Effect of the Frequency and Duration of Land-based Therapeutic Exercise on Pain Relief for People with Knee Osteoarthritis: A Systematic Review and Meta-analysis of Randomized Controlled Trials

The Impact of Exercise Prescription Variables on Intervention Outcomes in Musculoskeletal Pain: An Umbrella Review of Systematic Reviews

BACKGROUND

Musculoskeletal pain conditions are the largest contributors to disability and healthcare burden globally. Exercise interventions improve physical function and quality of life in individuals with musculoskeletal pain, yet optimal exercise prescription variables (e.g. duration, frequency, intensity) are unclear.

OBJECTIVE

We aimed to examine evidence gaps, methodological quality and exercise prescription recommendations in systematic reviews of exercise for musculoskeletal pain.

METHODS

In our prospectively registered umbrella review, PubMed, SPORTDiscus, Cochrane Database of Systematic Reviews, EMBASE, and CINAHL were searched from inception to 14 February 2023. Backward citation tracking was performed. We included peer-reviewed, English language, systematic reviews and meta-analyses of randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that compared exercise with conservative treatment, placebo or other exercise interventions in adults with musculoskeletal pain. Data were extracted from the following groups of reviews based on their reporting of exercise prescription data and analysis of the relationship between prescription variables and outcomes: (1) those that did not report any exercise prescription data, (2) those that reported exercise prescription data but did not perform a quantitative analysis and (3) those that performed a quantitative analysis of the relationship between exercise prescription variables and outcomes. Outcome measures were physical function, pain, mental health, adverse effects and adherence to treatment. AMSTAR-2 (A MeaSurement Tool to Assess systematic Reviews) was used to assess methodological quality.

RESULTS

From 6757 records, 274 systematic reviews were included. 6.6% of reviews did not report any exercise prescription data, and only 10.9% quantitatively analyzed the relationship between prescription variables and the outcome(s). The overall methodological quality was critically low in 85% of reviews.

CONCLUSION

High methodological quality evidence is lacking for optimal exercise training prescription variables in individuals with musculoskeletal pain. To better inform practice and evidence gaps, future systematic reviews should (1) identify optimum exercise prescription variables, for example, via dose-response (network) meta-analysis, (2) perform high-quality reviews per AMSTAR-2 criteria and (3) include outcomes of mental health, adverse events and exercise adherence.

PROSPERO REGISTRATION NUMBER

CRD42021287440 ( https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021287440 ).

Active Neurodynamics at Home in Patients with Knee Osteoarthritis: A Feasibility Study

The aim was to evaluate the feasibility of a home-based neurodynamic programme for patients with knee osteoarthritis (KO). Thirty participants (70% women) ≥ 50 years old with KO (Kellgren-Lawrence grades I-II) were included. Active mobilisation of the femoral nerve was performed at home over a period of 6-8 weeks. The feasibility of the programme was assessed using a survey that included questions related to understanding of the activity; adherence to the intervention; the burden caused by the intervention; self-perceived effects on the participant; follow-up; the barriers; and facilitators. Pain intensity, using the numerical rating scale (NRS); pressure pain thresholds (PPT); temporal assessment; pain modulation; Knee Injury and Osteoarthritis Outcome Score (KOOS), 12-item Short Form Survey questionnaire (SF-12), and the Central Sensitization Inventory questionnaire (CSI) were also collected, before and after the intervention. All patients performed the intervention, completed at least 42 days of activity, and considered the exercise adequate, with 28 participants (93.3%) reporting that the intervention was good for them. Statistically significant values (p < 0.05) were found for NRS, elbow PPT, external knee PPT, internal knee PPT, elbow CPM, CSI, and KOOS. Home-based active neurodynamic treatment has been shown to be a feasible and safe intervention for KO patients. In addition, this intervention has shown positive effects on pain and function.

Effect of Systematic Exercise Rehabilitation on Patients With Knee Osteoarthritis: A Randomized Controlled Trial

OBJECTIVES

We aimed to compare the outcomes of exercise rehabilitation and conventional treatment in patients with knee osteoarthritis.

METHODS

This trial included a total of 166 patients diagnosed with knee osteoarthritis; they were randomly divided into groups. The experimental group underwent systematic exercise rehabilitation, while the control group received naproxen (n = 28), diclofenac (n = 27), or celecoxib (n = 19). Improvement in symptoms, knee function, and quality of life were compared. SPSS Statistics 24.0 was used for the data analysis.

RESULTS

The mean age of patients was 56.0 ± 10.5 years, and the average follow-up time was 12 ± 2.3 weeks. No statistically significant differences were seen in age, body mass index, and sex (P > 0.05) between the groups. The average Western Ontario and MacMaster Universities (WOMAC) scores after treatment were 84.4 ± 15.2, 108.3 ± 3.9, 107.4 ± 5.4, and 107 ± 6.0 in the exercise rehabilitation, diclofenac, naproxen, and celecoxib groups, respectively. The mean Lysholm scores were 60.3 ± 14.9, 41.0 ± 0.1, 43.5 ± 5.3, and 41.7 ± 3.6 in the exercise rehabilitation, diclofenac, naproxen, and celecoxib groups, respectively. The mean SF-36 (Short Form-36 Survey) scores were 105.4 ± 21.5, 82.5 ± 3.7, 84.2 ± 3.5, and 83.7 ± 5.0 in the exercise rehabilitation, naproxen, celecoxib, and diclofenac groups, respectively. The average ranges of knee motion were 125.0 ± 6.2°, 116.4 ± 1.4°, 114.7 ± 1.1°, and 115.7 ± 0.8° after exercise rehabilitation, diclofenac, naproxen, and celecoxib treatments, respectively. These data presented statistical differences between the groups.

CONCLUSION

Exercise better improved symptoms and quality of life in patients with knee osteoarthritis over a 12-week follow-up period than that achieved with nonsteroidal anti-inflammatory drugs and COX-2 inhibitors.

Effects of exercise on knee osteoarthritis: A systematic review

BACKGROUND

Knee osteoarthritis is the most common joint disease and a major cause of functional limitation and pain in adults. The aim of this literature review is to review the existing evidence regarding the impact of exercise in people with knee osteoarthritis concerning physical and functional outcomes. The secondary aim is to provide both healthcare professionals and patients with updated and high-quality recommendations for the management of this condition.

METHODS

A systematic search was performed at Pubmed, Scopus and Web of Science databases, limiting the studies to English, French and Portuguese language, from 2010 to May 2020. Eligible studies were randomized control trials or clinical control trials that compared an intervention consisting of an exercise programme in adult participants with knee osteoarthritis against no intervention.

RESULTS

A total of 4499 studies were retrieved and 19 articles met the inclusion criteria. Beneficial effects of exercise were found on pain and strength. Regarding function, functional performance and quality of life, evidence is controversial. Both strengthening and aerobic exercise showed positive effects and both aquatic and land-based programmes presented improvement of pain, physical function and quality of life. Relatively to stretching, plyometric and proprioception training, no concrete conclusions can be taken.

CONCLUSION

Exercise programmes appear to be safe and effective in knee osteoarthritis patients, mainly regarding pain and strength improvement. Pilates, aerobic and strengthening exercise programmes performed for 8-12 weeks, 3-5 sessions per week; each session lasting 1 h appear to be effective. Both aquatic and land-based programmes show comparable and positive effects.

Effects of Physical Activity in Knee and Hip Osteoarthritis: A Systematic Umbrella Review

INTRODUCTION

We conducted a systematic umbrella review to evaluate the literature relating to effects of physical activity on pain, physical function, health-related quality of life, comorbid conditions and osteoarthritis (OA) structural disease progression in individuals with lower-extremity OA.

METHODS

Our primary search encompassed 2011 to February 2018 for existing systematic reviews (SR), meta-analyses (MA) and pooled analyses dealing with physical activity including exercise (not mixed with any other intervention and compared to a no-activity control group). A supplementary search encompassed 2006 to February 2018 for original research related to physical activity (including exercise) and lower limb OA progression. Study characteristics were abstracted, and risk of bias was assessed.

RESULTS

Physical activity decreased pain and improved physical function (strong evidence) and improved health-related quality of life (moderate evidence) among people with hip or knee OA relative to less active adults with OA. There was no evidence to suggest accelerated OA progression for physical activity below 10,000 steps per day. Both physical activity equivalent to the 2008 Physical Activity Guidelines for Americans (150 min·wk of moderate-intensity exercise in bouts ≥10 min) and lower levels of physical activity (at least 45 total minutes per week of moderate-intensity) were associated with improved or sustained high function. No SR/MA addressing comorbid conditions in OA were found. Measurable benefits of physical activity appeared to persist for periods of up to 6 months following cessation of a defined program.

CONCLUSIONS

People with lower-extremity OA should be encouraged to engage in achievable amounts of physical activity, of even modest intensities. They can choose to accrue minutes of physical activity throughout the entire day, irrespective of bout duration, and be confident in gaining some health and arthritis-related benefits.

One-year results of voluntary-based supervised exercise or treatment at orthopedic clinic for radiographic severe knee osteoarthritis

[Purpose] In this study, we investigated the efficacy of supervised physical exercise or conventional treatment on symptomatic knee osteoarthritis with severe morphological degeneration. [Subjects] Sixty-six patients with severe radiographic knee osteoarthritis were enrolled. [Methods] Participants were separated into two groups: in one group patients conducted physical exercise under supervision; while in the other group they were treated by conventional clinical methods for one year. Participants filled out two types of questionnaires; the Japanese Knee Osteoarthritis Measure and the Pain Disability Assessment Scale at baseline and one year following enrollment in the study. Two-way repeated measures analysis of variance was used to examine the effects over time and by group for a total of 43 participants; consisting of an exercise group (n=20) and a clinical group (n=23) excluding 23 dropouts. [Results] Analysis did not show a significant time-course effect or interaction between time-course and the groups in both questionnaires. On the other hand, there were significant group effects in both questionnaires with an advantage in the exercise group. [Conclusion] These results indicate that patients with knee osteoarthritis under supervised exercise conditions are more likely to maintain a better clinical outcome at one-year follow-up, despite the severe morphological degeneration in their knees.

Effects of increased standing balance on pain in patients with knee osteoarthritis

[Purpose] The purpose of this study was to examine the relationship between standing balance increased through muscle-strengthening exercises and pain in knee osteoarthritis patients. [Subjects and Methods] Thirty knee osteoarthritis patients were equally divided into a strengthening exercise group and an unstable exercise group. Before and after the six-week experiment, the visual analogue scale was measured, and bilateral one-leg standing tests were performed. [Results] In both the strengthening exercise group and unstable exercise group, the bilateral one-leg standing time significantly increased after the six-week experiment. Regarding the visual analogue scale, a pain measurement scale, the strengthening exercise group had significantly decreased pain. The unstable exercise group also had decreased pain, but the decrease was not statistically significant. [Conclusion] In knee osteoarthritis patients, exercises using an unstable base of support and knee-extensor strengthening exercises with gradually increased loads had a positive effect on improving balance ability and decreasing pain.

The effects of standing balance in anteroposterior and mediolateral directions on knee strengthening in post-total knee replacement

[Purpose] The purpose of this study was to examine the association between muscle-strengthening exercises applied to the knee extensor muscles and the maintenance of standing balance in both, the anteroposterior and mediolateral directions in patients who had undergone total knee replacement. [Subjects and Methods] Thirty patients who underwent total knee replacement with bilateral artificial joints participated in this study. During the eight-week study period, the load on the knee extensors was gradually increased, and the standing balance ability was measured by differentiating the anteroposterior and mediolateral directions both, before and after the experimental period. [Results] In both, the anteroposterior and the mediolateral directions, there were statistically significant increases after the eight-week experiment, with a 29% increase in standing balance maintenance in the anteroposterior direction and a 22% increase in the mediolateral direction. [Conclusion] In patients who underwent bilateral total knee replacement, strengthening exercises applied to the knee extensor muscles with gradually increasing load positively affected standing balance in both anteroposterior and mediolateral directions.

Osteoarthritis year in review 2015: rehabilitation and outcomes

OBJECTIVE

The purpose of this narrative review was to highlight recent research in the rehabilitation of people with osteoarthritis (OA) by summarizing findings from selected key systematic reviews and randomized controlled trials (RCTs).

METHODS

A systematic search was conducted using the PubMed, Physiotherapy Evidence Database (PEDro) and Cochrane databases from April 1st 2014 to March 31st 2015. A selection of these is discussed based on study quality, relevance, contribution to new knowledge or controversial findings. Methodological quality of RCTs was assessed using guidelines from PEDro.

RESULTS

From 274 articles, 74 were deemed to meet the eligibility criteria including 24 systematic reviews and 50 studies reporting on findings from RCTs. Overall the methodological quality of the RCTs was moderate. The studies were grouped into several themes covering; evidence of rehabilitation outcomes in less studied joints including the hand and hip; new insights into exercise in knee OA; effects of biomechanical treatments on symptoms and structure in knee OA; and effects of acupuncture.

CONCLUSIONS

Exercise was the most common treatment evaluated. Although little evidence supported benefit of exercise for hand OA, exercise has positive effects for hip and knee OA symptoms and these benefits may depend upon patient phenotypes. The first evidence that a brace can influence knee joint structure emerged. The latest evidence suggests that acupuncture has, at best, small treatment effects on knee OA pain of unlikely clinical relevance.

Does exercise therapy improve the health-related quality of life of people with knee osteoarthritis? A systematic review and meta-analysis of randomized controlled trials

[Purpose] The aim of this study was to examine the effects of exercise therapy on the health-related QOL of people with knee osteoarthritis. [Subjects] Four databases (PubMed, Cochrane Central Register of Controlled Trials, the Physiotherapy Evidence Database, and the Cumulative Index to Nursing and Allied Health Literature) were searched for randomized controlled trials that evaluated the effects of exercise therapy on health-related QOL assessed by the SF-36 for inclusion in our systematic review. The methodological qualities of the trials were assessed independently by two reviewers using the PEDro scale. Pooled analyses with a random-effects model or a fixed-effects model were used in the meta-analyses to calculate the standardized mean differences and 95% confidence intervals. [Results] Twelve studies met the inclusion criteria. Our meta-analysis provides high-quality evidence that exercise therapy increases the summary score, physical functioning score, and role-physical score of knee osteoarthritis sufferers. Our meta-analysis also provides moderate-quality evidence that the physical component summary and mental component summary scores were improved to a greater extent by exercise therapy than by control interventions. [Conclusion] Exercise therapy can improve health-related QOL, as assessed by the SF-36, of knee osteoarthritis sufferers.

Whole-Body Vibration Exercise for Knee Osteoarthritis: A Systematic Review and Meta-Analysis

Objectives. To assess the effects of WBV exercise on patients with KOA. Methods. Eight databases including Pubmed, EMBASE, Cochrane Library, CINAHL, Web of Science, the Physiotherapy Evidence Database, CNKI, and Wanfang were searched up to November 2014. Randomized controlled trials (RCTs) of WBV for KOA were eligible. The outcomes were pain intensity, functional performances, self-reported status, adverse events, and muscle strength. A meta-analysis was conducted. Results. Five trials with 168 participants provided data for the meta-analysis. No significant difference was shown in pain intensity and self-reported status between WBV and other forms of exercise. Improvement in functional performance (evaluated by BBS; WMD, 2.96; 95% CI, 1.29 to 4.62; P = 0.0005) was greater in WBV group, but the other parameters of functional performance (including 6MWT and TGUG) revealed no statistically significant difference. Adverse events were only reported in one trial and no significant difference was discovered in muscle strength. The overall quality of evidence was very low. Conclusion. Currently there is only limited evidence that suggested that WBV is effective in the treatment of KOA. Large, well-designed RCTs with better designs are needed.