessing their reaction to the contraindications of pulsed shortwave diathermy (PSWD), while the second consisted of continuous shortwave diathermy (CSWD).

Results

Approximately 270 physiotherapists were eligible to participate in this investigation. Only 150 questionnaires were distributed to the therapists who agreed to the study. One hundred twenty-eight were returned for an average response rate of 85.3% (128/150). Respondents had good agreement about using SWD for cardiovascular condition, however, 24 respondents (19%) thought PSWD can be used over venous thrombosis. Only 64% of the respondents was aware that pacemakers are contraindicated for PSWD. Approximately 14% to 32% seem unaware that tuberculosis and osteomyelitis are contraindicated for both CSWD and PSWD. About 21% to 28% have been unaware that the use of PSWD is contraindicated for specialized tissues (eg, eyes, gonads, or malignant tissues) and 29% during pregnancy.

Conclusion

Jordanian physiotherapists generally agreed on the widely acknowledged contraindications of CSWD for specific conditions. However, there was considerable uncertainty among Jordanian physical therapists about the contraindications of PSWD. This discrepancy highlights the need to improve physiotherapist awareness and for more fact-based research to the contraindication of SWD modality.

The amygdala connectivity with depression and suicide ideation with suicide behavior: A meta-analysis of structural MRI, resting-state fMRI and task fMRI

In recent decades, the primary intention of neuroscientists and psychiatrics is to evaluate the connectivity between brain regions and psychiatric disorders. The amygdala has central immersion in memory alliance, stress response, emotional perception, and automatic responses to emotional stimuli. This paper uses a meta-analysis approach to establish the relationship between structural resting state and functional amygdala connectivity with depression and suicide ideation with suicide behavior. In addition, this study explores the moderating effect of patients' demographic characteristics (gender and age) based on 30 studies. The results show that structural amygdala connectivity is positively related to the instability of depression, while for resting and task functional connectivity amygdala shows a significant negative connection with depression. Furthermore, the amygdala showed a partial activation for non-suicide self-injuries and suicide ideation. From structural and functional magnetic imaging, the current findings also support the moderating effect of the age of the participants on the amygdala connectivity with psychiatric conditions. Generally, amygdala connectivity with psychiatric disorders was not significantly moderate with the role of gender, however, this study enhances the existing hypothetical review articles and confirms the connectivity of the psychological condition with the amygdala region. It concludes that the amygdala plays a vital role in regulating and responding to emotions.

A Review of Chronic Pain and Device Interventions: Benefits and Future Directions

Chronic pain is a debilitating condition with a growing prevalence both in the USA and globally. The complex nature of this condition necessitates a multimodal approach to pain management that extends beyond the established pharmaceutical interventions currently employed. A variety of devices comprising both invasive and noninvasive approaches are available to patients, serving as adjuvants to existing regimens. The benefits of these interventions are notable for their lack of addiction potential, potential for patient autonomy regarding self-administration, minimal to no drug interaction, and overall relative safety. However, there remains a need for further research and more robust clinical trials to assess the true efficacy of these interventions and elucidate if there is an underlying physiological mechanism to their benefit in treating chronic pain or if their effect is predominantly placebo in nature. Regardless, the field of device-based intervention and treatment remains an evolving field with much promise for the future chronic pain management.

Laser therapy versus pulsed electromagnetic field therapy as treatment modalities for early knee osteoarthritis: a randomized controlled trial

BACKGROUND

This randomized controlled trial aimed to compare the effects of pulsed electromagnetic field therapy (PEMFT) and low-level laser therapy (LLLT) on pain and physical function of participants with knee osteoarthritis (KOA).

METHODS

According to the Kellgren-Lawrence classification, participants with grade 2-3 KOA were randomized to receive PEMFT or LLLT for six sessions lasting 15 min/session over a 3-week period. Pain at rest and when walking, standing from a sitting position, and climbing the stairs was assessed using the visual analog scale. Functional level was measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), timed up-and-go test (TUG), and 10-m walk (10 MW) test. Measurements were obtained before and after the interventions. Significance was determined at p ≤ 0.05.

RESULTS

Forty participants were included in the study. Pain and physical function improved significantly (p < 0.0001) in both groups. PEMFT was significantly more effective in reducing pain at rest, when standing from a sitting position, and when climbing the stairs, and in improving both WOMAC scores and TUG results (p ≤ 0.0003). The improvements in pain during the activities and the WOMAC scores reached the minimal clinically important difference. No adverse events occurred.

CONCLUSION

Six sessions of PEMFT and LLLT had immediate positive effects on pain and physical function in individuals with low-grade KOA, with PEMFT resulting in significantly better results.

TRIAL REGISTRATION

ISRCTN registry trial ID: ISRCTN17001174.

Near-Infrared Photobiomodulation of the Peripheral Nerve Inhibits the Neuronal Firing in a Rat Spinal Dorsal Horn Evoked by Mechanical Stimulation

Photobiomodulation has analgesic effects via inhibition of nerve activity, but few reports have examined the effects on the spinal dorsal horn, the entry point for nociceptive information in the central nervous system. In this study, we evaluated the effects of laser irradiation of peripheral nerve axons, which are conduction pathways for nociceptive stimuli, on the neuronal firing in lamina II of the spinal dorsal horn of a rat evoked by mechanical stimulation with von Frey filaments (vFF). In order to record neuronal firing, electrodes were inserted into lamina II of the exposed rat spinal dorsal horn. The exposed sciatic nerve axons were irradiated with an 808 nm laser. The 26.0 g vFF-evoked firing frequency was inhibited from 5 min after laser irradiation and persisted for 3 h. Sham irradiation did not alter the firing frequency. Laser irradiation selectively inhibited 15.0 and 26.0 g vFF-evoked firing, which corresponded to nociceptive stimuli. Histopathological evaluation revealed no damage to the sciatic nerve due to laser irradiation. These results indicate that neuronal firing is inhibited in lamina II of the spinal dorsal horn, suggesting that laser irradiation inhibits Aδ and/or C fibers that conduct nociceptive stimuli.

Pulsed Electromagnetic Field Therapy and Direct Current Electric Field Modulation Promote the Migration of Fibroblast-like Synoviocytes to Accelerate Cartilage Repair In Vitro

Articular cartilage injuries are a common source of joint pain and dysfunction. As articular cartilage is avascular, it exhibits a poor intrinsic healing capacity for self-repair. Clinically, osteochondral grafts are used to surgically restore the articular surface following injury. A significant challenge remains with the repair properties at the graft-host tissue interface as proper integration is critical toward restoring normal load distribution across the joint. A key to addressing poor tissue integration may involve optimizing mobilization of fibroblast-like synoviocytes (FLS) that exhibit chondrogenic potential and are derived from the adjacent synovium, the specialized connective tissue membrane that envelops the diarthrodial joint. Synovium-derived cells have been directly implicated in the native repair response of articular cartilage. Electrotherapeutics hold potential as low-cost, low-risk, non-invasive adjunctive therapies for promoting cartilage healing via cell-mediated repair. Pulsed electromagnetic fields (PEMFs) and applied direct current (DC) electric fields (EFs) via galvanotaxis are two potential therapeutic strategies to promote cartilage repair by stimulating the migration of FLS within a wound or defect site. PEMF chambers were calibrated to recapitulate clinical standards (1.5 ± 0.2 mT, 75 Hz, 1.3 ms duration). PEMF stimulation promoted bovine FLS migration using a 2D in vitro scratch assay to assess the rate of wound closure following cruciform injury. Galvanotaxis DC EF stimulation assisted FLS migration within a collagen hydrogel matrix in order to promote cartilage repair. A novel tissue-scale bioreactor capable of applying DC EFs in sterile culture conditions to 3D constructs was designed in order to track the increased recruitment of synovial repair cells via galvanotaxis from intact bovine synovium explants to the site of a cartilage wound injury. PEMF stimulation further modulated FLS migration into the bovine cartilage defect region. Biochemical composition, histological analysis, and gene expression revealed elevated GAG and collagen levels following PEMF treatment, indicative of its pro-anabolic effect. Together, PEMF and galvanotaxis DC EF modulation are electrotherapeutic strategies with complementary repair properties. Both procedures may enable direct migration or selective homing of target cells to defect sites, thus augmenting natural repair processes for improving cartilage repair and healing.

Safety of Electrotherapy Treatment in Patients with Knee Osteoarthritis and Cardiac Diseases

OBJECTIVE: To assess the safety of electrotherapy applied in the knee area in patients with known atrial arrhythmias or ischemic heart disease, as it is not known whether this treatment induces or aggravates arrhythmias during or immediately after therapy. MATERIAL AND METHODS: The analytical and transversal study involved 46 patients with degenerative knee osteoarthritis (OA), with or without cardiac diseases, from the Clinical Rehabilitation Hospital inpatient center, Cluj-Napoca, Romania. All patients underwent a 10-day physical therapy program for knee OA (electrotherapy, massage and kinesiotherapy). Heart rate and the total number of ventricular and supraventricular extrasystoles were evaluated before and after treatment, by 24 h Holter ECG monitoring. RESULTS: There was no significant increase in heart rate or in the number of ventricular or supraventricular extrasystoles before or after electrotherapy treatment, regardless of the positive or negative history of arrhythmia or ischemic heart disease (all p > 0.05). Mean values during day 1 were: 35.15 (95% CI [9.60−60.75]) for ventricular ones extrasystoles and 91.7 (95% CI [51.69−131.7]) for supraventricular ones, which during day 2 were 38.09 (95% CI [3.68−72.50]), 110.48 (95% CI [48.59−172.36]), respectively. CONCLUSION: One of the most important things to consider when dealing with an OA patient is that they are most likely older than 65 years, which increases the chance of having a cardiac disease. This raises the need for viable interventions regarding the management of this disease in patients that probably have multiple comorbidities, and where pharmacological and surgical management are not possible, limited or have multiple side effects. Electrotherapy used for treating knee OA did not cause a significant increase in heart rate or number of ventricular and supraventricular extrasystoles in this category of patients.

Is high intensity laser therapy more effective than other physical therapy modalities for treating knee osteoarthritis? A systematic review and network meta-analysis

Background

The use of physical therapy modalities, especially high intensity laser therapy (HILT), for individuals with knee osteoarthritis (KOA) is still controversial.

Objective

To compare the effects of HILT to other physical therapy modalities on symptoms and function in individuals with KOA.

Methods

Six databases (PubMed, Embase, Cochrane Library, Web of Science, EBSCO, and PEDro) were searched in March 2022. Included studies were randomized controlled trials involving HILT conducted on individuals with KOA. The end-trial weighted mean difference (WMD) and standard deviations (SD) with 95% confidence intervals (CI) were analyzed.

Results

Ten studies with 580 participants were obtained, of which nine were included in the final network meta-analysis. In terms of relieving pain, HILT demonstrated the highest probability of being among the most effective treatments, with surface under the cumulative ranking (SUCRA) = 100%, and compared to a control (placebo laser or exercise or a combination of both) on the visual analog scale (VAS) for pain it demonstrated significant benefits (WMD 1.66, 95% CI 1.48–1.84). For improving self-reported function, as measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total scores, the HILT SUCRA value led with 98.9%. When individuals with KOA were treated by HILT, the improvement in stiffness was statistically significant (WMD 0.78, 95% CI 0.52–1.04) but the amount of improvement was smaller than the minimal clinically important difference (MCID).

Conclusion

The current evidence suggests that HILT may be more effective than other physical therapy modalities for improving pain and function in individuals with KOA. For improving stiffness, however, it may not be clinically effective.

Systematic review registration

[https://www.researchregistry.com], identifier [1148].

Effects of pulsed electromagnetic field therapy on outcomes associated with osteoarthritis : A systematic review of systematic reviews

Background

Osteoarthritis (OA) is a chronic degenerative disease of multiple joints with a rising prevalence. Pulsed electromagnetic field (PEMF) therapy may provide a cost-effective, noninvasive, and safe therapeutic modality with growing popularity and use in physical medicine and rehabilitation. The purpose of this study was to synthesize the current knowledge on the use of PEMF in OA.

Methods

A systematic review of systematic reviews was performed. The PubMed, Embase, PEDro and Web of Science databases were searched based on a predetermined protocol.

Results

Overall, 69 studies were identified. After removing the duplicates and then screening title, abstract and full text, 10 studies were included in the final analysis. All studies focused on knee OA, and four studies also reported on cervical, two on hand, and one on ankle OA. In terms of the level of evidence and bias, most studies were of low or medium quality. Most concurrence was observed for pain reduction, with other endpoints such as stiffness or physical function showing a greater variability in outcomes.

Conclusion

The PEMF therapy appears to be effective in the short term to relieve pain and improve function in patients with OA. The existing studies used very heterogeneous treatment schemes, mostly with low sample sizes and suboptimal study designs, from which no sufficient proof of efficacy can be derived. A catalogue of measures to improve the quality of future studies has been drawn up.

Effect of transcutaneous electrical nerve stimulation (TENS) on knee pain and physical function in patients with symptomatic knee osteoarthritis: the ETRELKA randomized clinical trial

OBJECTIVE

To determine the effectiveness of TENS at relieving pain and improving physical function as compared to placebo TENS, and to determine its safety, in patients with knee osteoarthritis.

METHODS

Multi-centre, parallel, 1:1 randomized, double-blind, placebo-controlled clinical trial conducted in six outpatient clinics in Switzerland. We included 220 participants with knee osteoarthritis recruited between October 15, 2012, and October 15, 2014. Patients were randomized to 3 weeks of treatment with TENS (n = 108) or placebo TENS (n = 112). Our pre-specified primary endpoint was knee pain at the end of 3-weeks treatment assessed with the WOMAC pain subscale. Secondary outcome measures included WOMAC physical function subscale and safety outcomes.

RESULTS

There was no difference between TENS and placebo TENS in WOMAC pain at the end of treatment (mean difference -0.06; 95%CI -0.41 to 0.29; P = 0.74), nor throughout the trial duration (P = 0.98). Subgroup analyses did not indicate an interaction between patient/treatment characteristics and treatment effect on WOMAC pain at the end of treatment (P-interaction ≥0.22). The occurrence of adverse events was similar across groups, with 10.4% and 10.6% of patients reporting events in the TENS and placebo TENS groups, respectively (P = 0.95). No relevant differences were observed in secondary outcomes.

CONCLUSIONS

TENS does not improve knee osteoarthritis pain when compared to placebo TENS. Therapists should consider other potentially more effective treatment modalities to decrease knee osteoarthritis pain and facilitate strengthening and aerobic exercise. Our findings are conclusive and further trials comparing TENS and placebo TENS in this patient population are not necessary.

The use of transcutaneous electrical nerve stimulation along with functional tasks for immediate pain relief in individuals with knee osteoarthritis

BACKGROUND

Knee pain is the major complaint in individuals with knee osteoarthritis (OA), and the effects of transcutaneous electrical nerve stimulation (TENS) on knee pain are controversial. The present study applied TENS along with functional tests to investigate its effect on pain level in individuals with mild to moderate knee OA.

METHODS

Twenty volunteers with knee OA classification of graded 2-3 performed four functional tests (stair climb test - SCT, timed up and go test - TUG, 6-minute walk test - 6MWT, knee extensor strength test - KES, and 2-step test from the locomotive syndrome risk test - LSR_2ST) while wearing either an active or inactive TENS. Knee pain level before and after each test was self-accessed by the visual analog scale (VAS). The effect of TENS (active vs. inactive) on pain level was submitted to statistical analyses.

RESULTS

Knee pain during SCT, TUG, and LSR_2ST tests was significantly lower when subjects used the active TENS, compared to using the inactive unit. The effect of the active TENS on pain level was also more significant in subjects with no anxiety or depression.

CONCLUSIONS

The results provided evidence of immediate pain relief in individuals with mild to moderate knee OA when TENS is applied along with functional activities, that usually induced pain in people with knee OA.

Photobiomodulation Therapy Partially Restores Cartilage Integrity and Reduces Chronic Pain Behavior in a Rat Model of Osteoarthritis: Involvement of Spinal Glial Modulation

OBJECTIVE

Chronic pain associated with osteoarthritis (OA) often leads to reduced function and engagement in activities of daily living. Current pharmacological treatments remain relatively ineffective. This study investigated the efficacy of photobiomodulation therapy (PBMT) on cartilage integrity and central pain biomarkers in adult male Wistar rats.

DESIGN

We evaluated the cartilage degradation and spinal cord sensitization using the monoiodoacetate (MIA) model of OA following 2 weeks of delayed PBMT treatment (i.e., 15 days post-MIA). Multiple behavioral tests and knee joint histology were used to assess deficits related to OA. Immunohistochemistry was performed to assess chronic pain sensitization in spinal cord dorsal horn regions. Furthermore, we analyzed the principal components related to pain-like behavior and cartilage integrity.

RESULTS

MIA induced chronic pain-like behavior with respective cartilage degradation. PBMT had no effects on overall locomotor activity, but positive effects on weight support (P = 0.001; effect size [ES] = 1.01) and mechanical allodynia (P = 0.032; ES = 0.51). Greater optical densitometry of PBMT-treated cartilage was evident in superficial layers (P = 0.020; ES = 1.34), likely reflecting the increase of proteoglycan and chondrocyte contents. In addition, PBMT effects were associated to decreased contribution of spinal glial cells to pain-like behavior (P = 0.001; ES = 0.38).

CONCLUSION

PBMT during the chronic phase of MIA-induced OA promoted cartilage recovery and reduced the progression or maintenance of spinal cord sensitization. Our data suggest a potential role of PBMT in reducing cartilage degradation and long-term central sensitization associated with chronic OA.

Hydrogel-hydroxyapatite-monomeric collagen type-I scaffold with low-frequency electromagnetic field treatment enhances osteochondral repair in rabbits

BACKGROUND

Cartilage damage is a common medical issue in clinical practice. Complete cartilage repair remains a significant challenge owing to the inferior quality of regenerative tissue. Safe and non-invasive magnetic therapy combined with tissue engineering to repair cartilage may be a promising breakthrough.

METHODS

In this study, a composite scaffold made of Hydroxyapatite-Collagen type-I (HAC) and PLGA-PEG-PLGA thermogel was produced to match the cartilage and subchondral layers in osteochondral defects, respectively. Bone marrow mesenchymal stem cells (BMSC) encapsulated in the thermogel were stimulated by an electromagnetic field (EMF). Effect of EMF on the proliferation and chondrogenic differentiation potential was evaluated in vitro. 4 mm femoral condyle defect was constructed in rabbits. The scaffolds loaded with BMSCs were implanted into the defects with or without EMF treatment. Effects of the combination treatment of the EMF and composite scaffold on rabbit osteochondral defect was detected in vivo.

RESULTS

In vitro experiments showed that EMF could promote proliferation and chondrogenic differentiation of BMSCs partly by activating the PI3K/AKT/mTOR and Wnt1/LRP6/β-catenin signaling pathway. In vivo results further confirmed that the scaffold with EMF enhances the repair of osteochondral defects in rabbits, and, in particular, cartilage repair.

CONCLUSION

Hydrogel-Hydroxyapatite-Monomeric Collagen type-I scaffold with low-frequency EMF treatment has the potential to enhance osteochondral repair.

Low-level laser therapy and static stretching exercises for patients with knee osteoarthritis: A randomised controlled trial

OBJECTIVES

To investigate the laser effect associated with stretching exercise on pain and functionality in patients with knee osteoarthritis.

DESIGN

A randomised controlled trial.

SETTING

Special Rehabilitation Services.

SUBJECTS

We enrolled 215 knee osteoarthritis patients (430 knees were treated).

INTERVENTION

Group Laser + Stretch (n = 43), Placebo + Stretch (n = 43), Stretch (n = 43), Laser (n = 43) and Control (n = 43) were treated with active laser and stretching exercises; placebo laser and stretching exercises; stretching exercises; active laser, and control, respectively. Interventions were conducted 3 times a week for 8 or 11 weeks.

MAIN OUTCOME MEASURES

The primary outcome was the change in knee pain and disability. Secondary outcomes included severity of osteoarthritis, mobility, knee range of motion, flexibility, activity, severity of osteoarthritis and medication intake for pain relief.

RESULTS

The patients' average age was 63.52 (6.8) years. Pain scores at baseline and post treatment (p < 0.001) were 7.43 (2.10) and 2.79 (1.92) for group Laser + Stretch, 7.39 (1.98) and 4.47 (2.82) for group Placebo + Stretch, 6.83 (1.42) and 4.24 (2.43) for group Stretch, 6.61 (1.68) and 2.94 (2.65) for group Laser, 6.74 (1.75) and 6.47 (2.29) for group Control, respectively. Disability score at baseline and post treatment (p = 0.000237) were 12.36 (5.02) and 8.08 (4.64) for group Laser + Stretch, 12.71 (5.12) and 9.90 (4.95) for group Placebo + Stretch, 11.83 (2.77) and 7.20 (5.28) for group Stretch, 11.58 (5.59) and 8.21 (6.18) for group Laser, 11.23 (4.68) and 11.45 (4.83) for group Control, respectively.

CONCLUSION

Laser therapy combined with stretching exercises improves pain during rest, activities of daily living, stiffness, muscle shortening and range of motion in patients with knee osteoarthritis.

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

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.

Low-energy laser therapy application on knee joints as an auxiliary treatment in patients with polyarticular juvenile idiopathic arthritis: a dual-arm randomized clinical trial

Patients with juvenile idiopathic arthritis (JIA) always experience persistent pain and stiffness which induces muscle weakness, fatigue, and functional limitations. This study evaluated whether applying low-energy laser therapy (LLT) on the knee joint could be an effective adjuvant intervention for patients with JIA. Sixty children with polyarticular JIA participated and were randomly allocated to receive either LLT (wavelength λ = 903 nm; power output of 50 mW; and energy of 1.5 J) plus exercises (LLT group) or exercises alone (control group). Pain, peak concentric torque of quadriceps muscles, fatigue, and functional status were measured by the visual analogue scale, isokinetic testing system, Pediatric Quality of Life Inventory Multidimensional Fatigue Scale, and Childhood Health Assessment Questionnaire, respectively pre- and post-intervention, and at 6-month follow-up. Per the mixed-model analysis of variance, the LLT group showed a statistically more favorable improvement in pain (P = .003, η_p² = .014), fatigue perception (P = .004, η_p² = .015), and functional status (P = .022, η_p² = .09) across the three assessment occasions, as compared to the control group. However, no significant difference was demonstrated between both groups concerning peak concentric torque (all P > .05). Incorporation of LLT into the standard physical rehabilitation program for patients with JIA has the potential to induce more conducive improvements in pain, fatigue, and functional performance, but is not effective for improving muscle performance.

Accelerated burn wound healing with photobiomodulation therapy involves activation of endogenous latent TGF-β1

The severity of tissue injury in burn wounds from associated inflammatory and immune sequelae presents a significant clinical management challenge. Among various biophysical wound management approaches, low dose biophotonics treatments, termed Photobiomodulation (PBM) therapy, has gained recent attention. One of the PBM molecular mechanisms of PBM treatments involves photoactivation of latent TGF-β1 that is capable of promoting tissue healing and regeneration. This work examined the efficacy of PBM treatments in a full-thickness burn wound healing in C57BL/6 mice. We first optimized the PBM protocol by monitoring tissue surface temperature and histology. We noted this dynamic irradiance surface temperature-monitored PBM protocol improved burn wound healing in mice with elevated TGF-β signaling (phospho-Smad2) and reduced inflammation-associated gene expression. Next, we investigated the roles of individual cell types involved in burn wound healing following PBM treatments and noted discrete effects on epithelieum, fibroblasts, and macrophage functions. These responses appear to be mediated via both TGF-β dependent and independent signaling pathways. Finally, to investigate specific contributions of TGF-β1 signaling in these PBM-burn wound healing, we utilized a chimeric TGF-β1/β3 knock-in (TGF-β1^Lβ3/Lβ3) mice. PBM treatments failed to activate the chimeric TGF-β1^Lβ3/Lβ3 complex and failed to improve burn wound healing in these mice. These results suggest activation of endogenous latent TGF-β1 following PBM treatments plays a key role in burn wound healing. These mechanistic insights can improve the safety and efficacy of clinical translation of PBM treatments for tissue healing and regeneration.

Interferential current and photobiomodulation in knee osteoarthritis: A randomized, placebo-controlled, double-blind clinical trial

OBJECTIVES

To evaluate the effects of interferential current and photobiomodulation in patients with knee osteoarthritis.

DESIGN

A randomized, placebo-controlled, double-blind clinical trial.

SETTING

Physiotherapy Clinic of City University of São Paulo.

SUBJECTS

A total of 184 patients with knee osteoarthritis were recruited and, of these, 168 were included and randomized into four groups with 42 each: interferential current, photobiomodulation, interferential current plus photobiomodulation or placebo groups. One hundred and sixty-four patients completed the study.

INTERVENTION

Patients received 12 sessions (three times a week) of treatment: 30 minutes of interferential current (active or placebo) followed by photobiomodulation (active or placebo).

MAIN MEASURES

Primary outcome: pain intensity at rest and during movement (numeric rating scale) after 12 sessions. Secondary outcomes: functional capacity (Timed Up & Go and Sit and Lift tests and Lequesne and WOMAC questionnaires), pressure pain threshold, conditioned pain modulation, and muscle strength production (isokinetic evaluation). Patients were assessed at baseline, after 12 sessions, and three and six months after the end of the treatment.

RESULTS

Interferential current plus photobiomodulation reduced pain intensity at rest and during movement compared to placebo and interferential current at all time points (P < 0.05). Photobiomodulation reduced pain intensity at rest compared to placebo at all time points (P < 0.05) and compared to interferential current at six months follow-up (P < 0.05). Photobiomodulation reduced pain intensity during movement compared to placebo at six months follow-up (P < 0.05).

CONCLUSION

Interferential current plus photobiomodulation or isolated photobiomodulation improve pain intensity in knee osteoarthritis.

Resolving Long-Standing Uncertainty about the Clinical Efficacy of Transcutaneous Electrical Nerve Stimulation (TENS) to Relieve Pain: A Comprehensive Review of Factors Influencing Outcome

Pain is managed using a biopsychosocial approach and pharmacological and non-pharmacological treatments. Transcutaneous electrical nerve stimulation (TENS) is a technique whereby pulsed electrical currents are administered through the intact surface of the skin with the intention of alleviating pain, akin to 'electrically rubbing pain away'. Despite over 50 years of published research, uncertainty about the clinical efficacy of TENS remains. The purpose of this comprehensive review is to critically appraise clinical research on TENS to inform future strategies to resolve the 'efficacy-impasse'. The principles and practices of TENS are described to provide context for readers unfamiliar with TENS treatment. The findings of systematic reviews evaluating TENS are described from a historical perspective to provide context for a critical evaluation of factors influencing the outcomes of randomized controlled trials (RCTs); including sample populations, outcome measures, TENS techniques, and comparator interventions. Three possibilities are offered to resolve the impasse. Firstly, to conduct large multi-centered RCTs using an enriched enrolment with randomized withdrawal design, that incorporates a 'run-in phase' to screen for potential TENS responders and to optimise TENS treatment according to individual need. Secondly, to meta-analyze published RCT data, irrespective of type of pain, to determine whether TENS reduces the intensity of pain during stimulation, and to include a detailed assessment of levels of certainty and precision. Thirdly, to concede that it may be impossible to determine efficacy due to insurmountable methodological, logistical and financial challenges. The consequences to clinicians, policy makers and funders of this third scenario are discussed. I argue that patients will continue to use TENS irrespective of the views of clinicians, policy makers, funders or guideline panel recommendations, because TENS is readily available without prescription; TENS generates a pleasant sensory experience that is similar to easing pain using warming and cooling techniques; and technological developments such as smart wearable TENS devices will improve usability in the future. Thus, research is needed on how best to integrate TENS into existing pain management strategies by analyzing data of TENS usage by expert-patients in real-world settings.

Photobiomodulation and Sida tuberculata combination declines the inflammation's markers in knee-induced osteoarthritis

The aim of this study was to assess potential combination effects of photobiomodulation therapy (PBMT) with Sida tuberculata extracts on the oxidative stress and antioxidant activity, as well as on the inflammatory process. Rats with knee osteoarthritis (OA) were treated with S. tuberculata extracts and PBMT (904 nm, 18 J/cm²). The animals were evaluated for nociception and edema. The blood, knee lavage and structures, spinal cord, and brainstem were collected for biochemical analyses (lipid peroxidation, protein carbonyl content, superoxide dismutase activity, non-protein thiol levels, and measurement of nitrite/nitrate). The knee structures were also used to measure cytokine levels. PBMT lowered the damage due to oxidative stress in the knee and at distant sites from the lesion. PBMT also reduced the levels of nitric oxide and cytokines, which could explain the nociception reduction mechanism. Similarly, S. tuberculata decreased the damage by oxidative stress, levels of nitrite/nitrate, and cytokines. The therapy combination reduced levels of cytokines and nitrite/nitrate. PBMT and S. tuberculata extracts reduced the oxidative stress and inflammation. It is noteworthy that PBMT increased the antioxidant activity in the knee and at sites distant from the lesion, contributing to a more significant decrease in nociception. The combination of therapies did not present significant effects on the analyzed parameters. Therefore, it is suggested that PBM is sufficient to minimize the signs and symptoms of the knee OA in our rat model.

A Comparison of Treatment Effects for Nonsurgical Therapies and the Minimum Clinically Important Difference in Knee Osteoarthritis: A Systematic Review

BACKGROUND

The minimum clinically important difference (MCID) was developed to ascertain the smallest change in an outcome that patients perceive as beneficial. The objectives of the present review were (1) to compare the MCIDs for pain assessments used among guidelines and meta-analyses investigating different nonsurgical therapies for knee osteoarthritis and (2) to compare the effect estimates of different nonsurgical interventions against a single commonly-utilized MCID threshold.

METHODS

Systematic and manual searches were conducted to identify guidelines and meta-analyses evaluating pain outcomes for nonsurgical knee osteoarthritis interventions. Individual treatment effects for pain were presented on a common scale (the standardized mean difference [SMD]). To evaluate the perception of the relative benefit of each nonsurgical treatment, the variation in MCIDs selected from the published MCID literature was assessed.

RESULTS

Thirty-seven guidelines and meta-analyses were included. MCIDs were often presented as an SMD or a mean difference (MD) on a validated scale and varied in magnitude across sources. This analysis demonstrated that intra-articular hyaluronic acid, intra-articular corticosteroids, and acetaminophen all had relatively larger effect sizes than topical nonsteroidal anti-inflammatory drugs (NSAIDs). Higher-molecular-weight intra-articular hyaluronic acid had a greater relative effect compared with both non-selective and cyclooxygenase-2-selective oral NSAIDs. Evaluating the treatment effect estimates against a commonly utilized MCID revealed similarities in which observations attained clinical significance among treatments; however, this observation varied across the range of reported MCIDs.

CONCLUSIONS

The present review confirmed the variability in the MCIDs for pain assessments that are used across guidelines and meta-analyses evaluating nonsurgical interventions for knee osteoarthritis. This variability may yield conflicting treatment recommendations, ranging from rejecting treatments that are indeed efficacious to accepting treatments that may not be beneficial. Additional research is required to determine why some nonsurgical therapies are more consistently recommended in knee osteoarthritis guidelines than others as these findings suggest similarities in their effect estimates for pain. Relevant stakeholders need to reach a consensus on a standard approach to determining the MCIDs for these therapies to ensure that appropriate and effective treatment options are available to patients prior to invasive surgical intervention.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Guidelines versus evidence: what we can learn from the Australian guideline for low-level laser therapy in knee osteoarthritis? A narrative review

This narrative review analyses the Australian Guideline (2018) for the treatment of knee osteoarthritis (KOA) developed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The Guideline recommended against the use low-level laser therapy (LLLT). Why this conclusion was reached is discussed in this review in the context of evidence provided in other systematic reviews, the latest of which was published in 2019 and which provided strong support for LLLT for knee OA. We evaluated the reference list cited for the recommendation “against” LLLT and compared this with reference lists of systematic reviews and studies published before and after the publication date of the Guideline. Eight randomised controlled trials (RCTs) of LLLT were cited in the Guideline the latest of which was published in 2012. There were seventeen additional RCTs, five of which together with one systematic review were located in the year of publication, 2018. The most recent systematic review in 2019 included 22 RCTs in its analysis. Discordance with the levels of evidence and recommendations was identified. Although GRADE methodology is said to be robust for systematically evaluating evidence and developing recommendations, many studies were not identified in the Guideline. In contrast, the latest systematic review and meta-analysis provides robust evidence for supporting the use of LLLT in knee OA. The conflict between guidelines based on opinion and evidence based on meta-analysis is highlighted. Given the totality of the evidence, we recommend that the Australian Guideline should be updated immediately to reflect a “for” recommendation.

Low Level Laser Therapy in Knee Osteoarthritis: A Narrative Review

Knee osteoarthritis (KOA) is the most common musculoskeletal disorder, especially in middle up to old age. KOA also results in many complications like changes in gait. Nowadays, changes in lifestyle and the reduced physical activity make people more vulnerable to KOA. Therefore, considering the increasing prevalence of KOA in many societies and the costs imposed on the afflicted people and their governments, providing conservative management approaches with a view to saving time and money is important. There are an assortment of conservative strategies in the management of KOA including low level laser therapy (LLLT). Since the introduction of lasers in the medical field in 1960, various types of lasers with widespread administration programs are used for medical conditions from cosmetics to surgery. However, there are conflicting findings on the application of lasers in osteoarthritis. To discuss the basis of the highest level of evidence, only systematic reviews with or without meta-analyses published up to January 2019 were included in the present work. In this regard, Scopus, PEDro, Medline, ISI Web of Science, Cochrane, PubMed, Irandoc, Iran Medex, Magiran, and SID were searched to retrieve articles in English or Persian. A total of 22 systematic reviews and meta-analyses were found, 14 of which were included in this study. The accepted articles were published between 1991 and up to 2019. The purpose of this narrative review was to investigate the effect of LLLT on pain and function in subjects with KOA. The result of the present review may help clinicians in making evidence-based decisions on optimal care in relation to administering LLLT.

Photobiomodulation therapy does not decrease pain and disability in people with non-specific low back pain: a systematic review

QUESTION

In people with non-specific low back pain (LBP), what are the effects of photobiomodulation therapy (PBMT) on pain, disability and other outcomes when compared with no intervention, sham PBMT and other treatments, and when used as an adjunct to other treatments?

DESIGN

Systematic review of randomised trials with meta-analysis.

PARTICIPANTS

People with acute/subacute or chronic non-specific LBP.

INTERVENTIONS

Any type of PBMT (laser class I, II and III and light-emitting diodes) compared with no treatment, sham PBMT and other types of treatment, or used as an adjunct to another treatment.

OUTCOME MEASURES

Pain intensity, disability, overall improvement, quality of life, work absence and adverse effects.

RESULTS

Twelve randomised controlled trials were included (pooled n = 1,046). Most trials had low risk of bias. Compared with sham PBMT, the effect of PBMT on pain and disability was clinically unimportant in people with acute/subacute or chronic LBP. In people with chronic LBP, there was no clinically important difference between the effect of PBMT and the effect of exercise on pain or disability. Although benefits were observed on some other outcomes, these estimates were imprecise and/or based on low-quality evidence. PBMT was estimated to reduce pain (MD -11.20, 95% CI -20.92 to -1.48) and disability (MD -11.90, 95% CI -17.37 to -6.43) more than ultrasound, but these confidence intervals showed important uncertainty about whether the differences in effect were worthwhile or trivial. Conversely, PBMT was estimated to reduce pain (MD 19.00, 95% CI 9.49 to 28.51) and disability (MD 17.40, 95% CI 8.60 to 26.20) less than Tecar (Energy Transfer Capacitive and Resistive) therapy, with marginal uncertainty that these differences in effect were worthwhile.

CONCLUSION

Current evidence does not support the use of PBMT to decrease pain and disability in people with non-specific LBP.

REGISTRATION

CRD42018088242.

Biomedical applications of electrical stimulation

This review provides a comprehensive overview on the biomedical applications of electrical stimulation (EStim). EStim has a wide range of direct effects on both biomolecules and cells. These effects have been exploited to facilitate proliferation and functional development of engineered tissue constructs for regenerative medicine applications. They have also been tested or used in clinics for pain mitigation, muscle rehabilitation, the treatment of motor/consciousness disorders, wound healing, and drug delivery. However, the research on fundamental mechanism of cellular response to EStim has fell behind its applications, which has hindered the full exploitation of the clinical potential of EStim. Moreover, despite the positive outcome from the in vitro and animal studies testing the efficacy of EStim, existing clinical trials failed to establish strong, conclusive supports for the therapeutic efficacy of EStim for most of the clinical applications mentioned above. Two potential directions of future research to improve the clinical utility of EStim are presented, including the optimization and standardization of the stimulation protocol and the development of more tissue-matching devices.

Photobiomodulation therapy associated with supervised therapeutic exercises for people with knee osteoarthritis: a randomised controlled trial protocol

BACKGROUND

Physical exercise, a cornerstone of the conservative management of knee osteoarthritis (KOA), is exhaustively recommended by important clinical guidelines. A strength therapeutic exercise program (STEP) relieves pain, improves physical function and ultimately ameliorates quality of life (QoL). Furthermore, photobiomodulation (PBM) has been used as an adjunct treatment for people with KOA; however, there are still controversial recommendations regarding its use on this population. Thus, we hypothesised that PBM, when associated with a STEP protocol on patients with KOA, could induce better clinical outcomes than a STEP protocol alone.

METHODS AND ANALYSIS

The study is a 6-month triple-blind placebo-controlled randomised clinical trial with intention-to-treat analysis. The trial will include 120 people with clinic and radiographic signs of KOA. The intervention consists of a supervised STEP and PBM protocols conducted over an 8-week intervention period. Assessments are performed at baseline, right after treatment, and 3-month and 6-month follow-up periods. The primary clinical outcome is pain intensity according to a 10 cm Visual Analogue Scale. Secondary outcomes are the global Western Ontario & McMaster Universities Osteoarthritis Index; QoL assessed by the 36-item Short-Form health survey questionnaire; and performance-based physical parameters assessed by the 30 s chair stand test; the stair climb test; and the 40 m fast-paced walk test.

ETHICS AND DISSEMINATION

The trial was approved by the Human Research Ethics Committee of the Federal University of São Carlos, São Paulo, Brazil (REC no 2.016.122). Results will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Brazilian Clinical Trials Registry (U1111-1215-6510).

Pulsed electromagnetic fields promote repair of focal articular cartilage defects with engineered osteochondral constructs

Articular cartilage injuries are a common source of joint pain and dysfunction. We hypothesized that pulsed electromagnetic fields (PEMFs) would improve growth and healing of tissue-engineered cartilage grafts in a direction-dependent manner. PEMF stimulation of engineered cartilage constructs was first evaluated in vitro using passaged adult canine chondrocytes embedded in an agarose hydrogel scaffold. PEMF coils oriented parallel to the articular surface induced superior repair stiffness compared to both perpendicular PEMF (p = .026) and control (p = .012). This was correlated with increased glycosaminoglycan deposition in both parallel and perpendicular PEMF orientations compared to control (p = .010 and .028, respectively). Following in vitro optimization, the potential clinical translation of PEMF was evaluated in a preliminary in vivo preclinical adult canine model. Engineered osteochondral constructs (∅ 6 mm × 6 mm thick, devitalized bone base) were cultured to maturity and implanted into focal defects created in the stifle (knee) joint. To assess expedited early repair, animals were assessed after a 3-month recovery period, with microfracture repairs serving as an additional clinical control. In vivo, PEMF led to a greater likelihood of normal chondrocyte (odds ratio [OR]: 2.5, p = .051) and proteoglycan (OR: 5.0, p = .013) histological scores in engineered constructs. Interestingly, engineered constructs outperformed microfracture in clinical scoring, regardless of PEMF treatment (p < .05). Overall, the studies provided evidence that PEMF stimulation enhanced engineered cartilage growth and repair, demonstrating a potential low-cost, low-risk, noninvasive treatment modality for expediting early cartilage repair.

The effect of physical therapy and rehabilitation modalities on sleep quality in patients with primary knee osteoarthritis: A single-blind, prospective, randomized-controlled study

Objectives

In this study, we aimed to evaluate the effect of physical therapy modalities on pain, sleep, mental status, and quality of life of patients with osteoarthritis (OA).

Patients and methods

Between January 2017 and June 2017, a total of 40 patients (9 males, 31 females; mean age 56.6±8.9 years; range, 40 to 70 years) who were diagnosed with knee OA according to the American College of Rheumatology (ACR) criteria and were in Kellgren- Lawrence Grade 2-3 were included in the study. The patients were divided into two groups equally. Both groups received 15 sessions of exercise therapy, whereas the intervention group also received 10 consecutive physical therapy sessions in the form of hot pack, therapeutic ultrasound (US), and transcutaneous electrical nerve stimulation (TENS) by a single physiotherapist. Isometric and isotonic exercises were planned as 10 reps for three times a day as a home-based program. Clinical assessments were performed using the visual analog scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Beck Depression Inventory (BDI), Pittsburg Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and Short Form 36 (SF-36) before and after treatment.

Results

Pre-treatment VAS, ESS, PQSI, BDI, WOMAC, and SF-36 scores showed no significant difference between the groups, whereas post-treatment scores showed a significant difference in the intervention group (p<0.05). The difference between the pre- and post-treatment VAS, ESS, PQSI, BDI, WOMAC, and SF-36 scores were significantly higher in the intervention group, compared to the controls (p<0.05).

Conclusion

Our study results show positive effects of exercise and physical therapy modalities on pain, disease activity, sleep quality, depression, and quality of life in knee OA patients.

Exercise program combined with electrophysical modalities in subjects with knee osteoarthritis: a randomised, placebo-controlled clinical trial

BACKGROUND

It is not yet clear which of the various electrophysical modalities used in clinical practice is the one that contributes most positively when added to an exercise program in patients with knee osteoarthritis (OA). The aim of the present study was to analyze the clinical effects of the inclusion of interferential current therapy (ICT), shortwave diathermy therapy (SDT) and photobiomodulation (PHOTO) into an exercise program in patients with knee OA.

METHODS

This prospective, five-arm, randomised, placebo-controlled trial was carried out with blinded participants and examiners. We recruited 100 volunteers aged 40 to 80 years with knee OA. Participants were allocated into five groups: exercise, exercise + placebo, exercise + ICT, exercise + SDT, and exercise + PHOTO. The outcome measures included Western Ontario and McMaster Universities (WOMAC), numerical rating pain scale (NRPS), pressure pain threshold (PPT), self-perceived fatigue and sit-to-stand test (STST), which were evaluated before and after 24 treatment sessions at a frequency of three sessions per week.

RESULTS

In all groups, there was a significant improvement (p < 0.05) in all variables over time, except pressure pain threshold. We observed significant differences (p < 0.05) between the groups for WOMAC function (exercise vs. exercise + placebo, mean difference [MD] = 5.55, 95% confidence interval [CI] = 3.63 to 7.46; exercise vs. exercise + ICT, MD = 3.40, 95% CI = 1.46 to 5.33; exercise vs. exercise + SDT, MD = 4.75, 95% CI = 1.85 to 7.64; exercise vs. exercise + PHOTO, MD = 5.45, 95% CI = 3.12 to 7.77) and WOMAC pain, with better scores achieved by the exercise group. However, these differences were not clinically relevant when considering the minimum clinically important difference.

CONCLUSION

The addition of ICT, SDT or PHOTO into an exercise program for individuals with knee OA is not superior to exercise performed in isolation in terms of clinical benefit. clinicaltrials.gov: NCT02636764, registered on March 29, 2014.

High-Frequency Near-Infrared Diode Laser Irradiation Attenuates IL-1β-Induced Expression of Inflammatory Cytokines and Matrix Metalloproteinases in Human Primary Chondrocytes

High-frequency near-infrared diode laser provides a high-peak output, low-heat accumulation, and efficient biostimulation. Although these characteristics are considered suitable for osteoarthritis (OA) treatment, the effect of high-frequency near-infrared diode laser irradiation in in vitro or in vivo OA models has not yet been reported. Therefore, we aimed to assess the biological effects of high-frequency near-infrared diode laser irradiation on IL-1β-induced chondrocyte inflammation in an in vitro OA model. Normal Human Articular Chondrocyte-Knee (NHAC-Kn) cells were stimulated with human recombinant IL-1β and irradiated with a high-frequency near-infrared diode laser (910 nm, 4 or 8 J/cm²). The mRNA and protein expression of relevant inflammation- and cartilage destruction-related proteins was analyzed. Interleukin (IL) -1β treatment significantly increased the mRNA levels of IL-1β, IL-6, tumor necrosis factor (TNF) -α, matrix metalloproteinases (MMP) -1, MMP-3, and MMP-13. High-frequency near-infrared diode laser irradiation significantly reduced the IL-1β-induced expression of IL-1β, IL-6, TNF-α, MMP-1, and MMP-3. Similarly, high-frequency near-infrared diode laser irradiation decreased the IL-1β-induced increase in protein expression and secreted levels of MMP-1 and MMP-3. These results highlight the therapeutic potential of high-frequency near-infrared diode laser irradiation in OA.

Simultaneous ice and transcutaneous electrical nerve stimulation decrease anterior knee pain during running but do not affect running kinematics or associated muscle inhibition

BACKGROUND

Runners often experience anterior knee pain and this pain is associated with altered running neuromechanics. The purpose of this study was to examine potential therapeutic benefits (reduced pain and restored running neuromechanics) of simultaneously applied ice and transcutaneous electrical nerve stimulation on experimentally-induced anterior knee pain.

METHODS

Nineteen healthy subjects completed a sham and treatment data collection session. For both sessions, hypertonic saline was infused into the infrapatellar fat pad for approximately 80 min to induce experimental anterior knee pain. Perceived pain levels were measured every two minutes and running neuromechanics were recorded at four time points: pre-pain, pain before treatment, pain immediately post-treatment, and pain 20 min post-treatment.

FINDINGS

The saline infusion significantly increased perceived knee pain from 0 to 2.8 cm. The ice/transcutaneous electrical nerve stimulation treatment significantly reduced perceived knee pain by 35%, six minutes after the treatment initiation. Perceived knee pain remained reduced until eight minutes after the treatment termination. The knee pain significantly decreased peak gluteus medius, vastus lateralis, and vastus medialis activation during running, each by an average of 17% plus/minus 6%; however, none of these decreases were resolved via the therapeutic treatment. Neither the knee pain nor the therapeutic treatment significantly affected peak gluteus maximus activation or peak hip adduction angle.

INTERPRETATION

The experimental pain model effectively produced anterior knee pain and decreased muscle activation during running. The simultaneous ice/transcutaneous electrical nerve stimulation treatment effectively decreased anterior knee pain, but did not restore running neuromechanics that were altered due to the pain.

Acupuncture for the Relief of Chronic Pain: A Synthesis of Systematic Reviews

Background and Objectives: It is estimated that 28 million people in the UK live with chronic pain. A biopsychosocial approach to chronic pain is recommended which combines pharmacological interventions with behavioural and non-pharmacological treatments. Acupuncture represents one of a number of non-pharmacological interventions for pain. In the current climate of difficult commissioning decisions and constantly changing national guidance, the quest for strong supporting evidence has never been more important. Although hundreds of systematic reviews (SRs) and meta-analyses have been conducted, most have been inconclusive, and this has created uncertainty in clinical policy and practice. There is a need to bring all the evidence together for different pain conditions. The aim of this review is to synthesise SRs of RCTs evaluating the clinical efficacy of acupuncture to alleviate chronic pain and to consider the quality and adequacy of the evidence, including RCT design. Materials and Methods: Electronic databases were searched for English language SRs and meta-analyses on acupuncture for chronic pain. The SRs were scrutinised for methodology, risk of bias and judgement of efficacy. Results: A total of 177 reviews of acupuncture from 1989 to 2019 met our eligibility criteria. The majority of SRs found that RCTs of acupuncture had methodological shortcomings, including inadequate statistical power with a high risk of bias. Heterogeneity between RCTs was such that meta-analysis was often inappropriate. Conclusions: The large quantity of RCTs on acupuncture for chronic pain contained within systematic reviews provide evidence that is conflicting and inconclusive, due in part to recurring methodological shortcomings of RCTs. We suggest that an enriched enrolment with randomised withdrawal design may overcome some of these methodological shortcomings. It is essential that the quality of evidence is improved so that healthcare providers and commissioners can make informed choices on the interventions which can legitimately be provided to patients living with chronic pain.

Effects of Complex Medical Rehabilitation Treatment on Ligament Instability in Patients with Knee Osteoarthritis

Knee osteoarthritis represents one of the most frequent conditions in the elderly population. This condition affects the whole joint, having an important impact on the patient’s quality of life.

In this study, we evaluate the effect that medical rehabilitation treatment has on ligament instability in patients with knee osteoarthritis.

Material and method: we evaluate, using specific tests, the anterior, posterior, lateral and medial stability in patients that undergo rehabilitation treatment. Evaluations were done initially, at 6 months after the first admission and at 12 months after the first admission. We compare the results in order to evaluate the impact the complex therapies that are applied have.

Results: in all cases, except posterior instability, there is a good effect in lowering the percentage of patients with positive tests after the first round of rehabilitation treatment. At six month after the second round of rehabilitation treatment (12-month evaluation) the results show a slight, non-statistically significant improvement over the 6-month evaluation.

Effects of genotype on TENS effectiveness in controlling knee pain in persons with mild to moderate osteoarthritis

BACKGROUND

This study examined the extent to which genetic variability modifies Transcutaneous Electrical Nerve Stimulation (TENS) effectiveness in osteoarthritic knee pain.

METHODS

Seventy-five participants with knee osteoarthritis were randomly assigned to either: (a) High-frequency TENS, (b) Low-frequency TENS or (c) Transient Placebo TENS. Pain measures were collected pre- and post-treatment. Participants were genotyped on genes implicated in central or peripheral pain pathways: NGFB, NTRK1, EDNRA, EDNRB, EDN1, OPRM1, TAC1, TACR1, BDNF, BDKRB1, 5HTT, COMT, ESR2, IL6 and IL1B. Genetic association using linear regression modelling was performed separately for the transient placebo TENS subjects, and within the High-frequency TENS + Low-frequency TENS participants, including TENS level as a covariate.

RESULTS

In the placebo group, SNPs rs165599 (COMT) was significantly associated with an increased heat pain threshold (β = -1.87; p = .003) and rs6827096 (EDNRA) with an increased resting pain (β = 2.68; p = .001). Within the treatment groups, TENS effectiveness was reduced by the SNP rs6537485 (EDNRA) minor allele in relationship to mechanical sensation (β = 184.13; p = 5.5E-9). Individuals with the COMT rs4680 minor allele reported lowered pain at rest after TENS (β = -42.30; p = .001), with a higher magnitude of pain reduction (28 unit difference) in the low-frequency TENS group compared to the high-frequency TENS group (β = 28.37; p = .0004).

CONCLUSIONS

EDNRA and COMT are implicated in osteoarthritic knee pain and provide a basis for tailoring TENS interventions according to individual characteristics.

SIGNIFICANCE

Findings from this study demonstrate that genetic variation within the COMT and EDNRA genes influences the effectiveness of TENS, a non-pharmacologic pain-reduction intervention, in the context of osteoarthritic knee pain. Evidence such as this may contribute to risk models that provide a clinically useful tool for personalizing TENS interventions according to individual characteristics in order to best control pain and maximize functional status.

Efficacy of low-level laser therapy on pain and disability in knee osteoarthritis: systematic review and meta-analysis of randomised placebo-controlled trials

OBJECTIVES

Low-level laser therapy (LLLT) is not recommended in major knee osteoarthritis (KOA) treatment guidelines. We investigated whether a LLLT dose-response relationship exists in KOA.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Eligible articles were identified through PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Physiotherapy Evidence Database and Cochrane Central Register of Controlled Trials on 18 February 2019, reference lists, a book, citations and experts in the field.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We solely included randomised placebo-controlled trials involving participants with KOA according to the American College of Rheumatology and/or Kellgren/Lawrence criteria, in which LLLT was applied to participants' knee(s). There were no language restrictions.

DATA EXTRACTION AND SYNTHESIS

The included trials were synthesised with random effects meta-analyses and subgrouped by dose using the World Association for Laser Therapy treatment recommendations. Cochrane's risk-of-bias tool was used.

RESULTS

22 trials (n=1063) were meta-analysed. Risk of bias was insignificant. Overall, pain was significantly reduced by LLLT compared with placebo at the end of therapy (14.23 mm Visual Analogue Scale (VAS; 95% CI 7.31 to 21.14)) and during follow-ups 1-12 weeks later (15.92 mm VAS (95% CI 6.47 to 25.37)). The subgroup analysis revealed that pain was significantly reduced by the recommended LLLT doses compared with placebo at the end of therapy (18.71 mm (95% CI 9.42 to 27.99)) and during follow-ups 2-12 weeks after the end of therapy (23.23 mm VAS (95% CI 10.60 to 35.86)). The pain reduction from the recommended LLLT doses peaked during follow-ups 2-4 weeks after the end of therapy (31.87 mm VAS significantly beyond placebo (95% CI 18.18 to 45.56)). Disability was also statistically significantly reduced by LLLT. No adverse events were reported.

CONCLUSION

LLLT reduces pain and disability in KOA at 4-8 J with 785-860 nm wavelength and at 1-3 J with 904 nm wavelength per treatment spot.

PROSPERO REGISTRATION NUMBER

CRD42016035587.

The clinical efficacy of transcutaneous electrical nerve stimulation (TENS) for acute and chronic pain: a protocol for a meta-analysis of randomised controlled trials (RCTs)

INTRODUCTION

The aim of this systematic review with meta-analysis is to evaluate the clinical efficacy of transcutaneous electrical nerve stimulation (TENS) for any type of acute and chronic pain in adults.

METHODS AND ANALYSIS

We intend to search electronic databases (Cochrane Library, MEDLINE, Embase, CINAHL, PsycINFO, LILACS, PEDRO, Web of Science, AMED and SPORTDiscus) from inception to the present day to identify all randomised controlled trials (RCT) on the use of TENS in adults for any type of pain including acute pain, chronic pain and cancer-related pain. We will screen the RCTs against eligibility criteria for inclusion in our review. Two reviewers will independently undertake RCT selection, data extraction and risk of bias assessment. Primary outcomes will be: (i) participant-reported pain relief of ≥30% expressed as frequency (dichotomous) data; and (ii) participant-reported pain intensity expressed as mean (continuous) data. We will conduct meta-analyses to determine risk ratio for dichotomous data, and mean difference (MD) or standardised MD for continuous data for TENS versus placebo TENS, no treatment or waiting list control, standard of care, and other treatments. Subgroup analyses will include different pain conditions (eg, acute vs chronic), TENS intensity, during versus after TENS, TENS as a sole treatment versus TENS in combination with other treatments and TENS administered as a single dose versus repetitive dose.

ETHICS AND DISSEMINATION

This systematic review will not use data from individual participants, and the results will be disseminated in a peer-reviewed publication and presented at a conference.

PROSPERO REGISTRATION NUMBER

CRD42019125054.

Design and In Vivo Pharmacokinetic Evaluation of Triamcinolone Acetonide Microcrystals-Loaded PLGA Microsphere for Increased Drug Retention in Knees after Intra-Articular Injection

A novel polymeric microsphere (MS) containing micronized triamcinolone acetonide (TA) in a crystalline state was structured to provide extended drug retention in joints after intra-articular (IA) injection. Microcrystals with a median diameter of 1.7 μm were prepared by ultra-sonication method, and incorporated into poly(lactic-co-glycolic acid)/poly(lactic acid) (PLGA/PLA) MSs using spray-drying technique. Cross-sectional observation and X-ray diffraction analysis showed that drug microcrystals were evenly embedded in the MSs, with a distinctive crystalline nature of TA. In vitro drug release from the novel MSs was markedly decelerated compared to those from the marketed crystalline suspension (Triam inj.^®), or even 7.2 μm-sized TA crystals-loaded MSs. The novel system offered prolonged drug retention in rat joints, providing quantifiable TA remains over 28 days. Whereas, over 95% of IA TA was removed from joints within seven days, after injection of the marketed product. Systemic exposure of the steroidal compound was drastically decreased with the MSs, with <50% systemic exposure compared to that with the marketed product. The novel MS was physicochemically stable, with no changes in drug crystallinity and release profile over 12 months. Therefore, the TA microcrystals-loaded MS is expected to be beneficial in patients especially with osteoarthritis, with reduced IA dosing frequency.

Randomised study of the effects of neuromuscular electrical stimulation and low-level laser therapy on muscle activation and pain in patients with knee osteoarthritis

Background

The combined effects of low-level laser therapy and neuromuscular electrical stimulation on knee osteoarthritis have yet to be analysed. This study aimed to determine the individual and combined effects of laser therapy and electrical stimulation on muscle activation and pain in older people with knee osteoarthritis.

Methods

A total of 45 women aged 60–75 years with knee osteoarthritis were randomised into three groups to receive stimulation, laser or stimulation plus laser therapy. All three groups underwent a 4-week control period (without intervention) followed by an 8-week intervention period. The effects of the interventions on muscle inhibition, electrical activity and pain were analysed.

Findings

There was a decrease in muscle inhibition (effect size ≥0.6) and a reduction in pain (effect size >1.2) in all three groups. All therapies generated an increase in electrical activity (effect size 0.1–0.5).

Conclusions

Laser alone or in combination with electrical stimulation promoted similar increases in muscle activation and pain relief.

Efficacy and Safety of a Stimulator Using Low-Intensity Pulsed Ultrasound Combined with Transcutaneous Electrical Nerve Stimulation in Patients with Painful Knee Osteoarthritis

Objective

Studies regarding the combination of ultrasound and transcutaneous electrical nerve stimulation (TENS) are rarely reported. In this study, we aimed to elucidate the efficacy and safety of a stimulator using low-intensity pulsed ultrasound (LIPUS) combined with TENS in patients with painful knee osteoarthritis (OA). We evaluated the effectiveness of this therapy against pain, physical function, and cartilage regeneration. Moreover, we aim to prove the superiority of the effects of LIPUS combined with TENS therapy compared with only TENS therapy.

Methods

Of the 40 included patients, aged 45-85 years with painful knee OA, 20 patients received only TENS therapy and 20 patients received LIPUS combined with TENS therapy for 8 weeks (a total of more than 80 treatment sessions). We evaluated visual analogue scale (VAS), Western Ontario and McMaster Universities (WOMAC) osteoarthritis index, MOS 36-Item Short-Form Health Survey (SF-36), and femoral articular cartilage (FAC) thickness. The evaluation was performed at three visits: visit 1 (V1, pretreatment, within 28 days after screening), visit 2 (V2, posttreatment period 1, ±3 days after treatment), and visit 3 (V3, posttreatment period 2, 21 ± 3 days after treatment).

Results

We expected that LIPUS combined with TENS therapy would be superior to only TENS therapy. However, there was no significant difference between the two therapies. In the within-group comparison, both treatments (only TENS therapy and LIPUS with TENS therapy) demonstrated statistical differences from baseline values for pain and physical function outcomes. FAC thickness showed no significant differences after treatment in both groups.

Conclusion

The effects of a stimulator using LIPUS with TENS on pain relief and functional improvement were not superior to the only TENS therapy. Cartilage regeneration, which was expected as an additional benefit of LIPUS, was also not significantly evident. Therefore, further investigation is warranted to determine whether the combination therapy is beneficial. This trial is registered with KCT0003883.

Pharmacokinetic Profile of Intra-articular Fluticasone Propionate Microparticles in Beagle Dog Knees

OBJECTIVE

The objective of this pilot study was to determine time point(s) at which maximum concentration of fluticasone propionate (Cmax) occurs in synovial fluid and plasma in Beagle dog knees after intra-articular injection of EP-104IAR.

DESIGN

EP-104IAR is composed of fluticasone propionate drug crystals coated with heat-treated polyvinyl alcohol (PVA) to result in extended release properties. Thirty-two Beagle dogs had an injection of EP-104IAR into the knee joint at 2 different dose levels (0.6 mg and 12 mg). Outcome measures included plasma, synovial fluid, and articular cartilage fluticasone propionate concentrations as well as histological analysis of cartilage and synovium at a variety of time points up to 58 days postdosing.

RESULTS

Intra-articular administration of 0.6 and 12 mg EP-104IAR was well tolerated. Early minor abnormalities found on microscopy resolved by the end of the study. There were no quantifiable concentrations of fluticasone propionate in plasma of animals administered 0.6 mg at any of the sampling time points. Highest concentrations in plasma following 12 mg administration occurred 1 day postdose and declined with a half-life of approximately 45 days. Highest concentrations of fluticasone propionate in synovial fluid and cartilage generally occurred 5 days postdose in both dose groups and declined with a half-life of approximately 11 to 14 days.

CONCLUSIONS

EP-104IAR is capable of providing a safe and prolonged local exposure to a corticosteroid in the synovial joint while minimizing systemic exposure, with peak exposures occurring within a matter of days after dosing before declining in all tissues in a predictable manner.

Exploring the efficacy of low-level laser therapy and exercise for knee osteoarthritis

Background

Knee Osteoarthritis (KOA) is a prevalent, chronic disorder with excessive functional, social and economic burdens. The goal of treatment is to alleviate the symptoms and slow the progression. Documenting the effects of exercise and LLLT as co-modalities in the management of KOA allows practitioners to implement this management tool as part of KOA rehabilitation, resulting in the earlier discharge from a supervised rehabilitation setting.

Objective

The purpose of this study was to determine the effect of low-level laser therapy (LLLT) in the treatment of knee osteoarthritis (KOA). A randomised controlled trial (RCT) was conducted on 111 participants (aged between 40-75 years) diagnosed with KOA. Participants were randomised into an exercise (n=39), LLLT (n=40), or a combined exercise-LLLT (n=32) group.

Methods

The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scale was used to assess pain and functionality. Knee range of motion was assessed using a goniometer, and the one-minute timed sit-to-stand test measured physical functionality at four time points: (T1) baseline, (T2) post 12-session intervention, (T3) one-month post intervention and (T4) three-month's post intervention. Knee circumference was measured using a measuring tape.

Results

WOMAC pain and functionality scale and knee circumference scores decreased in all three groups (P<0.05), but the combined exercise-LLLT group demonstrated better outcomes than the LLLT or exercise alone groups respectively. The combined exercise-LLLT group showed better acute and long-term benefits with participants experiencing a 3.5 centimetre decrease in knee circumference, 24 point improvement in the WOMAC pain and functionality scale, and a four repetition increase in physical functionality.

Conclusion

The findings suggest that LLLT is a viable tool for managing KOA when used in conjunction with physical exercise.

[Low level laser therapy : A narrative literature review on the efficacy in the treatment of rheumatic orthopaedic conditions]

BACKGROUND

In low level laser therapy (LLLT) low wattage lasers are used to irradiate the affected skin areas, joints, nerves, muscles and tendons without any sensation or thermal damage. Although the exact mechanism of its effect is still unknown, it seems beyond dispute that LLLT induces a variety of stimulating processes at the cellular level affecting cell repair mechanisms, the vascular system and lymphatic system. LLLT has been popular among orthopaedic practitioners for many years, whereas university medicine has remained rather sceptical about it.

OBJECTIVES

Overview of studies on the efficacy of LLLT in the treatment of rheumatic orthopaedic conditions, i. e. muscle, tendon lesions and arthropathies.

MATERIALS AND METHODS

Narrative literature review (PubMed, Web of Science).

RESULTS

While earlier studies often failed to demonstrate the efficacy of LLLT, several recent studies of increasing quality proved the efficacy of LLLT in the treatment of multiple musculoskeletal pain syndromes like neck or lower back pain, tendinopathies (especially of the Achilles tendon) and epicondylolpathies, chronic inflammatory joint disorders like rheumatoid arthritis or chronic degenerative osteoarthritis of the large and small joints. In addition, there is recent evidence that LLLT can have a preventive capacity and can enhance muscle strength and accelerate muscle regeneration.

CONCLUSION

LLLT shows potential as an effective, noninvasive, safe and cost-efficient means to treat and prevent a variety of acute and chronic musculoskeletal conditions. Further randomized controlled studies, however, are required to confirm this positive assessment.

Cardio-light: nitric oxide uncaged

Photobiomodulation (PB) is a utilization of low-level laser therapy (LLLT) in the far red (R) to near infrared (NIR) spectrum (600-1000 nm) to wield its therapeutic effects. To explore the therapeutic potential of biomodulation of different tissues, LLLT has been extensively researched, especially in the light of its very low side effect profile. We believe there is an opportunity to unearth its dynamic effects on the coronaries which can be promising for the patients with chronic stable angina. NIR treatment of the heart may be protective on patients after acute myocardial infarction or on ischemic heart conditions that are not accessible to current revascularization procedures.