Influence of ROM Exercise on the Joint Components during Immobilization

Effects of lower-limb active resistance exercise on mobility, physical function, knee strength and pain intensity in patients with total knee arthroplasty: a systematic review and meta-analysis

BACKGROUND

Total knee arthroplasty (TKA) successfully alleviates pain from knee osteoarthritis, but muscle strength and function are reduced for a long period postoperatively. Postoperative active resistance exercise may play a relevant role.

PURPOSE

To systematically evaluate effects of lower-limb active resistance exercise (ARE) on mobility, physical function, muscle strength and pain intensity in patients with TKA.

METHODS

A search was conducted in PubMed, EMBASE, and Cochrane Library databases from inception to September 2023. Only randomized controlled trials (RCTs) that compared the effects of ARE and no intervention or other rehabilitation program without PRE were included. The outcome variables were mobility (Maximal walking speed [MWS]/6-Minute Walk Test[6MWT]), physical function (Stair Climb Test [SCT]/Timed Up and Go [TUG]), knee extension/ flexion power(KEP/KFP), joint range of motion (ROM) and pain. Standardized Mean Differences (SMD) or Mean Differences (MD) and 95% confidence intervals (CI) were calculated and combined in meta-analyses. The Cochrane Collaboration's Handbook were used for the methodological quality assessments. GRADE was used to assess the quality of evidence. The meta-analysis was performed using the RevMan 5.4 software.

RESULTS

A total of 14 randomized controlled trials, involving 880 patients, were finally included. The lower-limb ARE exhibited significantly greater improvement in MWS (MD 0.13, 95%CI 0.08-0.18, P < 0.00001), TUG(MD -0.92, 95%CI -1.55- -0.28, P = 0.005), KEP (SMD 0.58, 95%CI 0.20-0.96, P = 0.003), KFP (SMD 0.38, 95%CI 0.13-0.63, P = 0.003), ROM-flexion (MD 2.74, 95%CI 1.82-3.67, P < 0.00001) and VAS (MD - 4.65, 95% CI - 7.86- -1.44, p = 0.005) compared to conventional exercise(CE) immediately post-intervention. However, there were no statistically significant differences between both groups in regard to 6MWT (MD 7.98, 95%CI -4.60-20.56, P = 0.21), SCT (MD -0.79, 95%CI -1.69-0.10, P = 0.08) and ROM-extension (MD -0.60, 95%CI -1.23-0.03, P = 0.06).

CONCLUSIONS

According to the results of meta-analysis, patients undergoing TKA who receive the lower extremity ARE show better clinical effects in terms of pain relief, strength recovery and knee ROM. Simultaneously, it may be beneficial to improve mobility and physical function of patients after TKA.

Daily and short-term application of joint movement for the prevention of infrapatellar fat pad atrophy due to immobilization

[Purpose] To mobilize the knee joint during cast fixation and to determine whether infrapatellar fat pad changes can be prevented. [Materials and Methods] We randomly allocated Wistar rats into 3 groups as follows: normal group, raised in normal conditions (n=5); contracture group, immobilized with cast fixation (n=5); and prevention group, treated with joint movement during immobilization (n=5). We immobilized the right hindlimb using cast fixation. Joint movement in the prevention group was accomplished by repeatedly pulling the right hindlimb caudally and then returning the leg to the bent position for 10 minutes every day for 2 weeks. We used a metronome to maintain a constant speed, with one set lasting 2 seconds (1-second traction and 1-second return). [Results] The contracture group had adipose cells of various sizes and fibrosis in the infrapatellar fat pad. These changes were also found in milder forms in the prevention group. We found significant differences in the cross section of adipose cells and in knee extension restriction between the groups. [Conclusion] Promoting joint movement may not only have a therapeutic effect on adipose cells but also a preventative effect.

Continuous Passive Motion After Total Knee Arthroplasty: A Systematic Review and Meta-analysis of Associated Effects on Clinical Outcomes

OBJECTIVE

To evaluate the efficacy of continuous passive motion (CPM) after total knee arthroplasty (TKA) and whether the use of CPM is related to improved clinical and functional outcomes.

DATA SOURCES

A systematic MEDLINE search via Web of Science, Cochrane Library, and PubMed databases was conducted.

STUDY SELECTION

English-language articles published between January 2000 and May 2018 reporting the related clinical outcomes of CPM after TKA were included. A total of 3334 titles and abstracts were preliminarily reviewed, of which 16 studies were included according to the eligibility criteria.

DATA EXTRACTION

Two different reviewers were selected to perform the study extraction, independent of each other. If there were any disagreements regarding the final list of studies, the third reviewer reviewed the list as an arbitrator for completeness.

DATA SYNTHESIS

A total of 16 trials with 1224 patients were included. The pooled results revealed that use of CPM did not show a statistically significant improvement of postoperative knee range of motion (ROM) except for middle-term passive knee extension and long-term active knee flexion ROM. Also, CPM therapy did not show a significant positive effect on the functional outcomes. No significant reduction in length of stay (LOS) and incidence of adverse events (AEs) was identified.

CONCLUSION

Among patients undergoing TKA, neither the ROM nor the functional outcomes could be improved by CPM therapy. Moreover, the risk of AEs and LOS could not be reduced by application of CPM. The current available evidence suggested that this intervention was insufficient to be used routinely in clinical practice.

Long-term histopathological developments in knee-joint components in a rat model of osteoarthritis induced by monosodium iodoacetate

[Purpose] This study was performed to evaluate the long-term histopathological changes in knee-joint components including synovial membrane and joint capsule in a rat model of osteoarthritis (OA) induced by monosodium iodoacetate (MIA). [Subjects and Methods] Fifty male rats were used. OA was induced through intra-articular injection of MIA, and ten rats were randomly allocated to each of five groups induced with OA for 1, 2, 4, 6, or 8 weeks. At the end of each period, the knee components were examined histopathologically. [Results] After 1 and 2 weeks, chondrocytes were weakly stained. After 4 weeks, fibrillation, fissuring, and eburnation were observed, whereas after 6 weeks, chondrocyte clustering and osteophyte formation were detected. In the synovial membrane, the proliferation of spindle-shaped cells and a multilayered structure of the surface cells were observed at 1 and 2 weeks, but the degree of these changes decreased over time. In the joint capsule, a narrowing of the space between collagen fiber bundles was observed at 4–8 weeks. [Conclusion] The long-term histopathological changes of the joint components observed in a rat model of OA induced by MIA were similar to those detected in OA, but differed at specific times and tissues.

Continuous passive motion and its effects on knee flexion after total knee arthroplasty in patients with knee osteoarthritis

PURPOSE

This study evaluated the effects of continuous passive motion (CPM) on accelerated flexion after total knee arthroplasty (TKA) and whether CPM application measures (i.e. initial angle and daily increment) are associated with functional outcomes.

METHODS

A retrospective investigation was conducted at the rehabilitation centre of a university-based teaching hospital. Patients who received CPM therapy immediately after TKA surgery were categorized into rapid-, normal-, and slow-progress groups according to their response to CPM during their acute inpatient stay. Knee pain, passive knee flexion, and knee function-measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)-were assessed preoperatively at discharge and at 3- and 6-month outpatient follow-up visits.

RESULTS

A total of 354 patients were followed for 6 months after inpatient-stay discharge. The patients in the rapid-progress group (n = 119) exhibited significantly greater knee flexions than those in the slow-progress group did (n = 103) at the 3-month follow-up [mean difference (MD) = 10.3°, 95 % confidence interval (CI) 4.3°-16.3°, p < 0.001] and 6-month follow-up (MD = 10.9°, 95 % CI 6.3°-15.6°, p < 0.001). Significant WOMAC score differences between the rapid- and slow-progress groups were observed at the 3-month follow-up (MD = 7.2, 95 % CI 5.4-9.1, p < 0.001) and 6-month follow-up (MD = 16.1, 95 % CI 13.4-18.7, p < 0.001). CPM initial angles and rapid progress significantly predicted short- and long-term outcomes in knee flexion and WOMAC scores (p < 0.001).

CONCLUSION

When CPM is used, early application with initial high flexion and rapid progress benefits knee function up to 6 months after TKA.

LEVEL OF EVIDENCE

II.

Analysis of scapular kinematics during active and passive arm elevation

[Purpose] Early postoperative passive motion exercise after arthroscopic rotator cuff repair remains controversial. To better understand this issue, this study was aimed at evaluating scapular kinematics and muscle activities during passive arm elevation in healthy subjects. [Subjects and Methods] The dominant shoulders of 27 healthy subjects were examined. Electromagnetic sensors attached to the scapula, thorax, and humerus were used to determine three-dimensional scapular kinematics during active arm elevation with or without external loads and passive arm elevation. Simultaneously, the activities of seven shoulder muscles were recorded with surface and intramuscular fine-wire electrodes. [Results] Compared with active arm elevation, passive elevation between 30° and 100° significantly decreased the scapular upward rotation and increased the glenohumeral elevation angle. However, no significant differences in scapular posterior tilt and external rotation were observed between active and passive arm elevation, and scapular plane kinematics were not affected by muscle activity. [Conclusion] Unlike active motion with or without an external load, passive arm elevation significantly decreased the scapular upward rotation and significantly increased the mid-range glenohumeral elevation. These data, which suggest that passive arm elevation should be avoided during the early postoperative period, may expand the understanding of rehabilitation after arthroscopic rotator cuff repair.

An immunohistochemical study of the sciatic nerve in a rat knee immobilization model

[Purpose] This study was performed to immunohistochemically evaluate changes in the periphery of the sciatic nerve in a rat model of knee immobilization, and to assess the effects of range of motion exercise. [Subjects and Methods] Twenty-one male rats were divided randomly into three groups: control (C), immobilized (I), and exercise (E group). Rats in the I and E groups had the right knee joint immobilized for 2 weeks. In the E group, range of motion exercise was also performed. After the experimental period, the periphery of the sciatic nerve was immunohistochemically observed. [Results] Immunohistochemical staining revealed that the myelin sheath and the perineurium in all groups were laminin positive. In the C and E groups, all rats showed normal staining. In contrast, 4 rats in the I group exhibited weak labeling. [Conclusion] Our results suggest that immobilization alters the perineurium at a molecular level and the range of motion exercise is essential for maintaining the environment of the perineurium.

Remobilization causes site-specific cyst formation in immobilization-induced knee cartilage degeneration in an immobilized rat model

An understanding of the articular cartilage degenerative process is necessary for the prevention and treatment of joint disease. The present study aimed to examine how long‐term immobilization‐induced cartilage degeneration is aggravated by remobilization. Sixty 8‐week‐old male Wistar rats were used in this study. The unilateral knee joint was immobilized using an external fixator for 8 weeks. The rats were killed at 0 and 3 days, and at 1, 2, 4 and 8 weeks after removing the fixator. After the rats were killed, the maximum knee extension angles were measured. Histological sections at the medial mid‐condylar region (non‐contact, transitional and contact regions of the femur and tibia) were prepared and scored. The cartilage thickness and number of chondrocytes were measured, and CD44 and Col2‐3/4c expression levels were assessed immunohistochemically. The histological assessment revealed progressive aggravation of cartilage degeneration in the transitional region, with a decreased number of chondrocytes and CD44‐positive chondrocytes as well as poor scoring over time, particularly in the tibia. Cyst formation was confirmed in the transitional region of the tibia at 8 weeks post‐remobilization. The cartilage thickness in the transitional region was thicker than that in the contact region, particularly in the tibia. Col2‐3/4c expression was observed in the non‐contact and transitional regions, and the knee extension angle was recovered. In conclusion, immobilization‐induced cartilage degeneration was aggravated by remobilization over time in the transitional region, followed by observations of a decreased number of chondrocytes and morphological disparity between different cartilage regions.

Adhesive capsulitis: An age related symptom of metabolic syndrome and chronic low-grade inflammation?

Adhesive capsulitis (AC) is very poorly understood, particularly it's underlying etiology. Obesity and metabolic syndrome, which are strongly associated with chronic low grade inflammation, are becoming increasingly understood to underlie a raft of morbid states including upper limb pain syndromes, diabetes (DM), cardiovascular disease (CVD), cancer and central nervous system dysfunction and degeneration. Notwithstanding age, two of the strongest established risk factors for AC are DM and CVD. The hypothesis argues that similar to DM and CVD, the inflammation and capsular fibrosis seen in AC is precipitated by metabolic syndrome and chronic low grade inflammation. These pathophysiological mechanisms are highly likely to be perpetuated by upregulation of pro-inflammatory cytokine production, sympathetic dominance of autonomic balance, and neuro-immune activation. The hypothesis predicts and describes how these processes may etiologically underpin and induce each sub-classification of AC. An improved understanding of the etiology of AC may lead to more accurate diagnosis, improved management, treatment outcomes, and reduce or prevent pain, disability and suffering associated with the disease. The paper follows on with a discussion of similarities between the pathophysiology of AC to general systemic inflammatory control mechanisms whereby connective tissue (CT) fibrosis is induced as a storage depot for leukocytes and chronic inflammatory cells. The potential role of hyaluronic acid (HA), the primary component of the extracellular matrix (ECM) and CT, in the pathophysiology of AC is also discussed with potential treatment implications. Lastly, a biochemical link between physical and mental health through the ECM is described and the concept of a periventricular-limbic central driver of CT dysfunction is introduced.

Use of micro-computed tomography to evaluate the effects of exercise on preventing the degeneration of articular cartilage in tail-suspended rats

Space flight has been shown to induce bone loss and muscle atrophy, which could initiate the degeneration of articular cartilage. Countermeasures to prevent bone loss and muscle atrophy have been explored, but few spaceflight or ground-based studies have focused on the effects on cartilage degeneration. In this study, we investigated the effects of exercise on articular cartilage deterioration in tail-suspended rats. Thirty-two female Sprague-Dawley rats were randomly divided into four groups (n=8 in each): tail suspension (TS), tail suspension plus passive motion (TSP), tail suspension plus active exercise (TSA), and control (CON) groups. In the TS, TSP, and TSA groups, the rat hindlimbs were unloaded for 21 days by tail suspension. Next, the cartilage thickness and volume, and the attenuation coefficient of the distal femur were evaluated by micro-computed tomography (μCT). Histological analysis was used to assess the surface integrity of the cartilage, cartilage thickness, and chondrocytes. The results showed that: (1) the cartilage thickness on the distal femur was significantly lower in the TS and TSP groups compared with the CON and TSA groups; (2) the cartilage volume in the TS group was significantly lower compared with the CON, TSA, and TSP groups; and (3) histomorphology showed that the chondrocytes formed clusters where the degree of matrix staining was lower in the TS and TSP groups. There were no significant differences between any of these parameters in the CON and TSA groups. The cartilage thickness measurements obtained by μCT and histomorphology correlated well. In general, tail suspension could induce articular cartilage degeneration, but active exercise was effective in preventing this degeneration in tail-suspended rats.