Effects of combined application of progressive resistance training and Russian electrical stimulation on quadriceps femoris muscle strength in elderly women with knee osteoarthritis

Dose-Response Relationships of Resistance Training in Adults With Knee Osteoarthritis: A Systematic Review and Meta-analysis

BACKGROUND AND PURPOSE

To determine the effects of resistance training (RT) on symptoms, function, and lower limb muscle strength in patients with knee osteoarthritis (KOA), and to determine the optimal dose-response relationships.

DATA SOURCES

We searched the PubMed, MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and ClinicalTrials.gov databases from inception to January 23, 2022.

ELIGIBILITY CRITERIA

Randomized controlled trials that examined the effects of RT in KOA patients (mean age ≥50 years) were included.

DATA SYNTHESIS

We applied Hedges' g of the random-effects model to calculate the between-subject standardized mean difference (SMDbs). A random-effects metaregression was calculated to explain the influence of key training variables on the effectiveness of RT. We used the Grading of Recommendations Assessments, Development and Evaluation (GRADE) method to appraise the certainty of evidence.

RESULTS

A total of 46 studies with 4289 participants were included. The analysis revealed moderate effects of RT on symptoms and function (SMDbs =-0.52; 95% CI: -0.64 to -0.40), and lower limb muscle strength (SMDbs = 0.53; 95% CI: 0.42 to 0.64) in the intervention group compared with the control group. The results of the metaregression revealed that only the variable "training period" (P< .001) had significant effects on symptoms, function, and lower limb muscle strength, and the 4 to 8 weeks of training subgroup showed greater effects than other subgroups (SMDbs =-0.70, -0.91 to -0.48; SMDbs = 0.76, 0.56 to 0.96).

CONCLUSIONS

Compared with inactive treatments, RT is strongly recommended to improve symptoms, function, and muscle strength in individuals with KOA. Dose-response relationship analysis showed that 4 to 8 weeks of RT had more benefits.

Effect of Superimposed Russian Current on Quadriceps Strength and Lower-Extremity Endurance in Healthy Males and Females

CONTEXT

More studies are needed to compare the effect of voluntary contraction, electrical stimulation, and electrical stimulation superimposed onto voluntary contraction in improving trained and untrained homolog muscle strength and lower-extremity endurance.

DESIGN

Seventy-six healthy young adults (age = 20.41 [3.07] y, 61 females and 15 males) were included in the study. Subjects were randomly divided into 3 groups as voluntary isometric contraction (IC) group, Russian current (RC) group, and superimposed Russian current (SRC) group.

METHODS

All training regimens were performed under physiotherapist supervision for a total of 18 sessions (3 times per week for 6 wk). In each session, 10 ICs were achieved with voluntary isometric exercise only, RC only, or RC superimposed onto ICs. Main outcome measures were trained and untrained quadriceps strength (maximal voluntary isometric contraction [MVIC]) and lower-extremity endurance (sit-to-stand test).

RESULTS

After 6 weeks of training, all outcome measures improved in all groups (P < .05), except the untrained quadriceps MVIC score of RC group (P = .562). The trained quadriceps MVIC score (P < .001, η2 = .478), untrained quadriceps MVIC score (P = .011, η2 = .115), and sit-to-stand test score (P < .001, η2 = .357) differed significantly among the 3 groups; post hoc analysis revealed that the trained quadriceps MVIC score was higher in SRC and RC groups than in the IC group, untrained quadriceps MVIC score was higher in SRC group than in the RC group, and sit-to-stand test score was higher in SRC group than in the RC group and IC group.

CONCLUSIONS

RC and RC superimposed onto IC are superior to IC in improving quadriceps muscle strength, and RC superimposed onto IC is superior to RC and IC in improving lower-extremity endurance. RC superimposed onto IC and voluntary IC created cross-education effect on untrained quadriceps.

Osteoarthritis of the Knee in Middle-age Athletes: Many Measures are Practiced, but Lack Sound Scientific Evidence

Osteoarthritis of the knee generally affects individuals from the fifth decade, the typical age of middle-age athletes. In the early stages, management is conservative and multidisciplinary. It is advisable to avoid sports with high risk of trauma, but it is important that patients continue to be physically active. Conservative management offers several options; however, it is unclear which ones are really useful. This narrative review briefly reports the conservative options for which there is no evidence of effectiveness, or there is only evidence of short-term effectiveness.

The effects of neuromuscular electrical stimulation on strength, pain, and function in individuals with knee osteoarthritis: a systematic review with meta-analysis

ABSTRACT We aimed to investigate the effects of neuromuscular electrical stimulation on muscle strength, pain relief, and improvement in function in patients with knee osteoarthritis. Databases were searched from December 2017 to July 2020 and included PubMed, Embase, LILACS, and the Cochrane Central Register of Controlled Trials. A manual search was also performed by checking the reference lists of eligible articles. The PRISMA guidelines were followed. The studies selected compared NMES with an exercise program on isometric muscle strength as a primary outcome. The secondary outcomes were pain and function. The quality of the studies was assessed using the Risk of Bias assessment and PEDro scale, and the overall quality of the evidence was assessed using the GRADE approach. Eight studies were included in this systematic review. A total of 571 patients were analyzed. Neuromuscular electrical stimulation associated with exercise promoted an increase in isometric strength of the quadriceps muscle compared to the active control group, demonstrating heterogeneity and statistical difference (95% CI=1.16 to 5.10, I2=97%, p=0.002; very low-certainty evidence). NMES associated with exercise did not improve physical function (95% CI=−0.37 to 0.59, I2=0%, p=0.67; low-certainty evidence) and showed controversial results for pain compared to an active control group (qualitative assessment). In conclusion, NMES induces an increase in muscle strength in patients with osteoarthritis compared to an active control group. No differences were found for physical function and pain outcomes. Further research is needed due to the uncertain level of evidence.

The influence of whole-body electromyostimulation training in middle-aged women

BACKGROUND: Whole-body electromyostimulation (WB-EMS) is a new tendency in training used to complement conventional training. OBJECTIVE: The aim was to analyze the effects of training with WB-EMS on body composition, strength and balance in middle-aged women. METHODS: Twenty-eight women were randomly assigned to two groups: the WB-EMS group (age = 48.1 ± 4.3 years) or the control group (CG) (age = 51.1 ± 5.4 years). All participants continued their training of 2 days⋅week-1 and 60 min⋅day-1 of endurance-dynamic strength exercises and additionally did 20 minutes more of dynamic strength exercises one day⋅week-1: the WB-EMS group did the additional training with WB-EMS and the CG did the same training but without WB-EMS. Body composition, muscle isokinetic strength of the knee flexors/extensors and postural stability were measured before and after 8 weeks of training. RESULTS: After the training program, the WB-EMS group showed lower values for the waist circumference (83.00 ± 7.37 vs. 78.50 ± 7.30 cm; p< 0.01), hip circumference (104.80 ± 8.61 vs. 101.00 ± 6.78 cm; p< 0.05) and total fat mass (37.04 ± 6.08 vs. 36.26 ± 5.78%; p< 0.05). In balance stability the WB-EMS group reduced their Fall Risk Index (1.70 ± 0.51 vs. 1.30 ± 0.38 AU; p< 0.01) and deviation (1.50 ± 0.43 vs. 1.03 ± 0.74 AU; p< 0.01) after training and showed lower values in the Fall Risk Index (p= 0.007) and deviation (p= 0.024). CONCLUSIONS: The WB-EMS training program helps reduce the risk of falling and improves body composition variables and balance results in middle-aged physically active women.

New Guidelines for Electrical Stimulation Parameters in Adult Patients With Knee Osteoarthritis Based on a Systematic Review of the Current Literature

OBJECTIVE

The goal of this systematic review was to provide guidelines for treatment parameters regarding electrical stimulation by investigating its efficacy in improving muscle strength and decreasing pain in patients with knee osteoarthritis.

DESIGN

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standard, three electronic databases (CINAHL, PubMed, and PEDro) and gray literature were used. Randomized control trials comparing electrical stimulation and conservative physical therapy were critically appraised using the 2005 University of Oxford standard.

RESULTS

Nine randomized control trials were included in our review. First, our review confirmed that neuromuscular electrical stimulation is the most effective electrical stimulation treatment in the management of knee OA, and its efficiency is higher when combined with a strengthening program. Second, frequency of at least 50 Hz and no more than 75 Hz with a pulse duration between 200 and 400 μs and a treatment duration of 20 mins is necessary for successful treatment.

CONCLUSIONS

For the first time, our review provides standardized clinical treatment parameters for neuromuscular electrical stimulation to be included in a strengthening program for the adult patient with knee OA.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Recall the impact of quadriceps femoris weakness on joint stability; (2) Summarize the mechanism of action of neuromuscular electrical stimulation (NMES) on reducing pain and increasing muscle strength; and (3) Plan the clinical treatment parameters of NMES to be included in a strengthening program for an adult patient with knee osteoarthritis.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Effects of the Russian current in the treatment of low back pain in women: A randomized clinical trial

BACKGROUND

Low back pain (LBP) is a high impact condition that affects the working population, generating social and economic repercussions, the most relevant symptoms being pain and functional disability. Conservative treatment is often based on stabilizing spinal muscles with exercises: the Russian current (RC) is reported as an alternative, because it promotes muscle contraction, providing muscle strengthening and hypertrophy.

OBJECTIVE

To assess the effectiveness of the RC in aiding the treatment of low back pain.

METHODS

This randomized study included 23 women aged 18-30 years, divided into two groups: the control group (CG) and the Russian current group (RCG), for four weeks. Pain (visual analogue scale, VAS; pressure algometer, PA), function (Oswestry Low Back Disability Index), resistance (trunk resistance [TR] test) and thickness changes in the muscle (ultrasound image) were evaluated before and after the RC protocol and at one-month follow-up.

RESULTS

There were significant VAS reductions in both groups, but at follow-up these had only been maintained in the RCG, which presented lower values than the CG in the second evaluation. For PA, Oswestry and TR, there were differences only in the RCG. In a comparison of LBP between the groups, the initial difference disappeared in subsequent evaluations; TR presented higher values in evaluation 2 and 3 in the RCG group. In terms of thickness changes, differences between the groups were reduced after treatment.

CONCLUSION

The proposed treatment was effective in the reduction of LBP, with short-term improvement in resistance and thickness changes of the multifidus.

Strengthening the quadriceps femoris muscle versus other knee training programs for the treatment of knee osteoarthritis

People with knee osteoarthritis have atrophy of the muscles surrounding the knee joint. Therefore, exercise programs primarily have been focused on the strengthening of quadriceps femoris muscle (QFM). Primary aim of this systematic review was to determine which exercise increases strength of the QFM and describe the details of the training programs. Secondary aim was to determine effectiveness of strengthening of the QFM alone on pain and dysfunction in patient with knee osteoarthritis. PubMed, PEDro, and Cochrane were searched. PEDro for methodological quality of randomized controlled trials and Cochrane Collaborations' tool for risk of bias were used. A total of 1128 articles were identified from the database searches. Ten studies which were moderate-to-high level of evidence were included. In the comparison of different strengthening exercises of the QFM, significant difference was not found between training groups. However, strengthening of the QFM exercise training was superior to proprioceptive training. Additional hot packs plus shortwave diathermy or ultrasound or transcutaneous electrical nerve stimulation had superiority to isokinetic strengthening of the QFM alone. Only additional Russian electrical stimulation showed the significant difference compared with strengthening of the QFM exercise. Most of the included studies showed that strengthening of the QFM exercises has an effect on pain reduction and improvement of function. This review indicated that the strengthening of QFM training compared with other knee exercises provided muscle strengthening, pain reduction, and improved function while combination with other electrotherapy modalities or combination with Russian electrical stimulation had superiority to alone strengthening QFM training.

Combining Russian stimulation with isometric exercise improves strength, balance, and mobility in older people with falls syndrome

One of the main causes of falls in older people is muscle strength loss associated with aging. Russian stimulation can improve muscle strength in healthy individuals, but the effect has never been tested in older individuals with falls syndrome. The aim of this study was to evaluate the usefulness of Russian stimulation plus isometric exercise to improve muscular strength, balance, and mobility in older people with falls syndrome. The recruited participants (older than 60 years, at least one fall in the past year) were evaluated by a physiatrist, who collected clinical data and performed baseline and final evaluations (muscle strength, Berg balance scale, Tinetti mobility test, get up and go test, and 6-min walk test). A physical therapist applied the 10/50/10 protocol for Russian stimulation, stimulating the quadriceps and tibialis anterior muscles separately; simultaneously, the participants performed isometric exercise at a frequency of three sessions per week for 12 weeks. Descriptive statistics, the paired-sample t-test, and the χ-test were performed. The study included 25 participants (96% women, mean age 65.2±5.5 years). After the intervention, there was a significant improvement in the strength of the quadriceps (~30%) and tibialis anterior (~40%) muscles as well as the results of the balance (Tinetti 22%, Berg 10%) and mobility (get up and go 25%, 6-min distance 20%) tests. On the basis of the improvements in the Tinetti and Berg scores, significantly fewer participants were classified as being at increased risk for falls. The muscle strength correlated with several clinical evaluation results, but not with the Tinetti test score. Russian stimulation plus isometric exercise improves strength, balance, and mobility, which may decrease the fall risk.

Additive effect of tDCS combined with Peripheral Electrical Stimulation to an exercise program in pain control in knee osteoarthritis: study protocol for a randomized controlled trial

BACKGROUND

Knee osteoarthritis (OA) has been linked to maladaptive plasticity in the brain, which may contribute to chronic pain. Neuromodulatory approaches, such as Transcranial Direct Current Stimulation (tDCS) and Peripheral Electrical Stimulation (PES), have been used therapeutically to counteract brain maladaptive plasticity. However, it is currently unclear whether these neuromodulatory techniques enhance the benefits of exercise when administered together. Therefore, this protocol aims to investigate whether the addition of tDCS combined or not with PES enhances the effects of a land-based strengthening exercise program in patients with knee OA.

METHODS

Patients with knee OA (n = 80) will undertake a structured exercise program for five consecutive days. In addition, they will be randomized into four subgroups receiving either active anodal tDCS and sham PES (group 1; n = 20), sham tDCS and active PES (group 2, n = 20), sham tDCS and PES (group 3, n = 20), or active tDCS and PES (group 4, n = 20) for 20 min/day for five consecutive days just prior to commencement of the exercise program. The primary outcomes will be subjective pain intensity (VAS) and related function (WOMAC). Secondary outcomes will include quality of life (SF-36), anxiety and depression symptoms (HAD), self-perception of improvement, pressure pain thresholds over the knee, quadriceps strength, and quadriceps electromyographic activity during maximum knee extension voluntary contraction. We will also investigate cortical excitability using transcranial magnetic stimulation. Outcome measures will be assessed at baseline, 1 month after, before any intervention, after 5 days of intervention, and at 1 month post exercise intervention.

DISCUSSION

The motor cortex becomes less responsive in knee OA because of poorly adapted plastic changes, which can impede exercise therapy benefits. Adding tDCS and/or PES may help to counteract those maladaptive plastic changes and improve the benefits of exercises, and the combination of both neuromodulatory techniques must have a higher magnitude of effect.

TRIAL REGISTRATION

Brazilian Registry on Clinical Trials (ReBEC) - Effects of electrical stimulation over the skull and tight together with exercises for knee OA; protocol number RBR-9D7C7B.

TRIAL REGISTRATION

ID: RBR-9D7C7B . Registered on 29 February 2016.

Comparative effects of burst mode alternating current and resisted exercise on physical function, pain intensity and quadriceps strength among patients with primary knee osteoarthritis

Background and objective: The benefi cial effect of Resisted Exercise (RE) in Knee Osteoarthritis (OA) rehabilitation is often hamstrung by the presence of other comorbidities affecting exercise implementation, hence the need for comparative alternative therapies. This study compared the effect of Burst Mode Alternating Current (BMAC) and RE in the management of patients with knee OA. Methods: Forty-seven consenting patients with primary knee OA participated in this study. The participants were recruited from the outpatient physiotherapy department of a Nigerian teaching hospital. The participants were randomly assigned into either RE plus BMAC (RBMAC) or RE Only (REO) groups. The effects of intervention were assessed in terms of physical function, pain intensity and quadriceps strength at the 4th and 8th week of intervention. Descriptive and inferential statistics were used to analyze data at p<0.05 alpha level. Result: RBMAC and REO led to signifi cant mean changes in physical function (RBMAC – p=0.001: REO – p=0.001), pain intensity (RBMAC − p=0.001: REO – p=0.001), and muscle strength (RBMAC − p=0.001: REO – p=0.001) scores. However, there was no signifi cant difference in the mean change in physical function, pain intensity or muscle strength scores between RE plus BMAC and RE only groups (p>0.05). Conclusion: In conclusion, resisted exercise alone had signifi cant effects on physical function, pain intensity and quadriceps strength in patients with knee osteoarthritis. However, burst mode alternating current did not show additional effects.

Considerations of the Principles of Resistance Training in Exercise Studies for the Management of Knee Osteoarthritis: A Systematic Review

OBJECTIVE

To evaluate the methodologic quality of resistance training interventions for the management of knee osteoarthritis.

DATA SOURCES

A search of the literature for studies published up to August 10, 2015, was performed on MEDLINE (OVID platform), PubMed, Embase, and Physiotherapy Evidence Database databases. Search terms associated with osteoarthritis, knee, and muscle resistance exercise were used.

STUDY SELECTION

Studies were included in the review if they were published in the English language and met the following criteria: (1) muscle resistance training was the primary intervention; (2) randomized controlled trial design; (3) treatment arms included at least a muscle conditioning intervention and a nonexercise group; and (4) participants had osteoarthritis of the knee. Studies using preoperative (joint replacement) interventions with only postoperative outcomes were excluded. The search yielded 1574 results. The inclusion criteria were met by 34 studies.

DATA EXTRACTION

Two reviewers independently screened the articles for eligibility. Critical appraisal of the methodology was assessed according to the principles of resistance training and separately for the reporting of adherence using a specially designed scoring system. A rating for each article was assigned.

DATA SYNTHESIS

There were 34 studies that described a strength training focus of the intervention; however, the principles of resistance training were inconsistently applied and inadequately reported across all. Methods for adherence monitoring were incorporated into the design of 28 of the studies, but only 13 reported sufficient detail to estimate average dose of exercise.

CONCLUSIONS

These findings affect the interpretation of the efficacy of muscle resistance exercise in the management of knee osteoarthritis. Clinicians and health care professionals cannot be confident whether nonsignificant findings are because of the lack of efficacy of muscle resistance interventions, or occur through limitations in treatment prescription and patient adherence. Future research that seeks to evaluate the effects of muscle strength training interventions on symptoms of osteoarthritis should be properly designed and adherence diligently reported.

Exercises with partial vascular occlusion in patients with knee osteoarthritis: a randomized clinical trial

PURPOSE

The objective of this study was to evaluate whether women with knee osteoarthritis performing a rehabilitation programme consisting of low-load exercises combined with PVO exhibited the same results in changes in quadriceps strength, pain relief, and functional improvement when compared to women receiving a programme consisting of high-load exercises without PVO.

METHODS

Thirty-four women (mean age, 61 years) with a diagnosis of knee osteoarthritis were randomly assigned to a conventional or occlusion group. The women in the conventional group (n = 17) performed a 6-week quadriceps strengthening and stretching programme using a load around 70 % of the 1-repetition maximum (RM). The women in the occlusion group (n = 17) performed the same programme, however, only using a load around 30 % of the 1-RM, while PVO was induced. The PVO was achieved using a pressure cuff applied to the upper third of the thigh and inflated to 200 mmHg during the quadriceps exercise. An 11-point Numerical Pain Rating Scale (NPRS), the Lequesne questionnaire, the Timed-Up and Go (TUG) test, and muscle strength measurement using a hand-held dynamometer were used as outcome measures at baseline (pretreatment) and at the end of the 6-week of treatment. Pain, using the NPRS, was also assessed when performing the quadriceps exercises during the exercise sessions.

RESULTS

At baseline, demographic, strength, pain, and functional assessment data were similar between groups. Patients from both the conventional and occlusion groups had a higher level of function (Lequesne and TUG test), less pain (NPRS), and higher quadriceps strength at the 6-week evaluation when compared to baseline (all P < 0.05). However, the between-group analysis showed no differences for all outcomes variables at posttreatment (n.s.). Patients in the occlusion group experienced less anterior knee discomfort during the treatment sessions than those in the high-load exercise group (P < 0.05).

CONCLUSION

A rehabilitation programme that combined PVO to low-load exercise resulted in similar benefits in pain, function, and quadriceps strength than a programme using high-load conventional exercise in patients with knee osteoarthritis. However, the use of PVO combined with low-load exercise resulted in less anterior knee pain during the training sessions.

LEVEL OF EVIDENCE

I.

The effect of neuromuscular electrical stimulation on functional status and quality of life after knee arthroplasty: a randomized controlled study

[Purpose] The aim of this study was to investigate the effect of the addition of NMES to the post-TKA rehabilitation protocol on the functional status and quality of life of the patients. [Subjects and Methods] Patients were randomized into an exercise (control) and electrical stimulation (NMES) group. A home exercise program was prescribed for the control group. For the neuromuscular stimulation group 30 minute electrical stimulation applied to the vastus medialis muscle 5 days a week for 4 to 6 weeks. VAS, the timed up and go test, WOMAC and SF-36 scores were evaluated preoperatively and postoperatively at the first month and the third month of the follow-up period. [Results] Both the NMES group had 30 patients each, with 2 and 1 male patients respectively. The comparisons of WOMAC results at month 1 revealed that pain, stiffness, and total scores of the NMES group was significantly better than those of control group at the first and third months. Significantly better physical function and SF-36 subscales, except mental health, were found for the NMES group at the first month of follow-up. [Conclusion] The inclusion of the neuromuscular electrical stimulation program after knee arthroplasty was more effective at providing rapid improvements in knee pain, walking distance and quality of life.